Research Realities: health and care services for older people

The research

Title: Health and Care Services for Older People: overview report on research to support the National Service Framework for Older People

Author: Janet Askham

Affiliation: This report provides a summary of the key messages from research funded by the Department of Health to support the National Service Framework for Older People. Janet Askham, who was professor of social gerontology at King’s College London, prepared the report in her role as scientific adviser on older people to the DH policy research programme. It was completed just before her untimely death in July this year.

Objectives

The 16 projects funded under the Older People and their Use of Services (Opus) programme sought to inform the implementation of the National Service Framework for Older People (NSFOP), now in its seventh year. The projects were conducted between 2002 and 2007 and fall into three main groups:

● Exploration of the implementation of service or system changes: including NHS-funded nursing care in care homes intermediate care (three studies) the single assessment process reimbursement for delayed hospital discharge and the nurse education programme in palliative care.

● Evaluation of local initiatives: including treatment of depression in primary care assessment of falls by ambulance staff and structured follow-up after a disabling stroke.

● Identification of needs and problems: including the experiences of people with dementia from different cultures the palliative care needs of people with heart failure the timing of palliative care specialist services and staff for older people and the challenges of hospital discharge (two studies).

The programme embraced studies of varying design, complexity and scale, ranging from England-wide surveys to small-scale exploratory studies in a single locality. The study of reimbursement compared experiences in England with those in Scotland. Eleven of the studies involved the collection of data directly from older people and 10 from family members or carers. Overall, data from records for 8,500 older people was gathered, and 1,200 older people and 1,100 health and social care staff related their views and experiences through interviews or surveys.

Findings

The NSFOP set out eight key standards focused on: rooting out age discrimination person-centred care intermediate care general hospital care stroke falls mental health and health promotion. The report identifies six key principles which underpin these standards. Five of these are used as the focus for summarising the findings from the variety of studies. An indication of the headlines for each of these areas is given further detail, together with a broad outline of each study and its key findings can be found in the report, while those who have an interest in a particular study can access the individual report specific to that study.

There should be no discrimination in health and social care services

The projects demonstrated the tension between a positive view of the ageing process and the perception of old age as a period of decline. There was evidence from some studies of ageist attitudes and stereotyping among service providers and of age and cultural discrimination.

Five studies also revealed geographical variations in care, leading to a great deal of confusion over the meaning of “equitable treatment”. There was a need for evidence about what works in targeting specific groups of older people.

Older people with health and care needs specific to old age should have services from professionals who are trained in the care and treatment of older people

The study focusing on specialist services for older people revealed the confusion that surrounds such discussion. While the concept of a specialist for specific needs or conditions was readily accepted, the notion of specialists in older people or older people’s services appeared harder for respondents to grasp. This made it more difficult to counter discrimination. The report concludes that some of the confusion may be semantic but there is an obvious need to determine when specialist services may be required.

Services should be person-centred

The report highlights some amusing exchanges between an interviewer and an older person who had been asked their views on whether their service was “person-centred” and demonstrated a “holistic approach”. More generally, the studies both confirmed the need for a person-centred services and highlighted the lack of them.

This included the provision of palliative care, the provision of NHS-funded nursing care in nursing homes, intermediate care, hospital discharge, and the paucity of services for people with mental health problems. The report also acknowledges “the importance of recognising person-centredness as a complex, negotiated process” (p49) and highlights examples of some of the challenges involved, including service gaps, lack of information and inappropriate practices.

Older people with health problems should be helped to manage their own conditions, to regain independence and to remain living in the community

A key element in the NSFOP drive to support more people to live at home was intermediate care. The report concludes from the studies there is some evidence for the effectiveness of such provision, but that it can be jeopardised if other services such as information and advice, carer support, or mental health are inadequate.

Older people with complex needs should receive integrated and long-term care services

The report’s conclusions reflect problems of definition, of separating health and social care needs, and of service availability. There were also tensions between a policy focus on rehabilitation and recovery, and the need for comprehensive care. As the report says: “It is about how services interweave over the longer term for people making transitions between illness and supported independence or towards long-term care and the end of life.”

Analysis

Research activity relating to policy implementation is beset with challenges and frustrations. The policy may change emphasis during the course of the research meaning the results answer yesterday’s questions implementation in a study area may develop in an unanticipated direction, shifting the spotlight individual studies may be too modest or too specific to answer what is seen as the “big question”. Much of this is inevitable, so the benefit of a synthesis of this type, which scans across a programme of studies, is that it allows the findings from individual studies to be set against others to provide a more detailed and nuanced account. Issues where findings appear consistent can be identified, alongside others where contradictory findings suggest the need for more detailed investigation.

The report itself highlights four key recommendations for service development emerging from the studies:

● Firstly, attention should be given to the changing, long-term support needs of frail older people and those with continuing chronic conditions in the community, for example those living with the effects of a disabling stroke, those with dementia, and those whose intermediate care has ended.

● Secondly, mental health in later life needs to be given a higher priority: the promotion of psychological well-being in later life support to people with depression and strategies for meeting the needs of individuals with dementia.

● Thirdly, the provision of services to support end-of-life care in the community should be addressed, integrating services and tailoring them to individual needs.

● Finally, the role of GPs in the support of older people with long-term conditions is key they need to be more involved in the assessment process and to understand more fully what support is required and the potential of what can be achieved.

Policy implementation

The implementation chain from national policy to local service development and the receipt of support by individuals is beset by what this study summarises as “ambiguities, contradictions and tensions”. This is true both for set pieces such as National Service Frameworks that have been presented as standards, and for more fluid policy drivers, which may require further interpretation and specification. Explicit recognition of this ambiguity and tension allows those at different stages in the process to acknowledge their existence and to be alert for potential problems and unintended consequences.

Age-specific support

Uncertainties remain about the extent to which support for older people should be identified and delivered through specialist or generic provision. The likelihood is that a proportion of needs can be met through generic services while others would benefit from more specialist provision. It is not possible as yet to be prescriptive as to the correct balance.

Evidence base

The example of age-specific support highlights the need to develop and disseminate a stronger evidence base on what is known about what works for particular individuals or groups in particular circumstances. This should assist with attaining the promoted ideal of person-centred support.

Research Translation

This report demonstrates the value of synthesising project findings in relation to key policies, offering a clear analysis of the implications of the findings from a number of studies for health and social care for older people. It should encourage those primarily involved with implementation to stimulate the production of similar summaries which distil the key findings from a raft of studies and translate their implications for current practice.

The DH report is available here

Alison Petch is director of Research in Practice for Adults

This article appeared in the 20 November issue under the headline “Overview of health and social care services for older people”