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ITEM EX12

EXECUTIVE – 7 DECEMBER 2004

PREVENTION AND DAY SERVICES STRATEGY FOR OLDER PEOPLE

Report by Director for Social & Health Care

1. A 5-year Strategy has been drawn up within the Social & Health Care Directorate to develop and modernise preventive and day services. The Strategy will inform the Directorate’s 3 year Commissioning Strategy, and implementation will be through the overall developments that are undertaken as part of the Commissioning Strategy. The purpose of this report is to highlight this significant area of activity, and seek agreement to the overall objectives of the Strategy and the service model that is being proposed.
2. Members of the Executive have received a copy of the Strategy with the agenda for the Social & Health Care Scrutiny Committee meeting on 27 October. The Committee’s comments are set out later in this report. A copy of the Strategy can be seen in the Members’ Resource Centre and is available for public inspection.

Background

3. A number of policy documents issued over the last three years have developed and expanded on a consistent theme of services that promote independence, reduce dependency and improve well being and quality of life for older people. In April 2004 Dr. Stephen Ladyman, Minister of State in the Department of Health, announced that he wanted to develop a new vision for the future of adult social care. He said:

‘The vision should be one that puts the person needing support at its centre rather than the institutions providing that support, one that promotes social inclusion and diversity and supports people in their choices and aspirations rather than cares for them once all choice and hope is gone.’

The proposed strategy is in line both with this vision and the direction of the recent White Paper on Public Health promotion Choosing Health: Making Healthy Choices Easier.

4. There is a strong national driver to change the focus of investment and service provision from acute care to primary and community-based services. National Guidance on ‘Fair Access to Care Services’ requires local authorities to target resources on those most in need, but also requires strategies to ensure access and ‘signposting’ to preventive services for people who do not meet eligibility criteria for mainstream services.
5. In the Local Government Association/Association of Directors of Social Services paper All our Tomorrows: Inverting the Triangle of Care, preventive services for older people are categorised into two broad areas:

• Strategies and approaches that promote the quality of life of older people and their engagement in the community
• Services that prevent or delay the need for more costly intensive services

6. A Scrutiny Review report on ‘Geographical Equity for Older People’s Day Care Services in Oxfordshire’ was presented to the Executive on 22 July 2003, and a progress report was given to the Executive on 20 April 2004. The latter report included an Action Plan with specific recommendations (2 and 4) relating to implementation of this Strategy:

• Implement recommendations of Special Transport Demand Forecasting (Halcrow, Feb 2004) as resources permit.
• Report to Executive on Day Care with recommendations for action.
• Implement ‘Phase 1’ of Strategy (2004/5) including minor accommodation upgrades and recruitment of several ‘Passenger Assistants’, subject to in-year budget.
• Bid for ‘Phases 2-4’ (2005-8) funding in 2005/6 budget round.
• Shift resources from long-term care to Day Services in support of ‘Intensive Home Care’ packages.

7. The ‘Oxfordshire Compact’ (2004) is a partnership agreement between statutory, voluntary, community and faith sectors. This document emphasises the importance of a strong, sustainable voluntary sector infrastructure, with appropriate statutory funding or support in kind for capacity building.
8. The Social & Health Care Directorate already works closely with other Directorates on the broader prevention agenda, and is strongly committed to improving social inclusion and learning in later life. Preventing dependence and promoting well-being for older people is not just the responsibility of Social & Health Care. This report deals with services designed to cope with significantly disabled people. However, there is a wider agenda which the County Council and other stakeholders can address which helps to keep older people active and well. This wider agenda includes public transport, access to libraries, well-maintained pavements, further education opportunities, sport and recreation.
9. Examples of jointly supported schemes include exercise programmes, inter-generational projects in schools and day centres, reminiscence work in libraries and community transport services. The Strategy contributes directly to 4 County Council Priorities:

• Reducing delayed discharges from hospital
• Support for older people to live at home
• Better use of property
• Commitment to social inclusion

10. The impact of changes in the demographic profile in Oxfordshire is that by 2009 the number of people aged over 65 will increase by 9,800. It is estimated that there will be an additional 1600 people over the age of 85, a significant proportion of whom will suffer from some form of dementia and/or physical frailty and will require a high level of support. As well as an increase in the number and dependency of potential service users there will be an increasing number of carers aged over 65 many of whom identify themselves as not in good health.

The Views of Users and Carers

11. We know from a number of national and local user surveys and forums that people want and value services which promote and maintain independence and support people to remain living in the community and enable people to make choices about how they want to live their lives. Further details are set out in the full strategy document.

Current Prevention/Day Service Configuration

12. This is the last of the three core areas of provision (Prevention/Day Services, Home Support, Residential) to be considered for significant investment. The Homes for Older People development programme, workforce issues and market forces have already led to increased investment to support high user dependency in residential care and home support services.
13. Day services are increasingly supporting a similar level of dependency to the other two long-term services on a significantly lower budget per hour of care. The current gross budget for older people for day, preventive and transport provision is £5m (7% of total), compared with £45m (63%) for Residential and Nursing Care and £22m (30%) for Home Support
14. A range of preventive services has been commissioned by the Directorate, including carers services, exercise programmes, foot care, falls prevention programmes and advice and information. However, there is concern about the funding arrangements, which rely largely on short-term grants (in contrast to the spirit of the Compact), and therefore the longer term security and sustainability of some of these services is in doubt. The total cost of preventive services for older people to Social & Health Care is £1.9m in 2004/5.
15. Service development across the County has been piecemeal and opportunistic depending in part on funding available and also on the drive and initiative of local voluntary groups or individuals. This has led to inequity of provision, particularly in rural areas. For example, there is no specialist mental health or 5-day provision of day services in West Oxfordshire. In addition, staff in many of the day centres work in poor physical environments, which are inappropriate for the levels of dependency of service users and lack basic facilities such as special baths. These conditions are far from ideal to provide the right sort of service for people who have high levels of physical and/or mental frailty.
16. 3000 day places a week are provided through 64 day centres of which 8 are managed by the Directorate and provide over half of the places; a number are delivered by larger local and national voluntary sector organisations, and the remainder by local independent management committees.
17. Usage of places is limited by lack of transport, staffing or facilities, particularly for people with significant physical or mental health needs. As a consequence, Care Managers tend to under-refer for day and preventive services. As a result of the increasing levels of dependency and restrictions on funding, the short-term survival of some smaller day centres is uncertain. Many management committees are fragile, and the current reliance on volunteers is not sustainable as dependency rises.

Key Elements of the Strategy

18. The objective of the Strategy is to develop an equitable spread of preventive and day services across the County, achieving the dual outcomes of promoting independence and preventing more people entering long-term care. Resources will be directed to both longer-term, low-level ‘social inclusion’ services, as well as more intensive input to help highly dependent people remain at home.
19. The Strategy proposes:

• Working in partnership with the voluntary sector, district councils, housing providers, PCTs and the Oxfordshire Mental Health Care Trust to maximise shared use of resources for current and new preventive and day services.
• Increased capacity in preventive and day services to respond to demographic pressures and reduce dependency levels of people supported at home. This will include extension of opening hours and days to meet the needs of carers.
• Consolidation of funding to existing preventive services, and limited development of new ‘social inclusion’ projects which total £390k. Examples would be maintaining rural day centres, new foot care, exercise and falls prevention services, hospital discharge schemes and support to ethnic minority Day Services.
• The development of 17 Resource Centres in the main population hubs, providing ‘core services’ supported by a ‘cluster’ of smaller (mainly rural) or specialist day centres and preventive services. These are described in more detail below.

20. Resource Centres will provide ongoing support for those with high levels of dependency or complex needs, have higher staffing levels, and will be open for extended hours including weekends. They will offer specialist services such as dementia care, Intermediate Care and relief to carers. Intermediate Care (e.g. rehabilitation assistance with improving mobility or self care) will be delivered in Resource Centres to around 300 service users to prevent further deterioration and possible admission to hospital, and also to support people on discharge. This will allow a continuum of rehabilitation opportunities from hospital through residential/nursing homes to day centres and in domiciliary settings.
21. The Centres would also provide a community resource for other services and facilities including health promotion activities, falls and exercise programmes. The ‘cluster’ of smaller, rural day centres would open for fewer days and hours per week, respond to the needs of the local population and increase opportunities for social inclusion in the local community.
22. It is being proposed that a total around 1,100 new Day Centre places will be created across the County by 2010, subject to resources being available.
23. A major expansion will be required in the amount and type of transport provision by 2010 (including Passenger Assistants on larger vehicles) to match rising dependency (both physical and mental) and the increase in overall capacity.

Consultation to Date

24. Key elements of the Strategy have been discussed with some stakeholders:

• Operational Service Managers
• Community Rehabilitation Service team co-ordinators
• Users and carers and internal providers
• External providers.
• Oxford City Locality Planning meeting.

25. This is a significant modernisation and development programme due to historic under-investment in this sector. The strategy implementation will need to be phased over a number of years subject to funding within the resources allocated to Social & Health Care and evidence of performance. Funding priorities will be incorporated into the 3 year commissioning strategy and the annual service plan for Older People, the Capital Programme and Minor Works budget. In particular, investment will be required for:

• Buildings and accommodation: in some localities there may be opportunities presented by the reconfiguration of the Learning Disability Services and the change of use of buildings. In others there will be a requirement for refurbishment of existing buildings or a new build. There may also be opportunities through working with NHS or independent sector partners for joint use of premises.
• Transport: transport consultants Halcrow have provided information and costings for a transport service to support the new day services. Their estimate was of a 100% increase required in Social & Health Care transport activity and budget because of lack of capacity in the voluntary sector and increasing volume/dependency.

26. The strategy has major capital and revenue implications for Social & Health Care. Proposals for funding will be submitted for inclusion in the Capital Programme, the Medium-Term Financial Plan and the Commissioning Strategy for 2005/8. In the longer term this development is likely to be funded by reductions in long-term care because demand will be reduced by improvements in prevention and day services.
27. The need for new sites, integration with other services or re-development of day centres will be included in the Property Assets Review.
28. There will be an overall increase in numbers of staff and an improved skill mix to deliver intermediate care and support to those with complex physical and mental health needs. Passenger assistants on vehicles will be essential. In the mid-term, day centres will be open for longer periods and at weekends, and there will be some impact on conditions of service.

Environmental Implications

29. There will be local environmental impact from any construction work involved in new-build or refurbishment. Some additional vehicle journeys can be expected due to the increase in passengers, extended functions of day centres and weekend opening.

Implementation

30. This is a major project which will require careful implementation. The Head of Planning, Partnerships & Commissioning will be the project sponsor. The Directorate will appoint a Project Manager and establish a Steering Group to support stakeholder involvement and implementation of the Strategy.
31. The project manager, when appointed, will be responsible to a Project Board. They will draw up a project plan which will prioritise developments as capital and revenue funding become available. The Project Board will be accountable to the Senior Management Team in Social & Health Care .

Conclusions

32. It is necessary to increase the investment in preventive services that reduce dependency in existing service users through Intermediate Care, or complement intensive home support packages. The Resource Centres will be the focus of these services. The cluster of smaller, local day centres will provide a range of opportunities for enhancing the inclusion of older people in a range of supportive activities, and significantly will provide services in partnership with the voluntary sector that will give support and relief to carers.
33. Doing nothing is not an option. The current day service provision and configuration is not sustainable even in the short term, nor will it meet the demographic pressures both in terms of overall numbers and dependency of people in our community. It is essential to develop and sustain a comprehensive network of provision across the County which will encourage social inclusion and the involvement of older people in their local communities.

Social & Health Care Scrutiny Committee

34. A draft of this report was presented to the Social & Health Care Scrutiny Committee on 27 October. Welcoming the strategy, the Committee agreed to advise the Executive:

• that they have noted the demographic pressures facing the county and the unsuitability of the premises used by many of the Day Centres;
• that they hope that sufficient funding would be provided to fund the proposals outlined in the Strategy; and
• to add the Older People’s Panel to the list of consultees.

35. In the light of comments form members of the Committee officers undertook to make some textual changes to the Strategy for greater clarity, in particular, to specify what is meant by the term ‘places’ in the context of Day Centres; to supply more information on the services provided by Resource Centres; and to clarify the timescales in the table in Annex 7 and how much of the funding required for 2004/5 has already been identified.

RECOMMENDATIONS

36. The Executive is RECOMMENDED to:

1. welcome the comments of the Social & Health Care Scrutiny Committee, note the textual changes to be made to the Strategy and agree the extension of consultation as the Committee recommends:
2. agree the strategic direction set out in the report, noting the resource implications that will require further consideration;
3. approve the Project Management arrangements set out in paragraphs 30 and 31.

CHARLES WADDICOR
Director for Social & Health Care

Background Papers: Nil

Contact Officer: Nick Welch, Head of Service (01865 815714)

October 2004

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