29 projects across London, in two phases (phase one lasted about 18 months and phase two lasted about nine months) Each led by a Project Manager
Supported by a small central team consisting of:
Val Jones, Director
Kerry Gilmour, Programme Manager
Dave Walton, Programme Manager
Catherine Pugh, Project Officer (Office Manager)

The aim of the two-year programme was to promote independence in the London community of older people, through the delivery of person-centered, coordinated services.

The specific objectives were:

• To identify vulnerable older people at risk in the community, using a case finding or case management approach
• To initiate the single assessment process (a new government led multi-agency, multi-disciplinary, whole person assessment system to reduce duplication and speed processes), wherever the person enters the system
• To deliver coordinated services in the community
• To gather systematically the views of older people and caregivers

Monthly key measures/run charts, agreed by a Reference Group, included:

• Numbers of older people found to be at risk and referred on for further assessment or services
• Numbers of high-resource users intensively case managed
• Improvements in single assessment recorded through audits of case notes
• Numbers of interviews held with older people and caregivers (used to identify practical issues that need changing and ensure a person-centered focus for changes)

In addition, to reflect the complexity of local systems and need, and to promote innovation, projects had to develop local coordinated service measures that record improvements and sustainability.

The UK has possibly the world’s most ambitious health modernisation programme. The London programme extended the IHI health improvement/modernisation model beyond narrowly defined health systems (hospitals and primary care or specific clinical pathways/specialties) to the "whole" wider health system including social care, housing and environmental support and voluntary sector support. Research shows that older people need the whole system working as they tend to have multiple problems and many of the underlying problems that lead to hospital entry and ill health are not just medical.

Taking a person-centered approach based on whole person assessment and joint working, with the powerful collaborative tools, enabled front-line staff to find out what older people really wanted/needed (often not health related) and improve services for individuals and groups of older people. A small central team supported 29 (including 3 medicine management projects and an Older Patients as Teachers project) projects by providing funding for 25 project managers, workshops, training, a "how to" handbook, monthly measures, monthly meetings, information sharing (Smartgroups, Newsletters and website), local training and presentations and one-to-one support.

As well as implementing evidence-based case finding and intensive case management approaches and single assessment, each programme used discovery interviews to get user and caregiver views to identify specific issues for improvement and to use process mapping and PDSAs to test practical changes leading to measurable improvements and more coordinated services.

Projects came up with a whole range of coordinated service improvements, including the following:

• Screened and supported almost 10,000 older people at risk within the first 15 months of operation.
• Reduced number of attendances at hospital and General Practitioner (GP) surgeries by preventing unnecessary visits through targeted screening, early detection and treatment, and by intensive care management of issues leading to admissions – not just medical issues but including social, financial and environmental issues of importance to the user.
• Reduced waiting times, e.g., for assessments, for information, for treatment, for GPs to get information about patients discharge from hospital and users to be able to see their GP.
• Speeded service provision through direct referrals, accepting other agencies' referrals, eliminating unnecessary stages in processes; combined referral forms, reducing the need for separate assessment.
• Developed protocols (written agreements) for direct joint commissioning of specific services, i.e., one agency can commission specific services from another without re-assessment.
• Developed joint training to improve understanding of each agency's roles and how we can work together better (staff involved included consultants, doctors, GPs, hospital nurses, occupational therapists, physiotherapists, rehabilitation workers, social workers, pharmacists, health visitors, district nurses, housing and voluntary sector staff, as well as users and caregivers).
• Multi-skilling, where staff are trained to do simple tasks normally done by other agencies/professions, and can then provide services directly – therefore reducing waiting lists for assessment and delivery.
• Improved information for users, caregivers and staff so people can make informed choices and access or refer people on for services faster and more easily.
• Improved processes, e.g., designing a single multi-service referral form to replace 5 separate ones (that asked for the same core information and just a few extra specialist items).
• Improved networking and links with other services and with modernisation work elsewhere in the locality. The programme developed a list of collaboratives and modernisation projects in each locality. There were a number of very useful links, e.g., with medicines management, emergency services collaborative.
• Setting up new integrated services, e.g., falls pathway in Wandsworth, voluntary sector network (providing a range of practical services) in Waltham Forest.
• Empowered front-line staff to work together to make positive changes.
• Improved services for people from London’s many minority communities, including improved access, information, translation/interpreting/ health promotion, and more culturally sensitive assessment tools and services.
• Provided evidence of cost savings through preventing expensive episodes of emergency or hospital care.

Given the size of the programme, only some key measures are given. A full report is available on http://www.london.nhs.uk/modernising/olderpeople.htm.

"Summary of service use in 29 patients" graph:
Example of reduced hospital bed days and GP house calls in 29 high-health-and-social-care-using patients by using intensive case management of frequent re-attendees at Emergency Care. This confirms results from the US and the UK Castlefields intensive case management project, which was used as the source of this evidence-based targeted approach.

• Hospital admissions down by 47 percent (9 admissions)
• Nights spent in hospital down by 48 percent (252 nights)
• Accident and Emergency Room (A&E) attendances down by 53 percent (9 A&E attendances)
• GP home visits down by 53 percent (10 home visits)
• Use of the GP out-of-hours service down by 82 percent (9 calls/visits)
• GP appointments down by 19 percent (9 appointments)
• Length of stay was reduced by a total of 145 nights over 13 patients
• Re-admission of people over 75 years was reduced by 3 percent when compared to the same period last year.

At Central Middlesex Hospital, length of stay was reduced by a total of 145 nights over 13 patients, and re-admission of people over 75 years was reduced by 3 percent when compared to the same period last year.

"Days taken for discharge notes to reach GP" graph:
Example of coordinated service improvement in one locality. The problem was identified by users discharged from hospital who wanted to see their GP because of concerns about medication and aftercare.

Overall, the programme has:

• Shown that the collaborative method works effectively for older peoples services and in complex geographical health, social and voluntary care systems.
• Shown that work with older people and whole system working are essential to meeting key targets.
• Developed and applied effective preventive approaches, which have reduced unnecessary attendance at hospital and use of health and social care services. A separate report is available from the programme.
• Developed simple but effective ways of targeting and managing screening and case management.
• Developed some simple but effective ways of spreading in complex local health, social, housing and voluntary care communities
• Supported evidence that targeted, whole system work with older people not only works in preventing unnecessary admission to accident and emergency room and hospital, but is also cost effective.
• Shown that person-centered, user-focused methods work, and that older people and caregivers can and should be involved in and be equal partners in collaborative working and system improvement (Older people were positively involved in workshops, steering groups, discovery interviews (a powerful, semi-structured interview method used to find out users experiences of the system developed by the UK Coronary Heart Disease Collaborative, which works extremely well with older people), in training staff and in interviewing older users. The programme also supported an innovative "Patients as Teachers" project which got users' views and used them to train medical and social care staff in the practice of assessment.
• Developed and tested (3 evaluated pilots) practical ways of including medicines management and pharmacist reviews in single assessment. (Research suggests that 5 to 17 percent of hospital admissions may relate to medicine problems and 50 percent of older people have some kind of medicine-related problem.)
• Developed and tested practical ways of screening, assessing and developing care pathways for older people who fall. (Falls are major causes of death, disability and emergency hospital admission in older people.)
• Developed effective training and work force development to ensure the complete range of staff (acute and primary health, social care, voluntary sector, housing etc) and users and caregivers can take part in collaborative and whole system work.
• Piloted single assessment in all agencies, developed trusting relationships, joint protocols and direct referrals so that people accept each other's referrals and speed the whole process up for older people.
• Piloted screening and support for people with early dementia and chronic diseases, e.g., COPD.
• Developed culturally appropriate information and services for people from minority ethnic and faith communities.
• Shown that collaborative projects can be led by a whole range of agencies and staff. Project Managers had health (acute and primary), social care, voluntary sector and housing backgrounds.
• Shown that service improvement work with older people is essential and can also be cutting edge and fun.
• Come up with some simple and practical methods that you can apply in your area.

More details of the programme, lessons learned and "how to do it" papers are available on the Programme’s website http://www.london.nhs.uk/modernising/olderpeople.htm

Val Jones
London Older People’s Service Development Programme
val.jones@swlha.nhs.uk