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In the past, social care practitioners may well have had cause to wonder at the stream of unpiloted and unevaluated initiatives they are expected to put into practice. But a new programme for older people in London is using a revolutionary approach -Êasking the people who actually provide services to come up with innovative new ways of working, and carefully evaluating the results.

The London Older People's Programme was launched in Autumn 2001, a joint initiative established between the Social Services Inspectorate and the NHS's Directorate of Health and Social Care (London). In headline terms, it is the capital's response to the National Service Framework for Older People and part of government's wider "modernising" agenda.


But behind the jargon, this pan-London experiment is working at grass-roots level to develop more intuitive, responsive and co-ordinated services. Essentially, this two-year, two-phase programme is testing out a key part of the NSF -Êstandard 2, which talks about the importance of person-centred care.

The idea is that care services should flow seamlessly around the older person. A central part of this is the single assessment process, which is a multi-disciplinary assessment of an older person's health, environment and social care needs. The projects within the London programme aim to support the use of the single assessment process by piloting small-scale innovations in the way services are provided, in various settings including hospitals, communities and intermediate care.

The London programme uses a tried and tested way of assessing services and improving outcomes that involves focusing on a small number of individual cases and identifying the barriers to a seamless service in each case. Over a number of cases, staff develop a hunch about what factors are causing problems, and come up with possible solutions. These solutions are then tried out with small numbers, assessed and then tried more widely. But whereas this collaborative methodology is well established in health settings, people involved in the London programme are faced with the much more complex, multi-dimensional relationship between health and social care.

In the programme's first year, 13 care communities in London boroughs were selected as pilots, with a further 12 boroughs coming on board in 2002. Care communities include a whole range of statutory and voluntary services from acute health services and social services to occupational therapists and physiotherapists. Each of the 25 projects has appointed a project manager -Êa local champion and co-ordinator -Êpaid for by the programme, which has a budget of less than £2m over two years. Of this, £1.6 million has been given to the projects as seed funding, with the remaining £300,000 spent on the co-ordinating team, workshops and training.

Project managers are responsible for working with individual teams in health and social care settings to try -Êon a small scale -Ênew approaches to the care of older people. The work of each project is typically supported by "strategic groups" of senior managers and "working groups" of front-line staff and practitioners.

Each project focuses on one of two different approaches to person-centred care. The first is case management. Case managers work with a specific group of older people -Êusually those with a range of chronic health problems and social care needs -Êand work in a holistic way supporting the older person to manage their own situation and become more independent.

This form of case management has enormous benefits for the older person and potential cost savings where independence can be maintained. It is extremely skilled work, and very labour intensive for the staff involved, but is generally only applicable to a relatively small number of older people and is time limited to around 10 weeks.

Redbridge Council is one of the second phase of pilots, and project manager Rebecca Hadley started work identifying potential pilots and setting them in motion this summer. She says: "We've found that when we ask the teams to identify people who would benefit, they've been very enthusiastic and keen to get involved."

Redbridge has two older people who are being case managed within the project and both have high needs. The criteria the project selected for older people to be involved were that they were over-75, in need of at least 25 hours of care per week, had been taken to accident and emergency twice in the previous 12 months, and were on four or more medications.


The Redbridge project is also involved in piloting a new approach to the role of care co-ordinators, whose job is to pull together the package of care following the single assessment. Hadley is involved in piloting the use of non-professionals as care co-ordinators, with a working title of "older person's link worker". This division of labour enables professional staff such as social workers and occupational therapists to focus on their area of expertise, and the post of "link worker" could also help to develop a new career pathway for non-professional staff.

The second approach is the case finding model -Êwhere older people are screened by telephone or in person to identify any needs they have. This approach makes contact with many older people who may not be aware that there is help available for them, and staff follow up about one in 10 older people whose responses indicate they may have undiagnosed health problems or unmet social care needs. Case finding approaches have helped identify people with undiagnosed heart disease and prostate cancer, as well as helping other people obtain services like chiropody and claim the benefits they are entitled to.

There have been significant improvements for older people within pilots already. One man's panic attacks and breathing difficulties had resulted in no less than 32 visits to A&E in one 12-month period. Yet following on from his single assessment, he built a relationship with his case manager, whose support and reassurance over the phone have meant that he can control his own symptoms to the extent that he has only been to A&E once in a three-month period. Staff on the acute side are very impressed with one A&E worker saying the programme has provided "conclusive proof that joint working and co-ordinated care can have enormous benefits for local services, but more importantly can provide a holistic and greatly improved care pathway for the patient".

Dave Walton and Kerry Gilmour joined the programme in July 2002 as programme managers -Êresponsible for supporting the 25 care communities in the programme. They feel the great strength of the programme is its flexibility and the focus on manageable changes. Pilots can try out new approaches to find out what really works, what things are necessary and which can be changed or omitted. And an important part of the programme's work is sharing and learning from experience, and disseminating the results. Individuals involved in the pilots talk to other team members who are not involved, thus spreading information and good practice examples to a far wider group of practitioners. As one of the leaders of the programme, Elizabeth Lowe, puts it: "It's about good practice becoming common currency."

The programme comes to an end next summer. When the funding runs out, some pilots may prove to be sustainable in the longer term, others may not. But the aim of the project was to establish evidence-based good practice within the NSF and the single assessment process, and to that end the programme has been subject to rigorous evaluation. King's College, in London, is currently evaluating the second phase pilots, which should produce some good quality evidence on which to base practice. With this to build on, older people's experience of health and social care services in the capital could eventually be changed beyond recognition. 

- For further information on London Older People's Programme go to www.london.nhs.uk/olderpeople