ARGYLL & BUTE CHP Helensburgh & Lochside Locality

Argyll & Bute CHP Committee

6 October 2006

Item No: 8.1

REDESIGN OF SERVICES FOR OLDER PEOPLE: Helensburgh & Lomond Locality

Report by Susan M. Spicer, Integration Project Manager

Background and Summary

The predecessor groups of Lomond LHCC and Argyll & Clyde Health board previously agreed the community infrastructure plan for Helensburgh in principle. The plan however did not progress to full implementation due to the impact of the redrawing of health board boundaries and the aligning to local authority areas, which has been highly significant for this locality and has therefore naturally incurred delays. The paper sets out the way forward for a joint approach to community service delivery for the older people in this locality. Resource released from the closure of the continuing care beds will be used to re-provide care that is focussed within the community rather than on beds. It reflects the spectrum of care and support required for a modernised service with a whole system approach. It states the potential benefits and outcomes that will meet the expectations of both service users and providers. It proposes strong monitoring and evaluation systems.

Redesign Proposals

Redesign of Services for Older People (Attached) sets out the OPS objectives and how these are translated into a local plan. The main components of the proposals can be defined as:

1)The formal closure of redundant NHS continuing care beds and refocusing care into the community using the resource released to develop alternative models of care.

2)The development of a range of community based services targeted at key points of intervention:

anticipatory/preventative care,
intermediate/acute care,
rehabilitative care,
ongoing maintenance & support.

Each component is inter-related and co-dependant, facilitating a transition from medical dependence to functional independence.

3)Enhances current provision in both the CHP and Local Authority by additional commitment to: Community Nursing & AHP services, Joint Social Work Daycare with specialist NHS Day hospital type intervention for rehabilitation, joint equipment services, social care packages including homecare for personal and intensive care needs, day care, respite, and rapid response.

4)Identifies how this meets the agenda for the modernisation of service in a whole systems manner aimed at redressing the balance of care. Thus, by preventing avoidable admission to hospital and supporting discharge or transfer of care, contribute to tackling the delayed discharge agenda; the model will ultimately support a significant increase in the number of people being able to stay in their own homes for longer and if or when needing admission it should be clearly appropriate and for a much shorter period.

5)The proposals incorporates an:

Outcome framework that states many significant, measurable expected outcomes for the locality.
Financial framework that states the resource implications
Outline implementation plan

Contribution to Local Delivery Plan and Corporate Objectives

The key thrust of the plan is that joint planning, commissioning and provision of services that are developed in partnership with the local community will deliver a modernise service that helps meet the majority of the following objectives,

Meeting the principles of the Kerr Report “Delivering for Health” and the Argyll & Bute Joint Future Partnership Service Plan For Older People
Changing the balance of care to community and targeting resources appropriately
Improving access, promoting independence and good health for older people, with preventative, anticipatory care and care management; seeking to avoid admissions to hospital and provide care as locally as possible.
Performance management and evaluation of the services will significantly help meet the Local Improvement Targets and make a major impact on Delayed Discharges

Governance Implications

Staff Governance. Supports the workforce to sustain local services through education and training and focused development of new skills particularly in; preventative, anticipatory care and care management to reduce dependence.
Patient Focus and Public Involvement. This proposal is to provide person centred services, which improves access, with services being delivered as locally as possible to help maintain people as long as possible within their own community. In essence it has been created from, and in conjunction with, public involvement over many years and reflects the stated desires of the Older Peoples Pathways, Older Peoples Strategy and locality work.
Clinical Governance: Helps meet the standards set by; QIS Standards, National Care Standards for Older People, National Services Framework for Long Term Conditions, Better Outcomes for Older people, Draft Rehabilitation Framework.
Financial Impact: as attached financial framework (in progress of being reconciled to 06-07 uplifted budgets so will have minor adjustments made).

Impact Assessment

Requirement to impact assess all policies and functions and to include reference to impact assessment with regard to the issue in respect of equality and diversity.

Susan M. Spicer

Integration Project Manager

Argyll & Bute CHP

ARGYLL & BUTE COMMUNITY HEALTH PARTNERSHIP

ARGYLL & BUTE COUNCIL

Helensburgh & Lomond Locality

REDESIGN OF SERVICES FOR OLDER PEOPLE

August 2006

Introduction

This paper outlines proposals for further developing the Community Infrastructure for Helensburgh and the Lomond Locality to meet the needs of a modernised community based service for Older People; which shifts the emphasis of care away from hospital based services to provide as much care as possible in local communities and in peoples’ own homes. This is known as changing the “balance of care”. This has been a key component of transforming services both nationally and locally over the past few years. There is a growing elderly population, 95% stay at home and most wish to do so; to deliver services in this context there is a requirement to disinvest from NHS Continuing Care beds and substantially re-invest resources in a range of local community based health and social care services.

This paper is not noting a new direction but restates the position that has been developed with practitioners and stakeholders over at least the past five years. There has been a long-held desire to deliver more community services but resources have been tied up in long-term NHS care and have been slowly released through a phased approach elsewhere in the Lomond area. Extensive preparatory work has already occurred but change in practice over the past few years now means that urgent and significant progress has to be made to ensure that the community infrastructure is in place to meet these changing needs. Beds previously categorised as NHS Continuing Care are no longer needed and have been increasingly used for patients awaiting a more appropriate care setting. Local authorities have made a concerted effort to reduce delays in providing either care packages or care home placements to support people returning to their own home or local community, but the range of care options remain constrained by availability and finance. It is only now with the potential release of resource from the closure of the Jeannie Deans Unit that previously agreed locality plans can be actioned.

Background

The Argyll & Bute Joint Future Partnership (NHS and Local Authority) has previously agreed to replace NHS Continuing Care with more appropriate service models of care for older people and has stated the ultimate intention is to move towards having no NHS long-stay beds. Since 2001 it has pursued a phased reprovision programme within the Lomond area, resulting in a retraction of 60 NHS Continuing Care beds (for the whole previous LHCC area). Agreement already exists with partners that the reprovision of the Jeannie Deans Unit would complete Phase 3 of the implementation.

As these plans have been phased over a number of years there has been ample time to examine the evidence for care being delivered against a backdrop of improved hospital and community health and social care which supports the model of; assessment, rehabilitation and care in the community. This experience corroborates changing patterns of care with more rapid hospital assessment; shorter stays and people no longer being assessed for long-term NHS inpatient care (previously known as Continuing Care) with most people returning to community for ongoing support. A small number of NHS beds must be retained to deliver intensive levels of care to older people with complex medical needs that can only be addressed within an acute hospital setting and for a short period, usually in the last stages of life. Local plans identify this as being currently provided appropriately at the Vale of Leven Hospital under the care of the Consultant Geriatrician and multi-disciplinary team in the Department of Medicine for the Elderly (DOME). The current provision has been proven by the Consultant to be an accurate reflection of local activity since November 2003. Therefore when the unit closes Argyll & Bute will no longer be investing in NHS Continuing Care beds within the Helensburgh & Lomond Locality and in-patient services for older people will be provided at the Vale of Leven, alongside the specialist outpatient clinics and day hospital.

In addition to the thirty beds previously designated as Continuing Care within the unit, there are two beds accessed by patients of all ages for palliative care. The palliative care funding will be treated separately as it is outwith the Continuing Care and Older Peoples service remit. The attached resources will be appropriately retained to implement this service within the locality palliative care plan, which is currently being developed within the community for consultation and agreement.

Resource released from the closure of the Continuing Care beds will be used to re-provide care that is focussed within the community rather than on beds. This joint resource will provide additional funds to complement existing services and to build on the locality community infrastructure to support modernised health and social care services for Older People. Whilst this is significant investment and progress it must be noted this contribution cannot solely reform all deficits for the locality care plan and does not attempt to do so. For example, a repeated request from patients and carers within the community is to recognise the difficulties the lack of transport makes on access to care. Whilst delivering services as local as possible helps improve access, development of public transport for communities cannot be tackled by this resource release.

Objectives

There is a wealth of clear documentation (see attached bibliography) identifying the national drivers and policy frameworks for change including the fundamental precepts of “Delivering for Health”, but the principles contained within them are summarised as:

Joint Planning, commissioning and provision of services; which are developed and delivered in partnership with local communities
Modernising Services with a whole systems approach
Developing a person-centred service
Maintaining good health for older people and promoting independence
Preventative and anticipatory care
Care management and preventative strategies for older people
Avoiding admissions
Providing care as locally as possible
Managing transfer of care and discharge, thus reducing delays
Developing new skills to support local services through education and training
Evaluation and performance management

These objectives translate into local plans, with the most recent being the “Argyll & Bute Joint Future Partnership Service Plan for Older People” which provides in-depth analysis of locality population trends and requirements. This recognises that the locality has enough care home places available in total to meet the Scottish average, but that there are significant deficits in preventative, anticipatory and community based rehabilitation, maintenance and support for older people; especially in specialist Nursing and AHP input, homecare, respite, day care and equipment to aid activities of daily living.

Current position

Local partners in health & social care require a service plan agreed that reflects the spectrum of care and support required for the modernisation of OPS services for Helensburgh and Lomond. Whilst it is acknowledged positive and effective work has already started, many of the newer locality developments have been achieved by jointly targeting resources, especially specific delayed discharge monies. These rightly focussed on people in an acute phase of care to provide a rapid response and to reduce delayed discharges; by providing support in the community to prevent unnecessary admission to hospital and by enhancing levels of support that enable earlier discharge from hospital. There is however acknowledgment of the challenges and steps needed for more progress, particularly in providing an enabling and rehabilitative framework to underpin this work in a more sustained way for the majority of the populace who are not acutely ill. This, alongside anticipatory care has to be provided if the long-term strategy of driving down delayed discharges and significantly shifting the balance of care to the community is to be attained. There are also clear service gaps for residents of the Lochside & Peninsula who are disadvantaged by having virtually no access to Day Hospital and Day Care facilities mainly owing to rural and travel factors. The proposals offer an opportunity to ensure that more equitable access is provided throughout the locality.

Current Services

Community Nursing, including; District Nursing, Evening Nursing Service, Health Visiting, Treatment Room and Practice Nursing
Social Care, including; Homecare, Day Care, Respite Care, Independent intensive homecare, Independent nursing and residential beds in care homes
Charitable & Voluntary Organisations; Respite Care, Day Care, Lunch Clubs, Meals on wheels, etc.
Joint Overnight Nursing & Social Care Service
Use of technology such as community alarms (Telecare), to support people in their own homes
Joint Integrated Care (Lomond Care Team) ~ rapid acute intervention to prevent admission to hospital and support early discharge
Delayed Discharge Care Manager ~ intensive case management to prevent delays
Joint single shared assessment for community care
Area Resource Group (ARG) – locality joint process to progress single shared assessments and jointly manage community care packages.
Care Home Liaison Nurse ~ to give specific advice, support & education re. continence care pathways and implementation.
Pilot completed for a satellite outreach service from the Vale Day Hospital to provide specialist rehabilitation closer to home for patients in Helensburgh & Lomond ~ this will inform the design for the model of care to be delivered at other sites, including the new joint development proposed for Garelochhead.

In progress

The newly built Kilcreggan Health Centre incorporates a therapy room, which new rehab services should be able to utilise fully to provide more local input.
Garelochhead joint health and social care facility, with commissioned independent provision of day care (Crossreach) and access to therapy room on the same site as the General Practitioners and community nurses.

These projects provide opportunities to fill earlier noted gaps in service by substantially improving access to the broad spectrum of professional input, both more locally and more equitably. Additionally, the current draft document identifying resources spent jointly in providing Older Peoples’ Services shows this locality spends less per head of population than any other Argyll & Bute locality ~ therefore this plan goes part of the way to addressing this imbalance, not by additional spend but by refocusing resources on community services.

Proposed Model

There must be a cohesive pathway for individuals, ensuring they receive the right intervention, in the right place, at the right time and must have easy access to community services that “fit” within the whole health and social care systems.

The spectrum covers access to professional assessment, with individual care plans developed and agreed with the patient/client and carers, to provide appropriate:

Early preventative care & support to promote health and well-being
Early recognition of pending health problems
Interventions and rehabilitation for those with achievable goals to restore function and to promote independence
Targeted ongoing maintenance for those whose function is unlikely to improve but where anticipatory care could prevent or delay further deterioration
Early and rapid assessment and interventions during acute episodes.

This breadth of provision will be delivered in a co-ordinated multi-agency and multi-disciplinary approach and provided in a range of settings most appropriate to the individual’s needs. These include care delivered at home, in the local health centre, social day care setting, independent or local authority provider, or other community setting, e.g. in a sheltered housing complex or care home (single/residential/nursing).

It may be necessary to attend the Consultant Geriatrician and multi-disciplinary specialist clinics or day hospital for a short period for further specialist investigation and/or diagnosis and treatment intervention. There would be specific intent to progress an individual rapidly (when clinically ready) to their care plan being delivered in a setting closer to home.

With effective and timely intervention and support a hospital admission would be required only if clinically necessary. It would be expected that when medically fit, discharge would progress with the most appropriate package of care to help meet the individual’s community care plan. This is in line with the findings of the OPS Clinical Strategy Pathways work with patient and community representation and involvement; which highlighted that most people want to be cared for as near to home as possible, but recognise that when requiring specialist support this might necessitate travel to an acute care centre. It would be expected that more people would achieve this routinely through this substantial investment in the model’s increased spectrum of care.