Back home

Everyone agrees that home care with support is
preferable to institutionalised care, but outlooks diverge among
health and social care professionals once the front door has been
opened and the client crosses the threshold. Ruth Winchester
reports.

First the good news. If you are an older
person, the chances of ill-health, a fall or a stroke landing you
permanently in a nursing home are getting smaller. Now the bad
news. If you are a health or social care professional, it is a lot
more complicated than that.

The
government’s drive to develop intermediate care services and
improve the opportunities for rehabilitation for older people is
undoubtedly starting to pay off. An array of innovative services
are springing up including mobile rehabilitation units that visit
patients at home after discharge from hospital, community-based
rehabilitation teams and rapid response home care services. A
number of pilots have also been set up to explore new approaches
(see panel on page 30).

This
enthusiasm for rehabilitation has been spurred on by significant
amounts of money. There has been cash for change, the performance
fund, partnership and challenge grants, and the £900m
announced as part of the NHS plan, which included the promise that
intermediate care would end bed-blocking by 2004.

But
while a casual observer may perceive intermediate care as a swan
gliding gracefully on a lake towards its destination, under the
water there is a lot of frenzied paddling going on – and it’s not
all in the same direction.

For a
start, a fair amount of the money seems to have disappeared into
black holes – particularly in the NHS where there is some suspicion
that it has been used to pay off deficits rather than being
invested in new services. The cash has also been used by social
services to help clear a backlog of people waiting for residential
and nursing home care. And there are mutterings that the impact of
the switch-over of people still on preserved rights – people whose
residential care was paid for by central government but who are now
local authorities’ responsibility – has taken some of the shine off
the sums involved.

As for
the remainder, a significant number of established services and
schemes have been “re-badged” to take advantage of the new funding
streams. There was concern when the intermediate care programme was
first announced that generalist services were going to have parts
hived off to form “rehabilitation units”, despite the fact that
neither the environment nor the staff were geared up to promote
independence. The majority of local authorities seem to have chosen
this route, rather than setting up specialist provision, but it
remains to be seen whether the dire predictions materialise. In
some areas part of the problem has been the lack of a central
rehabilitation strategy, leaving services to be set up on a
one-off, opportunistic basis.

And
unfortunately, there is still confusion in intermediate care. Even
what is meant by rehabilitation depends on who you talk to. Does it
mean, for instance, the physical process of learning to walk again
following a stroke, or does it mean regaining the confidence to go
shopping alone?

And
how long does rehabilitation go on for? At present there is a
government-imposed time limit of six weeks for intermediate care,
yet people can be still regaining their mobility and confidence 12
months after a stroke or a fall. Which brings up still more
questions about the point at which rehabilitation becomes ongoing
care – crucial since intermediate care is free at the point of
delivery, but ongoing social care is very often not. Local
authorities, with their health partners, are currently working on
their eligibility criteria for “continuing care” – services which
are needed after the initial rehabilitation period. Government
guidance about fair charging policy is expected to be in place
later this year.

A more
pressing concern among both those running and assessing
rehabilitation services is that the divide between health and
social care is still very firmly in place. There is evidence that
health money is still regarded as health money, to the extent that
NHS trusts and primary care trusts are going ahead with
rehabilitation schemes without even telling their social care
partners what they are up to.

This
is perhaps understandable, given the amount of pressure and
attention being applied to acute services by the government and the
stringent targets many are battling to meet. But observers argue
that the government’s focus on the problems of acute services has
resulted in a blindness to the importance of the rest of the
system. There are real problems with massively investing in
services that send people speedily back home from hospital, without
a corresponding investment in the services they will need when they
get home. Ploughing a lot of money and effort into reducing
bed-blocking and improving rehabilitation has not been followed
through with significantly increased investment in home care
services.

According to Roger Sinden, head
of independent living and older people’s services for Essex
Council: “There is a resolve on the acute side and in social care
to meet the targets, and the acute targets are certainly more
challenging than ours. But they are simply concerned about clearing
the beds – they don’t have to cope with the long-term implications
of what happens to those people.

“Intermediate services are very
short term, very intensive services that are about promoting
independence so that people can go home, rather than into
institutional care,” Sinden adds. “Which of course presupposes that
there is a home care service to pass them on to. The difficulty is
that no one wants to be a home carer, which means that we don’t
have a long-term service to offer, which means that intermediate
care gets silted up.”

Glenys
Jones, director of social services at Middlesbrough and Association
of Directors of Social Services lead on older people, thinks there
are longer term issues at stake. “Certainly many people need
intensive rehabilitation, but what many need after that is ongoing
help and support to stay independent. We have a situation where you
receive six weeks’ rehabilitation, and that’s your lot – you’re
expected to go home and cope alone.

“Reablement work is much longer
term – it’s about preventing someone from deteriorating, and
continuing to promote independence,” Jones says. “That’s the real
challenge to long-term care services – how you train home care
workers and other staff to become reablement officers. Intermediate
care is very sexy right now, but the more interesting bit is how
you promote independence over the longer term. The challenge is the
long haul.”

Jan
Stevenson is rehabilitation programme manager for the King’s Fund.
She says: “There isn’t a single solution to the redesign of care
and support for older people – changes are needed to many different
parts of the system to make it work as a whole. You’ve got to
attack the problem on lots of different fronts.”

Few
people are in a position to take that “helicopter vision”, she
adds. “We need to take an overview. For a start, we could do more
to prevent older people’s health from deteriorating by regular
screening. Primary care teams and social services are well-placed
to identify people who are at risk. They could avert some crises by
offering better assessment, support and care management to people
living at home, which would stop some older people from coming
through the doors of A&E.

“There’s a real danger that
intermediate care is seen as a health responsibility, and that a
very medical model of care will result. Much of the investment to
date has come through the NHS. Social services also need to invest
in rehabilitation, for instance by offering home services that
promote independence rather than the traditional model which does
things for people.”

Stevenson argues that at present
there is insufficient attention being paid to leading the
intermediate care agenda. “Unless the very senior people start to
drive and lead change, middle managers will find it very difficult
to plan and manage the complex changes needed both in services and
working practices. You need senior people in all the partner
agencies to share the vision and make sure that everyone is signed
up to turning it into reality.”

There
is clearly quite a long way to go before services work as they
should, but generally there is a feeling that things are heading in
the right direction – and that assumptions about older people are
being challenged.

According to Jonathan Ellis,
health policy officer for Help the Aged: “There’s been a sea change
around attitudes to older people. For a long time the natural
reaction of services has been to pack people off to residential
care the minute they needed help. That’s starting to change now,
and nobody automatically assumes that’s the best place for
them.”

Staffordshire success

Sandra Daniels, reablement team manager,
Staffordshire social services, describes the success her department
has had in implementing intermediate care.

Staffordshire has been working hard on its
rehabilitation and reablement schemes, to which 350 people have
been referred in the first six months of this year. Almost 90 per
cent of these people have been able to return to or remain in their
own homes.

The projects were originally funded by
partnership grants, which encouraged them to develop
collaboratively with input from a wide range of professionals and
specially trained care workers. Extra support is also available
from the voluntary sector with an Age Concern worker attached to
the residential units to help with home discharge and provide
similar support to other schemes. Good communication with local
health partners has ensured financial support.

Much of the initial work involved training and
briefing staff, showing them what was achievable with creative
approaches to care planning. Early successes also helped to get
staff on board – successes like the 94-year-old woman who went back
to her own home after being a resident of a nursing home for three
years and who described the experience as “the great escape”.

Further training sessions for area social
workers and nursing colleagues were set up to encourage them to
consider reablement for those people on hospital wards or in the
community who might have been “written off” before all options had
been explored.

Collaborative working for all the team members
is another essential element. Having all the staff in the same
office helped to ensure everyone understood each other’s roles and
responsibilities. Joint training days were also set up and helped
to dispel some of the myths associated with different types of
professionals working together.

The staff group is committed to a
person-centred approach. Written notes remain with the service
user, and staff attend weekly reviews in the service user’s own
home. They give their final evaluation of the service via
questionnaires that have been used to shape service developments.
The feedback from service users using the schemes has been very
positive.