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Without wallsBy:
Paul Dinsdale
The
Guardian, March
19, 2003
This "intermediate
care" project has grown out of a collaboration between South West
Dorset primary care trust (PCT) and Dorset social services. The spur was
the difficulties in recruiting and retaining domiciliary care staff and a
need to improve the effectiveness of existing homecare services. But the
project's broader aims are to facilitate earlier discharge of hospital
patients, to help prevent avoidable hospital admissions of older people
and to reduce the incidence of re-admissions. With the audit commission
reporting that, despite improvement in the picture, some 4,000 older
people in England and Wales are still taking up hospital beds
unnecessarily because of delayed discharge, schemes such as Dorset's could
be one of the best ways to speed up discharge and support people returning
to independent living in their own homes. The PCT, which is taking the
lead in the project, now has 10 health and social care assistants deployed
in its rehabilitation teams, although they remain directly employed by
social services. "We had identified intermediate care as a priority
area when we first set up our focus groups as a PCT, and we looked at the
needs of the population and how we could best meet those needs with the
resources we had," says Carole Lawrence-Parr, deputy chief executive
of the PCT. "It seemed to make sense
to us, as we talked the whole thing through, to have these as joint posts
to work seamlessly - to use the jargon - between home, the community and
community hospitals." A key factor in the Dorset
approach is that it involves working with the client prior to their
discharge on activities to regain independence - with the support
continuing post-discharge for a finite period at home. Kaye Hoare, intermediate care
coordinator for the PCT, says: "Members of the team are allocated to
clients who are involved in in-patient rehabilitation, in either community
or acute hospitals, or in one of the two rehabilitation schemes in
residential homes run in the area. The health and social care assistants
can also contribute to preventing avoidable hospital admission. They and
their teams work to pick people up at home, following an event that
adversely affects independent activity, such as a fall, but which can be
restored with a limited period of supportive rehabilitation. As part of the PCT's
intermediate care agenda, the health and social care assistants are
located firmly within the health team with which they work. And because
the teams are distinct from conventional home care services, the client
does not face the usual means-tested charges for the limited intermediate
care treatment period of up to six weeks. This enables the assistants to
be flexible and client-focused in responding to need, says Hoare. "In
conventional homecare, while there is often a clear commitment to
'enabling' rather than 'doing for', the client is often unwilling to pay
for the increased amount of time that enabling can take up." So far, the care teams have
taken some 50 referrals, mainly older people, but also clients in their
50s who have perhaps had a stroke but can be helped to regain their
independence. Care assistants are given extra training and are expected to
reach level three of the national vocational qualification. Because of the
positive results, Dorset social services is looking to develop the scheme
as fast as possible. Some NHS managers, however,
want to use this kind of model to produce a new type of
"generic" or specialist community worker combining the roles of
care assistant and community nurse - a hybrid extolled by the health
secretary, Alan Milburn, who has asked the general social care council to
help develop the template. At a recent conference on homecare, Graeme
Betts, chief executive of Hillingdon PCT in west London, outlined his
ideas for creating a cadre of older people's workers who would become the
frontline of care, capable of taking on a full range of tasks to ensure
that older people were able to remain in their own homes. "It seems absurd that
there are so many different services, with so many types and grades of
staff, and we are still not delivering what older people want," says
Betts. "We need to cut through
the professional and staff issues and begin to recruit and train older
people's workers. They must be trained to carry out caring tasks as well
as providing healthcare services, such as administering eye-drops, giving
injections and medicines management." These tasks, he points out, are
often already carried out routinely by homecare assistants, but are not a
formal part of their role and in fact form an as yet untested legal grey
area. Betts argues that whereas the
government is fixed on the number of so-called "delayed
transfers" among older people in hospital, it has failed to recognise
the need to invest in lower cost community services that could prevent
admissions in the first place. "We need a radical shift away from
thinking about beds to considering how community resources are used,"
he says. "A hospital stay should be seen as a positive intervention
in a long-term plan to support people in their own homes." Several other changes are
needed, Betts believes. As older people see their family doctor as the
centre of care services, a core of GP specialists in care of older people
should be trained and supported so they become a resource for their
colleagues. Care managers should become integral members of primary care
teams, ensuring that they are fully involved with planning care for people
in their own homes. And 24-hour community services should be developed as
an alternative to casualty departments, preventing inappropriate hospital
admissions from which older people may not return home. "I would like to see PCTs
take responsibility for the entire service for older people, as all the
relevant staff are there - GPs, community nurses and therapists,"
says Betts. "In addition, care managers are increasingly attached to
primary care teams and they commission the homecare, so it makes sense for
them to work together." In another project, funded by
the Joseph Rowntree Foundation, the Leeds-based Nuffield Institute for
Health is examining how flexible, person-centred health and social
services could be provided more efficiently to frail older people in their
own homes. "We aim to review what is happening in the light of the
identified barriers, and to devise alternative ways of commissioning and
providing home care services that older people need and want," says
Gill Herbert, senior researcher for the project. Lucianne Sawyer, chairwoman of
the UK Homecare Association, representing care providers, is coordinating
the Nuffield study. She warns that none of the grand ideas is likely to
come to pass unless the government takes a fresh approach to attracting
staff in the first place."We're wanting to recruit lovely, caring
people, but we're putting all sorts of obstacles in their way," says
Sawyer. "Recruitment and retention of homecare staff is a big problem
and good quality staff can be poached from local authorities by agencies. "We need to attract the right sort of people and give them opportunities to develop their roles" Copyright
© 2002 Global Action on Aging |
