What ‘whole systems’ events can achieve

In the workshops described above, the aim was to help participants widen their perspectives on how rehabilitation and intermediate care can be offered to clients across different care settings and agency and professional boundaries in an integrated way. The discussion should bring out the need for stakeholder involvement in setting and developing the agenda for change, with contributions by older people and by commissioners and providers from health, housing, social care, leisure and recreation in both the statutory and independent sectors.

The debate should not focus solely on intermediate care, but should recognise that it forms part of the continuum of care, and needs to be planned and commissioned in this context.

It is not about:

■ commissioning more of the existing services

■ renaming existing services without changing their practices

■ setting up isolated single services

■ adding therapy staff to existing services and calling them ‘intermediate care’. It is about:

■ managing change: leading, empowering staff and users, supporting, training

■ developing agreements, criteria and protocols on pathways of care

■ using Health Act flexibilities – pooled budgets, lead agency, charging policy

■ employing an intermediate care co-ordinator

■ decision-making and prioritising

■ having clear aims for new developments

■ developing a single assessment process, involving client-held records that follow people as their condition changes and as they move through the service system

■ before introducing change, developing an evaluation framework to test outcomes

■ deciding on who could benefit by carrying out local needs assessment, based on categories of care needs, condition/disease specific needs, etc, as illustrated above

■ refocusing home care so that it is enabling

■ reorganising community staff into teams that include therapists, skilled-up assistants and social services staff

■ negotiating for ‘missing’ therapy skills, such as speech and language therapy, psychology, dietetics and chiropody

■ case finding and early intervention, treatment and support, using the voluntary sector to provide, for example, preventative support to combat isolation or enable discharge

■ rehabilitation in day care settings

■ using housing options.

Figure 9 (above/below) shows a model of future services, as constructed using a stakeholder day similar to those previously described. It illustrates the pattern of care arrived at – a focus on community rehabilitation teams – and outlines a range of other community-based settings which would form part of the intermediate care system. A single point of access was seen as important, where the assessment and co-ordination of care, as well as the commissioning of services, would be concentrated.

After following such a process, more work is necessary to decide how much of each service component is required to meet the care needs of the local population. However, local stakeholders must agree on a vision and a direction of travel before the detailed service and financial planning, service specification, commissioning and operational planning can proceed.

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OLDER PEOPLES SERVICES IN SHEFFIELD – LAYERS OF SERVICE PROVISION

CSUH site

Specialist Ambulatory and In-patient care (e.g. neurology; urology; cancer therapy)

Specialist Liaison (e.g. COPD; diabetics)

A&E Trauma

NGH site

Specialist Ambulatory and In-patient care

(e.g. orthogeriatrics; specialist cardiac; renal) In-patient Rehab Ambulatory Assessment (Day hospital; Out-patients; diagnostics) In-patient Acute Crisis assessment (EAU) Assessment and Intensive Care Scheme (AICS) In-patient Acute Crisis Assessment (Huntsman Ward) In-patient Rehab Ambulatory Assessment (Day hospital; Out-patients; diagnostics) Layers 5—7 National/ Regional/ Sub-Regional Layer 4 District Layer 3 Sub-District Layer 2 Primary Care Group/Trust Layer 2a Locality Layer 1 Primary Care Layers

General Professional Services Primary and Community Nursing Specialised Primary Care

Assessment and complex care planning Single Access Point

Co-ordination, Communication, Commissioning

Rehab, Treatment and Care Team

Own Home

Un-sheltered Sheltered

Short Term Beds

Nursing Residential Locality support Transport Day Centre Therapy Centre Out Patients

Long Term Beds

Key points from this section

■ Begin by agreeing shared values and principles with all stakeholders.

■ Ensure that stakeholders know what is expected in terms of national policy and how this relates to local circumstances.

■ Using one of the available diagnostic tools, analyse how people use existing services, looking for gaps and bottlenecks and checking on whether access is equitable.

■ Once you have established needs, decide upon the services that are required to meet them – rather than trying to fit people into existing services.

■ One of the most effective ways of consulting with stakeholders is to hold a ‘whole systems’ event.

In document Developing Intermediate Care (Page 66-69)

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Further reading

Key points from this section