medwayjoint health & social care commissioning … and... · care pathways. enablers to...
TRANSCRIPT
2010 -
2013
MEDWAYJOINT HEALTH & SOCIAL CARE
COMMISSIONING STRATEGY FOR OLDER PEOPLE
Contents Page Number Foreword 3 Introduction 4 Our Vision for Older People in Medway 6 Commissioning Intention 1: 13 Managing Long Term Conditions Commissioning Intention 2: 18 Preventative Services Commissioning Intention 3: 23 Managing Dementia Commissioning Intention 4: 29 Managing Admissions Commissioning Intention 5: 35 Personal Budgets for Health & Social Care Effective Governance 40
FOREWORD People are living longer than ever, and the trend is set to continue into the future. Increased life expectancy is something that we should all celebrate, but great longevity means that we need to plan ahead both collectively and individually, to ensure that we can ensure the benefit of a long life. The term ‘older people’ is self-defining for each individual and therefore it cannot be defined by an arbitrary age. People do not think of themselves as becoming old at a particular moment in time. The ageing process varies from person to person and older people are as diverse in their circumstances, interest, activities and abilities as the rest of the population. This strategy recognises that the services required to meet the needs of older people must be flexible, diverse and deliver value for money. The vast majority of older people are living longer and require support and care much later in life. This can be attributed to the advances in modern medicine and improved dietary and lifestyle habits. A relatively small number of older people who suffer from ill health and/or disability need care towards the end of their lives and this strategy includes provision for their special needs. This Commissioning Strategy focuses on how to maintain older people’s independence. Our budget and services will necessarily focus on those who need them most. It is our intention that the people that use our services will inform their shape and diversity so that they are able to choose the right services that meets their assessed needs. Health and Social Care will work in partnership to make sure that strong and effective partnerships are established between the council and NHS Medway and with other key partner agencies, so that we commission in a way that puts people at the heart of decision-making. This makes real for Medway people the vision and values of the national Putting People First publication and puts into practice the discipline of World Class Commissioning. This is an exciting time to be a commissioning organisation in Medway. Through honest and open dialogue with older people, our key stakeholders, together we can make a difference in their life chances.
Councillor Tom Mason, Portfolio Holder for Adult Services, Medway Council David Griffiths, Chairman (Interim), NHS Medway
INTRODUCTION Welcome to the Integrated Commissioning Strategy for Older People. This strategy has been developed jointly by Medway Council and NHS Medway. It describes our shared values and vision for the future of older people’s services in our city, and begins to set out the changes that will be made between now and 2013 to achieve these. Above all else, this document is about how we will take a more strategic and joined-up approach to commissioning services for older people in Medway. The strategy has allowed us to set out clearly, and in one place, our key commissioning intentions – intentions that have been developed from analysis of local needs in our locality and, crucially, the feedback and involvement of local stakeholders, including older people themselves and their carers. This document sets out the commissioning intentions of Medway Council and NHS Medway for the medium term. It identifies priorities for joint working during the next three years, improving quality, enablement and strengthening joint commissioning arrangements. Figure 1 shows a summary of the key priorities. This strategy builds on the vision outlined in the Strategic Plan for Older People in Medway. It also complements other local strategies as detailed in Table 1. Figure 1: Summary of Priorities
Being Healthy and Feeling Well
Enjoy, Achieve and Contribute
Making Ends Meet
Being Safe Having Choice, Dignity and Control
Support and care when and where it is
needed.
Table 1: Related Local Strategies What do current plans and strategies say about services to older people?
Related Strategy Publication Date Key Messages for Older people Older Peoples Plan Estimated January 2010 To enable older people to live healthy,
fulfilling and independent lives. Voluntary and Community Sector Strategy
Estimated Summer 2010 Increase opportunities to take part in voluntary activities.
Housing for Older People September 2008 An aim to grow retirement accommodation at the same rate as the increase in the 60+ population.
Supporting People Strategy
Published for 2005 - 2010 Support services in Extracare and floating support.
Carers Strategy March 2009 Information, supported breaks and improved support for carers.
End of Life Strategy Estimated Spring 2010 Supporting people to die in place of choice Commissioning Intentions Our Commissioning Intentions set out below are built on these:
Case
management
Community
based support
services
Commissioning
Intention 1
Managing Long
Term Conditions
Promoting
independence,
choice and
control
Commissioning
Intention 5
Personal
budgets for
Health & Social
Care
Commissioning
Intention 4
Managing
Admissions
Commissioning
Intention 3
Managing
Dementia
Commissioning
Intention 2
Preventative
Services
Reduced
admissions to
residential and
hospital care
Improving health
& well being
Maintaining
independence &
quality of life
Early diagnosis
and intervention
Peer support
Home based
support services
Outcomes
OUR VISION FOR OLDER PEOPLE IN MEDWAY The joint vision for adult social care and health services in Medway is to enable all adults to live the lives they want, achieving their potential to live independently and exercising choice over the services they use. Improving the health of individuals and reducing health inequalities is a key element of this vision. We will ensure that tackling inequalities in health and social care is embedded in our commissioning processes. This means recognising the different needs of vulnerable groups when designing and delivering services. For older people in our locality, we need to strive for even more services for older people that will be delivered in a way that:
• promotes mutual respect • values their contribution and their diversity • ensures their dignity is maintained at all times • takes account, when necessary, of their need for protection
If we are to meet the needs of our older people in Medway we need to see a fundamental shift in the way we currently commission services. We need to stop thinking in terms of dependence and deficit and start thinking about independence and well-being. Inverting the triangle Services for older people can be described as a three tier service model where services are designed to meet need and promote independence. The three broad tiers of service are: Universal provision: available to all older people Targeted provision: to enable older people to maintain their independence and minimise the need for acute services Specialist provision: for older people who require more intensive support Traditionally our model of service provision has been one where both investment and focus has primarily been on specified services. See fig 2.
Figure 2: Current focus of service provision
By inverting the focus on specialist services and placing universal services at the top of the triangle (Fig 3) we will ensure that our investment and focus is primarily on maximising the independence and choice of older people. Figure 3: Vision for the future: Inverting the triangle of care Source: All our tomorrows 2003
By service users having access to a wider range of preventative services earlier on it should be more possible to maintain their health, fitness and independence and thereby reduce the need for access to more acute services in the future.
How will we make this happen? For many people, the distinction between health and social care can be confusing. Increasingly, however, services are being developed jointly by NHS Medway and the Council. We will continue to develop collaboration between local health and social services to take a strategic approach to shape the market to meet future need and strengthen our commissioning functions. This collaboration will go hand-in-hand with the effective involvement of service users, carers and service providers. Our expectation is that existing and new providers, including independent and third sector providers, will form partnership approaches to develop joint plans to meet our commissioning intentions for priority care pathways. Enablers to Community Service Transformation include:
• making health promotion everyone’s business through healthy workforce initiatives and developing health promoting skills across the NHS and social care work force;
• establishing systems that provide greater local information sharing and
analysis of data to predict future need, harnessing the use of data, digital technology and anticipatory care support;
• mainstreaming telehealth and telecare investment as an intervention to
improve the people’s experience and create greater capacity in the workforce;
• developing an integrated workforce plan and toolkits to skill up existing practitioners and provide role substitution;
• talking to people in localities and seeking their views and input to the
development of local health and well being strategy and plans;
• developing practice based commissioning within localities enabling greater autonomy for locally designed service provision with a devolved workforce and within a rigorous performance management framework;
• Using the world class commissioning framework and competences to drive
the pace for change and effective system management of delivery and performance.
The age profile in Medway The following information has been extracted from the Joint Strategic Needs Assessment that provides health and other factors to enable us to take a strategic approach to tackling inequalities.
Medway has a smaller proportion of older people aged 65 and over than the UK as a whole, and this is expected to continue into the future. Nevertheless, the rate of growth for those 65 years of age or over is greater than the UK rate and over the next 10 years the age profile of Medway’s population will change significantly. By 2018 the number of people 65 and over is projected to grow by 33%, with the number over 85 years of age will grow by 41%.
These demographic changes will drive a growth in relatively high intensity users and the numbers of people over 65 years of age with limiting long term illness is expected to increase by 34% by 2020.
Table 2: Medway population growth
Year Population Count Medway Population Growth (over 2006)
National Population Growth (over 2006)
2006 251,700 - - 2011 256,200 1.8% 1.4% 2013 258,600 2.7% 3.8% 2018 264,900 5.2% 9.4% 2023 271,400 7.8% 13.4%
The most stark percentage increase is expected in the over 85 year old age group (41.5% increase)
Figure 4: Older People in Medway Projections
-
10,000
20,000
30,000
40,000
50,000
60,000
2008
2010
2012
2014
2016
2018
2020
2022
2024
85+
75-84
65-74
Table 3: Older People in Medway Projections
2008 2010 2015 2020 2025 65-74 19,100 20,300 24,100 25,200 24,900 75-84 11,300 11,600 13,300 15,200 18,600 85+ 4,100 4,200 4,800 5,800 7,300 Total, 65+ 34,500 36,100 42,200 46,200 50,800
Source: ONS Projections
The increasing number of older people have clear consequences on the demand placed on health and social care services.
Health NHS Medway commissions health services for the residents of Medway in conjunction with its partners within the Medway Practice Based Commissioning Groups and the Local Authority. NHS Medway spends approximately £380m worth on services each year with a range of providers, the major local providers being Medway Maritime Acute NHS Foundation Trust, Kent & Medway Partnership Mental Health Trust, Medway Community Healthcare, GPs, Dentists and Opticians. These organisations provide a wide range of services for residents of Medway including Older People. Within NHS Medway’s boundary, there are 67 GP practices, 38 Dental Practices offering NHS dental care, 21 opticians and 47 pharmacists and a range of intermediate care beds. Medway Community Healthcare provides a range of services including community nurses. In addition, NHS Medway and the local authority provide joint integrated teams, which include a Rapid Response Team. Fig. 5: How NHS Medway currently spends its budget
Practice-based commissioning (PBC) continues to play a vital role in health reform as it puts clinicians at the heart of NHS commissioning and allows groups of family doctors and community clinicians to develop better services for their local communities. Whilst Primary Care Trusts (PCTs) are the budget holders and have overall accountability for healthcare commissioning, practice-based commissioning is crucial at all stages of the commissioning process. Practice based commissioning will lead to high quality services for patients in local and convenient settings. GPs, nurses and other primary care professionals are in the prime position to translate patient needs into redesigned services that best deliver the flexibility in services that local people want.
The World Class Commissioning Framework provides guidance and direction to ensure we develop and improve our competencies as commissioners and enable us to deliver improved health and care outcomes for our local population.
Social Care
The number of older people over 65 receiving social care support from Medway Council is approximately 4,500. While this represents only 12.75% of older people in Medway, it is still a significant number of people. The percentage rises to 42.3% for people aged 85+, a total of 1,777 people. As the number of 85+ is set to experience the most significant rise in coming years, this poses a very real challenge to ensure that services are effective, efficient and responsive to changing needs. The Council is required to set its eligibility criteria for services in accordance with the Government’s Fair Access to Care guidance. In order to access services Older People will be assessed as having a need that poses a substantial or critical risk to their independence. This means that home care services are usually only available to people in the higher eligibility bandings who require personal care on a regular basis. Those in low and moderate bandings are signposted to community infrastructure services in order that their needs can be met. The council’s spend on older people in Medway is shown below.
Fig 6: How Social Care Services currently spend their budget for Older People (Source: outturn for Medway Council 2008/09)
Expenditure on Social Care Services for Older People in 2008/09
Total expenditure, £25,083,544
£1,484,414
£8,855,050
£8,377,377
£1,862,176
£277,413£530,837
£3,696,277
Carers ServicesOPMHN residential careAssistive technologyHomecareIntermediate CareNursing care homesDay care
There is a continuing trend for older people to be supported at home rather than going into long stay residential and nursing care. Furthermore, support packages are tending to become larger, as increasing numbers of older people with high support needs remain at home. Given that the number of frail elderly people over 75 is projected to increase rapidly over the coming years, there will be severe pressure on the funding of social care services. In order to manage to manage this Medway Council will be introducing and developing an effective prevention and enablement service. This will be short term early intervention to maximise older people’s ability to care for themselves, enhance their quality of life and reduce reliance on social care services. In July 2009, the government launched the Big Care Debate. The debate was in recognition of the huge pressures that are being put on existing services. More people need care because they are living longer and for the first time, nationally, there are more people over the age of 65 than there are under the age of 18. The funding of social care is perceived to be unfair. Some people pay tens of thousands of pounds or sell their house, to pay for care. Someone with Alzheimer’s, for example, could pay up to £200,000 over the years that they need care. Big Care Debate suggests that a National Care Service will create a level playing field and end the postcode lottery of care services, with a view that it will deliver:
• Prevention services – the right support to stay independent and well for as long as possible and to delay care needs getting worse;
• national assessment - care needs will be assessed and paid for in the same way across the country;
• joined-up services - all the health and social care services will work together smoothly;
• information and advice – the care system will be easy to understand and navigate;
• personalised care and support - services will be based on personal circumstances and need;
• fair funding – money will be spent wisely and everyone will get some help meeting the high cost of care needs.
Equality and Diversity Medway’s population consists of a wide range of ethnic backgrounds. Approximately 7% are of black and minority ethnic origin. The largest ethnic minority group is the Asian or Asian British group. There is also a significant number of Irish, Polish, Ukrainian and Serbian older people spread across the locality. Studies of health and long-term illness for black and minority ethnic groups such as the older Asian population suggest that there are factors such as diabetes, coronary heart disease. These issues have implications not just for the planning of health and social care, but also housing and support services.
There are differences between older men and women which have to be considered when evaluating the gender needs of the older population. As a rule, women live longer and as a result, spend a high proportion of their old age in poor health compared to men. The economic and social conditions of older people are significantly different across gender. Older men and women bear a different share of caring responsibilities and men and women develop and maintain different social networks in later life. All these differences have important consequences in terms of the demand for and access to social and health services and should be adequately taken into account. The specific health inequalities experienced by people with learning disabilities or mental health problems have been widely documented. Although the evidence indicates differences both within and between the two groups, there are also several points of commonality. More people with learning disabilities are living into old age. They tend to have a greater variety of healthcare needs, many of which are unrecognised and unmet. Research shows that people with learning disabilities, particularly Down’s syndrome develop dementia at a younger age and they also have an increased risk of early death compared with the general population. The main cause of death for people with learning disabilities is respiratory disease, linked to pneumonia, swallowing and feeding problems and gastro-oesophageal reflux disorder. This is followed by coronary heart disease, which is increasing as life expectancy improves and more people live in the community; almost half of all people with Down's syndrome have congenital heart problems. People with mental health problems have higher than average rates of physical illness. The higher death rates of people with severe mental health problems reflect, in particular, the greater prevalence of smoking-related fatal disease among people with schizophrenia.
COMMISSIONING INTENTION 1: MANAGING LONG TERM CONDITIONS Long Term Conditions As people live longer, growing numbers of people have medical conditions that they will live with for the rest of their lives. These long term illnesses are extremely common and the ability to respond well to the needs of these patients with them has become an important part of modern healthcare. Over fifteen million people in the United Kingdom report living with a long term condition. Due to an ageing population, the number of people with a long term condition is set to rise by a quarter in the next 25 years. Long term conditions are those conditions that cannot, at present, be cured, but can be managed by medication and other therapies. They include diabetes, asthma, heart failure, enduring mental health problems and chronic obstructive pulmonary disease. Of those affected, many live with a condition that limits their ability to cope with day-to-day activities. In the UK in 2000, the leading causes of death for persons 65 years of age and older were coronary heart disease (21%), stroke (11%), other circulatory diseases (9%), cancer (23%) and respiratory disease (19%). In addition, lifestyle changes are impacting on the development of some long term conditions at an early age, such as obesity, lack of exercise, excess alcohol and smoking. The government’s aims around long term conditions are to produce better health outcomes and quality of life, slow disease progression and reduce disability and there are three key themes:
• Enabling and supporting health, independence and well being; • Rapid and conventional access to high quality, cost effective care; • Putting people more in control of their own health.
These themes aim to result in improved quality of life, helping to relieve discomfort and stress and reduce the need for hospital admission. Strategic Relevance Our Health, Our Care, Our Say, (Department of Health (DoH) 2006), identifies the management of long-term conditions as a priority. The White Paper supports an integrated approach to developing health and social care plans, integrated teams and carer support.
The NHS Operating Framework, (DoH 2008), expects PCTs to improve care for people with long-term conditions and to ensure there is more choice for these patients. PCTs are required to develop a model of care for long-term conditions, which focuses on effective care planning. The National Service Framework, (DoH 2001), sets out the direction of travel to ensure older people are supported by newly integrated services with a well co-ordinated, coherent and cohesive approach to assessing individual's needs and circumstances and for commission and providing services for them. The paper describes the need for effective coordination of the work of practitioners and the organisations involved across traditional service and team boundaries. There has also been disease management standards established in the National Service Frameworks for Coronary Heart Disease, mental health, older people, diabetes, long term neurological conditions and renal services. An NHS and Social Care Model to support local innovation and integration was published by the Department of Health in January 2005. This document set out a strategy for the management of people with long term conditions. One of the key aspects of the model is a requirement for local health communities to identify all patients with long term conditions within their area. In order to provide the most appropriate treatment for each individual, the patients identified should be stratified into one of three levels according to their needs: Supported self care, disease specific care management and case management. Finally, the National Indicators for Local Authorities and Local Authority Partnerships, (DoH 2001), include a new joint indicator on the number of people with a long-term condition supported to be independent and in control of their condition.
Needs Assessment
In Medway we are committed to supporting people with Long Term Conditions to enjoy the best possible quality of life through world class commissioning and providing systematic patient-centred and appropriate health and well-being services. We will develop a shared health and social care vision and commitment to deliver quality care for those people with long term conditions and plan to commission long term conditions services that will add years to life and life to years. The Office of National Statistics predicts an increase of 4.6% in the number of older people with a long term condition by 2010, accelerating to 18% by 2015. People with long term conditions tend to be more intensive users of health services. Nationally people with long term conditions account for 52% of all GP appointments, 65% of all outpatient appointments and 72% of all inpatient days. Again there is a strong correlation between hospital admission for long term conditions and deprivation. Smoking, excessive alcohol consumption, physical inactivity and unhealthy diets are major risk factors for many long term conditions and the burden of long-term conditions on individuals, communities and health services could be significantly reduced by supporting people to live healthier lifestyles.
Currently in Medway it is estimated that 39,000 people have a long term illness. the majority being older people. The numbers are higher in the older age groups with 46.8% of people over 65 and 58% people over 85 suffer from a limiting long-term illness. By 2020 it is expected that the number of people aged 85 and over with a limiting long term illness will increase by 41.5%; the number of people over 65 with a limiting long-term illness will increase by 34%.
Table 4: People aged 65 and over with a limiting long-term illness, by age projected to 2025
Age 2008 2010 2015 2020 2025
65 - 74 7,688 8,171 9,701 10,144 10,023
75 - 84 6,088 6,250 7,166 8,189 10,021
85 and over 2,379 2,437 2,786 3,366 4,236 Total 65 and over 16,156 16,859 19,652 21,699 24,281
Source POPPI 2.2
The table below gives projected numbers of people aged 65 and over expected to have a long-standing health condition by disease type. Table 5: Prevalence and projections of key health areas
Medway % Medway
Practice, %
National
07/08
Medway Projections, %
2006/07 2007/08 Min Max % 2010 2015 2020 2025
Diabetes 3.8 4.1 1.9 6.0 3.9 4.5 4.9 5.4 5.9
Cancer 0.7 0.9 0.1 1.9 1.1 - - - -
CHD 2.9 2.9 1.0 4.6 3.5 3.8 3.8 3.8 3.8
Stroke 1.2 1.2 0.3 2.5 1.6 - - - -
COPD 1.3 1.4 0.4 2.9 1.5 1.6 1.7 1.7 1.8
Hypertension 12.5 12.9 6.7 23.4 12.8 22.4 22.4 22.4 22.4
Mental Health 0.5 0.5 0.0 1.3 0.7 - - - - Source Diabetes, Cancer, CHD, Stroke, COPD, Hypertension & mental Health: QOF data COPD projections: APHO Modelling COPD Prevalence Tool CHD/Hypertension projections: APHO Modelled data for 2007/08 LDPs. Premature deaths from long term conditions are a major contributor to Medway’s lower than average life expectancy and are strongly associated with deprivation. Long-term conditions present a significant and growing problem for Medway and are a major contributor to health inequalities in the locality.
In order to ensure that each person with a long term condition has the opportunity to achieve the best health and level of independence that they can the approach to their care needs to:
• Be personal to them • Address their clinical needs • Offer informed choice • Support them to learn how to manage their condition effectively
Strategic commissioning needs to drive system and process improvement across health and social care providers to enable local integrated working. This will provide the infrastructure within which those responsible for individual care planning can ensure a seamless and holistic approach for individual service users.
Key challenges
• Developing appropriate care pathways in the community • Integrating case management systems • Adopting an approach which focuses on self care • Effective operation of integration • Achieving outcomes required by the Common Assessment Framework • Personalised care plans and support plans Key outcomes we want to achieve
Older people who experience illness, short or long term, or have spent time inhospital are supported to enable a quick recovery and successfully maintainindependence and control of their daily lives. The individual requirements of older people have been met through a range ofresponsive services. Older people’s independence is retained and they stay in their own homes and withtheir families for as long as possible with ease of access to local services. People who are identified at risk of developing a long term condition have access toa range of preventive programmes to promote health and wellbeing. Harness technology to support those who care for and those who live with long termconditions – take advantage of the possibilities opened up by new technologies People with long term conditions receive more services close to home – providepersonalised community-based integrated care Older people are treated with respect and fairness so that so that they receive aservice that respects then as an individual and equal member of the community.
Summary of Action Plan Short term actions 3 years A1 Develop a Health & Well being strategy A2 Develop pathways of care that works across health and social care boundaries A3 Expand the Expert Patient Programme and establish an expert through
experience scheme A4 Review current service provision in disease specific areas to identify where
services can be remodeled and delivered in the most appropriate setting A5 Commission responsive evidence based and outcome focused support services that help people manage their condition better A6 Improve the access and availability of psychological therapies for people who require help and support A7 Further develop Telehealth and Telecare systems A8 Focus on developing integrated health and social care services at a
community level A9 Develop a workforce strategy that responds to the health and social care needs of older people Long term actions objectives L1 Expand availability of bereavement services L2 Value and develop our people through leadership, training and investment L3 Encourage research and development L4 Ensure all people with long term conditions receive a personal care plan
COMMISSIONING INTENTION 2: PREVENTATIVE SERVICES Preventative services are a means of ensuring good health, well-being and independence in later life, by promoting and encouraging uptake of comprehensive health and social care services for older people. This means providing information, advice and guidance at the right time and in the right format; ensuring that there are a range of activities and services that help people to stay physically and mentally active and commission services that enable people to gain or regain their independence in the community. The outcomes of preventative services for individuals and their families it ensures that our aim to increase the life expectancy of older people is about not just adding years to life but life to years. In addition, any increase in demand for more specialist services, due to the forecast demographics, will be managed through ensuring good health and well-being mitigates against the need to use such services. Strategic Relevance The Prevention Package for Older People, (DoH 2009), raises the focus on prevention as a means of ensuring good health, well-being and independence in later life, by promoting and encouraging uptake of comprehensive health and social care services for older people. The Putting People First Concordat, (DoH 2004), requires Adult Social Care to work with other statutory agencies to radically reform public services, so that people are able to live their own lives as they wish, confident that services are of high quality, are safe and promote their own individual needs for independence, well-being and dignity. This ministerial concordat establishes the collaboration between central and local government, the sector's professional leadership, providers and the regulator. (December 2006) Our Future Health Secured; A Review of NHS Funding & Performance, (DoH 2008), identifies intermediate care services as having made a significant contribution to the reduction in delayed discharges from hospital. Our Health, Our Care, Our Say, (DoH 2006), explains that investment in intermediate care since 2001 has already resulted in significant reduction in delayed discharge from hospital. The White Paper advocates greater use of intermediate care services to enable more people to be cared for in the community.
The National Service Framework for Older People, (DoH 2001), looks at the problems older people face in receiving care in order to deliver higher quality services that promote health and well-being. Needs Assessment Life Expectancy The gap in life expectancy between the wards with the highest and lowest values (River and Cuxton & Halling respectively) is 6.8 years. The latest data for 2002-06 show a decrease in the inequality gap between the top and bottom wards of 0.8 years compared with 2001-05. The prevalence of deprivation and older people People over the age of 65 are more likely to live within the least deprived areas; 17.1% of older people live in the 20% most deprived wards in Medway. However, this needs to be considered in the context of evidence shown in the figure below. The figure shows that the proportion of older people experiencing income deprivation has grown across Medway between 2004 and 2007. Forecasting future problems in health and well-being The JSNA references a geo-demographic tool used to identify and understand the UK population and the demand for products and services. The tool offers an insight into the diet, exercise and illness attributes of the people in a locality. It gives a ‘pen portrait’ of their local communities and can use postcodes to describe the health style characteristics of any group of people. Medway has a proportionately high number of people classified that are likely to have “Future Problems”. The categories of people that fall in future problems are:
• Multi-ethnic, high-smoking, high fast food consumption • Poor single parent families with lifestyle related illnesses • Urban estates with sedentary lifestyle and low fruit & vegetable consumption • Metropolitan multi-ethnic, smokers and overweight • Disadvantaged multi-ethnic younger adults, with high levels of smoking
The percentage of each ward falling into these categories can be seen in the table below. The existing problems and future problems are broadly related to the deprivation of an area. It is interesting to note that those categorised under “possible future problems” tend to come from the more affluent areas where there are potential long-term issues with diets and alcohol consumption. Given that older people tend to live in less deprived areas, the need for preventive services demonstrates the importance of targeting this support in the areas that will benefit most from this intervention.
Table 6: Ward View of Health
Existing Problems
Future Problems
Possible Future Problems
Healthy Unclass.
Gillingham North 1.6 (18) 35.9 (2) 28.4 (12) 34 (3) 0
Chatham Central 7.6 (11) 41.6 (1) 28.1 (13) 22.6 (1) 0
Luton and Wayfield 15.4 (3) 32.5 (3) 17.7 (21) 34.2 (4) 0
Strood South 12.7 (5) 17.2 (6) 31.1 (11) 38.8 (5) 0
Gillingham South 3.6 (15) 11.8 (8) 39.1 (3) 45.3 (8) 0
River 10.5 (7) 27.5 (4) 23.5 (15) 28 (2) 10
Rochester East 11.8 (6) 10.7 (10) 21.1 (18) 56.2 (13) 0
Twydall 16 (2) 6.6 (12) 31.2 (10) 46 (10) 0
Princes Park 8.1 (9) 17.8 (5) 13.1 (22) 60.8 (17) 0
Strood North 2 (17) 14 (7) 38.2 (4) 45.7 (9) 0
Walderslade 8.1 (10) 6.3 (13) 20.8 (19) 64.6 (19) 0
Peninsula 14.6 (4) 2.8 (16) 23.1 (16) 59.2 (14) 0
Rochester West 9.1 (8) 10.8 (9) 22.4 (17) 49.5 (12) 8
Strood Rural 4.9 (13) 3.3 (15) 32.3 (7) 59.3 (15) 0
Lordswood and Capstone 0 (19) 3.7 (14) 26.9 (14) 69.2 (21) 0
Rainham North 16.5 (1) 0 (19) 35.7 (6) 47.7 (11) 0
Rochester S & Hors. 4.7 (14) 0 (19) 31.8 (9) 63.4 (18) 0
Watling 0 (19) 1.9 (18) 37.8 (5) 60.1 (16) 0
Cuxton and Halling 0 (19) 0 (19) 32.3 (8) 67.6 (20) 0
Rainham South 0 (19) 8.3 (11) 17.9 (20) 73.6 (22) 0
Rainham Central 6.1 (12) 2.6 (17) 48.8 (2) 42.3 (7) 0
Hempstead & Wig. 2.9 (16) 0 (19) 55.1 (1) 41.9 (6) 0
Source: CACI Health ACORN, 2008 Remaining years in life expectancy and the potential burden of ill health and disability The table below shows that the remaining years in life, healthy life and disability free life years at 65 in Medway was worse than both the South-East and England & Wales for males and females. Again the proportion of the expected remaining life spent in a healthy and disability free state (in brackets) is higher in the South East as a whole than in Medway. Table 7: Life expectancy; added years, healthy and disability-free, remaining years at age 65, figures in brackets indicate the proportion of remaining life (2001 data)
Males Females Life expectancy (years) at 65
Added years Healthy Disability free Added
years Healthy Disability free
Medway 15.3 12.0 (78%) 7.7 (50%) 18.5 14.3 (77%) 8.8 (48%)
South-East 16.8 13.7 (82%) 9.3 (55%) 19.8 15.8 (80%) 10.3 (52%)
England & Wales 16.1 12.5 (78%) 8.1 (50%) 19.2 14.5 (76%) 9.1 (47%)
Source: ONS, 2001
e.g. Males in Medway can expect to live an additional 15.3 years over the age of 65. Of those additional 15.3 years they should
be healthy for 12 years and free of disability for 7.7 years.
Key challenges Self care:
• Case management based on independence and prevention • Ensure that all citizens have accessible information, advice and guidance that
enables self care • Developing effective public health strategies • Ensure that the infrastructure of all community services is strengthened to
provide preventive services • Ensure that there is a range of affordable services and activities that enable
people to remain active • Increase the effective use of assistive technology • A minimum of 3% cashable savings are released as a result of the
preventative strategies • Evidence joint planning of preventative services that apportions costs and
benefits across the ‘whole system’.
Intermediate care and enablement services: • Extend the care pathway to include step-up and step-down provision • Commission an integrated intermediate care pathway • Configure an effective Community Rehabilitation Service • Develop services with an enabling ethos • Support the workforce to develop its skills to meet the emerging needs of
older people Key outcomes we want to achieve
The individual requirements of older people have been met through a range ofresponsive services Older people are engaged in a range of community and social activities of theirchoice and contribute to the life of their communities Older people and their carers’ use a range of preventative services so that theycan remain physically active and healthy Older people who pay for their own care and services have better access toimproved information and assistance, make good care decisions and put theirmoney to best effect. Older people are treated with respect and fairness so that so that they receive aservice that respects then as an individual and equal member of the community.
Summary of Action Plan Short term actions – 3 years A10 Develop an information pack to help self-funders when choosing a service to
help them identify quality services they might want to use. A11 Review and remodel Intermediate Care Services A12 Finalise the agreement of Section 256 arrangements for voluntary sector
funding A13 Progress the development of the Community Rehabilitation and Enablement Service A14 Work together to establish current service provision and develop joint proposal to expand the use of assistive technology more telehealth and telecare systems. A15 Review current falls service, identify gaps, and work with partner organisations to develop a Falls Strategy A16 Develop a network of advice and information that meets the diverse needs of all residents in our community. A17 Develop a Citizen’s Portal that enables everyone to exercise choice and control over their care. A18 Develop and support a network of retirement groups in partnership with local employers.
COMMISSIONING INTENTION 3: MANAGING DEMENTIA Dementia The issue of how health and social care agencies assist people with dementia is gaining a much higher public and political profile. Dementia is a progressive and eventually terminal condition, but with early intervention and the right support, people with dementia can achieve a good quality of life for many years. Dementia challenges the person in all aspects of their daily life. It is imperative that we develop support services that will help them take control of their condition and help them remain active and independent for as long as possible. In Medway the population of older people will see a growth of 33% for those 65 years old and over and 41% for those 85 years old and over by 2018. The corresponding growth in older people with dementia will require more resources and a new approach to service delivery. There is a need for additional investment and to realign services so that they promote independence, maintain cognitive function and prevent deterioration. By focusing on prevention and early intervention for those with dementia, health and social care agencies can reduce the costs of institutional care and offset some of the increased demand arising from the impact of an ageing population. Significant progress in the development of services that supports a comprehensive integrated care pathway will be necessary in the next few years if we are to ensure that we can deal properly with future need. Strategic Relevance The National Dementia Strategy 2009 lays out seventeen objectives to improve the care of people with dementia over the next 5 years. The Strategy is ambitious; its aim is that all people with dementia and their carers should live well with dementia. The Strategy is consistent with the wider policy context which is highly relevant to people affected by dementia. Putting People First, the rigors of World Class Commissioning, the increased clarity brought by the Carers’ Strategy, the End of Life Care Strategy
and the strategic
shift to prevention and early intervention, should dovetail to strengthen the commissioning and delivery of services to people with dementia and their carers. The Dignity in Care campaign
and improvements flowing from the consultation on adult
safeguarding are also pertinent to the vision set out in the Strategy for a system where
all people affected by dementia have access to high quality care and support from which they would benefit. In June 2009 the Department of Health published the Joint Commissioning Framework
which provides best practice guidance on commissioning each of the service objectives set out in the Strategy. New information from the evaluation of demonstrator sites
to
enable easy access to care, support and advice following diagnosis and for structured peer support will inform a rolling programme for implementation of the Strategy. Crucially, this Implementation Plan also describes how regional teams will take a national baseline measure of services using data that is already collected, which will enable progress to be reviewed and ensure that support is targeted regionally and locally at those areas where services are less developed. Making quality of care the key organising principle of the health service was a key recommendation of Lord Darzi’s report, High Quality Care for All. Needs Assessment Dementia by its very nature does not lend itself to the construction of a clear and sequential care pathway as it affects people in very individual ways. This presents significant challenges to those involved in the design, planning and commissioning of services. There is estimated to be approximately 2,367 people living with dementia in Medway. Currently 1,000 of them are recorded as having received a formal diagnosis, i.e., they appear on GP’s dementia registers. With an increasing ageing population, incidents of dementia, which is most common in the over 65s, will increase. Specific areas for service improvements have been highlighted by the NICE-SCIE clinical guidelines from 2006 and the 2009 National Dementia Strategy. In 2008/9, £2,411,000 was invested by NHS Medway in specialist mental health services for older people provided by Kent & Medway Partnership Trust (KMPT). This is likely to be the most significant proportion of investment in services. However, a figure for total NHS investment is not available as investment in non-statutory organizations is not give. In the same year, Medway Council invested £2,801,406 in statutory and non statutory provision. The majority of health (directly) commissioned dementia care is provided by Kent & Medway Partnership NHS Trust and Darland House who deliver continuing health care funded dementia care. Medway Council directly commissions the majority of their dementia care from care homes, day care services and domiciliary care as required. In the last year, a number of dementia specific services have been commissioned including carer education, advocacy, dementia crisis support and the Dementia Adviser demonstrator pilot programme. Care Advisers will have a mixture of navigator, brokerage and support worker responsibilities. They will not be responsible for intensive case management, but will provide a single identifiable point of contact with
knowledge of and direct access to the whole range of services available. This will allow them to work with high numbers of people diagnosed with dementia in their area, in collaboration with both social and health care services and we are hopeful that following evaluation there will be significant reductions in people entering the system in crisis.
A Joint Strategic Needs Assessment for dementia was completed in March 2009 and closer analysis reveals that in Medway we have a higher than average investment in high-intensity, high-end and high-cost services such as acute care, residential and nursing homes and suggests that there is much scope for productivity and efficiency savings through re-design. Current dementia services are already producing compelling evidence that not only could more be done with existing resources, but targeted up-stream interventions can have a dramatic impact on reducing acute, secondary care service spend.
Currently, there is no definitive care pathway for dementia with people accessing care through various entry points. In part this is due to the historical national policy and organisation of services in which dementia services were commissioned and provided through Older People’s Mental Health services. This was always unsatisfactory for younger people with dementia and people with learning disabilities who tend to develop dementia much earlier in life. There is no single point of access to advice and support services for people with dementia. This leads to many key and unnecessary issues for people with dementia and their carers. These issues include lack of access to services, lack of continuity within and between a range of services and service providers, inconsistencies between funding sources during the disease journey and lack of advanced care planning. People with dementia often enter the health or social care system in crisis resulting in otherwise avoidable admission to hospital, nursing, or residential care with attendant distress to patient and the family, and substantial cost to both organisations. People who have just been diagnosed with a dementia illness have a range of needs from information to emotional support and medical intervention. To a large degree these are currently unmet needs and greatly affect quality of life.
This fragmented nature of service delivery along with the high levels of activity and expenditure in the acute sector has led to the joint health and social care commissioning of dementia care to become a shared strategic priority for both the Primary Care Trust and Medway Council. Over the last 12 months good progress has been made in advancing this ambition with close collaboration between all commissioning teams. Increasingly, a whole-system approach now needs to being taken so that the potential for productivity and efficiency savings are considered across both health and social care. Potentially, this could mean for example that savings from reduced admissions to care homes could be re-invested in preventative health services. To improve the quality of care and deliver cost benefits through the health and social care system we aim to commission a fully integrated care pathway for people with dementia.
Figure 7: Future model for Delivery of Integrated Primary & Community Care
The ambition is for services to be configured in a way that facilitates joint working in communities to achieve a seamless and personalised service for the local people. The standards required will be set by way of a high level service specification. This will set out the requirements in a way that drives effective design but allows flexibility for providers to work with each other to tailor design to meet the different local needs and circumstances of each community. Key challenges • Develop investment plans which respond to demographics • Achieve compliance with national guidance • Shift balance from institutional care to community-based services • Commissioning new community-based services • Developing services and support programmes for carers • Case management based on independence and prevention • Developing joint commissioning arrangements • Upskilling and enabling the workforce to manage people with dementia effectively • Developing consistency and ownership of the pathway across organisational
boundaries
Access Primary Care and Social Care
Single point of access
Response Residential
Care
Response Intermediate Care
Step down model
Response Short term Intensive
management beds
Response – Care at home Case management
Local multi agency teams providing holistic personalised support and care
in a coordinated way
Specialist Assessment Specialist Acute Services
Voluntary Services Family/Carer
Out of hours/ Ambulance
Key outcomes we want to achieve Summary of Action Plan Short term actions – 3 years A19 Develop future investment plans for dementia services taking into account the
change in demographics, the likely increase in demand and current under investment
A20 Map current service provision A21 Review all current service provision A22 Work with Practice Based Commissioners to influence business planning
The individual needs of older people have been met through a range of responsive services. Older people’s independence is retained and they stay in their own homes and with their families for as long as possible with ease of access to local services. Older people are helped to use a range of resources to better meet their needs in ways that suit their personal circumstances. People with dementia are cared for in an environment that promotes inclusion, well being and quality of everyday living. People with dementia are cared for and receive support services in their own home to avoid unnecessary admissions and attendances at hospital People with cognitive impairment receive an early diagnosis and avail of early intervention and support schemes in the early stages of the condition. People with dementia receive the right care, in the right place at the right time and become less institutionalised. Staff in care homes and hospitals who care for people with dementia are trained to manage their condition better The experience of living with dementia is a positive experience.
Older people are treated with respect and fairness so that so that they receive a service that respects then as an individual and equal member of the community.
A23 Develop a Dementia Action group to take forward the actions set out in this
commissioning strategy A24 Explore potential for joint commissioning for dementia services, including a joint
performance management framework A25 Develop the dementia care pathway and implement the new service model. A26 Commission Intermediate Care and short term intensive management beds
utilising the revolving door model. A27 Adopt a Case Management Approach which incorporates the six strategies for
promoting independence identified within NICE guidance.
A28 Establish Dementia Forums to in each locality involving all provider organisations and voluntary sector.
A29 Remodel and commission localised memory services. A30 Develop services and support mechanisms aimed at supporting carers A31 Establish action plan for reducing prescribing of anti psychotic medication A32 Commission mental health support workers to work in residential care homes to
help manage behaviour and reduce inappropriate attendances at A&E. A33 Establish an implementation plan to ensure the objectives within the National
Dementia Strategy are met. A34 Deliver a programme of dementia awareness training and skill development for
the health and social care workforce including the independent sector. Longer term actions L5 Develop a fully integrated service with primary and acute care. L6 Develop community based rehabilitation services aimed at reducing length of
stay and improving outcomes L7 Work with local Universities to develop accredited dementia care training
courses.
COMMISSIONING INTENTION 4: MANAGING ADMISSIONS TO HOSPITAL & RESIDENTIAL CARE
Managing admissions to acute hospital beds, residential and nursing homes is a key part of this commissioning strategy for older people. The population of Medway is changing and people are living longer and this will increase the pressure on acute services and residential care placements. In both health and social care there is a greater emphasis on providing care at home rather than in care homes. More choice is being given to individuals to say how, when and by whom services are provided, making them more flexible and responsive to need, and helping maintain dignity. This is in response to what older people want. The renewed focus on promoting health and well-being, and working with the voluntary sector and other partner organisations to ensure older people do not become isolated, meeting their increasing expectations to stay active and engaged in their communities. It is recognised that most older people want to remain living in their own homes. Social care provision will increasingly focus on helping people to achieve this aim with the expansion of enabling and preventative services and the development of Extra Care Housing in Medway. Healthier lifestyles and advances in medicine, through increasing specialisation and technology based in centres of excellence, like the recently opened cancer unit at Medway Maritime, are being developed that will help to reduce mortality rates and treat illnesses in ways that were not previously possible. However, more can be done outside of hospital and closer to home to prevent older people being admitted into acute beds or residential and nursing homes. Robust preventative services are effective, and the effects of living with long-term conditions are being better managed in the community. Strategic Relevance In 2001 the government published its National Service Framework (NSF) for Older People. This set out a programme of action and reform to address the needs of older people and to deliver higher quality services for older people by modernizing NHS and Social Services and promoting new ways of working.
Following on from the NSF, the Government set out, in 2006, how the NHS and Adult Social Care services should work together in the future. The White Paper ‘Our health, Our Care, Our say: a new direction for community services’ set out the vision for community services. Other more recent policies include ‘Choosing Health’ which addresses public health and health promotion issues, and ‘Strong and Prosperous Communities’, both of which give emphasis to similar themes, especially the need for public sector agencies to work more closely together in planning and delivering better, more responsive and cost-effective services.
Needs Assessment
Hospital activity Both NHS Medway and Medway Council are working together to reduce demand on hospital admissions and attendance at A&E departments. Medway Foundation Trust experiences intense pressures especially during the winter period. The chart below shows the reason for A&E attendances for people aged 65 years and above, which may lead to hospital admission. Fig 8:
A&E Attendances from 1st July to 31st December 2008 for over 65 years of AgeEyes
Fall
Fractures andother InjuriesGynaecology
Head injuries
Limb problem
Long termconditionMental Health
Minor complaint
Overdose
Pain
Pneumonia
Surgical
Unknown
Unwell
64
812
361
28
235
841
903
1239834
1381
31535
2049
Managing Falls - Falls can have a serious effect on the physical and mental health of older people, leading to reduced independence. The risk of falling is being reduced by GPs by reviewing medications, home hazards being removed and exercise being taken in organised classes. Ambulance crews have been trained to treat minor injuries in the home to avoid having to go to A & E, and help is available for those who fall at home to be helped up and settled. Integrated teams accept referrals of those screened as being at risk of falling in the future, and carry out multi-factor assessments and provide care and treatment to address needs. Stroke – Healthier lifestyles and GP prescribing are reducing the risk of first and future strokes, and as specialist care in hospitals and from community rehabilitation teams is known to improve outcomes. Long term conditions such as Chronic Obstructive Pulmonary Disease (COPD) (made up of various respiratory diseases) – Help with stopping smoking is the best way to prevent COPD and reduce its severity. Our specialist teams that can support patients to manage their COPD can prevent acute episodes which currently result in hospital admissions. We will review how we manage our services to support this particular client group. For all these reasons it is important that we understand the changing needs and expectations of older people, make the most of our money by adopting best practice, and deliver services in the future that improve outcomes and satisfaction. Continuing Nursing Care Since October 2001, everyone in need, regardless of setting and means, is eligible for NHS-paid care from a registered nurse. NHS Medway has a 40 bed nursing home (Darland House) which is at maximum capacity and a number of private nursing home beds in which 43 patients are currently placed. Table 8:
Darland House will be reviewed as part of the future development of rehabilitation services. The commissioning intention will be to develop a ‘revolving door’ approach to continuing care beds by developing effective interventions that will prevent crisis admissions. The rehabilitation teams will work alongside continuing care services to get patients rehabilitated where possible and back into the community.
Regional Care group
Expenditure: Apr-Sep 08 (£)
No. care packages
Elderly Frail
364,804.10 35
OPMH 81,376.08 8
Total 446,180.18 43
Residential Care for Older People Medway has a mixed economy of social provision and provides some direct residential care alongside those provided by the private and voluntary sector. 95% of residential care provision is the independent sector. The role of adult social care services in relation to the provision of care homes is therefore to facilitate the market of providers through its commissioning arrangements. Social care commissioning ensures that there is appropriate capacity within the market; that commissioning decisions by the local authority and people who fund their own care (commonly known as self-funders) are made based on identifying appropriate services for presenting need which are affordable and effective. The following charts show the projected trend of total residential placements if we take no action in our commissioning activity in relation to care homes. Table 9: Older people aged 65 and over in local authority residential care, independent sector residential care, and nursing care during the year, purchased or provided by Medway Council projected to 2030.
2009 2015 2020 2025 2030
Total number of older people in residential and nursing
care during the year, purchased or provided by the
Council
1,375 1,643 1,799 1,978 2,204
Source: Community Care Statistics 2007-08
Table 10: Older people aged 65 or over admitted to permanent residential and nursing care during the year, and financially supported by the council, projected to 2030
2009 2015 2020 2025 2030
Number of older people admitted to supported permanent residential and nursing care
309 370 405 445 496
Source: Social Services Performance Assessment Framework Indicators: Care Quality Commission, reference A0/C72.
People’s aspirations for housing are changing. Many older people in Medway live in properties that are difficult to adapt to their changing care needs. This can result in accidents, which lead to hospital attendance and/or loss of confidence. In turn this can
result in developing long term care needs or a premature move into long term residential care. We are developing Extra-Care housing, which is a model of care that is designed to reduce admissions to long term residential care and reduce hospital admissions. ‘Self-Funders’ People who fund their own care are entitled to an assessment by social care professionals to understand their care needs. By receiving this assessment people should then be advised about the services available to meet these needs. Without this information independence can be lost by prematurely moving into residential care, as well as reducing personal wealth through purchasing inappropriate and high cost care. Where a self-funder’s wealth depletes such that they become financially eligible for local authority support; this can result in added pressure on Adult Social Care budgets. This explains the importance of investing in preventative services and information, advice and guidance services for all. Key challenges • Minimise mixed sex wards • Stopping repeat admissions to acute services • Developing integrated pathways of care • Further development of services which focus on reducing admissions to hospital and
residential care • Effective use of assistive technology • Develop services with an enabling ethos • Development of affordable Extra Care housing in the current financial climate Key outcomes we want to achieve
Older people’s independence is retained and they stay in their own homes and withtheir families for as long as possible with ease of access to local services The individual requirements of older people have been met through a range ofresponsive services Older people are helped to use a range of resources to better meet their needs inways that suit their personal circumstances Older people use a range of preventative services so that they can remain physicallyactive and healthy Older people who experience illness, short or long term, or have spent time inhospital are supported to enable a quick recovery and successfully maintainindependence and control of their daily lives Older people are treated with respect and fairness so that so that they receive aservice that respects then as an individual and equal member of the community.
Summary of Action Plan Short term actions – 3 years A35 Develop a strategy for reducing inappropriate A&E attendance rates. A36 Develop a care home liaison service which focuses on reducing hospital
admissions and meeting mental health needs A37 Develop contract monitoring procedures for health-elements of
residential/nursing care contract A38 Develop joint assistive technology strategy A39 Review the Community Equipment Service A40 Increase the availability of enabling and preventative services. A41 Evaluate the business case for joint commissioning arrangements for the
Occupational Therapy Service A42 Develop an Integrated Falls Care pathway Longer Term Objectives L8 Ensure that all appropriate people can access Extra Care Housing as an
alternative to residential care
COMMISSIONING INTENTION 5: PERSONAL BUDGETS FOR HEALTH & SOCIAL CARE Personal Budgets This is a way of giving people greater control and choice over the services and support they need so that it can be tailored to suit their individual preference. In practice, it means that people will be given an indication of the amount of funding from either Medway Council Social Care (i.e. a local authority Personal Budget) or from the Primary Care Trust (i.e. a Personal Health Budget) or both to meet agreed outcomes identified in their assessment. The person decides how to spend their budget to achieve the agreed outcomes and makes a support plan showing what is important to them and what would work for them. It will also identify any risks there might be and the plans to reduce them. They can receive whatever help is appropriate to do this. People can choose how to manage their personal budgets either through a Direct Payment or by choosing someone to manage it for them, which could be the Council/NHS Medway. Personal Health Budgets are possible in those areas that the Department of Health have accepted as pilot sites. Medway has been chosen as a pilot site so that in-depth evaluation of the new scheme can be undertaken and NHS Medway and Medway Council are working in partnership with other organisations. In Medway, Personal Health Budgets will initially focus on individuals with a long term condition who require end-of-life care. Strategic relevance The White paper Our health, Our care, Our say outlined the key elements of a reformed adult social care system in England. This led to the landmark protocol Putting People First Concordat which is guiding this transformation and requires a collaborative approach from all agencies. Putting People First requires system-wide transformation but recognises that, for people who require social care support, personal budgets are a key element in assisting them to achieve choice and control over their lives.
The Department of Health has set clear targets for Personal Budgets for adult social care: 7% by March 2010, 30% by March 2011 and 90% by March 2012. Personal budgets are offered to all new service users and to existing service users at the time of their review, and all eligible people are encouraged to take a Direct Payment. According to Impact Assessments for the Health Bill, May 2009, the experience in social care in England and in healthcare systems overseas shows significant gains in health, wellbeing and efficiency are possible when people have appropriate control of their own health and well being through self-directed care. It is clear from High Quality Care for All, NHS Next Stage Review Final Report that people want greater control and influence over their health and healthcare. People want care that is personal to them to enable them to stay healthy and improve the health of those most in need. Following the publication of this report the Department of Health announced that from 2009 there will be a pilot, building on experience with individual budgets in social care, to test personal health budgets as a way of giving people greater control over the services they use. Needs assessment Although Medway currently has a significantly smaller percentage of its population over 65 years of age when compared to the South East or England, as discussed in the demographic section the older population will grow faster in Medway than the national average over the longer term (10-20 years)
In the years to 2020 there is expected to be a 33% increase in over 65 year olds; the most stark percentage increase is expected in the over 85 year old age group (41.5% increase). Figure 9: Older People in Medway Projections Source: ONS Projection
-
10,000
20,000
30,000
40,000
50,000
60,000
2008
2010
2012
2014
2016
2018
2020
2022
2024
85+
75-84
65-74
An increasing number of older people have clear consequences on the demand placed on health and social care services. Table 10.3 shows the current link between age and the usage of social care services. It shows that there were 1,733 clients of over 85 years of age with open referrals to adult social care; this represents 42% of the estimated over 85 year old population. An increase in the number of older people, and in particular, the high increase in the number of aged 85+, will inevitably lead to a corresponding high increase in the number of people receiving support from health and social care. This poses a particular challenge to ensure that services are responsive to the needs of older people and, in particular, that Personal Budgets produce the support to meet the health and social care needs of Older People in the future. Based on the figures below we forecast that the number of people eligible for a personal budget will be well in excess 4000 by 2015, which is approximately a 20% increase on current numbers. Table 11: Estimated percentage of population with open referrals to adult social care
Age Group
Estimated % of population with open referrals to adult social care
25-34 1.0% 35-44 1.2% 45-54 1.9% 55-64 2.7% 65-74 5.1% 75-84 15.1% 85+ 42.3%
Source: ONS Projections, RAISE system extract (Medway Council)
Projecting Older People Population Information (POPPI) 2.2 assumes that the proportion of those people over 65 years of age living on their own will stay broadly in line with current proportions, but the implication of this is that the number of people over 65 years of age living on their own will increase by 31.5% (from approximately 12,100 to 15,900).
Table 12: Older people aged 65 and over helped to live at home, projected to 2030
2009 2015 2020 2025 2030
Number of older people helped to
live at home 3,4784,158 4,552 5,006 5,577
Key Challenges
• Achieve the Department of Health target of 30% of all Service Users in receipt of a Personal Budget by March 2011 and 90% by March 2012
• Culture and operational changes required in order to delivered personalised services
• More information and support for people who fund their own care support to ensure they understand the impact of these changes
• Need to review current service provision and contracts to enable people to easily set up and use individual budget
• Ensure that the Independent Sector (wider than traditional Health & Social Care) is responsive to the agenda
• Challenge of mainstreaming personal health budgets • Overcoming the perceived reluctance of Older People to take a personalised
budget as a direct payment. • Managing the potential safeguarding issues • Transitional commissioning arrangements • Managing people’s expectations in the context of choice • Support the workforce to develop its skills to meet the emerging needs of Older
People Outcomes we want to achieve:
Support Older People to make choices for personalised social care through individual budgets The individual requirements of older people have been met through a range of responsive services Older people are helped to use a range of resources to better meet their needs in ways that suit their personal circumstances Older people who pay for their own care and services have better access to improved information and assistance, make good care decisions and put their money to best effect Evaluate and learn from the national pilot Programme for the implementation of Personal Health Budgets to inform mainstreaming Older people have access to a wider choice of local health services Older people are treated with respect and fairness so that so that they receive a service that respects then as an individual and equal member of the community.
Summary of Action Plan Short term actions – up to 3 years A44 Co-production of a market development strategy with providers to respond to the
Putting People First agenda. A45 Finalise the Resource Allocation Tool for calculating the Personal Budget for
social care service users A46 Introduce the Medway Card which is a pre loaded debit card to simplify the
management of a direct payment A47 Deliver the target of NI 130, ensuring that Older People benefit from Direct
Payments whenever appropriate A48 Review the business case for brokerage services A49 Put into practice the safeguarding concepts in the context of personalization A50 Understand the wider strategic and tactical challenges to be addressed in
establishing Personal Health Budgets A51 Determine the systems changes and cost implications arising from
implementation of Personal Health Budgets A52 Assess the benefits for people arising from Personal Health Budgets in
delivering improved care outcomes and overall patient experience in order to inform mainstreaming
Longer term objectives L9 Both organisations to develop a workforce strategy that responds to the Health
and Social Care needs of Older People
EFFECTIVE GOVERNANCE Strategic relevance The Commissioning Framework for Health & Social Care moves health and social care partnerships from being optional to mandatory. The Commissioning Framework specifies that local authorities and PCTs should plan together and share information to ensure improvements in efficiency and choice, this is effectively integrated commissioning. In March 2007 the Department of Health and the Department for Communities and Local Government begun consultations this March 2007, on their paper ‘A Commissioning Framework for Health & Well-being’ and this was published in 2008. In many ways this is a re-statement of earlier themes, with further emphasis on: • Improve links between health care and local people and communities and ensure
people are put at the centre of commissioning; • Promote joint strategic needs assessment of populations and individuals by health
and local authority partners; • Increase and improve sharing of information between health care and local
authorities; • Develop the provider market for health and social care in order to increase choice
and assure high-quality providers for all services; • Encourage commissioners to work with partners who can help people find
employment, recognising the interdependence between work, health and well-being; • Develop incentives within commissioning systems that encourage partnerships
between different parts of the health service and between health and social care; • Establish an accountability framework for joint commissioning; and improve
commissioning skills in general through capability and leadership. Medway Council and NHS Medway have a history of successful joint working we have some challenges we need to address in relation to the national agenda for increased integration. NHS Medway and Medway Council have different planning mechanisms, their budget cycles do not synchronise and they operate within different legislative frameworks. Both organisations have their own systems of performance management, separate lines of accountability and a range of cultural disparities which impact on the way commissioners operate. Development of a Joint Commissioning Framework A Joint Commissioning Framework will describe how the Council and the NHS pool their resources and act together to implement a common strategy.
The development of this framework will be a significant step towards the development of a fully integrated health and social care commissioning framework. It will incorporate a commitment to adopt a staged approach to embedding and extending joint commissioning. The key features of the vision for joint commissioning are to; • Strengthen joint working relationships through joint planning and joint performance
targets • Develop integrated health and social care teams • Integrate planning and commissioning where there is a common interest • Establish a whole system approach to planning the use of resources. There is recognition within the Joint Commissioning Framework that it will be necessary to enhance the governance arrangements as the joint commissioning and service integration agenda develops. A joint commissioning framework could describe how the council and the NHS could plan together to align resources in implementing this strategy. This could enhance the governance arrangements that would support joint commissioning to ensure that the ‘whole system’ invests in, and benefits from, efficient and effective planning and service delivery.
The values that should underpin a framework are as follows:
• We believe that giving people control over what happens to them is in itself promoting good health and wellbeing. We will seek to maximise people’s control over their lives as an integral part of the services we provide.
• We believe it is better to prevent health and social problems than to deal with them once they have occurred. We will focus our attention and resources on prevention and early intervention.
• We believe that some people’s social and economic circumstances lead to them having poorer health, wellbeing and life chances than others. We will work to tackle these inequalities by focusing our efforts on areas and groups at highest risk.
• We believe it is right to offer people services as close to home as possible. We will focus on services in the community rather than in acute hospital or institutional settings where appropriate.
• We believe in working in partnership. Tensions will inevitably arise, but we will work collaboratively to resolve these. We will seek to understand the impact our plans have on partners, and work with them to ensure that these are managed appropriately in a way that causes the least possible problem for partner organisations.
• We believe in a single health and social care economy. We will invest the total resource of the health and social care economy wherever it will have the greatest impact on meeting our shared objectives, rather than being restricted by artificial organisational boundaries.
• We recognise the complex interdependencies between adult services and health services. We will therefore take a holistic approach to service provision, considering each individual in the context of their family and social circumstances.
• We value the views of people who use our services. We will involve the public in decision making, both about overall patterns of service provision and about the services offered to them.
• We value the diversity of Medway. It brings strength as well as challenges. We will work ever more closely with our diverse communities to ensure that they can contribute fully to the health and wellbeing of Medway, and that their needs are adequately addressed by services.