Active steps to prevention

A shift towards more preventive services is paying dividends in reducing older people’s stays in hospitals, write Gerald Wistow and Derek King, who present early results from the Innovation Forum’s older people project

One of the ambitious proposals in the white paper Our Health, Our Care, Our Say is the commitment to shift resources from hospital to the community. The intention is that spending on primary and community care should grow faster than spending on hospitals in order to support a fundamental realignment of the whole health and social care system. As a result, the white paper pledges a shift towards prevention and the provision of more services closer to home.

The results from the first year of a council-led initiative suggest this objective is beginning to be achieved. The Innovation Forum project, Improving Futures for Older People, was set up by the Office of the Deputy Prime Minister and the Local Government Association in 2003 as a partnership between central government and the highest-rated local authorities to pioneer ways of delivering public services.

Its older people’s theme was based on the idea that good housing, a range of facilities (especially for transport, leisure and entertainment), and families and friends can help “older people thrive, retain their independence, maintain a quality of life, and stay healthy”. It also says that hospital admissions can “undermine self-confidence, disrupt diet and increase dependency and the likelihood of infection” and so are best avoided or reduced to an absolute minimum.(1)

The project adopted a single headline target for all participating authorities: to achieve over three years from April 2004 a 20 per cent reduction in unscheduled hospital in-patient bed days occupied by older people aged 75 or older compared with the predicted level. Despite the ambitious nature of this target, more local authorities signed up to it than any other Innovation Forum project. The pilot councils are Kent (the lead council), Cornwall, Cheshire, Dorset, Hampshire, Hertfordshire, City of Westminster, West Sussex and Wigan.

The councils were committed to providing strong community leadership and forming effective local partnerships to deliver the target with acute trusts, housing, the voluntary sector and other agencies. They would play an innovative strategic commissioning role to ensure that local partners took a broad view of how investments were directed across the whole health and social care system.

These commissioning strategies would encompass social care, health services in the community and hospitals, with low-level support services. It was also a central tenet that the 20 per cent target was a means to achieve healthier and more independent lives for older people and give them greater choice of holistic services and increased community participation.(2)

Considerable success was recorded during the first year.(3) The number of bed days used for 2004-5 was 17 per cent below the prediction for 2006-7 and 4.8 per cent less than the actual
figure for the previous year. The latter finding means that some 55,000 fewer bed days were used in 2004-5 compared with 2003-4.

At first sight, these results suggest that the project had achieved most of its three-year headline target in year one. In practice, the position is less straightforward. The councils and their partners face two more years of growing demographic and other pressures that were factored into the 20 per cent headline target. We are currently evaluating how far these pressures were absorbed in year two.

Long-term sustainability requires continuing partnerships, joint investment and increased capacity and also depends on reinvesting acute sector savings in community services.
In addition, further work is being undertaken to gain a better understanding of how these results were achieved on the ground. Each locality created additional capacity – intermediate care, better care management services, community matrons, sheltered housing, better co-ordinated discharge schemes, low-level support in the community such as wardens – as alternatives to hospital admissions and stays. These initiatives were designed to improve the quality of life for older people and sustain independent living rather than cut hospital beds.

The evaluation was not commissioned to establish causal relationships between such interventions and the bed days used but the project aims to learn more about some of these relationships.

The project has already influenced the public service agreement (PSA) target to reduce emergency bed days by 5 per cent over three years to 2008 by improving care in primary and community settings. It has also influenced the Partnerships for Older People Projects, a 60m initiative set up by the Department of Health for councils to invest in developing preventive and other community-based services and reducing the amount for institutional and hospital-based care. The first set of projects, involving about 19 local authorities, started this April and the second set are due to start next April.

So, there are already grounds for welcoming these first-year results. First, they represent an initial reversal in the historic trend of year-on-year increases in emergency bed days, which national policy has subsequently sought to address. Second, the absolute reduction of nearly 5 per cent in one year is close to the three-year national PSA target. Third, the results suggest that locating a lead commissioning role in local government can successfully begin to shift the balance between acute and community services. Fourth, the local authorities were able to negotiate a single, demanding target in an area of shared priority with central government and make initial progress towards it without additional resources. Finally, it represents the exercise of local freedoms and flexibilities to design local interventions and delivery systems to support such shared priorities.

All these findings show social care working within the overall leadership role of the council to co-ordinate the realignment of the whole care system. It provides an example of the partnership working expected by DH and of the community governance role advocated by the Department of Communities and Local Government.

If the first year’s progress can be sustained, the project will be a pathfinder, not only in improving futures for older people but also for the future of local democracy more generally.

Gerald Wistow is a visiting professor at the London School of Economics and the University of Durham. He chairs the Hartlepool Connected Care project and is leading the evaluation of the Innovation Forum older people’s project. Derek King is a research officer in LSE Health at the London School of Economics.


Training and learning
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

Abstract
A long-term objective for health and social care has been to re-balance services and investments so that older people have fewer hospital admissions. The results from the first year of a local authority-led initiative suggest this objective is beginning to be achieved. If sustained, it will demonstrate the ability of councils to initiate and lead the co-ordination of change in acute hospital and community services.

References
(1) Kent Council and Department of Health, Innovation Forum Proposal: Reducing Hospital Admissions for Older People – Commissioning Template, Kent Council, 2003
(2) ibid
(3) G Wistow, D King, Findings Reducing Emergency Hospital Stays For Older People: Innovation Forum First Year Report, Report No3, Kent Council, 2006

Further information
The project is being evaluated by researchers attached to each field site and co-ordinated by the London School of Economics. They calculated that it would require 265,450 fewer emergency bed days for over-75s compared with the 2006-7 projection. Compared with the 2003-4 baseline, the target represented a reduction of 8.5 per cent (97,571 bed days).

Contact the author
gerald.wistow@btinternet.com