Barrier busters

Amid acrimonious finger-pointing and accusations of culture incompatibility the joint relationship between health and social care in the London Borough of Barking & Dagenham has broken down. So it is comforting that similar arrangements are seemingly in rude health in the Borough of Knowsley, on the fringes of Liverpool.

Both boroughs are remarkably similar in size and in make-up: an uneasy conglomeration of small towns lumped together through geographic convenience in 1965 (Barking & Dagenham) and 1974 (Knowsley, bringing Huyton, Kirkby, Halewood, Prescot, Whiston and Stockbridge Village together). But while the flagship of joint working has failed in Barking, the Knowsley model appears to be cutting through the calm waters with ease. And perhaps the community older persons team (Copt) is the darling of the fleet.

“The team was set up in 2000 to provide a single point of access for older people in order to reduce duplication and the barriers that people face accessing services,” says Dave Doyle, service manager, intermediate care, who manages the team and who came from social services. He emphasises the team’s gradual evolution.

Setting up the arrangement was a big step, but moving in together in December 2001 into the Gresford medical centre in Huyton kick-started a sense of togetherness. “It prompted our next phase of development. It was like beginning all over again,” says Doyle. Indeed the importance of co-location is recognised by the government’s green paper Every Child Matters.

Then began the work of drawing up day-to-day protocols on how they would work together. “We now have much more integrated policies and ways of working. Initially we all followed our own referral patterns but now we have joint allocation meetings,” adds Doyle.

District nurse assessor, Janet Raine, Copt’s first appointment, saw the potential immediately: “It soon became apparent that the people who were coming through social services were virtually the same people we were seeing in the clinic. I think we have benefited a lot from working with social work teams,” she says.

The district nurses, who carry out full health assessments on everyone over 75, can also commission small packages of care: “If we went out to somebody and assessed that they needed meals-on-wheels or help to get washed and dressed, then we would commission that on our own,” says district nurse assessor Wendy Noonan. “A social worker need not be involved.”

One social worker who is involved is Elaine Pugh, who works on the well-being project that aims to remove traditional barriers preventing older people from using services. She realised that closer-to-home barriers between health and social care needed to be broken down first. “A lot of those have gone because we know we’re not going to take each other’s jobs and we’ve become more understanding of each other’s work. And it’s greatly improved our access to consultants and GPs,” she says.

The well-being project, staffed by Pugh, health visitor Karen Hornshaw and district nurse Maureen Sweeney, typifies the Copt preventive approach. “Often people might ask for help with cleaning but are told we don’t do that anymore. But sometimes they have more needs – that was just their opening question. We felt there were big gaps in the area,” says Pugh.

She continues: “We look at lifestyle: what they did before, what their hopes are and what they want to do. We try not to access health or social services if we can help it. We also advocate for older people. The big buzz for me is that I feel like I’m a social worker again. It’s like going back to the good old days when we were counselling people, giving people opportunities and looking at lifestyles rather than the modern care management approach.”

The skill mix of the team is impressive. Having pharmacist Jill Edwards is no bitter pill. “If needed, I can contact the GP to pull off the current medical history and go out and review a person straightaway, depending on the case. I can assess whether they are on the right medication – so it’s all a lot quicker,” she says.

The team’s drive towards prevention is again highlighted through its accident prevention project through which home safety advisers visit people who have had or fear a fall. The advisers, who can issue small items, including replacement deep fat fryers for more dangerous chip pans, contract the services of a joiner, who fits banisters and grab-rails, and an electrician. And all services are free. This includes the handyman scheme through which other service users are employed to help with tasks such as tacking down carpets. “It’s a double winner for us. Our service user gets the job done, which is partly done by someone else who has their own needs, be it mental health or learning disability, as part of their rehabilitation programme,” says Doyle.

Contact numbers are always left even after cases are closed. “Often they do phone back again and it means a lot for them just to be able to do that. Isolated and vulnerable people don’t often have anybody to be a voice for them,” adds Pugh.

The open, approachable and ongoing nature favoured by Copt is further reflected in its therapy services. “Our role is different to therapists in hospital,” says senior therapy assistant Sue Williams. “We carry our own caseload and go out and see users in their houses independent of the physiotherapist. We assess their needs and their environment and can issue things like a walking stick.” But as Pugh adds: “It’s not just about equipment, it’s about self-esteem. One woman I’ve worked with hadn’t been out shopping for three years, and that changed because of visits from our therapy assistants.”

Doyle agrees: “We hope that we demonstrate that integrated working is a valuable way of meeting the needs of older people. We’d all agree that there’s more than enough work out there for all of us – so by having a co-ordinated approach we are more efficient. The best outcome for me is that we have managed to keep a lot of people out of services.”

One of the services tapped into by the team is the Kirkby rehabilitation scheme based in a social services day centre. Crucially, the service needed to be local. “This service for me is a lifesaver,” says service user Enid Caldwell. “When I first came here a couple of weeks back I couldn’t walk, I couldn’t do anything. We’re always pulling each other’s legs and for me that’s great because at home I sit and watch telly and the telly watches me. This is a marvellous service. They paid me to say this, you know!” Another user, Tommy McDermott, is equally impressed: “I had a new hip that didn’t take and I was falling. I was in a wheelchair when I came here. I left needing only a stick. It’s great.” But Tony Madigan, a former union activist, sums up the effect of the services: “I had lost contact with people. But this place gave me hope.”

Despite such testimonials, Doyle is aware of challenges ahead. “We have a long way to go. We have separate employers through the PCT and the council – with separate terms and conditions – and sometime soon we need to negotiate those things to create a truly integrated team.”

Harold Wilson, former prime minister and ex-MP for Huyton, referring to new technology, famously spoke in 1963 of a Britain being forged by the “white heat of this revolution”. Forty years on, the Knowsley model of joint working could see the future of health and social care being forged by the warm glow of evolution.

Background

Scheme: Community older person’s team.

Location: Knowsley.

Staffing: Manager, occupational therapist, physiotherapist (x2) Therapy assistants (x2), district nurse assessors (x4), pharmacist, health visitor, home safety advisers (x2), social workers (x2), podiatrist, community nurse, and administrators (x2).

Inspiration: To provide an integrated service approach to meeting the social and health care of vulnerable older people.

Cost: £1.57m including intermediate care developments.

Edie’s story

I am a widow and I live on my own. I’ve lived nearly 70 years in my house. I sleep in the back and one night I heard this tap, tap, tap. I got up and saw two people breaking into next door’s shed – and they were heading for my shed. I couldn’t put my light on because I didn’t want them to know that I had seen them. I could not get back into bed from half past one until nearly five o’clock in the morning.

I used to have just one lock on my door. The safety advisers recommended window locks in the bathroom. I had a new viewer put on the door because I had to stand on a stool to see through the original one. The back door had a lock and chain, two Chubb locks and a viewer put on. In the house all carpets were secured. I had an extra banister on the stairs and a rail put outside down the steps, which are unbelievably steep. I now feel so safe and secure in my home. Now I can hear noises out the back and I’ve got no worries. I can’t speak highly enough of what the older people’s team has done for me.

Edie McKinney (not her real name) is a service user.