Adults and Older People

In 2005 we achieved national recognition for our older people service when it achieved Beacon status for its partnership approach to service delivery. It capped a remarkable year for an adults and older people service, which continues to grow from strength to strength as our programme of modernisation and integration starts to bear fruit.

We recognise that the complex problems facing our communities can only be tackled in partnership with others. Our success in delivering improved services for older people is a reflection of our wider approach to partnership across Southwark, which is central to our overall improvement strategy.

Rod Craig, Head of Services for Older People and People with Physical Disabilities Services, said: “Older people often have complex physical, psychological and social care needs and require support from a variety of providers and agencies. Comprehensive multi-disciplinary assessment of an older person’s health and social care needs, setting objectives and implementing integrated care programmes, can reduce dependency and improve the quality of life.”

Outcomes
Our partnership working has delivered significantly improved outcomes for older people and added to their life chances and quality of life. It has:

• reduced the numbers who are delayed in transferring from hospitals to home. This helps reduce uncertainty and minimises time spent out of the home.  The number of delayed discharges per 100,000 population in older people has fallen from 75 in 2003/04 to 10
• enabled older people who live at home to enjoy a better quality of life.  The number of people helped to live at home was 132 per 1,000 population aged 65
• the number of older people requiring intensive homecare to remain at home was 22.2 per 1,000 people aged 65 or older in 2004/05
• made direct payments to people allowing them to tailor care packages to meet their needs and personal preferences. The number in receipt of direct payments per 100,000 population has risen 114% from a low base of 28 in 2003/04 to 60 currently
• ensured ready access to a GP or Primary Care Professional (PCP) for older people. The percentage of the population able to access a GP appointment within 48 hours or a PCP appointment within 24 hours has been 100% for more than a year
• combined the Intermediate Care teams previously run as separate Social Services and PCT teams, reducing duplication, confusion and waste by having one system of referral, paperwork and point of contact.

 
Actions
Over the past year actions to improve services include:

• introducing integrated services for social workers and district nurses, ensuring a single system of management for these community teams
• agreeing a partnership arrangement between health and social care (using Section 31 Health Act flexibilities) that will lead to a pooled budget for all services delivered to older people in the community including residential, nursing, intermediate, palliative and continuing care
• implementing a single assessment system
• introducing an integrated community equipment service across Southwark Health and Social Care
• developing new services and pathways for care services such as stroke and falls services.

Some key initiatives and benefits that flow from these initiatives include:

The Older Adults Support in Southwark (OASIS) pilot project
This project aims to provide specialist home care to individuals with mental health needs, with the emphasis on enabling them to live independently in the community, producing better quality of life, mental well-being, support to carers and cost savings. The project is a partnership between Southwark Health and Social Care, the South London and Maudsley NHS Trust (SLaM) and Supporting People. It targets older adults with dementia and other functional mental health conditions in crisis or potential crisis situations and offers tailored help with a wider variety of needs from personal care, through financial and benefit related issues, to shopping and community and social occasions.
To find out more contact Peta Smith, 020 7525 3629 peta.smith@southwark.gov.uk

The Health and Social Care Urgent Care Team
There is a tendency for older people to attend A&E to receive responsive help, rather than primary care services. The multi-professional urgent care team provides rapid assessment and support for older people who are in crisis in the community. This is followed by a package of home-based rehabilitation, as an alternative to hospital or care home admission. Referrals are from GPs, district nurses, social workers, A&E departments, ambulance service paramedics and community-based staff. The team operates seven days a week, with an extended hours on-call service, and operates in partnership with an external provider of home care services.
To find out more contact Jo Daley, 020 7346 6198  jo.daley@southwarkpct.nhs.uk

The introduction of multi-professional, hospital-based intermediate care teams
Consisting of social workers, nurses, occupational therapists, physiotherapists and rehabilitation support workers, the main role of these teams is to promote an older person’s chances of regaining or maintaining independent living within the community this maintains their individuality, culture and lifestyle, and their physical and emotional well-being. 

The teams allow people to leave hospital as early as possible, or to ensure people do not enter care homes unnecessarily or too early. They provide an intensive package of rehabilitation and support for up to six weeks. The teams operate according to established core principles including equity of service provision, recognising the needs of carers and aspiring to meet the cultural and linguistic needs of Southwark’s diverse community.
To find out more Sam Mayne, 020 7525 3879 sam.mayne@southwark.gov.uk

A groundbreaking mental health intermediate care team
With skilled mental health professionals supporting physical health and social care services, this is a relatively new concept which demands a new way of thinking as well as a new way of working, concentrating on flexibility, communication and patient choice. This team ensures older people with mental health needs are not automatically rejected from rehabilitation services.
To find out more please contact Dr Tresa Andrews, 020 7346 6189 tresa.andrews@nhs.net

The introduction of a carers’ strategy
The introduction of a carers’ strategy ensures that effective, integrated support services are offered to carers.  There are an estimated 25,000 carers in Southwark who provide regular, unpaid care for a relative, friend or partner. The strategy is based around a number of core factors including: improved identification and engagement with carers; access to quality information and advice for carers; training, development, support and respite services; and recognition of the health and other needs of carers.  In addition, each client based Partnership board in Southwark will have two carer representatives to ensure their views are heard at this level.
To find out more please contact Joanne Koen, 020 7525 3603 joanne.koen@southwark.gov.uk