Social & Community ServicesScrutiny Review

of

the Single Point of Access to Rehabilitation and Care (SPARC)

Corporate Policy, Performance & Review
August2008

SC008

CA_OCT2108R04.doc

page 1

GLOSSARY

This report is written as far as possible in plain English with the minimum of jargon. All acronyms are spelt out in full when they first appear but for sake of clarity their meanings are repeated here.

A&E / Accident and Emergency Department (Hospitals)
AIS / Access to Information and Services (the Access team)
BPR / Business Process Reengineering
CAO / Contact Assessment Officer
CAF / Common Assessment Framework
CPA / Comprehensive Performance Assessment
CSCI / Commission for Social Care Inspection
CYP&F / Children, Young People & Families
DP / Direct Payment
DH / Department of Health
EDT / Emergency Duty Team
ESCR / Electronic Social Care Record
FACS / Fair Access to Care Services
I&A / Income & Assessment team
IC / Intermediate Care
IM&T / Information management and technology
JSNA / Joint Strategic Needs Assessment
LAA / Local Area Agreement
LAC / Local Authority Circular
LD / Learning Disabilities
NCRS / NHS Care Records Service
NPfIT / National Programme for Information Technology
NSF / National Service Framework
MH / Mental Health
O.C.C. / Oxfordshire County Council
OT / Occupational Therapy
PCT / Primary Care Trust
PD / Physical Disabilities
PHR / Person Held Record
PI / Performance Indicator
PID / Project Initiation Document
S&CS/SCS / Social & Community Services
SAP / Single Assessment Process
SPARC / Single Point of Access to Rehabilitation and Care
STOP / Services to older people

NEW CONTENTS PAGE

GLOSSARYpage

SECTION 1 – SUMMARY6

RECOMMENDATIONS7

SECTION 2 – BACKGROUND9

Aims of the Review 9

The Strategic Context10

SECTION 3 – FINDINGS13

The Current Situation13

Single Assessment Process (SAP) and Common Assessment

Framework (CAF)

Gaining Access to Information and Services15

(Access Team)

Background

Strengths of the Access Team in Oxfordshire

Areas for development

Consistency and quality of information

Awareness of the Access Team

Ongoing care; the relationship between health19

and social care

Strengths of the system

Electronic Social Care Record

Areas for development

Trust

Confidentiality

Disconnected Information Systems

Lead professional

Commissioning

Acute Need26

Hospital discharge

What is a Single Point of Access to Rehabilitation and Care

(SPARC)?

Failure of the system to implement SPOC

Areas for development

SECTION 4 – CONCLUSIONS29

Appendix 1 – Scoping Document31

Appendix 2 – Bibliography35

Appendix 3 – List of witnesses38

SOCIAL & COMMUNITY SERVICES SCRUTINY COMMITTEE

10 SEPTEMBER 2008

The Single Point of Contact to Rehabilitation and Care (SPARC)

Report of the Lead Member Review Group

Section 1 ~ SUMMARY

  1. Often older people receive a disjointed, confused response when they need help or advice – one that meets their needs only in part. The needs and aspirations of older people will only be achieved if agencies work together as a whole system. Nationally, there is a challenging agenda for change, with a commitment to having more integrated services which are built around the individual. Partnership stands out as a core theme, consistently reinforced in numerous national documents.
  2. Integrated working is where everyone supporting a client/patient, works together effectively to put the person at the centre, meet their needs and improve their lives. Integrating services for a rounded approach to each individual is seen by the government (and indeed by many users of services) as a means to support citizen choice, improve services and reduce risk. Although the focus is ultimately on outcomes, process improvements and more effective working practiceswill help to ensure enhanced care levels through greater efficiency and value for money..
  3. In developing this report and the recommendations,the Lead Member Review Group was asked to establish any deficiencies in the way social care and health services work, to the detriment of patients/ clients and their carers. The specific objectives of the review are set out in the scoping document in Appendix 1.
  4. The Review Group recognised that a lot of work is being done by extremely hardworking staff in a number of agencies in Social & Community Services (S&CS/SCS) and Health. However it is widely recognised that there is a great deal to do, as the report explains.
  5. Measures of whole system performance are needed. Currently only the performance of component parts is assessed. Incentives to deliver collectively against shared outcomes remain weak. The Review Group looks to the Local Area Agreement and its related structures to rectify this.

RECOMMENDATIONS

The Cabinet is RECOMMENDED:
  1. That the Access Team is provided with training concerning the range of advice (especially financial guidance) they may offer to clients.
  1. To note that Social &Community Services contact assessment forms are held electronically and that it is desirable to attach to them images of GP referral letters; there should be further investigation of the possibility of incorporating GP’s letters in the contact assessment forms.
  1. To authorise the Director of Social & Community Services to advertise theAccess Team’s contact details and to promote it as the Single Front Door in future editions of the Oxfordshire Care Directory, with consideration for a further study.
  2. That the Authority should aspire to a Single Front Door Access to all public services.
  3. To acknowledge the “mobile solution” using tablets and laptops to support the development of Electronic Social Care Records and to endorse these if the trial is successful when evaluated in September.
  1. To ask the Director of Public Health (Oxfordshire) to lead work to implement Oxfordshire’s Information Sharing Protocol by December 2008 and in the light of (7), to remove all barriers that prevent the e-mailing of records between Health and Social Care.
  1. With respect to issues around patient confidentiality, to explore further the possibility of implementing an encrypted e-mail system to allow protected, shared access to patient information. [note, a link encrypted e-mail system is not appropriate).
  1. To request that a feasibility study is carried out to establish whether it is possible to transfer NHS patient identification numbers locally onto S&CS so that a unique patient reference can be used in common across agencies.
  1. To ask for a report from the Oxfordshire Information Governance Steering Group annually identifying improvements in information sharing that occurred in the previous year.
  1. Alongside the Oxfordshire PCT and the acute hospital trusts, to issue a joint statement in response to this Reviewsetting out a set of clear shared expectations as to what degree of integration and coordination can be expected by 2010.

Section 2 ~ BACKGROUND

Aims of the Review

  1. A scoping document was formally adopted on 24 October 2007 (Appendix 1), although some initial preparatory work had taken place prior to this date. The Review originated from a desire to understand how the twin concepts of ‘single front door’ and ‘common assessment’ were being realised locally. It sought to uncover what was working well and what wasn’t and thereby identify any problems or barriers to greater effectiveness. Three further aims were distilled out of this starting point, namely to:
  • Examine the extent to which ‘Time to Change’ projects are having a beneficial effect in offering an improved customer focus.
  • Consider if the ‘Time to Change’ projects are positively improving the Directorate’s approach to prevention, and how such an outcome can be demonstrated.
  • Assess the extent of information sharing between the Directorate and its partners (principally health bodies), and its impact on the smooth flow of customers through the care pathway (regardless of which team provides them with advice or services).
  1. The Social & CommunityServices Scrutiny Committee was tasked with commissioning the Review and appointed twoCouncillors to carry it out (Councillors Mrs Anda Fitzgerald-O’Connor and TimothyHallchurch). The Review has identified key issues by gathering a large amount of relevant written information and hasexamined a number of documents relating to services and strategies (listed in Appendix 2). Members have held a number of semi-structured interviews with council officers and a number of organisations external to the County Council (listed in Appendix3). In addition they have talkedto service users themselves and carers; this has been a powerful way for Councillors to uncover directly what people think about these issues.
  2. It was felt that this was an important area for Scrutiny because it is a Government requirement to ensure service improvements for citizens, which will ultimately reflect on the Council via its Commission for Social Care Inspection (CSCI) inspections and Comprehensive Performance Assessment (CPA) scores, but also because of its potential to make a real difference to the quality of life for local people. Declining satisfaction in the local residents’ survey with services for older people, combined with an ageing population, made this a timely and important area for investigation.
  3. The Review topic was considered to be important as it related strongly to, for instance, the creation of better access to information and support via the Access Team and the delivery of a Single Assessment Process (SAP), both of which were required by the Local Area Agreement (LAA) 1: Target 8 of the Healthier Communities & Older People block is to: “establish a countywide common referral and assessment process for preventive services with a 20% increase in number of referrals from various agencies.”
  4. The implementation of SAP:“Implement overview Single Assessment Process in all adult social care teams by August” and “Implement electronic recording of Electronic Social Care Records(ESCR) by Dec 2007” were Balanced Scorecard targets for 2007/08. Improving access to appropriate assessment and developing preventative services are two service improvement priorities within the Older People’s Business Plan. Moreover, substantially enhancing preventative and rehabilitation services and increasing user choice and control over services are key aims of the commissioning strategy for older people.
  5. It should be noted that the Review could not cover everything and in line with good project management methodology deliberately restricted its focus to keep the scope of the assessment manageable. The Councillors comprising the Review Group chose only to examine issues relating to older people. However, these findings can be used to suggest learning points for allthe other client groups that are supported by social care.Subsequent to the completion of the review’sevidence and data collection, it has been brought to our attention that electronic social care records and document management have now been introduced to S&CS. However, this does not materially alter the findings from the evidence covered by the Review.

The Strategic Context

  1. Innumerable pieces of legislation and government guidance lay down a framework which calls for better integration. Principal amongst these are the White Paper ‘Our Health, Our Care, Our Say’, which is the main driver for change alongside the ‘National Service Framework for Older People’ and ‘All Our Tomorrows: Inverting the Triangle of Care’. The Government’s vision for social care, as set out in the White Paper, highlights four goals: prevention and early intervention; choice; access; and support for long term needs. The proposed outcomes areimproved health and emotional well being; improved quality of life; making a positive contribution; increased choice and control; freedom from discrimination; economic well being and maintaininga Single Assessment Process (SAP) developed specifically for older people and extending it to all adults with a long-term condition, in the form of a Common Assessment Framework.[1]
  2. The Commissioning Framework for Health & Well-Being set out the Department of Health’s framework for building on the White Paper ‘Our Health, Our Care, Our Say’. It has a particular focus on partnership. Its main theme is that everyone who can contribute to promoting physical and mental health and well-being, including the business community, government regional offices and the third sector, has a responsibility to do so. The aim of the document is to help commissioners focus on outcomes for adults by providing personalised services that promote health and well-being, proactively prevent ill health and work in partnership to reduce health inequalities.
  3. This vision links to other significant strategic documents which have been published by central government, particularly within the last two years, to develop a coherent picture of the way in which people’s lives are supported to enable them to remain independent. Prevention, early intervention and integration are key concepts throughout. There is evidence that proactively identifying and responding to needs as they emerge and targeting people with low-level needs today, can prevent them from becoming people that need institutionalised,high intensity health and social care. For example, Social & Community Services knows that too many older people are admitted to hospital, often as an emergency, when that could be avoided if the right community services were in place. Crucially, joint large-scale information system reform across health and care services is needed to deliver the desired improvement in outcomes and the Committee may be minded to recommend this.
  4. Local authorities are being required to create a sustainable shift in resources and culture away from the focus on intensive and institutionalised care and towards earlier and better targeted interventions for older people by:
  • improved access to older people’s low-level care services, e.g. help with daily living;
  • proactive case-finding to identify older people most at risk of hospitalisation and of losing their independence;
  • integrated needs assessment and case management work to both prevent avoidable hospital admissions and to better support people following discharge through improved rehabilitation services;
  • new joint health and social care teams to better integrate care pathways;
  • improved access to universal services such as leisure, transport, education and employment opportunities.

The Department of Healthis encouraging local authorities through a number of pilots to push forward on preventative technology (e.g. tele-care, extra care housing), individualisation (e.g. direct payments, individual budgets), and stakeholder engagement (e.g. self-assessment).

  1. The Wanless Report highlights the economic argument for refocusing investment on preventative approaches to care. The report produced by the Local Government Association and the Association of Directors of Social Services reminds local authorities that they are required to try and ‘Invert the Triangle of Care, not least because of demographic pressures on their resources. This emphasises that traditionally resources for older people are focused on those with the most severe needs. Statutory services were concentrated at the very tip of the population triangle and focus on acute care for the frailest older people. Moves to redress this balance by improving preventative and supportive services that promote independence rather than dependency are partially what lay behind the creation of the Access Team.
  2. The NHS Plan 2000 sets out key challenges,the firstof which is “partnership”. The National Service Framework for Older People builds on this plan and developed ‘ensuring an integrated approach to the whole system of care’ as its second key theme. It refers not only to the SAP but also to the need for integrated provision and commissioning of services, especially in terms of Intermediate Care. It also emphasises the goal of a holistic approach to care for which the provision of an accessible and integrated source of information and advice is essential. Integrating health and social care information is an important part of the NHS “Connecting for Health” strategy. The “National Programme for IT” is an NHS initiative formed in October 2002 and Connecting for Health, a specific Department of Health agency, was formed in April 2005 to deliver (amongst other things) an electronic NHS Care Record Service to replace patients’ paper files. Originally 2008 was the deadline by which everyone who requires and wants a personal health and social care record, should have such a record, although this has now been relaxed to 2010 (“The Care Record Guarantee” – see elsewhere).
  3. The new duty for PCT’s and local authorities to co-operate, contained in the Local Government and Public Involvement in Health Bill, requires both organisations to work together on the production of a Joint Strategic Needs Assessment. This should describe the future health, care and well-being needs of local people and the strategic direction of service delivery to meet those needs.
  4. In essence, all of the aforementioned documents and strategies place a strong emphasis on closer working between health and local government. In recognition of these national aspirations, local authorities and other local partners accept they have a central role in delivering good quality integrated and accessible services that promote independence and dignity. This is reflected throughout a wide range of service plans and policies, including:

Oxfordshire’s Local Area Agreement (1), which features:

  • stretch targets – “reduce the number of falls among older people living in care homes”;
  • “increase the number of people supported to live in their own homes”.
  • non-stretch targets –“ reduce health inequalities in Oxfordshire”;
  • “reduce adult smoking and exposure to second hand smoking in Oxfordshire”;
  • “increase the participation of adult population in physical activities”;
  • ” improve the proportion of carers receiving a specific carers’ service”.
  • A Commissioning Strategy for Older People;
  • PCT’s Integrated Service Improvement Plan;
  • PCT’s Local Delivery Plan;
  • Supporting People Strategy;
  • Safeguarding Adults Plan.

The requirement to maximise choice means that service development should involve service users and carers, and this too is reflected in the Oxfordshire Carers Strategy Implementation Plan. The practical changes being made to the way services are provided and commissioned to better align care pathways with these strategic goals are outlined in the next section.