Prevention, Partnerships and Resources Professor John Bolton - Consultant JRFB Ltd

New Model of Social Care Based on three principles: Prevention Partnerships Promoting Independence Focus on interventions that produce outcomes that promote independence -

Public Bodies (Joint Working) (Scotland) Bill – Policy Memorandum Aim to integrate health and social care to improve consistency of approach so that people get the quality of care they need to remain (where possible) in their own homes. To meet the needs of increasing numbers of people with longer-term and complex needs. Focus on delayed transfers of care “ Too often older people are admitted to institutional care when an package ….. might have maintained their independence better”

Challenges for Social Care Can we manage demand at a time of increasing demographic pressures? Yes we can

Different levels of Prevention (Source Institute of Public Care) Universal provision (the preventative aspects of universally available services) Preventative provision for populations that contain some elements of vulnerability (specialist services that may tackle some aspects of need but not ones which would have led to an assessed social care intervention or an acute episode of health care). Targeted restorative interventions (interventions targeted on very particular populations in the evidence based belief that if successful they will lessen potential future demand for high intensity care). Deferred interventions (interventions that are preventative in that they defer people for a time from a poorer outcome). 5

Universal Interventions All Services that address issues that assist people in being diverted away from any direct help from health/ social care. Personal responsibility for our own health Includes neighbourhood and community teams – Public Health – “Every contact counts” Voluntary Sector – enabling people to help themselves Information and advice Targeted services at those deemed “at risk” Services where an intervention would expect to lead to an improved outcome that should need no further help Former Supporting people services/ Community Alarms Risk stratification models with health – virtual wards Telehealth – risk management Tackling social isolation through community networks Getting the right equipment Carers Centres/Vol Sector Getting the right housing The front end of the Services…

Services that support Recovery, Rehabilitation, Reablement, Recuperation Out of Hospital Care - Intermediate Care (Community and Residential) Training for employment Sensory impaired services Crisis Resolution Teams Promoting Independence Teams Interventions that defer the need for more intensive care Expert Patient – managing your condition Managing dementia after diagnosis – learning to live with a condition Supporting Carers Telecare products that are aids to daily living – monitoring and alarms Supported Housing and Extra-Care Housing The front end of the Directorate … Assessments for longer term care – personal budgets/ choice and control

Interventions NOT Assessments At every stage of the care pathway – we have two aims – to intervene in a way that will reduce longer term needs and to intervene in a way that maximises someone chance of being independent Never assess anyone for longer term care solutions when they are in a crisis We do need to still recognise when people need good quality care e.g. Palliative Care

WE HAVE TO MAKE THE BEST THING TO DO THE EASIEST THING TO DO Is it easier to call an ambulance or admit through A and E than assist someone into a step-up bed? Is it easier to admit from hospital to residential care than to make alternative provision – especially in the community?

The critical partnership with Health Priorities for Health - You don’t suffer from the same things that make you die Dementia – Incontinence – Falls – Stroke Recovery vs Cancers and Heart Failure.

How will integration with health help? Getting the interventions right at the right time (Dementia Care) Under the legislation (The Community Care Act 1990) the Council has a statutory responsibility to assess a person’s needs and identify how these needs will be met. This includes an assessment as to whether the council should meet those needs which is done through a combination of an eligibility assessment and a means test. Under the proposed operational model everyone who approaches the adult social care directorate will be offered some help based on a simple assessment of their presented need(s). From that initial contact either the person will be helped by another agency to which they have been directed or the council will offer further help and guidance through one of the many services it offers as laid out in paragraph 3.7 of this report. At each stage that help is offered the assessment is taking place and a picture is built up of how best to meet the person’s needs. At any point when those working with the person come to a view that they will need a long-term service a full assessment will take place. All assessments should be reviewed on a regular basis. For those customers where there is a clear immediate need that will not require or is unlikely to benefit from a preventive intervention e.g. palliative care or a safeguarding investigation an immediate response will include a full assessment.

Preventive actions Assistive Technology Maximising social capital Positive risk taking Listening to cares and users views Dementia cafes Dementia Advisors Dementia Support Workers Dementia awareness Training Supporting care homes Dementia Friendly communities Personal Assistants – Dementia Living with Dementia Programmes Every Contact Counts - prevention Early Diagnosis – GP awareness Assistive Technology Positive risk taking Listening to cares and users views Memory Assessment Reducing use of antipsychotics Dementia Trained workforce in hospitals Supporting nursing homes Primary Care Co-ordinators End of Life Care Living with Dementia Programmes Dementia Care

How will integration with health help? Shared understanding of desired outcomes (keeping people out of hospital / residential care) Getting the interventions right at the right time (Dementia Care) – understanding and accepting where investments might be required (Care Co- ordinators/ District Nurses) Getting the care pathway right Consistency in approach (Virtual Ward)

Some warnings! A little bit of care may be bad for you! Don't make a lasting decision in a crisis Dignity and Control – don't take these away Right result – wrong outcome (see below)

Case example from Vale of Glamorgan Health Board urged the local authority to help them in speeding-up hospital discharges

But the outcome was more cost to both health and social care

Steady reduction in numbers of older people in residential care in England

Reduced use of residential care in Wales

And in Scotland after blip….

Avoiding unnecessary admissions Always make sure that you have given time for a person to recover from the crisis that led to the assessment for possible residential care. Don’t assess a person for residential care from a hospital bed. Make sure that older people are receiving the best possible health care in both hospital and in the community (to avoid admission). Ensure that dementia is diagnosed and supported at the earliest opportunity. Ensure that Intermediate Care is delivering its intended outcomes (with Health). Consider housing based alternatives and the use of assisted technologies to reduce the levels of risk. Ensure that workers are taking proper time to assess and consider alternatives before agreeing to a placement.

The Resources Getting the care pathway for prevention right can lead in a 3 year period to: 33% reduction in admissions to residential care 10% reduction in people who need intensive home care 50% reduction in people who need low level home care

Constructing the new system (1) The Council will seek to ensure that its interventions in people’s lives are timely and effective. We will offer a short-term piece of help where we can ensure that this will help someone back into living independently. We will look to divert someone away from formal care by helping them access community based resources where this may offer effective help. Our focus is on recovery, recuperation, rehabilitation and re-ablement. The Council will look to offer joint services with the local health services where this is appropriate. The Councils aims to ensure that it offers value for money in all the services it has on offer. Any internal provision will be cost effective and be lean in its management and administrative costs. We will offer support to carers where this will help someone to live in the community. 23

Constructing the new system (2) We will develop housing options that enable people who have care needs to live independently in the community. We will use new technologies to ensure that we can respond to people’s care needs in a timely and effective way. The Council will work with the Voluntary Sector to help them develop the capacity to offer more voluntary work and to ensure that they are adding value with their contribution to social care. The council will target most of its resources on those people with the highest and most complex care needs. 24

For more help………. John Bolton Independent Consultant