Service Development and Innovation in the Delivery of Joint Health and Social Care and Support Services in Rural and Rem

1. Service Development and Innovation in the Delivery of Joint Health and Social Care and Support Services in Rural and Remote Areas � A Review Margaret Whoriskey, Assistant Director, JIT Tony Homer, Associate, JIT

2. Context Demographic; geographic; financial challenges and opportunities Implications for models of care and support Focus on outcomes

3. This first chart illustrates a trend that will be very familiar to all of us here: reducing emergency admission bed day rates for people aged 65+ by 10% by 2011 is one of our challenges in HEAT. The HEAT mark on the right hand side shows around where we want to be by March 2011. But what I�d like to do is think the unthinkable � What if these trends continue unabated into the future, spurred on exclusively as a consequence of Scotland�s increasingly ageing population. Specifically, what would happen if emergency admission rates by age group remained constant - and the historic trend in reducing average lengths of stay faltered? The next chart shows what this scenario looks like� This first chart illustrates a trend that will be very familiar to all of us here: reducing emergency admission bed day rates for people aged 65+ by 10% by 2011 is one of our challenges in HEAT. The HEAT mark on the right hand side shows around where we want to be by March 2011. But what I�d like to do is think the unthinkable � What if these trends continue unabated into the future, spurred on exclusively as a consequence of Scotland�s increasingly ageing population. Specifically, what would happen if emergency admission rates by age group remained constant - and the historic trend in reducing average lengths of stay faltered? The next chart shows what this scenario looks like�

4. The consequence, illustrated by this slide, is an increasing demand for extra beds: What we�re looking at is a 24% rise in beds occupied by older people admitted as emergencies by 2016 � that�s around 1800 more beds, which equates to three more Wishaw General Hospitals! By 2031 we would need 6000 more beds. We don�t have the luxury of tolerating the status quo. The chart underlines the pressing need to change some or all of the factors at play: to continue to reduce the average length of stay and to reduce admission rates. What�s shown here as a possible outcome is not sustainable given the workforce and financial challenges we face. But more importantly it�s also not in the best interests of older people. The consequence, illustrated by this slide, is an increasing demand for extra beds: What we�re looking at is a 24% rise in beds occupied by older people admitted as emergencies by 2016 � that�s around 1800 more beds, which equates to three more Wishaw General Hospitals! By 2031 we would need 6000 more beds. We don�t have the luxury of tolerating the status quo. The chart underlines the pressing need to change some or all of the factors at play: to continue to reduce the average length of stay and to reduce admission rates. What�s shown here as a possible outcome is not sustainable given the workforce and financial challenges we face. But more importantly it�s also not in the best interests of older people.

5. Current service provision by service type This chart illustrates longer term care of people aged 65 and over, according to three care approaches � essentially NHS Continuing Care, Care Home residents and people living at home receiving Home Care. NHS Continuing Care is so small a volume that it does not show up at all on the chart although it�s represented on the key � we�re only talking about a few thousand people in total across Scotland. Care home residents are shown in purple. People receiving any level of home care are in orange. Represented in blue are people who are essentially living at home, with just the universal services for support � the vast majority, obviously. This chart illustrates longer term care of people aged 65 and over, according to three care approaches � essentially NHS Continuing Care, Care Home residents and people living at home receiving Home Care. NHS Continuing Care is so small a volume that it does not show up at all on the chart although it�s represented on the key � we�re only talking about a few thousand people in total across Scotland. Care home residents are shown in purple. People receiving any level of home care are in orange. Represented in blue are people who are essentially living at home, with just the universal services for support � the vast majority, obviously.

6. Current service provision by age group This shows the same information by age band and illustrates the far greater proportion of people aged 85 and over in particular who are receiving the services illustrated. Again, care home residents are purple. Home care is orange and blue represents people using just universal services while living at home. This time you can just about see NHS Continuing Care in the 85+ diagram � it�s the red bit. The blue bits show that 97% of 65-74 year olds are making use of universal services only; it�s 88% for 75-84 year olds, and it�s 60% of those aged over 85. What this also shows us is how it is that most care of older people is provided by other older people � 65-74 year olds looking after 85 year olds, and so on. We need to be doing more to facilitate and enable that kind of support.This shows the same information by age band and illustrates the far greater proportion of people aged 85 and over in particular who are receiving the services illustrated. Again, care home residents are purple. Home care is orange and blue represents people using just universal services while living at home. This time you can just about see NHS Continuing Care in the 85+ diagram � it�s the red bit. The blue bits show that 97% of 65-74 year olds are making use of universal services only; it�s 88% for 75-84 year olds, and it�s 60% of those aged over 85. What this also shows us is how it is that most care of older people is provided by other older people � 65-74 year olds looking after 85 year olds, and so on. We need to be doing more to facilitate and enable that kind of support.

7. JIT supporting local health and social care partnerships National development programmes Reshaping Older People Programme Shifting the Balance of Care Opportunity to support the RRIG programme and engage stakeholders across health and social care

8. Nature and Scope of Review To identify examples of good practice and innovation in service delivery with a focus upon services that are delivered to people at home or in their local communities, including approaches to community capacity building 8 partnership areas � mainland, islands and both Initial scoping questionnaire Follow-up interviews and details of services

9. Key Challenges Population structure and distribution What does equality look like Local and specialist services The nature of rural communities Critical mass and opportunity costs Workforce Population structure and distribution OP time bomb Working age reductions Equality Equality of outcomes not the delivered service Local and specialist Availability close to home Recognised need for volume to sustain specialist skills and critical mass Rural communities Anxieties about change when living �on the margins� Recognition of the knife-edge between sustainability and retraction Critical mass etc. Impact of geography, topography, popn, distribution all impact likelihood of achieving a sufficient critical mass of demand The smaller the potential demand the greater is likely to be the opportunity cost and the risk of diversion of resource. Often reflecting a focus upon budgets and revenue costs rather than whole system costs over the long term and impact upon outcomes Workforce Need to move families an obvious issue but importance of new models of learning and support, initiatives to recruit locally and grow the local workforce also highlighted Population structure and distribution OP time bomb Working age reductions Equality Equality of outcomes not the delivered service Local and specialist Availability close to home Recognised need for volume to sustain specialist skills and critical mass Rural communities Anxieties about change when living �on the margins� Recognition of the knife-edge between sustainability and retraction Critical mass etc. Impact of geography, topography, popn, distribution all impact likelihood of achieving a sufficient critical mass of demand The smaller the potential demand the greater is likely to be the opportunity cost and the risk of diversion of resource. Often reflecting a focus upon budgets and revenue costs rather than whole system costs over the long term and impact upon outcomes Workforce Need to move families an obvious issue but importance of new models of learning and support, initiatives to recruit locally and grow the local workforce also highlighted

10. Strategies to address Challenges

11. Partnerships and Joint Working More effective services and better outcomes Prevent potential professional isolation Obligate networks Role of voluntary organisations

12. Community Based Services Service hubs � co-location and potential integration Routine night time care Importance of Telecare � and increasingly Telehealth Care at home � key changes in terms & conditions and commissioning approaches

13. Integrated Services and Equipment Integrated community care teams Intermediate Care Integrated OT services Joint Equipment Stores Telecare � links to assessment & care management v corporate one stop access Key-holder and responder arrangements

14. Care Homes and Specialist Housing Small scale, financially sustainable and locally accessible is the key Direction of travel towards housing based solutions Joint health and social care facilities emerging in response to difficulties of meeting sufficient spectrum of needs in care homes In concept, often associated with service hub

15. Workforce Strategies Workforce was a widespread challenge due to demographics and skills/learning requirements Annualised hours an increasingly common approach Integrated team working moving ahead positively in some areas Integration around personal care and healthcare roles limited in many areas but, Work around a Rural Support Worker (health & social care) role making significant progress

16. Community Resilience Voluntary sector providers widely recognised as having ability to be more flexible in responding to changing levels and types of small scale demand User and carer engagement did not emerge as an area of major activity/progress

17. Key Issues One size does not fit all in rural and remote areas The challenge of achieving change in rural and remote areas � joining up the service, employment, infrastructure and social benefits Varying expectations and what constitutes a �reasonable level of service� Workforce integration is the key to delivering better services in many situations Service hubs offer potential revenue savings and integration benefits but may be limited by short term capital considerations Developing community resilience could be the key to sustainable services and robust communities � substantial development activity is thin on the ground

18. Areas for further study Out of Hours Home Care What factors impact what is or is not sustainable regarding planned OOH care for people with LTC and unplanned OOH care in response to an emergency/potential admission Rural Support Worker (health & social care) Despite progress around role, registration, qualifications, training and CPD why have so few posts been created? � a look at the HR, management, operational and funding issues

19. Out of Hours Home Care Remoteness and sparcity of population present particular challenges for the organisation of social care at home Mobile, team-based, permanent services for delivering social care at night may not be a viable solution where demand for the service is highly variable from week to week Access to immediate, appropriately trained staff to provide direct support at home for a night or two, as a direct alternative to admission to hospital, is also much more difficult in rural settings Background commentary Remoteness and sparsity of population present particular challenges for the organisation of social care at home: recruiting, training and retaining social care staff for sporadic work; the problem of available day care; transport. In organising services to support continuing care at night in remote areas, the challenges come into sharp focus. Mobile, team-based, permanent services for delivering social care at night may not be a viable solution where demand for the service is highly variable from week to week. Getting access to immediate, appropriately trained staff to provide direct support at home for a night or two, as a direct alternative to admission to hospital, is also much more difficult in rural settings. There are unlikely to be commercial care agencies who can provide staff on request, and even if there are, the retention fees for being on standby to provide this occasional service are likely to make the unit cost for the service prohibitively high. It was against this background, in the context of the general challenges of providing viable services for low volume, highly variable demand, that one of the areas for specific follow-up work identified from the JIT report, �A Review of Service Development and Innovation in the Delivery of Care and Support Services in Rural and Remote Areas� was on joint working and integration aspects of overnight care services. This section of work is taking place in the Western Isles and Argyll & Bute, both of which have population clusters and very remote areas. Overnight care, to meet continuing care needs The service model of a mobile team delivering pre-planned social care services can work successfully in quite sparsely populated areas. There is a certain combination of (a) area covered and (b) reasonable regularity of demand which needs to be met to make this model sustainable The wider the area covered, the less opportunity there is to combine planned service with a responsive service, e.g. for tele-care alerts, without unacceptable disruption to regular users There are developing models involving local care centres, from which individually tailored night care services can be delivered Alternatives to through-the-night, including social care shifts that include service to 1am and that start at 6am, are being examined. Urgent Night Cover Very positive developments with the existing voluntary sector, to get access to appropriately trained staff to provide short-term night cover Crossroads-type providers have a pool of staff; while a service cannot be guaranteed, many of the issues seem to be about knowledge of pathways to access services For more remote areas, the options through statutory services are limited by the need to retain staff on call or standby, for demand that may be very sporadic Likewise, arrangement with private agencies, if they operate, are likely to carry costs for being prepared for service delivery that arises very irregularly Background commentary Remoteness and sparsity of population present particular challenges for the organisation of social care at home: recruiting, training and retaining social care staff for sporadic work; the problem of available day care; transport. In organising services to support continuing care at night in remote areas, the challenges come into sharp focus. Mobile, team-based, permanent services for delivering social care at night may not be a viable solution where demand for the service is highly variable from week to week. Getting access to immediate, appropriately trained staff to provide direct support at home for a night or two, as a direct alternative to admission to hospital, is also much more difficult in rural settings. There are unlikely to be commercial care agencies who can provide staff on request, and even if there are, the retention fees for being on standby to provide this occasional service are likely to make the unit cost for the service prohibitively high. It was against this background, in the context of the general challenges of providing viable services for low volume, highly variable demand, that one of the areas for specific follow-up work identified from the JIT report, �A Review of Service Development and Innovation in the Delivery of Care and Support Services in Rural and Remote Areas� was on joint working and integration aspects of overnight care services. This section of work is taking place in the Western Isles and Argyll & Bute, both of which have population clusters and very remote areas. Overnight care, to meet continuing care needs The service model of a mobile team delivering pre-planned social care services can work successfully in quite sparsely populated areas. There is a certain combination of (a) area covered and (b) reasonable regularity of demand which needs to be met to make this model sustainable The wider the area covered, the less opportunity there is to combine planned service with a responsive service, e.g. for tele-care alerts, without unacceptable disruption to regular users There are developing models involving local care centres, from which individually tailored night care services can be delivered Alternatives to through-the-night, including social care shifts that include service to 1am and that start at 6am, are being examined. Urgent Night Cover Very positive developments with the existing voluntary sector, to get access to appropriately trained staff to provide short-term night cover Crossroads-type providers have a pool of staff; while a service cannot be guaranteed, many of the issues seem to be about knowledge of pathways to access services For more remote areas, the options through statutory services are limited by the need to retain staff on call or standby, for demand that may be very sporadic Likewise, arrangement with private agencies, if they operate, are likely to carry costs for being prepared for service delivery that arises very irregularly

20. Overnight care to meet continuing care needs A mobile team delivering pre-planned social care services can work successfully in quite sparsely populated areas A combination of (a) area covered and (b) reasonable regularity of demand needs to be met to make this model sustainable The wider the area covered, the less opportunity there is to combine planned service with a responsive service without unacceptable disruption to regular users Alternatives include local care centres, from which individually tailored night care services can be delivered and alternatives to through-the-night using social care shifts that provide a service to 1am and that start at 6am

21. Urgent Night Cover In more remote areas, the options through statutory services are limited by the need to retain staff on call or standby, for demand that may be very sporadic Likewise, arrangement with private agencies, if they operate, are likely to carry costs for being prepared to deliver services for which demand arises very irregularly Developments with existing voluntary sector providers are emerging for appropriately trained staff to provide short-term night cover on a small scale, local basis Many of these agencies have a pool of staff which whilst unable to provide a guaranteed service, can respond quickly and flexibly. Many of the issues seem to be about knowledge of pathways to access services

22. Rural Support Worker (health and social care) Early work by SSC/NES to map skills and learning requirements across health and social care assistant posts Substantial body of work concluded on role definition, registration, qualifications, training/CPD Funded piloting of implementation work well underway in Shetland, Western Isles and Orkney Some appointments beginning to happen in context of intermediate care services All of which left some important practical questions unanswered�..

23. Outstanding questions Operational settings � how might RSW posts be deployed and what different demands would this create for staff? Gradings structure � how will RSW staff be managed and what promoted posts with specialist training of this sort will be required? Career opportunities � how will these posts equip staff to progress their future careers? Employment arrangements � who will be the employer and are issues of compatability of terms & conditions across local agencies a potential hurdle to progress? Financing of posts � what are the practical arrangements by which these posts will be funded where they are delivering an integrated service on behalf of multiple agencies?

24. Margaret.whoriskey@scotland.gsi.gov.uk anthonyhomer695@btinternet.com MalcolmIGSmith@aol.com www.jitscotland.org.uk