Helping older people to remain independent, and living well is a major challenge. Nationally, various approaches have been developed to respond to the needs of our ageing population, offering advice and support to older people. These include information and advice services, well-being, dementia support, social prescribing, frailty, integrated care and good neighbours projects. While each might be set up and targeted slightly differently, in reality they are serving similar functions, and achieving similar general outcomes, albeit the specific impacts vary according to the target groups and emphasis within the specific project.
People seeking support from such services are likely to be:
- aged over 75, with an increasing likelihood of people being aged over 80, and even over 90
- female, though the percentages vary in different places and projects
- frail and/ or in poor health, or living with dementia
- living with a long-term condition, or have undergone a life changing event, such as a bereavement; which is particularly true if they are aged under 75
- isolated as a result of their situation, such as inappropriate housing
- the partners, and de facto, carers of people in poor health
Younger people aged over 50 and making use of such support are likely to be the extended family, or partner of a frail older person; or they will have a life changing illness or condition. It is less usual for a younger person to use the service if they are fit and healthy, unless it is on behalf of another family member. Often, people only seek support once they are in crisis. Culture change is still needed to encourage people to plan (and save) for older age, and to take advice early, at a younger age.
People using these services tend to want “a point of contact” and “somebody to talk to” so they get “peace of mind”. Some are at crisis point when they finally seek help, and do not know where to turn, and see the staff as “friends”. They want:
1. financial advice and support, including improving their financial well-being through application for benefits such as attendance allowance, carers allowance, pension credits, housing and council tax benefits
2. support and advice concerning their home, its suitability and their options, including an assessment for aids and adaptations to enable them to continue to live independently, or advice on equity release and moving to a smaller or more suitable home
3. the security of knowing that there is someone they can contact when they don’t know how to manage a given situation
4. “a shoulder to cry on” when things go wrong and they feel unable to manage any longer
5. signposting and information on what is available, and how to do things so that they can solve their own problems
6. practical help and support, including support to get to hospital or other appointments
7. introduction to social activities and a chance to socialise, often with initial support to attend
8. links into bereavement services and counselling
9. support with transport, often related to isolation as they or their partner no longer drive, or because their personal mobility has reduced
Organisational / systemic approaches are required to achieve the biggest impact for both the individuals affected, and the public agencies. Bolt-on projects and new initiatives or services can have an impact, but we are trying to achieve systemic and cultural change in the way we support older people’s needs. This means the whole organisation behaving in ways that simplify an individual’s contact / relationship with the organisation.
1. Organisations require clear funding strategies for support services. Councils and CCGs should recognise the value and impact of such projects in reducing the use of health and social care services by older people. However in practice there appears to be a reluctance to fund such projects as they require upfront investment and ongoing revenue commitment at the very time that budgets are under pressure and secondary care demands are increasing. Hence the very real need for systemic change, but also for provider organisations to integrate these approaches into their core business and delivery strategies. Organisations also must understand and respond to local commissioner strategies and priorities.
2. Organisations must develop charging strategies that enable them to understand the implications and when they might be able to charge people who self-fund for support or for assessment if commissioners do not fund support. For example, will people pay for an assessment? Will family members pay for an assessment for an elderly loved one if they are living far way and want to know the person is properly supported?
3. There is also a difference between a person approaching an organisation and asking for its help and support, which might include buying a range of its paid-for services, and someone approaching an organisation for an assessment of needs – where other competing services might be available. Recent media interest in Age UK’s relationship with E-ON highlights the reputational and ethical issues that can emerge when relationships between assessment, support and service provision become linked. But such tensions can be managed.
4. Referral routes should be clear. Successfully engaging GPs, basing projects in GP Practices; and building referral routes from social care assessment processes helps to identify affected individuals in order to engage them. Otherwise the most isolated can be difficult to identify and reach. Finding the people we most need to support is imperative. It is not a case of “build it and they will come”. Without these routes and relationships in place, projects are more likely to struggle to reach people and engage them. There are projects where GPs are engaged in principle, but in practice they are not assessing and referring people for support. An open door approach, with self-referral and access via organisational referrals from multiple routes reduces reliance on key individuals or specific systems.
5. Properly resourced, effective triage helps make best use of resources and appropriate signposting of people, enabling those with simple or specific issues to have these dealt with, even if subsequent referral to a support service is beneficial. Effective triage is key to a successful approach. It is a skilled task that can take 15-20 minutes to deliver.
6. Flexibility / fluidity are required within organisations to develop a person-centred approach. An older person should only need to tell the organisation their story once. This requires that different service leads undertake holistic assessments developing support plans with individuals who do not face multiple service specific assessments. It involves co-designing a package of support which might include a mix of signposts, paid for and free services, and support and services provided by others.
7. The principle that the “person knows their own needs best” must be adopted, even when people need support / help to articulate the problem that they need to solve. Staff must acknowledge that an individual can make choices that we might not make ourselves, and is free to take risks. Such behaviours only become problematic if the individual does not have the capacity to understand the issues or to evaluate the risks involved.
8. Often people face multiple problems and challenges that appear complex and insurmountable. However, once broken down they may be complicated, but are likely to be multiple problems often with simple, practical solutions. People seek help and support to solve practical problems and achieve practical tasks. Complexity comes from:
a. the requirements of the public agencies for referral and assessment
b. the overlapping challenges that are presented by some problems, resulting in challenges and complications re timescales and sequencing.
These approaches are about HOW the organisation interacts with an individual older person. They are not about service solutions, but a continuum of support offered in a personalised way.
They require that staff have a certain set of skills and knowledge. How these are deployed can change subtly at points on the spectrum, for example for those who have greater needs and might need more practical hands-on support, compared to those who require more facilitative support and assessment, or joint problem-solving to enable them to tackle issues for themselves. The core skills are likely to be similar, only the levels and types of support required are likely to change.
Successful staff often have Advocacy, Information and Advice or a Social Work/ Learning Disabilities background. Experienced care staff can succeed, particularly when higher levels of direct hands-on support are required, but may not necessarily possess the skills or knowledge to identify and tackle some seemingly hidden challenges without appropriate training.
This means that staff must be flexible, capable of responding appropriately in a variety of situations turning their hands to a variety of tasks. A practical “can do” attitude and a positive resilient outlook is essential. However, organisations are also likely to need specific additional skills or sources of expertise to respond in more challenging situations particularly where some specialised or technical knowledge might be required. The basic approach remains unchanged, but additional/different resources are brought to bear. Some specific specialist input might be required:
- for people with complex care needs, or for some dementia related activity, particularly the emotional and psychological support needed, particularly by some partners / carers
- to provide formal advocacy support
- for formal advice services, or some financial and benefits support
- where support crosses over into issues requiring statutory support, e.g. Care Act, IMCA, IMHA, DOLs advocacy, information, advice
They are also likely to require access to a range of information on available services where specific support is required which cannot be provided directly by the co-ordinator/ assessor. This will vary between organisations but could include bereavement and other counselling, handyperson, personal care, domestic support, sitting, buddying, befriending or escort services.
The ultimate challenge is to produce a mix of free and paid for support and to convince individuals that they must pay for some support.
Written by Kevin Cooper of KHC Consulting – March 2016.