Framework marks assault on age discrimination

The needs of older people took a significant step towards the
top of the government’s agenda last week with the announcement of a
National Service Framework For Older People. But are staff and
systems across the health and social care sectors ready, asks Sarah
Wellard.

For decades, older people have been expected to settle for
second best. Within both the NHS and social services, services for
older people have often been the poor relations of those available
to younger people. But the announcement last week by the health
secretary Alan Milburn of the National Service Framework For Older
People is billed to change all this. For the first time, the
government has committed itself to rooting out age discrimination
and putting the needs of older people high on the health and social
care agenda.

Glenys Jones, chairperson of the Association of Directors of
Social Services older people’s committee, believes the National
Service Framework represents a significant shift in how we as a
society look at older people. She says: “It starts from such a
strong position of principle about tackling age discrimination and
looking at the whole person. It could have been a much narrower
document. We’ve been aware that public policy has been stacked
against elderly people, both in hospital and in community care.
Often they have limited choices and lower quality services than
those provided for younger people with disabilities.”

Older people’s organisations also regard the commitment to
ending age discrimination as a major step forward. Tessa Harding,
head of policy at Help the Aged, says: “It’s extraordinarily
helpful. The implications are very far reaching and raise a lot of
questions about how social services plan their services. Local
authorities will have to start looking at their policies and how
they apply different rules to different categories of people.”

For example, in most areas the older persons’ budget allows for
less expenditure per person on services like home care and
residential care than that spent on younger people. Too often in
social services care for older people has tended to be rather
patronising, as Jones readily admits. There has been insufficient
money in the system to provide for the kind of rehabilitation
services offered to younger disabled people, and which offer a much
more rounded life experience. She says: “In the older people’s
committee we are realistic about what has happened and welcome the
opportunity to rethink services.”

Jones believes there is a need to start thinking more
imaginatively about commissioning services, to extend the range of
opportunities for older people, for example by looking at extending
participation in lifelong learning and leisure. But levelling up
services for older people can only be achieved at a price. Over the
next three years the government is making an additional £1.4
billion available for both health and social services for older
people.

Another of the cornerstones of the framework is a single
assessment process across health and social care for older people.
The idea is that whenever an older person has contact with health
or social services, professionals should be aware that they may
have needs beyond their immediate problem. If it seems from talking
to the person that their problems are complex, a fuller assessment
will be carried out. Assessments will be conducted by a frontline
professional – social workers, community nurses or other health
workers. They will explore a set of domains of need, covering
social as well as medical needs. If other professionals have to be
involved to carry out more detailed investigations this will be
arranged for the person to provide a seamless service.

Ian Philp, national director for older people’s services at the
Department of Health, explains that the underlying principle is to
take a person-centred approach. “The starting point would be asking
a person about their needs and priorities. The finishing point
would be an individual care plan.”

The National Service Framework document covers the broad
principles of the new assessment, but many of the details have yet
to be resolved. An assessment working group is being established by
the DoH to provide guidance on issues such as assessment tools and
scales and the circumstances which would trigger a more focused
assessment.

Despite all the rhetoric about joint working, many older people
currently receive different assessments from different agencies,
who are not always talking to each other. Philp acknowledges that
assessment is often piecemeal and repetitive. “There’s a lot of
duplication. It’s uncoordinated and wasteful. The single assessment
framework will make assessment more systematic, with greater
sharing of information, especially between primary care and social
care.”

In many parts of the country health and social services are
already carrying out joint assessments, but only one or two areas
have gone beyond this and introduced single assessments. As Harding
points out, having a joint assessment, even where this is
co-ordinated by a joint health and social services team, does not
necessarily result in an integrated experience for the older
person. She says: “People don’t always realise an assessment is
being carried out. It can be hard for people to participate,
because they don’t understand the language used. They feel they
don’t have the right to make decisions about their lives.” So will
things be better under the single assessment process?

A lot will depend on the skills of the staff carrying out the
assessment. Philp is confident that community nurses and social
workers already have many of the skills required. He says: “If we
look at the experience across Europe we find that community nurses
and social workers are the best people to implement this. They have
a holistic and person-centred approach.”

Jones is also upbeat about social workers’ capacity to take on
board the new assessments. She says: “If we are committed to a
whole person approach then single assessments are the next logical
step. Initially, we had some concerns in social services that the
medical model would take over, but I don’t think that is going to
be the case. We’re used to looking at a wider spread of social care
needs. It’s more of a challenge to our health colleagues.”

Some specific training will be needed for the frontline staff
carrying out assessments. And shortages of key professionals in
many parts of the countries may cause difficulties with
implementation. However, health and social services managers are
hoping that the national workforce group on older people will come
up with some useful ideas for using skilled professionals
differently, so that they can be freed up to carry out more
specialist tasks.

Integrating information systems is likely to prove a bigger
challenge. At the moment there are different systems in local
government and the NHS. For the single assessment to be properly
implemented, systems will need to be able to talk to each other in
a way that protects client confidentiality but also provides
management information.

Philp says: “There’s potential for information systems to
revolutionise health and social care in the way that sewers changed
public health at end of the nineteenth century. They are boring but
absolutely vital.”

Micky Willmott, health policy officer at Age Concern, believes
the single assessment framework has the potential to make a big
difference for older people. However, she is concerned about how it
will be implemented locally. She says: “There are a lot of issues
to be sorted out. It’s not clear enough who will be leading this,
and what the accountability structures will be.”

Philp’s message to local government is that getting local
strategic partnerships up and running well is the key to effective
implementation. He says: “The framework gives us a historic
opportunity to address issues which in the past were too difficult
to crack. But it’s going to need genuine partnership between
health, all branches of local government and the voluntary
sector.”

Framework standards

The National Service Framework for Older People outlines
national standards aimed at improving the quality of health and
social care for older people. These are:

Tackling age discrimination,

Person-centred care,

Intermediate care,

General hospital care,

Stroke,

Falls,

Mental health,

Promoting an active and healthy life.

New measures to be introduced include the following:

Monitoring of access to health and social care services to
ensure there is no age discrimination,

Greater investment in procedures and services particularly
important for older people, including more cataract operations,
more hip and knee replacements and more heart bypass
operations,

A new single assessment process across health and social
care,

Patient champions on patient forums, NHS boards and councils to
take responsibility for the care of older people within their
organisations,

New emphasis on treatment at home and other settings to avoid
admission to hospital,

New emphasis on healthy living for older people,

Single assessment

Under the single assessment, health and social workers should
look at the following domains,

User’s perspective,

Clinical background,

Disease prevention,

Personal care and physical well-being,

Senses and communication,

Mental health,

Relationships, including social contacts and caring
arrangements,

Safety,

Immediate environment and resources, including care of the home,
accommodation, finances and access to local facilities and
services.