caredata CD Full Text - copyright NISW/Positive Publications

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1 caredata CD Full Text - copyright NISW/Positive Publications The Middleton Elderly Resource and Intervention Team was a pioneer in joint commissioning and care management, predating implementation of the NHS and Community Care Act 1990 by several years. Established to meet the growing demand for support in the community for elderly people suffering from dementia, depression and a range of related conditions, MERIT began as a multi-agency, multi-disciplinary team in Middleton, within the Rochdale metropolitan area, lies midway between Rochdale and Manchester. Traditionally, people in the town had sought psychogeriatric services from the North Manchester General Hospital which, by the 1980s. had formed links with Rochdale's social and community health services. But repeated complaints from the Middleton Carers Association about poor quality of support led to agreement between the two neighbouring health districts and Rochdale Social Services Department to set up the jointly-financed MERIT project. Following a service development feasibility study, the team decided to concentrate on outreach and service co-ordination in the belief that sound care management should come before "bricks and mortar". Emphasis was also placed on maximum flexibility in staff roles and ways of working. Much effort was spent on face-to-face contacts with local GPs and community groups in the belief that the project would achieve more if its model of service was known and accepted by the community. Principles The team's principles of care (See Operational Imperatives box) were established with immediate line managers and service clinical staff. As progress was made, a feeling was created within the team that MERIT was ahead of the field. This feeling helped overcome difficulties of multi-disciplinary teamwork and MERIT became not simply an assessment team but a point of access to a number of resources (See Services Used box). Accessing Services Despite the financial pressures of the last five years, Merit has shown that social and other community services can be responsive to the needs of elderly mentally frail people. More than 600 people have been referred to the team, coordination has been improved, professional demarcation broken down and queues for services reduced. The team has trebled the level of care provided to people referred to the team in addition to giving direct medical, nursing and social work support.

2 Pressure has also been eased on other services. Before MERIT was established, two consultant psychogeriatricians at the North Manchester General Hospital had to visit elderly people in the area. Now the Senior Clinical Medical Officer in the team discusses cases with the consultants and arranges hospital admission and respite care. The consultants pass clients straight to MERIT for community support. Undoubtedly, the SCMO has been important in establishing credibility with GPs, other community resources, clients and carers. GPs have also become more alert to mental health problems and have referred more people to the team. This has been helped by the care management system in Rochdale where nursing and social work staff are expected to act as care managers. As explained, team members were already working flexibly before the NHS and Community Care Act. From the start nurses have assessed health and social care needs, negotiated with providers, coordinated and reviewed services. Community Psychiatric Nurses arranged benefits, day care, respite and domiciliary care, and assist in rehousing. In this way people get a range of professional skills in one centre. The introduction of care management has now given the team access to Transitional Grant funding to augment community care packages through voluntary and private agency services. Some failures The team has not always met with success in its efforts. A specially written booklet was successful but an out-of-hours Helpline, operated by the Carers Association, was little used despite advertising in the local press. Attempts to link carers into a network also met with little response and a computer print-out system giving information on care, medication effects and contacts, was not user-friendly enough for GPs and carers. A volunteer/befriending service was also established following newspaper advertising and training given by MERIT staff. But again its success proved limited. Several supportive relationships emerged between volunteers and clients living alone and some volunteers went on to find paid employment in the care services. But it largely failed because of the difficulty of supporting volunteers in stressful carer/client situations. Maintaining progress Initially, the team's staff were funded by the participating agencies with core administration costs and co-ordination met by Research and Development in Psychiatry, now known as the Sainsbury Centre for Mental Health. In the early stages MERIT was also linked for overall management to Age Concern Rochdale to give it more flexibility, particularly financial.

3 In April 1992 the coordinator and the administrator were absorbed into social services under a joint finance arrangement with Rochdale Health Authority. Now Rochdale social services department is bearing most of the cost of providing the service through direct services or Transitional Grant monies. While a switch to community care was intended, a change from health to social services funding was not. MERIT outreach has now had to be curtailed because, without additional staff, a balance has to be struck between new work and support to existing clients. To sustain the cutting edge that MERIT has displayed for more than five years, it must: * Sustain innovation as well as accountability in the team's management group; 9 Develop a business plan that fits MERIT into authority-wide joint planning; * Develop measurements of success to help MERIT compete for more resources. Established in 1992, MERIT's management group has staff of mixed status and responsibilities who now have the challenge of fitting the team into the needs of authority-wide commissioning and care management. With consultancy funding from the Regional Health Authority, Dr Graham Lomas, a private consultant in social and urban affairs, who had previously written reports on the working of the team, produced a report for future development. It recommended that the field staff and the management group draw up a business plan, with a phased cycle of review and decision-making to fit the fiscal year of community care planning. Statistical indicators of the team's impact on services are also being considered with the expectation that they will help MERIT to compete for resources (See Performance Indicators) Future development Debate about management, business planning and service indicators is beginning to extend to all client groups in Rochdale. If ideas generated by MERIT are accepted, agencies might devolve budgets to other teams allowing them to purchase services in a more effective, efficient and flexible way than by centrally-controlled purchasing. Management groups like that of MERIT, could even develop into commissioning teams responsible for implementing strategic decisions taken by a commissioning board at inter-authority level. Hopefully MERIT will continue to provide a model for inter-agency and inter-professional working and, in future, will seek to show how innovation and risk taking can fit into care management and joint commissioning. References Lomas, Graham (1988) Co-ordinating Services for Elderly Mentally Frail People in the Community. Lomas, Graham (1990) Middleton Elderly Resource and Intervention Team-Stage One Evaluation.

4 Discussion Note on Service Components and Planning (1990). Lomas, Graham (1991) The MERIT Scheme-Overview and Evaluation of a Community Based Service Lomas, Graham (1991) MERIT in Middleton-Supplementary Paper in Strategic Management Data. Lomas, Graham (1994) Commissioning and Managing a Community Based Team. Project for North West Regional Health Authority. STAFF Team Manager - Rochdale Social Services Senior Clinical Medical Officer - North Manchester Healthcare Trust Community Psychiatric Nurse - Manchester Community Care Trust Community Staff Nurse (from 1993) - North Manchester Healthcare Trust Nursing Assistant (from 1994) - North Manchester Healthcare Trust Community Psychiatric Nurse - Rochdale Healthcare Trust Specialist Social Worker - Rochdale Social Services Administration Officer - Rochdale Social Services OPERATIONAL IMPERATIVES 1. Clearer identification of the client group. 2. Making services accessible, acceptable and understandable to users and carers. 3. Thorough assessment of individual cases. 4. Multi-disciplinary, inter-agency coordination. 5. Practical links to hospital, day care and community resources. 6. Continuity of care according to client need. 7. Development of working links with caring agencies generally in Rochdale and Manchester. SERVICES USED Hospital based Community based Acute assessment beds GP services Long-stay care LA/Private: Respite beds domiciliary care Day care places (ESMI unit) day care Occupational therapy respite care Psychology long-term care Chiropody Specialised ESMI home care Physiotherapy Outpatient clinics District nurses, Health visitors Benefits advice Carers Association Rehousing MERIT MANAGEMENT GROUP Consultant Psychiatrist and Clinical Director for North Manchester Community Care Co-ordinator for Rochdale based in the FHSA

5 Psychiatric Services Manager for Rochdale Healthcare Trust Area Manager for Rochdale Social Services Department Chairperson of Middleton Association of Carers Middleton GP - member of a fundholding practice PERFORMANCE INDICATORS 1. Outreach measurement - new referrals relative to estimated unmet need. 2. Problem identification - pattern of new GP referrals. 3. Service responsiveness - assessment time lag relative to workloads. 4. Maintaining independence- proportion of clients maintained at home. 5. Service innovation - comparing provision against demand ( eg respite care). 6. Service consistency and equity - client priority in domiciliary care banding. caredata CD Full Text - copyright NISW/Positive Publications