Recent projects: Review of Implementation of the National Service Framework for Older People (June 2004 - August 2005)

INTRODUCTION

• Jill Manthorpe, King's College, London;
• Roger Clough, Eskrigge Social Research;
• Steve Iliffe, Centre for Ageing Population Studies in the Department of Primary Care and Population Sciences, Royal Free & University College London Medical School,
• Les Bright;
• Michelle Cornes;
• Older People Researching Social Issues.

AIMS AND OBJECTIVES OF REVIEW

The aim of local reviews is to measure:

• the progress of NHS, social services and other providers of older peoples' services in implementing the standards as set out in the NSF and policy that has been introduced since
• the impact of this on older people and carer's experience of services

This study also aims to support organisations in further progressing and improving services to older people across health, community and social care settings.

To achieve these aims the local review will:

• measure progress against the NSF standards and milestones
• reflect the user and carer perspective on how older peoples services are being delivered
• report back to the local community the quality of local services to older people against the national standards in the NSF for older people and NHS Plan
• identify notable practice and share learning
• contribute to a national overview on progress to be presented to the Secretary of State for Health on older peoples services identifying good practice, barriers and approaches to improvement

SCOPE

This review will look at the whole system focusing on a range of services in a local community providing services to older people. The focus will be on all the standards in the NSF and will cover the physical, social, mental and well being aspects of older people living in local communities. This will include the functions of commissioning, planning and service delivery for services of health promotion, prevention, rehabilitation and caring at the end of life.

Since the NSF was launched in 2001 there have been significant changes in health and local government that have impacted on services for older people. These include:

• organisational change in the NHS (shifting the balance of power) and in local government (democratic renewal)
• changes in performance assessment frameworks through the star ratings system in the NHS and comprehensive performance assessment in local government
• policy changes including:
• Building Capacity and Partnership in Care 2001 Department of Health
• NHS Funded Nursing Care October 2001 Department of Health
• Fair Access to Care Services LAC (2002)13 Department of Health
• Information Strategy Older People March 2002 Department of Health
• Community Care Act Department of Health April 2003
• good practice guidance (e.g. Essence of Care 2001 updated 2003 DH)
• national reports (e.g. Getting Better, a report on the NHS Commission for Health Improvement 2003 and Promoting Well Being and Independence with Older People Audit Commission 2004).

The review of implementation of the NSF for older people will take account of these changes and will therefore be assessing against the NSF criteria within this wider policy framework. Six key themes have been identified that run through the NSF linking all of the standards. These cross cutting themes have been used to identify the NSF criteria and to represent it in a way that is up to date taking account of changes over the past three years.

The six key themes are:

1. engaging older people and carers
2. equity
3. person centred care
4. promoting independence
5. whole systems working
6. leadership and governance.

The criteria within each of the nine standards including medicines management have been organised by theme. These six themes form the basis of the review. They are reported under three headings:

1. older people's experiences of services
2. putting the older person at the centre of care
3. organisational development

The cross cutting themes

Engaging older people and carers

Engagement of older people is defined as their supported involvement in defining local priorities, policies and service planning. This covers the provision of:

• adequate information to older people and their champions about existing needs and the structure/operation of local services to meet those needsNHS funded nursing care October 2001 capacity and partnerships in care October 2001
• establishing frameworks to promote the attendance and contribution of local champions, as well as their ability to communicate with and represent local older people

This definition stems from wide ranging consultation with older people, which has identified that:

• views about what is important to quality of life change as an individual becomes older and cannot be accurately determined by younger people i.e. most service providers alone
• older people are willing to contribute their views but only if they feel there is some purpose in doing so
• the expectations of older people are influenced by how much they know about services.

Person-centred care

This is a recognised standard of the national service framework, however this has also become a major theme consistently seen in all the standards in relation to how care and services are delivered to older people.

This will apply to any health and social care organisation delivering older people services, in order to meet the needs of older people they will need to embrace the concept of being person centred. This is identified as meeting the physical, emotional, social and spiritual aspects that are the components of how people of any age live their lives.

Equity

Equity embraces the availability of, and access to local services that are comparable to those available elsewhere, in addition to the issue of age discrimination, which compares the access, range and quality of services received by older and younger people respectively.

Promoting well being and independence

The concepts of well being and independence are complex as they vary from person to person and in different situations. Older people say that independence is about making choices and having control over their lives Ð not about doing things for themselves.

There are a whole range of activities and factors that can promote well being and independence. These include housing, leisure, transport as well as health promotion activities and disease prevention programmes. Many of these activities and services are supported and delivered by local councils, voluntary organisations, community groups and others.

Whole systems working

Whole system working is a concept that is increasingly recognised as important to the delivery of older people's services. It occurs when:

• services are organised around the user
• all players recognise that they are interdependent and understand that action in one part of the system has an impact elsewhere
• vision, objectives, action, resources and risk are all shared
• users experience service as seamless and the boundaries between organisations are not apparent)

Leadership and governance

Management capacity embraces three fundamental principals of delivering services effectively that are based on the needs of older people living in local communities. These being;

• leadership - A style and approach to leading services that is able to establish and work in partnership and one that ably focuses upon relationship management. This includes partnerships with the voluntary and private sector, users, carers and the public.
• workforce - the capacity to develop and maintain the necessary skill base, the level of staffing and flexibility of staff to deliver services to older people.
• information - the effective use and dissemination of information internally and externally to an organisation and team.

The criteria

The criteria that will be used to assess performance against the NSF standards are in exhibit three below. More detailed matrices can be found at appendix one.

Selection of communities

For the review of the National Service Framework for Older People there will be 15 communities reviewed in the first year. Communities have been identified that are large enough to contain a reasonably representative range of local experiences. In the first year of the reviews this will enable a broad enough range of issues and information to be collected to be used for the national report due in 2005.

The communities were constructed by mapping local authorities to strategic health authorities. Using 2000/01 Hospital Episode Statistics (HES) data, acute trusts were linked to the local authorities that they serve. As it is likely that any one trust has treated a resident of every local authority over the course of the year, only those trusts contributing more than 20% of the local authority's overall activity were included, thus ensuring that it is only the main providers for each local authority that are included. Specialist trusts have been identified separately by mapping each one to the one local authority that they provided most services to. From this starting point, primary care trusts (PCTs), mental health trusts, ambulance trusts and NHS direct sites were also mapped to a community. Whilst a local authority can only fall into one community, trusts can fall into more than one community.

Communities - profiling and selection

Fifteen communities have been identified for the review of implementation of the NSF for older people in the first year. Each community is constructed of:

• one to eight local authorities
• one to four social services directorates
• one to seven acute trusts
• one to seven PCTs
• one to three mental health trusts
• one to two ambulance trusts
• one to two NHS direct sites

The majority of communities (87) have populations of between 250,000 and 750,000, a band that was set to ensure that the community was large enough to contain a range of experiences but not so large that it did not feel like a community.

The 15 communities were selected using stratified sampling across the following variables:

• percentage of the community over 65
• percentage of the community who are from an ethnic minority over 65
• deprivation levels (based on the Index of Multiple Deprivation)
• rurality (percentage of the wards in each community that are rural)

If the review programme for the National Service Framework for Older People is to be considered a success it should lead to sustainable improvement. To enable this the project team will provide: self assessment tools, good practice checklists, information on other tools and checklists available and examples of good practice. They may also facilitate change by putting organisations in touch with each other to share learning.

The project team are also in discussion with improvement agencies to explore how the improvement agency may follow on from the review by working with organisations where significant improvement is required but there is insufficient capacity within the organisation to achieve this.