ADULTS SERVICES KNOWLEDGE REVIEW 13. Outcomes-focused services for older people

Transcription

1 ADULTS SERVICES KNOWLEDGE REVIEW 13 Outomes-foused servies for older people

2 ADULTS SERVICES KNOWLEDGE REVIEW 13 Outomes-foused servies for older people Caroline Glendinning, Sue Clarke, Phillipa Hare, Inna Kothetkova, Jane Maddison and Liz Newbronner i

3 ADULTS SERVICES First published in Great Britain in Deember 2006 by the Soial Care Institute for Exellene University of York 2006 All rights reserved Written by Caroline Glendinning, Sue Clarke, Phillipa Hare, Inna Kothetkova, Jane Maddison and Liz Newbronner ISBN ISBN Produed by The Poliy Press Fourth Floor, Beaon House Queen s Road Bristol BS8 1QU tel fax [email protected] This report is available in print and online Soial Care Institute for Exellene Goldings House 2 Hay s Lane London SE1 2HB tel fax textphone ii

4 CONTENTS Exeutive summary v 1 Researh review Introdution to researh review Definitions: what are outomes? What outomes do older people value? Change outomes Maintenane or prevention outomes Proess outomes Outomes and diversity Views of the User Advisory Group Organisational arrangements impeding 9 outomes-foused servies Introdution Assessment Reviews Purhasing of are pakages Provider-level barriers Role of ommissioners Importane of ommuniation Impat of the health soial are divide Barriers and diversity Views of the User Advisory Group Organisational arrangements failitating 18 outomes-foused servies Introdution Assessment Reviews Miro-level ommissioning of are 21 pakages Provider-level fators Importane of ommuniation Overoming the health soial are divide Initiatives and diversity Views of the User Advisory Group Conlusions of researh review 24 iii

5 ADULTS SERVICES 2 Pratie survey Introdution to pratie survey Postal survey Aims Methods Respondent harateristis Nature and range of outomes work Ahievements and fators helping and 33 hindering ahievements Postal survey: disussion Case studies Introdution Outomes-foused ativities Outomes-foused servies Monitoring and evaluation Impat of outomes-foused servies: 50 the experienes of servie users Fators failitating outomes approahes What hinders outomes approahes? Plans for (further) outomes-foused 59 servie developments 3 Conlusions 63 Referenes 67 Appendix 1: User involvement in the knowledge 75 review Appendix 2: Methods used in the knowledge review 83 Appendix 3: Summary of ase study sites: servies 93 and ativities Appendix 4: Data olletion and projet douments 99 Appendix 5: Information about SPRU and 127 Aton Shapiro Index 129 iv

6 Exeutive summary Introdution to researh review This knowledge review inludes: a review of researh evidene on the outomes valued by older people and the fators that failitate and inhibit ahieving these outomes a postal survey of loalities and soial servies managers in England and Wales known to be interested in developing outomes-foused approahes to older people s servies; and in-depth studies in six loalities. This was supplemented by information supplied by members of the Outomes Network (originally established by SPRU and now supported by the DH Change Agent Team s Better Commissioning Learning and Information Network). The knowledge review was supported by a user advisory group of six older servie users who met three times during the projet. Definitions Outomes refer to the impats or end results of servies on a person s life. Outomes-foused servies therefore aim to ahieve the aspirations, goals and priorities identified by servie users in ontrast to servies whose ontent and/or forms of delivery are standardised or are determined solely by those who deliver them. Outomes are by definition individualised, as they depend on the priorities and aspirations of individual people. Researh into the outomes valued by older people Three groups of soial are servie outomes have been identified; these are very similar to the fators that older people identify as entral to their independene and well-being: v

7 ADULTS SERVICES Outomes involving hange Improvements in physial symptoms and behaviour. Improvements in physial funtioning and mobility. Improvements in morale. Outomes involving maintenane or prevention Meeting basi physial needs. Ensuring personal safety and seurity. Having a lean and tidy home environment. Keeping alert and ative. Having soial ontat and ompany, inluding opportunities to ontribute as well as reeive help. Having ontrol over daily routines. Servie proess outomes These refer to the ways that servies are aessed and delivered and inlude: Feeling valued and respeted. Being treated as an individual. Having a say and ontrol over servies. Value for money. A good fit with other soures of support. Compatibility with, and respet for, ultural and religious preferenes. The limited researh evidene indiates that older people from ethni minority ommunities and with different types of impairments value the same broad range of outomes. However the priority assigned to different outomes may vary aording to age, living irumstanes and type of impairment. vi

8 Exeutive summary Researh into fators failitating and inhibiting outomes-foused servies for older people Researh shows that a number of fators relating to the operation of soial are quasi-markets may affet the delivery of outomes-foused servies. Assessment, are planning and review Servie-led assessments that do not offer hoie. Assessments that emphasise dependeny or overlook psyhologial and emotional needs. Assessments that do not hallenge low expetations of servies or the limited range of help older people think it legitimate to request. Fragmented or irregular reviews of servie users. The health and soial are divide, where this prevents holisti assessment and are planning. Miro-level purhasing How are managers purhase servies from providers of home are servies has a major impat on the delivery of outomes-foused servies. Purhasing speified periods of time or help with speified tasks an restrit both the flexibility and personalisation of servies; purhasing just enough time (or tasks) to maintain physial well-being an threaten hange and proess outomes, as well as maintenane outomes relating to soial partiipation. Provider-level barriers Diffiulty reruiting and retaining staff redues the flexibility of providers to provide individualised servies, even where older people are willing to purhase (extra) servies privately. Levels of funding from soial servies purhasers an restrit providers opportunities to offer fair working onditions and training and thus attrat and retain good quality staff. vii

9 ADULTS SERVICES Commissioning and ontrating Commissioning and ontrating arrangements exert major influenes over the delivery of outomes-foused servies, partiularly by independent setor (rather than in-house) providers. Contrats allowing providers to vary the prie they harge purhasers offer inentives to respond to individual priorities and needs. Within quasi-markets, ommuniation is vital to outomes-foused servies. This inludes ommuniation between: are managers, ontrats managers and providers, so that ontrats reflet users needs and preferenes. providers and are managers, about hanges in users priorities and irumstanes. users, front-line staff, provider managers and purhasers, so that hanges in needs are quikly identified and any servie hanges implemented. In addition, front-line staff in regular ontat with older people need to be well-equipped with up-to-date information about other servies outside their immediate area of expertise. Researh evidene on initiatives promoting outomesfoused servies Researhed development projets onduted by the Soial Poliy Researh Unit, University of York have tested with soial servies partners ways of introduing outomes-foused approahes into routine soial are pratie. Using appropriately designed doumentation to shape front-line pratie, the following approahes have been suessfully implemented: Identifying and summarising older people s desired outomes during assessment. Briefing home are staff on older people s desired outomes. Identifying outomes for arers during assessments and reviews. Using postal questionnaires to ollet information on outomes. viii

10 Exeutive summary In addition, diret payments have been shown to enable older people to ahieve desired outomes. However, this suess appears to depend on the availability of loal support (formal or informal) to manage diret payments; take-up among older people remains low. Pratie survey I: Postal survey A postal survey aimed to establish the range and extensiveness of outomes-foused developments in older people s soial are servies aross England and Wales. Following areful sreening of existing ontats, at least 70 suh initiatives were identified. Soial servies were generally the sole or lead ageny; the most ommon partners were NHS primary are trusts and private servie providers. Signifiantly, most initiatives were desribed as urrently being planned, piloted or rolled out ; only 17 per ent had been established for up to three years and only 13 per ent for three-plus years. Outomes-foused initiatives were most likely to involve servies for older people living at home and/or following hospital disharge. Initiatives inluded developing outomes approahes in assessment, are planning and review; hanging existing servies and ommissioning new ones; and monitoring to see how far servies meet user outomes. Only moderate levels of user involvement in planning these initiatives were reported. Beause so many of the reported initiatives were still at an early stage, some respondents thought it was too early to judge whether they were suessful; those who were able to generally judged them to be partly or fully suessful. However, given the onstraints of a postal survey, it was not possible to know what suess riteria were being used or how far these judgements refleted the experienes of older people using outomes-foused servies. Respondents also identified a number of fators that helped and hindered progress in developing outomes-foused approahes, and ited measures to overome these barriers. These fators were explored in in-depth ase studies. ix

11 ADULTS SERVICES Pratie survey II: In-depth ase studies Six loalities where outomes-foused approahes were well established were seleted from responses to the postal survey. They overed a range of ativities (assessment, are planning and review, ommissioning and ontrating for new and existing servies); and servies (day are, intermediate are, prevention servies, ommunity-based rehabilitation, home are and residential are). Additional examples were obtained from members of the former SPRU Outomes network. Outomes-foused ativities Assessment, are planning and review Sites that had developed outomes-foused approahes had found them diffiult to integrate with the Single Assessment Proess. However a number of ways had been found to inorporate outomes into are planning; these ould also form the basis of reviews. Commissioning for hange outomes Loalities had reently established intermediate are servies jointly with NHS partners; some had also restrutured their in-house home are servies to provide short-term reablement servies to all new users, free of harge. Desired outomes (for example, being able to manage housework or walk to the shops) were identified during assessments. Care and rehabilitation staff had onsiderable autonomy over how they worked with older people to ahieve these outomes. Rebuilding onfidene and morale was onsidered as important as and underpinned improvements in physial funtioning. Commissioning for maintenane outomes Three sites had amended ontrats with independent home are providers to failitate more flexible, outomes-foused servies. Changes inluded: establishing zones for eah provider, thus reduing staff travel time x

12 Exeutive summary agreeing in advane estimated workloads and payments, with providers billing retrospetively for atual time spent building spare time into ontrats for providers to use flexibly to meet additional requests from users, free of harge. These hanges were expeted to provide flexibility for unexpeted emergenies; guarantee staff minimum weekly hours; allow staff to be employed on a shift basis; and offer opportunities for staff training. Only one suh hange in ontrating had been evaluated: higher levels of user satisfation and inreased job satisfation by front-line staff were reported; only eight per ent of are pakages exeeded their estimated budget. These hanges involve transferring power and responsibility from purhasers to providers and users. They require high levels of trust, open ommuniation hannels and appropriate performane and finanial management systems. Two sites had reently ommissioned low level preventive servies from Age Conern and other voluntary organisations these inluded shopping, home visiting and soial ativities. Outomes-foused servies Intermediate are and reablement servies These were areas where staff thought they had made most progress in establishing outomes-foused servies. Servies offered a holisti approah, tailored to meeting individual goals; progress towards these ould be easily monitored. Users onfirmed these outomes. Day are Users valued outomes-foused day servies that identified their interests and linked them to staff with similar interests. Ethni minority users valued day servies employing staff who spoke their languages. Residential are A loal quality development sheme for nursing and residential homes enouraged individualised servie user plans and plaed heavy emphasis on maximising hoie, ontrol and independene that ontributed to maintenane and proess outomes. xi

13 ADULTS SERVICES Monitoring and evaluation Systemati and routine monitoring, often using linial tools, was ommon in reablement and intermediate are servies. There was less evidene of routine outome monitoring among users of longer-term home are servies. Fators failitating outomes-foused approahes These inluded: national poliies suh as the National Servie Framework for older people and the Green Paper on adult soial are loal vision, leadership and investment in hange management, inluding staff indution and regular training workshops partnerships and whole-systems working; these helped seure aess to resoures and skills that were essential to user outomes but loated outside the remit of soial are new investments in intermediate are servies involving user-led are outomes. Establishing new servies also enabled outomes-foused ulture and pratie to be established from the start bidding for Partnerships for Older People Projets that would allow investment in preventive servies to meet desired maintenane outomes Fators hindering outomes-foused approahes These inluded: Single Assessment Proess other national poliies, inspetion regimes and performane indiators resoure onstraints staff ulture and attitudes at all levels user and arer attitudes. xii

14 Exeutive summary Older people s perspetives Older people interviewed in the pratie survey onfirmed the very signifiant benefits of intermediate are and reablement servies aimed at ahieving hange outomes. Users of these servies affirmed how they had been enouraged to identify important goals and helped to ahieve these. They reported signifiant improvements in onfidene and morale as well as physial funtioning. These improvements were attributed to the fat that these servies were delivered in ways that maximised users hoie and ontrol. Older people using residential and day are servies also onfirmed the proess outomes of highly individualised are. However, it was diffiult to find examples of holisti approahes in whih servies met a wide range of desired maintenane outomes. The User Advisory Group onfirmed the importane of servies responding to individual needs and differenes; of hoie and ontrol over servies; and of help with low level tasks suh as leaning, gardening and shopping. The Group highlighted the diffiulties experiened by some older people, partiularly from ethni minority ommunities, in aessing servies without additional support. Voluntary organisations and NHS servies, partiularly GPs, were thought to have important roles to play in helping older people aess servies and ahieve desired outomes. Voluntary organisations an also provide information and advoay for older people who are isolated or find it hard to aess servies. Conlusions Although reent poliies have emphasised outomes-foused servies, in some loalities suh approahes have been in operation for some time. SPRU s Outomes programme, with its assoiated training and development material, enabled some loalities to make signifiant developments, partiularly in outomes-foused approahes to assessment, are planning and review. More reently, targeted funding and performane indiators related to hospital admission and disharge have given a signifiant impetus to the development of servies foused on hange outomes, both in ollaboration with NHS partners and by loal authority in-house servies. xiii

15 ADULTS SERVICES However, in general, there remains a signifiant disjuntion between these developments and the apaity of independent home are servies to deliver long-term maintenane and proess outomes. Some loalities are building on the onlusions of extensive researh into are management and ommissioning within soial are quasi-markets and are developing less rigid and bureaurati approahes to ommissioning and purhasing servies, partiularly from independent home are providers. The impat of these new approahes on users experienes needs thorough and systemati evaluation. Resoure onstraints and poor relationships with independent providers in other areas ontinue to impede the introdution of more flexible, individualised home are servies. The emergent poliy emphasis on prevention means that efforts are being made to develop low-level preventive servies, often through partnerships with loal voluntary and ommunity organisations. These may ontribute to valued maintenane outomes suh as domesti help and soial partiipation. The Partnerships for Older People Projets will provide valuable evidene in the future about the effetiveness of these approahes to meeting desired outomes. Three broader issues remain. First, although this knowledge review found many examples of high quality, outome-oriented servies, these were often fragmented and servie-speifi. For example, the outomes fous of reablement servies was often not arried through into longterm home are servies. Similarly, good quality day servies addressed maintenane and proess outomes, but there was little support for maintaining these outomes outside the day entre. Seondly, the onept and pratie of outomes is subjet to multiple interpretations and disiplinary perspetives. Some servies had a strong outomes fous as a onsequene of other poliies, suh as the development of intermediate are and reablement servies, or new approahes to the inspetion of residential are. The onept and pratie of outomes mapped most readily onto intermediate are and reablement servies. However, even here, GPs and liniians were reported sometimes not to understand the onept of outomes, with onsequenes for the appropriateness of their referrals and advie to older patients. Moreover, many intermediate are servies sreen potential users arefully and admit only those able to ahieve hange outomes. This risks equating outomes with hange outomes. Longer-term maintenane xiv

16 Exeutive summary and prevention outomes, and groups of older people suh as those with dementia for whom maintenane, prevention and proess outomes are espeially important, onsequently risk being marginalised. Flexible, person-entred or responsive may be more appropriate and inlusive terms than outome. Third, as the user advisory group onfirmed, many of the outomes desired by older people do not, on the fae of it, appear to be derived from interventions that urrently fall within the remit of soial are servies. Partnerships with other statutory and voluntary agenies will be neessary to support older people, for example, in keeping alert and ative, ontinuing to partiipate in soial networks and other maintenane and preventive outomes. A whole systems approah to the ommissioning, review and evaluation of outomes-foused servies is therefore essential. xv

17

18 1 Researh review 1.1 Introdution to researh review The Soial Care Institute for Exellene (SCIE) ommissioned the Soial Poliy Researh Unit (SPRU) at the University of York to undertake a knowledge review on outomes-foused servies for older people. The knowledge review onsists of: a review of researh on outomes and outomes-foused servies a national survey and ase study examples of urrent and emerging approahes to ommissioning and delivering outomes-foused servies for older people aross England and Wales. A User Advisory Group was established to guide the knowledge review (see Appendix 1). The researh review aims to: summarise researh on the outomes that older people value and wish to ahieve from ontat with soial are servies identify fators that failitate or inhibit outomes-foused servies. Details of how the researh review was onduted are ontained in Appendix 2. Researh inluded in the review was mainly onduted before a number of important measures, likely to have impated on poliy and pratie, were implemented. Thus the impat of partnership working as promoted by Setion 31 of the Health At 1999, the National Servie Framework (NSF) for older people, the Single Assessment Proess (SAP), Fair Aess to Care Servies (FACS) guidane and measures to promote the take-up of diret payments by older people may serve to modify some of the onlusions of the review. However, evidene of their effets in promoting outomes-foused servies is not yet available. 1

19 ADULTS SERVICES 1.2 Definitions: what are outomes? For the purposes of this review, outomes refer to the impats or end results of servies on a person s life. Outomes-foused servies are therefore those that aim to ahieve the goals, aspirations or priorities of individual servie users. They an be ontrasted with servies whose ontent and/or form of delivery are standardised, regardless of the irumstanes of users; and with servies whose goals, ontent and mode of delivery are primarily determined by those who ommission or deliver them rather than those who use them. The onept of outomes is losely related to that of quality of life. There is a high degree of onsisteny between different studies in the outomes that are valued by older people; these also relate losely to fators that older people have identified as ontributing to quality of life. Reently the term personalisation has begun to be used. 1 Personalisation inludes the tailoring of servies to fit individual aspirations and priorities; and the ative partiipation of servie users in the proesses of designing and delivering servies: by putting users at the heart of servies, enabling them to beome partiipants in the design and delivery, servies will be more effetive by mobilising millions of people as o-produers of the publi goods they value 1, pp This approah is also refleted in proposals ontained in the adult soial are Green Paper 2 and the government-wide strategy on ageing. 3 Researh into experienes of personalising servies, as defined above, is as yet very limited; an evidene base is urgently needed. 2 However, as will be shown below, the importane of having a say in how servies are delivered is an important proess outome for older people, so muh of the researh reviewed in the first part of this report will also be relevant to the development of personalised servies. Another losely related onept is that of independene. 4 6 Again, onsiderable overlaps exist between ommonly desired or valued outomes and the dimensions of independene identified by older people. Indeed, it would be perverse if soial are servies did not ontribute to outomes that are onsistent with the dimensions of independene as defined by older people. Moreover, older people who antiipate servie outomes that are inompatible with their onepts of independene are likely to rejet servies and try to find other ways of meeting their needs. 7 2

20 Researh review This review aimed to identify researh on the outomes that older people aspire to ahieve from soial are servies. However, many of these outomes do not, on the fae of it, appear to be diretly related to the bulk of urrent soial are servies for older people home are, day are and residential are. Indeed, researh shows how older people have broad, holisti perspetives on desired outomes and may expet soial are servies to ontribute to ahieving these. 8 This holisti perspetive is ongruent with the Green Paper on adult soial are 2 and therefore with the shift in pratie that will be required to implement the Green Paper proposals. If health and soial are pratitioners find it diffiult to separate need from need for a speifi servie, 9, 10 then desired outomes that fall beyond the urrent limits of soial are servie provision risk remaining unmet. 1.3 What outomes do older people value? Qureshi et al 11 identified three lusters of soial are outomes valued by older people: hange outomes; maintenane or prevention outomes; and proess outomes relating to the ways that servies are delivered Change outomes Change outomes relate to improvements in physial, mental or emotional funtioning that are ahieved through servie interventions. Qureshi et al 11 found that older people value the following: hanges in symptoms and behaviour; for example, older people with mental illness may wish to feel less anxious or depressed, to relate better to family members and to be more ative and interested in life improvements in physial funtioning, whether through improvements in individual mobility or through the provision of equipment and adaptations improving onfidene and morale; older people antiipated feeling happier if they reeived servies that met their needs and addressed their problems. 3

21 ADULTS SERVICES Maintenane or prevention outomes The majority of the outomes valued by older people relate to maintenane or preventing deterioration in their health, wellbeing or quality of life. Meeting basi physial needs: being lean and presentable in appearane having appropriate food and drink at appropriate times being physially omfortable Ensuring personal safety and seurity: Minimising fear of rime and threats to personal safety. Personal safety is partiularly important for older people with dementia and an also be important in deisions to enter residential are. Feeling safe inludes reeiving servies from people who an be vouhed for 11, and trusted. Living in a lean and tidy environment: An untidy house or garden is a threat to self-esteem as it an indiate that an older person is less able to manage her/his own affairs. A lean and omfortable home an help to sustain soial inlusion, as older people are more likely to feel onfident having visitors if the home is lean, tidy and ontinues to reflet their soial identity However, it an be diffiult to get soial are support in this area and even when servies are available, they may not be ulturally appropriate 15, 16, p 11. One group of minority ethni older people opted for diret payments in order to obtain ulturally appropriate home are servies. 18 Keeping alert and ative: This inludes preventing boredom and having ativities that sustain ompetene, identity and independene. Losing a sense of purpose an be damaging to mental health. Remaining ative also helps to 11, 17, sustain soial interation. 4

22 Researh review Keeping alert and ative is partiularly important to older people in residential settings; the range of ativities available inluding opportunities to pursue individual hobbies, undertake tasks related to the running of the home, exursions and outings is an important dimension of the quality of homes as rated by older people 13, 23, 24, quoted in 25, p 13. Opportunities to go out and ativities that result in a sense of ahievement are also important for older people with dementia. 23 Aess to soial ontat and ompany: Close relationships and soial networks are entral to wellbeing in later life. For isolated older people, soial ontats with home are staff are 17, 19, 22, 26, 27 partiularly valued. Avoiding dependene on others is widely valued; onsequently the benefits of soial ontat are enhaned if relationships are haraterised by reiproity. Aepting pratial help and/or emotional support an be easier if there are opportunities to 17, 21, 28, 29, 30 reiproate quoted in 25. Soial ontat is important for older people with dementia as it an 14, 17, 23 promote a sense of ontinuing soial integration. Good quality soial relationships friendships with other residents and friendly staff attitudes are important outomes for older people 13, 31 in residential settings. Having ontrol over everyday life: This underpins all other outomes relating to maintenane and prevention. Being looked after involves a loss of ontrol and therefore of independene; older people therefore want servies that support them in looking after themselves. Having ontrol over everyday life does not neessarily mean doing everything for oneself, but being 5, 11, 12, 15, 17, 27, 29 able to deide how and when things are done. Older people with dementia also value autonomy and ontrol, inluding ontrol over delegating some responsibilities to another person 11, 14, 23 who they trust. 5

23 ADULTS SERVICES Choie and ontrol over daily living ativities are important outomes 13, 31, 32 for are home residents Proess outomes Proess outomes refer to users experienes of seeking, obtaining and using servies. Proess outomes are so important that they an undermine the impat of other outomes that might otherwise improve quality of life. Barriers to proess outomes inlude lak of information; diffiulties gaining aess to servies; delays in reeiving servies; ineffiient or disrespetful staff; lak of onsultation; and onsultation that is not ated on. 11, 12, 16 The quality of relationships with staff and the personal attributes of the latter are ruial to positive outomes and are valued 13, 16 equally by older people in their own homes and in residential are. Proess outomes inlude: Feeling valued and respeted, despite ultural differenes or ommuniation diffiulties; respet for privay and onfidentiality; and being treated as having a legitimate right to servies. Feeling valued and respeted is partiularly important for older people with mental 12, 14, 33, 34 health problems or dementia. Being treated as an individual. Interpersonal aspets of servie exhanges an assume great importane; older people want to feel at ease with soial are staff and value willingness, responsiveness, heerfulness, friendliness, understanding and an instintive aring nature. Suh attributes may be valued as highly as pratial help and 15, 29, rated more highly than formal professional qualifiations. Having a say and ontrol over servies, inluding the tasks and timing of servies and who delivers them. Puntuality is important for some 14, 26, 34, 36 older people, partiularly those with speial medial needs. Having ontrol inludes being able to make a ontribution being an ative partiipant rather than a passive reipient. 15, 19 This is important for people in residential are settings, who may value being able to ontribute to preparing meals, for example. 12 Having a say requires information, opportunities to disuss possible options with a knowledgeable person and being informed about hanges in servies. Older people from minority ethni groups may require providers who 6

24 Researh review an speak their own language in order to have a say. 11, 34 Having a say also requires servies to be flexible in response to hanges in older people s apaities and preferenes this is partiularly important for 7, 15, 22, 26, 34 those living alone. Value for money, whether servies are privately purhased or users ontribute means-tested o-payments. 11 A good fit with informal soures of support, espeially if servies 11, 15 prevent unwanted reliane on family are. Compatibility with, and respet for, ultural and religious preferenes. 34 Table 1 Summary of soial are outomes desired by older people Outomes involving hange Changes in symptoms and behaviour Improvements in physial funtioning Improving morale Outomes involving maintenane or prevention Meeting basi physial needs Ensuring personal safety and seurity Living in a lean and tidy environment Keeping alert and ative Aess to soial ontat and ompany Having ontrol over everyday life Servie proess outomes Feeling valued and being treated with respet Being treated as an individual Having a say and ontrol over servies Value for money A good fit with informal soures of support Compatibility with, and respet for, ultural and religious preferenes 7

25 ADULTS SERVICES Outomes and diversity Wealth, health status, gender, living arrangements and ethniity all ontribute to the diversity of older people s attitudes and aspirations 37. The previous setions have highlighted outomes that are partiularly important to older people with dementia, from blak and minority ethni ommunities, and living in residential are. In general, different groups of older people prioritise different outomes and dimensions of quality of life 8, 27, p 760. Netten et al 38 found that people aged 85+ were more onerned about food and nutritional outomes and less onerned about soial ontat than younger respondents; people living with others ranked soial partiipation and involvement muh higher than those living alone. Older people with reent sight loss also prioritise different outomes, 39 as follows: meeting people and friendship getting information and advie about speialist servies and equipment having someone to talk to about personal feelings building onfidene to go out and do things outside the home relearning how to arry out everyday tasks in the home getting help with pratial everyday tasks. There is relatively little evidene on the speifi outomes desired by minority ethni elders; muh of the researh literature fouses on barriers to are. However, despite their diversity, maintaining independene and having ultural needs reognised are ommonly desired outomes. Askham et al 40 found that speifi language and food provision was important to many blak older people, although for Afro-Caribbean elders being treated fairly, kindly and effiiently was more important. Reviews by Mold et al 41 of Asian and other minority ethni older people in are homes and by Butt and Mirza of blak ommunities and soial are 42 provide examples of how older people from minority ethni groups value the proess outome of ompatibility with, and respet for, individual ultural and other preferenes, inluding: 8

26 Researh review sensitivity to religious beliefs and praties interpreting servies staff from similar bakgrounds same-sex workers for intimate personal are halal and vegetarian food opportunities to meet others from similar bakgrounds. Older people with dementia partiularly value efforts to ensure that they an ommuniate preferenes; maximise ontrol over daily life; 43 and keep alert and stimulated. 44 Culturally appropriate servies, methods of working, language and ommuniation (inluding non-verbal ommuniation) were also highlighted in a study of minority ethni older people with dementia (although information was obtained from professionals rather than older people themselves) Views of the User Advisory Group Members of the User Advisory Group endorsed the importane of the outomes identified in researh with older people, partiularly the reognition of individual needs and differenes. However, they pointed out that some older people might need help to think about the outomes they want from someone who knows their situation in the round. These outomes may not neessarily be what other people, suh as arers, onsider is best for them negotiation and trade-offs are neessary. There was strong agreement about the ritial importane of hoie and ontrol; transport was also essential so that older people ould take advantage of available servies. 1.4 Organisational arrangements impeding outomesfoused servies Introdution This setion draws partiularly on researh into the organisation and impat of home are servies. Sine the 1993 ommunity are reforms, poliies have prioritised supporting older people in their own homes. This has led to a major expansion in home are servies, espeially for 9

27 ADULTS SERVICES very frail older people who would otherwise risk entering institutional are. Reent researh mirrors these poliy developments. The 1993 reforms enouraged quasi-markets, with loal authority soial servies departments purhasing servies from voluntary and forprofit providers. Muh reent researh therefore fouses on the operation of quasi-markets in delivering outomes-foused servies. More reent developments in soial servies assessment, are planning and ommissioning following initiatives suh as Fair Aess to Care Servies (FACS) guidane and the Single Assessment Proess (SAP) are not yet refleted in published researh Assessment Assessments are important in establishing eligibility for servies and an establish a baseline of desired outomes against whih later ahievements an be heked. 35 Outomes-foused approahes an be inhibited by bureaurati approahes in whih pratitioners report spending less time with users and inreasingly routinised proedures 45, quoted in (19, p 11) 46. Outomes-foused approahes are not enouraged by servie-led rather than needs-led assessments. 11, 47 Desired outomes may be ignored beause of health and safety onerns; thus lifting and handling restritions an redue older people s movement and reate unneessary dependene 19, p 21. The language used in assessments an be a barrier to an outomesfoused approah. Assessments need to be ompatible with older people s identity and self-image otherwise potential servie use may be disouraged. 48 Thus older people who define themselves as ompetent will refuse servies that emphasise their dependeny. 19 Despite poliies to the ontrary, in pratie assessments an overlook emotional and psyhologial needs and the meanings older people attah to these. 19, 49, 50 It is possible that reent assessment approahes vary markedly aross loal authorities and are likely to be less responsive to ertain needs of older people (for example, depression) 25, p 39. Indeed, one study found that developments in pratie following the NSF for older people and FACS have indeed redued the risk of assessment overlooking older people s emotional and psyhologial needs; however, no researh evidene was found on the impat of these measures. 10

28 Researh review Older people s servies remain under-funded. 51 Thus staff onduting assessments may find themselves juggling onfliting roles of neutral failitator, impartial advisor and resoure gate-keeper. Hardy et al 52, p 487 found that strit finanial ontrols and ost-eilings onstituted major onstraints on [are managers ] ability to operate within and between these roles. These resoure onstraints may lead to some desired outomes being overlooked. Older people themselves may find outomes-foused assessments diffiult, with their ability to identify outomes restrited by their pereptions of soial servies responsibilities; of the help they think it legitimate to request; and of the servies they think are available. 19 Older people from minority ethni groups are partiularly disadvantaged in knowing what servies are available 42 and in any ase may not use servies if they are pereived as ulturally inappropriate. 53 Being able to make hoies about servies is ruial to the outomes of having ontrol over everyday life and having a say. However, Hardy et al 52 found that during assessments older people and arers were offered little hoie between servies or how these were provided. For some users, hoies may be restrited by a shortage of providers, a partiular problem in rural areas, 9 or where purhasers ontrat only with lowest ost providers Reviews Outomes-foused approahes are failitated by regular reviews that monitor servie quality and ensure servies ontinue to meet the outomes identified at assessment or that reflet hanged irumstanes. However, this is diffiult if, as sometimes happens, assessment and review ativities are organisationally fragmented or onduted by different staff. 9 Moreover, workload pressures on soial servies staff may mean that reviews are onduted irregularly, if at all. 34, 35, 54 Domiiliary Care Standards Regulations (2003) require all providers to review their ustomers at least annually, but this may be unduly onerous for providers with high numbers of users reeiving only small levels of servies. 26 Hardy et al 52, p 489 also found review proedures to be underdeveloped and variable, both within and between soial servies authorities. Formal reviews and re-assessments ourred for only 42 per ent of soial serv- 11

29 ADULTS SERVICES ies lients during Reviews are likely to onentrate on older people whose servies are provided by independent agenies rather than in-house providers, on new servie users and on users onsidered 26, 52 problemati. Although some soial servies authorities have established speial review teams, these disrupt the ontinuity of relationships between users and are managers. Fragmentation may be further enouraged by performane indiators that measure user and arer assessments, reviews and satisfation surveys as separate ativities Purhasing of are pakages How are managers purhase servies from providers an reate barriers to outomes-foused servies. Again it is important to note that the researh reviewed here was onduted before the publiation of FACS guidane; no researh was found that evaluates the impat of this guidane on are managers purhasing ativities. The 1980s ommunity are demonstration projets gave are managers small aseloads and devolved budgets to purhase flexible, individually tailored servies. 46, 56 However, sine 1993 are managers have had less fae-to-fae ontat with lients; adopted inreasingly routinised approahes; and been restrited by finanial onstraints. 9, 46 There are signifiant variations between soial servies departments in their are management arrangements 46, p 682, partiularly whether the servies ommissioned extend beyond basi physial maintenane to wider, quality of life outomes. 57 There are also variations in the autonomy devolved by are managers to front-line servie providers, 26, 46, 57 with some provider managers frustrated by inflexible and unompromising ommissioning arrangements. For example, if no allowane is made for time spent travelling between appointments, home are staff may be tempted (or enouraged by their manager) to urtail visits one essential tasks are ompleted. Changes that users wish to make to the ontent or timing of a servie may have to be notified to are managers and new assessments onduted. 26, 34, 36 Suh restritions may be partiularly true of servies ommissioned from independent (voluntary and for-profit), rather than in-house, providers. 57 Purhasing home are servies for speified periods of time or for 12

30 Researh review speifi tasks has different impliations for servies ability to meet desired outomes: 26 Time-entred visits are easier to deliver puntually. The osts of time-entred visits are easier to alulate, whih may affet user pereptions of value for money. Time-entred visits offer opportunities to undertake extra tasks or just talk one essential jobs are ompleted. Task-entred visits an be extended or shortened aording to hanging irumstanes. Barriers to outomes-foused home are servies arise when soial servies purhasers plae restritions on the range of tasks they are willing to pay for. Older people have expressed partiular onern about the lak of help with housework and other domesti tasks, 9, 15, 34 despite the fat that having a lean and orderly home environment is an important maintenane outome. 15 A further barrier is the failure by are managers to reognise the importane of relationships between older people and paid are staff; the quality of these is entral to proess outomes. Thus older people may benefit from any spare time left in time-entred visits if are staff an use this simply to talk. However, some are managers disourage the 15, 26 development of suh relationships as unprofessional Provider-level barriers The environment within whih independent (voluntary and for-profit) servie providers operate an also impat on the delivery of outomesfoused servies. Relationships with staff are ruially important to the proess outomes of soial are. However, these relationships an be impaired by poor ontinuity, whih an itself be impaired by problems 9, 47, 56 of reruiting and retaining staff. There are substantial shortfalls in provider apaity, inluding both numbers of organisations (partiularly in rural areas) and problems of staff reruitment and retention (partiularly in rural, affluent and inner-ity areas). Sine 1993, both overall demand for home are servies and the range and omplexity of skills required of staff have inreased, 13

31 ADULTS SERVICES while the shift from in-house to independent setor provision may have worsened pay and onditions for some staff. These fators affet staff reruitment and retention; their availability to work the hours that users prefer; 9, 22, 26, 47 and ultimately the reliability, quality and responsiveness of servies. 26 For example, feeling in ontrol of daily life requires the delivery of servies at times that fit in with daily routines. 11 This an be jeopardised if providers annot meet heavy demand early in the mornings and in the evenings. 22 The organisational arrangements of provider organisations also affet relationship-based proess outomes. Relevant arrangements inlude the basis on whih home are staff are employed (part-time, full-time, guaranteed pay per week or pay per ase and so on); the number of workers alloated to eah older person; and organisations poliies on requests for additional or different tasks to be performed from those set out in the are plan. 26 For example, some providers prohibit staff from arrying out tasks suh as hanging light bulbs, finding a plumber or aring for pets that are unproblemati in other organisations. 57 Independent providers whose business depends on a few large loal authority blok ontrats may be unwilling to respond to older people s requests for additional privately purhased help to meet desired outomes beause of anxieties about jeopardising their main ontrats. 26, 57 Providers may also be relutant to offer low-skilled domesti help like shopping and houseleaning for private purhase by older people; having invested in staff training, providers may be relutant to ask staff to do lower-skilled work. Patmore 26 found providers anxious about being typeast as low skilled and therefore low ost. This assumption ould be at odds with the atual osts of delivering a quality servie and disadvantage providers in Best Value reviews Role of ommissioners Commissioners exert major influenes over whether providers deliver outomes-foused servies. 26, 57, 58 There is some evidene 26, 57 that these influenes are partiularly marked in relation to independent setor, rather than in-house, servies. One strand of researh has examined how ommissioning arrangements affet providers motivation. Some providers reported poor relationships with ommissioners, omplaining of late payments; poor 14

32 Researh review review and follow-up of lients; low pries; and systemati biases towards in-house providers. Any poor performane by providers was related to this dissatisfation. 52, Some in-house servie managers reported that the purhaser/provider split had made them subordinate to people they previously regarded as their soial worker peers and this was demoralising. 26 Different types of ontrat (spot, blok, all-off, ost-and-volume and grants) an affet the responsiveness and quality of home are. 58 Some loal authorities operate heapest first poliies when setting ontrats for home are servies; 9 driving down osts an drive down quality. The ontrats for home are servies offered by many authorities have been ritiised for being short term and inluding onditions that may be unattrative to providers. 59 Many ontrats ontain little flexibility to vary pries. This helps purhasers plan their expenditure (and may also help safeguard provider stability), but makes providers vulnerable to risk arising from hanges in osts that our during a ontrat and redues their ability to tailor servies to individual users requests and irumstanes. Flexible, spotpurhasing or ontingeny-sensitive priing would shift some of the risk bak to purhasers and provide greater inentives to providers to respond to hanges in users irumstanes Importane of ommuniation Researh emphasises the importane of ommuniation between providers and purhasers for outomes-foused servies. Communiation is important: Between are managers, ommissioners and providers, if ontrats with providers are to be adjusted to reflet user need and preferene 9, p 418. Between providers and are managers, with the latter ommuniating servie users preferred outomes; and providers keeping are managers informed about hanges in their poliies and praties and in users irumstanes. 9 Between provider managers and front-line home are staff, so that hanges in irumstanes or requests for different types of help are quikly identified. 15

33 ADULTS SERVICES Between users, providers and purhasers, with larity over who is responsible for notifying users of hanges in servies. Between front-line staff, if more than one worker is involved with an older person. Barriers to ommuniation at any of these points an threaten the flexibility and responsiveness of home are servies. 34 Care managers and front-line staff also have signifiant roles to play in providing older people with the information they may need to ahieve desired outomes. However, soial are servies often lak the resoures to develop, maintain and regularly update their information databases, partiularly about servies, benefits and failities outside the remit of their own ageny, thereby restriting staff apaity to fulfil this role Impat of the health soial are divide The division between health and soial are responsibilities an be a barrier to outomes-foused servies and a soure of frustration to servie users. 62 Godfrey and Callaghan 19, p 5 found that health and soial are needs were inextriably tied in with [older] people s soial and emotional lives need ould not be ategorised as soial or medial. However, soial servies are managers may be unaware of the potential for hange outomes that ould result from improvements in funtional abilities; health professionals may fail to appreiate that some disabilities an be improved by a range of non-health servies. 63 There is also onsiderable under-identifiation of mental health problems among older people, inluding those reeiving soial servies, 64, 65 despite evidene of the interrelationship between mental health, physial disability and poor soial networks. A ombination of servies, inluding both medial treatment and soial support, is therefore likely to be appropriate in maximising hange outomes. 66 Ware et al 9, p 420 found that separate budgets for health and soial are undermined joint working. The SAP, partnerships using Setion 31 of the Health At 1999 and ollaborative working in response to the introdution of reimbursement for delayed disharges may all have ontributed to reduing the operational barriers between health and soial are servies for older people. However, no researh into the impat of 16

34 Researh review these initiatives on the delivery of outomes-foused servies has yet been published Barriers and diversity Researh into the experienes of minority ethni older people fouses more on barriers to aessing servies than outomes. Barriers to reeiving good quality are inlude lak of knowledge about servies; language and ommuniation barriers; and septiism about the appropriateness and ultural sensitivity of servies. 41, 42, 67 In some loalities there may be few speialised servies, partiularly in residential settings, although day entres and lunh lubs are more ommon. 40 Researh with professionals into provision for minority ethni older people with dementia has also identified ulturally inappropriate servies, as well as lak of resoures and poor oordination between servies Views of the User Advisory Group Members of the User Advisory Group endorsed these findings. They onfirmed that assessment proesses ould be too bureaurati; and that there are many tasks important to older people that soial are servies do not help with, suh as leaning, gardening and taking lients out shopping (rather than doing their shopping for them). The quality of home are servies was thought to be affeted by the low pay and low status of many staff, whih leads to high staff turnover. In addition, the privatisation of many are servies was thought to have inreased ommuniation problems, partiularly between staff arrying out assessments and front-line are staff for this reason in-house servies were pereived to be more reliable. The harges that users pay for home are servies were pereived as expensive, potentially restriting some people from using servies and ahieving desired outomes. 17

35 ADULTS SERVICES 1.5 Organisational arrangements failitating outomes-foused servies Introdution This setion fouses on evidene about the organisational arrangements that an promote outomes-foused servies. In partiular, it highlights several projets onduted by the Soial Poliy Researh Unit (SPRU) at the University of York that developed and tested with loal authority partners ways that soial are servies ould ollet and use information about the outomes valued by users, as part of routine pratie. These projets were evaluated to assess their feasibility and impat. Other evidene is derived from broader researh projets investigating the delivery of soial are servies; this evidene sometimes inludes reommendations that have not been subjet to thorough evaluation Assessment While assessments may identify ativities with whih help is needed, they may fail to speify the ways in whih older people wish help to be given, inluding praties onsistent with personal, ultural or religious preferenes. Outomes-foused assessments therefore need to inlude these issues and inorporate them into the are plans that are agreed 34, 36 with servie providers. Qureshi 68 developed doumentation to summarise outomes and preferenes when older people are assessed. The douments aimed to link identified needs to servie delivery by giving lear information to providers about what they were expeted to ahieve. The doumentation reorded desired hange and maintenane outomes and preferenes relating to proess outomes. Doumentation inluded: summary of needs expeted hanges that ould affet future servie delivery a summary of agreed outomes options and preferenes for ahieving these outomes. Feedbak on the doumentation was obtained from soial workers/are managers; this was generally positive. Negative omments onerned the 18

36 Researh review omplexity and unfamiliarity of outomes-foused approahes and the time required to omplete the assessment, although this was expeted to redue with pratie. Staff agreed that expliit reording of desired outomes ould: differentiate more learly between good and less good pratie larify the basis for are plan deisions; improve the skills of are managers; help to fous servies; and provide the basis for subsequent reviews ontribute to omputerised lient information systems. Potential implementation barriers inluded: staff relutane to adopt new doumentation and assessment proedures staff unertainty about outomes and their appliation to soial are pratie workload and other organisational pressures Reviews Coneiving of review as a ontinuous proess rather than a disrete event may ensure desired outomes ontinue to be ahieved. 9 Other ways of ensuring servies remain ompatible with desired outomes inlude audits of servie users; fous groups with purhasers and providers; quality assurane shemes informed by users; user-led interviews; and diaries kept by servie users. 22, 69, 70 However, none of these has been evaluated. Niholas 71, 72 developed and tested tools to improve assessments and reviews of arers; similar tools ould be adapted for older people. The tools aimed to: involve arers in identifying needs and desired outomes during assessment vary assessment approahes aording to individual irumstanes and preferenes failitate disussion about and reording of intended servie outomes 19

37 ADULTS SERVICES provide a framework for aggregating outomes information to inform servie developments. Evaluation of the projet involved soial servies staff and arers themselves. It onluded that: arers felt reognised and listened to staff valued their greater understanding of arers needs and desired outomes professional judgement and flexibility were essential in determining for whom, when and how the tools ould be used most effetively limited resoures and workload pressures ould jeopardise the identifiation and monitoring of outomes and redue the usefulness of aggregate information. The benefits of the tools were enhaned by involving arers in their development; by ative management support; and by an enabling ulture. It is not lear how far these instruments are ompatible with urrent poliy and pratie following FACS and the SAP. A further method of reviewing outomes involved using postal questionnaires 73 to ollet information on the outomes of oupational therapy assessments and the subsequent provision of equipment and adaptations. Users, arers and staff and managers were involved in designing: questionnaires about minor adaptations or equipment and major adaptations a questionnaire for arers Questions about quality of life and servie proess outomes were inluded. Good response rates were ahieved (inluding responses from people aged over 80) through the use of reminders. The projet onluded that this approah was generalisable to other servies, depending on the harateristis of servie users, the types and diversity of outomes and the extent to whih an outomes fous was onsistent with the values and routine pratie of staff. Again, the feasibility of this approah was enhaned by ommitment from managers and 20

38 Researh review by front-line staff having a lear understanding of outomes. Appropriate management information systems were also important to suess Miro-level ommissioning of are pakages Franis and Netten 34 argue that are managers roles should be restrited to assessing needs and alloating resoures, with providers having autonomy to agree with users exatly how those resoures are used. Patmore 26 reommended that are managers should purhase a monthly allowane of unalloated time to be used by front-line home are staff as irumstanes require. However, there is no evidene on the effetiveness of suh approahes, nor on whether different are management arrangements are more or less effiient and effetive in delivering 46, 59 outomes-foused servies. One approah to miro-level ommissioning that has been demonstrated to have benefits, at least for some older people, is to devolve responsibility for miro-purhasing to older people themselves by substituting diret payments for servies in kind. Beause diret payments offer inreased hoie and ontrol, they have signifiant potential to enable older people to ahieve desired outomes. However, take-up of diret payments by older people has been muh less extensive than by younger disabled people and researh evidene is similarly limited. The one available study 18, 74 shows that older people were able to ahieve onsiderably more of the outomes they valued, partiularly support to get out and go shopping; help with tasks within the home that onventional home are servies were unable to perform; and improvements in personal safety and health. However, ahieving these outomes depended on loal support servies that were inlusive of older people Provider-level fators Initiatives that have been suggested to improve the reruitment and retention of home are staff, and therefore enhane proess outomes for older people, inlude: premium payments for unsoial working hours or inonvenient loations; bonus rates for extra work in response to oasional requests from users; mileage allowanes for travel between ustomers; and guaranteeing staff a speifi amount of work eah week. Patmore 26 argues for a mix of inentives and bonus payments, depending 21

39 ADULTS SERVICES on the partiular staffing diffiulties experiened by a provider, in order to retain experiened staff and meet users requests for servies at speifi times and plaes. None of these suggestions has been evaluated to assess the impat on the outomes orientation of home are servies Importane of ommuniation The previous setions have noted a number of points in the operation of quasi-markets in whih lear ommuniation is essential in ahieving outomes-foused servies. Measures that have been shown to help inludes extensive feedbak between purhasers and providers; enabling providers to feel in ontrol of their servies; and reating ommuniation hannels that reognise provider expertise. 61 One initiative to improve ommuniation between staff arrying out assessments and front-line servie providers involved an outomesfoused briefing sheet for home are staff. This ensured that individual preferenes, priorities and desired proess outomes were routinely identified and ommuniated by are managers to front-line home are staff. 75 Evaluation showed that the briefing sheet was useful in enabling desired outomes to be pursued more onsistently and in delivering more individualised servies. It also reminded home are staff to undertake rehabilitation or enablement ativities with older people, identify new needs, or persuade relutant users to aept extra servies Overoming the health soial are divide Researh on the implementation of the Health At flexibilities 76 foused on their organisational, finanial and governane onsequenes. Indeed, muh researh on health and soial are partnerships has foused on proess issues rather than user outomes. 77 Researh is urrently (2006) in progress into the outomes that older people and other groups of servie users expet from health and soial are partnerships. Interim findings from this researh indiate these outomes mirror losely those identified in the first part of this review, but with a partiular emphasis on proess and maintenane outomes. 78 Another study, also in progress, is investigating the impat of the Health At flexibilities on the delivery of positive outomes for frail and vulnerable older people. Interim findings 22

40 Researh review reveal that the main servie area in whih the flexibilities are being used is intermediate are Initiatives and diversity Individualised approahes to ommuniation and onsultation an help people with dementia to artiulate their views and preferenes. Maximising their ontrol over opportunities for ommuniation, using pitures, using the older person s own voabulary and phrasing and interpreting non-verbal ommuniation an be effetive, although they require time and onfidene on the part of staff. 43 Speialist servies and staff with skills in ommuniating with people with little language are vital to maintain quality of life of people with dementia in residential settings. 79 Reommendations from a Health Ation Zone projet for improving outomes for minority ethni elders with dementia inlude involving professionals from outside the loality to maintain onfidentiality; and working in partnership with religious ommunities. 80 Again these initiatives fous more generally on improving aess to servies rather than ahieving desired outomes Views of the User Advisory Group Members of the User Advisory Group alled for better training, pay and status for front-line home are staff. They also pointed to the potential role of GPs in helping to overome the health soial are divide; GPs are in regular ontat with many older people and an help them to aess soial servies. It was thought that the new ommunity matrons might also be able to fulfil this role. However, members of the group also drew attention to the problems some older people have in aessing or aepting soial are servies. They pointed out that some older people find the name off-putting; older people from minority ethni ommunities may have to overome language barriers, a partiular diffiulty if hildren have been born in England and do not speak the ommunity language and so annot interpret for their parents. Soial servies ould address this problem of aess by developing loser links with voluntary organisations suh as Age Conern, who are likely to be more easily aessible to many older people. Adequate funding for these organisations is essential. 23

41 ADULTS SERVICES 1.6 Conlusions of researh review Outomes widely desired by older people relate to hange, maintenane or prevention and the proesses of reeiving servies. These are ongruent with the dimensions of wellbeing and independene, as defined by older people. However, researh shows that barriers relating to the operation of quasi-markets an impede the ahievement of outomes. Additional barriers for minority ethni elders arise from a shortage of ulturally appropriate servies. Initiatives to improve outomes-foused servies have involved improving ommuniation between users, front-line providers, are managers and purhasers. However, evaluation of these has tended to fous on their implementation; there is still a lak of evidene on the effetiveness of initiatives in improving user outomes. 24

42 2 Pratie survey 2.1 Introdution to pratie survey This pratie survey omplements a review of published researh into the outomes of soial are servies desired by older people and the fators that inhibit or ontribute to the implementation of outomes-foused approahes. The pratie survey aimed to: identify features of the soial are poliy and pratie environments that support or inhibit the development of outomes-foused approahes in older people s servies identify examples of outomes-foused organisational arrangements and approahes that provide opportunities for wider learning explore how loalities intend to build on existing pratie to implement proposals in the Green Paper on adult soial are. 2 explore older people s perspetives on the impat of outomes-foused approahes. The pratie survey had two parts: a postal survey of soial are staff in England and Wales known to be interested in developing outomes-foused approahes in older people s servies in-depth studies of servies in six loalities urrently using outomesfoused approahes in their servie ommissioning and/or delivery. The methods used in the pratie survey are desribed in Appendix 2. Details of the outomes-foused ativities and servies in the six ase study sites are ontained in Appendix 3. Details of some other loal outomes-based initiatives were obtained diretly from members of the Outomes Network that was set up as part of the Department of Health-funded Outomes of Soial Care Researh 25

43 ADULTS SERVICES and Development Programme onduted by the Soial Poliy Researh Unit at the University of York between 2000 and The Network is now alled the Better Commissioning Learning and Information Network (LIN) and is part of the Department of Health Change Agent Team ( The two-stage design postal survey and in-depth ase studies means that the pratie survey had both breadth and depth. SPRU s Outomes Network brought together a relatively small number of managers who were keen to develop outomes-foused approahes in their loalities. The Network therefore provided opportunities to test out new approahes and learn from the experienes of others. However, members of the Network were self-seleting and thus may not be representative. Moreover, the support derived from the Network was not typial of the environment in whih managers in other loalities may try to introdue outomes-foused hanges to their older people s servies. With an expliit poliy fous on outomes in the adult soial are Green Paper 2 and the UK strategy for an ageing population, 3 it was important to apture the wider environment in whih soial servies managers are now attempting to introdue outomes-foused servies. The postal survey therefore aimed to identify the range of initiatives aross England and Wales and to apture wide-ranging views on the main failitating fators and obstales. However, postal surveys have limitations, partiularly in apturing information likely to be useful in repliating outomes-foused initiatives, or the different perspetives of stakeholders suh as managers, frontline staff and servie users. The six ase studies, involving interviews and disussions with managers, front-line staff and servie users, therefore provided a more detailed aount of loal ativities. A User Advisory Group was established to guide the knowledge review (see Appendix 1). 2.2 Postal survey Aims The aims of the postal survey were: 26

44 Pratie survey to asertain the range and nature of outomes-foused initiatives being developed by soial are servies (and partner organisations) for older people to identify fators onsidered to failitate or hinder outomes-foused approahes in soial are to identify a small number of loalities for in-depth investigation Methods The postal survey was targeted at individuals and organisations known to have an interest in outomes-foused soial are servies. An extensive list of relevant ontats had been developed by SPRU; many of these are now members of the Better Commissioning Learning and Information Network. However, some ontats were out of date; others were of people working with disabled adults or hildren. An extensive updating and sreening exerise was therefore onduted (see Appendix 2), so that the postal survey ould be targeted at a speifi group people in England and Wales who were known atually to have developed or be interested in developing outomes-foused approahes in older people s servies. Full details of the survey methods are reported in Appendix Respondent harateristis Two hundred and twenty-two questionnaires were sent out to individuals and organisations in England (n=200) and Wales (n=22). Following reminder letters and s, 54 valid responses were reeived, inluding six from Wales. These overed at least 70 servie developments (some respondents desribed an unspeified number of ativities). Most respondents (87 per ent) worked in loal authorities/soial servies (see Table 2), inluding six who had joint appointments with another organisation. Nine organisations returned two (n=4) or three questionnaires (n=5), with different respondents desribing their involvement in the same or different initiatives within these organisations; the total number of organisations is therefore less than the total number of respondents. This report refers to the number of respondents rather than organisations or areas. 27

45 ADULTS SERVICES Table 2 Organisations in whih respondents worked* Organisation Number of respondents Loal authority/soial servies 47 NHS aute trust 3 Voluntary organisation 3 Primary are trust 2 Private onsulting 2 Other (inludes loal health boards; 4 NHS are trust; Change Agent Team) Note: * Some respondents worked in two or more organisations, hene the total number exeeds the number of respondents (n=54). Thirty-six respondents (67 per ent) reported on outomes-foused servies involving two or more organisations, inluding 22 involving primary are trusts and 18 involving NHS trusts (see Table 3). Twenty-one respondents reported working with independent providers on outomes-foused servies. In ases of joint working, 46 per ent of respondents (n=25) identified loal authorities/soial servies as the lead ageny Nature and range of outomes work Many of the 70 initiatives that respondents desribed were at early stages of development (see Table 4). Only seven respondents desribed initiatives that had been established for three years or longer. All six Welsh respondents were involved in initiatives that were still at the planning stage. Respondents were engaged in a wide range of outomes-foused ativities, with planning servies that aim to identify and ahieve outomes valued by older people the most ommon (see Table 5). The seven projets that had been established for three years or more were more likely to be desribed as involving older people in the design and development of outomes-foused servies and promoting outomes- 28

46 Pratie survey Table 3 Respondents whose outomes work involved other organisations* Other organisations involved in outomesfoused work Number of respondents Primary are trust 22 Private servie provider 21 Loal authority/soial servies 20 NHS aute trust 18 Voluntary organisation 18 Private onsultany 5 Other organisations (housing/registered soial 7 landlords, loal health boards, servie user forums) Note: * Respondents outomes work may have involved more than one type of organisation. Table 4 Stages of outomes-foused projets Number of projets Stage reported by respondents* % sample n=54 Established 3 years or more 7 13 Established 3 years or less 9 17 Currently being rolled out Currently being piloted In planning stages Other stage 2 4 n/a 1 2 Note: * Some respondents were involved in more than one projet and reported the different stages of development of eah. 29

47 ADULTS SERVICES Table 5 Types of outomes-foused servie developments Type of work Planning hanges to identify and ahieve valued outomes Monitoring/evaluating the effetiveness of outomes-foused servies Commissioning servies to identify and ahieve valued outomes Providing servies to identify and ahieve valued outomes Involving older people in the development of outomes-foused servies Outomes-foused approahes to supporting arers of older people Other types of outomes-foused servies Independent onsultany/ development work with soial are servies Number of respondents % sample n= foused approahes to supporting arers of older people than the sample as a whole. Outomes-foused initiatives most often involved servies for older people living at home and least often servies for older people in residential are (see Table 6). However, five of the seven longest-established initiatives (three years plus) also inluded older people in residential are. 30

48 Pratie survey Table 6 Groups of older people overed by outomes initiatives Number of Group respondents Older people living at home Older people immediately after disharge from hospital % sample n=54 Older people with dementia Older people from blak and minority ethni groups Carers of older people Older people in day are Older people in hospital prior to disharge Older people in residential are The speifi ativities that omprised the reported outomes-foused work were diverse (see Table 7). The most frequent ativities involved adapting assessment, are planning and reviews to fous on user outomes. Most respondents who were engaged in these ativities reported that they overed all older servie users, but some reported their ativities overed only some rather than all older people. Fourteen respondents reported being involved in all six areas of work for all or some groups of older people; these inluded five of the seven respondents reporting initiatives that had been established for three years plus. Respondents desribing longer-established initiatives were also more likely to be involved in outomes-foused servie monitoring and evaluation than respondents as a whole. The postal survey asked how far older people themselves had been involved in planning outomes-foused developments (see Table 8). Only two of the seven respondents desribing initiatives that had been established for three years or more reported involving older people greatly. 31

49 ADULTS SERVICES Table 7 Fous of outomes work Number of respondents (n=for all older people/ Fous of work n=for some older people) Fous on outomes in are planning 35 (27/8) Identifying outomes desired by individual older people at assessment Reviewing whether outomes desired by individual older people at assessment are ahieved Changing existing servies to better meet older people s needs and preferenes Monitoring/evaluating servies to examine the extent to whih servies meet desired outomes Commissioning/developing new servies to better meet older people s needs and preferenes 34 (24/10) 33 (20/13) 26 (12/14) 25 (11/14) 22 (10/12) Table 8 Involvement of older people in planning outomes work Level of involvement Number of respondents % sample n=53 Greatly 6 11 Moderately A little Not at all 7 13 Don t know 3 6 No response

50 Pratie survey Ahievements and fators helping and hindering ahievements Respondents were asked to identify the main ahievements of their outomes-foused work to date; the researhers oded their answers. A fifth of respondents did not omplete this question, some of whom ommented that it was too early to say. Signifiantly, pereived ahievements were as likely to relate to the effets on servies as to the impat on servie users (see Table 9). Respondents identified a range of fators that helped and hindered progress in developing outomes-foused servies for older people; many also ited measures taken to overome pereived barriers (see Table 10). Of the 41 respondents who identified measures to overome barriers, the majority (n=30) felt that these had been partly or fully suessful, while the remainder thought it was too early to say. Table 9 Pereived ahievements of outomes work to date Improvements in servies Modernisation of servies Servie ratings Improved skills/engagement of staff Servie monitoring Joint working Dereased bureauray Changes in levels of servie provision Better use of resoures Development of servie speifiations Effets on older people/arers New or better quality servies for older people and their arers Better fous on individual needs and desired outomes More person-entred/less servie-led/more holisti approahes Empowerment of older people 33

51 ADULTS SERVICES Table 10 Summary of fators that helped and hindered progress, and measures taken to overome any pereived barriers Examples of what has helped progress Fators Training External, in-house and joint training for health and soial are staff; SPRU Outomes training resoures Examples of what has hindered progress Lak of training; arranging training for large numbers of staff Measures taken to overome barriers Developing training programmes/briefings; seonding staff Joint working/ partnerships Whole systems working with NHS/voluntary setor/ providers/older people forums; multidisiplinary teams; developing shared values and trust Poor/immature partnerships; poor relationships with providers Joint workshops; strategi partnerships; on-going work with providers 34

52 Pratie survey Fators Staff attitudes, priorities Organisational ulture hange Examples of what has helped progress Commitment, enthusiasm, attitudes of staff at all levels to outomes-foused approahes and related issues Organisational re-struturing to improve ustomer fous Examples of what has hindered progress Lak of ommitment from key olleagues (managers, Chief Exeutive, IT department); partner agenies; providers Staff lak of understanding of outomes Priority of performane measures/indiators Staff anxiety/resistane to hange Diffiulties in initiating and sustaining hanges in organisational ulture Measures taken to overome barriers Senior management leadership Regular disussions of outomes fous Mainstreaming outomes approahes and user/arer involvement Using other hanges to introdue outomes approahes 35

53 ADULTS SERVICES Examples of what has helped progress Fators Resoures Having suffiient resoures to review and develop servies; hanging how resoures are used Reording systems/tools New doumentation that inludes outomes Examples of what has hindered progress Funding pressures/ limitations; finanial assessment proedures; staff reruitment/retention Lak of IT apaity/ flexibility; diffiulties with new outomes-foused paperwork Measures taken to overome barriers Using small projets to demonstrate hange; more reative use of short-term and projet funding to introdue new approahes/ training Changes in IT/data olletion/monitoring/audit; new performane and workload management tools 36

54 Pratie survey Examples of what has helped progress Fators External fators Poliy emphasis on: independene and hoie UAP/SAP* NSFs* for older people/ long-term onditions diret payments CSCI* outomes-foused inspetions Change Agent Team Examples of what has hindered progress Managing: multiple poliy priorities (FACS, SAP/UAP, harging, CSCI, NSFs, ESCR,* prevention) workload pressures resoures vs targets reativity vs risk tensions between outomes for servies, for users and for arers Measures taken to overome barriers Challenged CSCI Links to hroni disease management initiatives * Note: FACS: Fair Aess to Care Servies, SAP: Single Assessment Proess, Unified Assessment Proess:, CSCI: Commission for Soial Care Inspetion, NSFs: National Servie Frameworks, ESCR: eletroni soial are reord 37

55 ADULTS SERVICES Postal survey: disussion The postal survey was sent to individuals known to be involved in developing outomes-foused approahes to servies for older people. Nevertheless, despite repeated reminders the response rate was low (24 per ent). It is possible that there are other examples that were not aptured by the survey. However, the responses reeived suggest that there may not be many other established pratie examples. Only 10 per ent of the reported developments had been established for at least three years, and another 13 per ent for up to three years. Three quarters of the reported initiatives were therefore being rolled out, piloted or planned. If outomes-foused approahes are mainly very reent, then it is possible that nonresponses refleted a lak of positive, substantive progress. Members of the User Advisory Group also queried how far the survey results were aurate. In a number of instanes, more than one response was reeived from the same organisation, allowing aounts to be ross-heked. User Advisory Group members suggested that the poor response rate ould reflet the low priority given to older people s servies. They were partiularly onerned about the relatively low involvement of older people in outomes-foused servie developments and about the low priority that appeared to be given to monitoring and evaluation. Not surprisingly, the longest-established initiatives appeared to have made most progress in terms of the number and range of ativities involved and the range of older people overed. Even so, only a minority of these long-established initiatives reported the extensive involvement of older people in planning and monitoring ativities. Outomes-foused initiatives were more likely to be desribed as planning, monitoring and evaluating or ommissioning servies that aim to identify and ahieve the outomes valued by older people, and least likely to involve supporting arers of older people. Initiatives overed a wide range of older people in different situations, the most ommon being older people living at home and the least ommon being older people in residential are. Fators that helped develop outomes-foused approahes inluded training, joint working, staff attitudes and values, hanges in organisational ulture, resoures, and appropriate douments and tools. National 38

56 Pratie survey poliies, suh as the adult soial are Green Paper, SAP, NSFs for older people/people with long-term onditions, the promotion of diret payments and new CSCI inspetion methodologies were all ited as failitating outomes-foused approahes. However, these fators ould simultaneously hinder progress if they generated too many (ompeting) priorities. In summary, the postal survey suggests that English and Welsh soial servies departments are still only beginning to develop outomes-foused servies for older people. This also limited the seletion of sites for in-depth study to the few that had made some progress in developing outomes approahes (see Appendix 2). 2.3 Case studies Introdution This setion desribes findings from in-depth studies of six English loalities that had been developing outomes-foused approahes in some or all of their servies for up to three years, or longer. It desribes outomes-foused approahes to assessment, are planning and review; to strategi planning, ommissioning and ontrating; and to servies most ommonly used by older people home are, day are, intermediate and rehabilitation servies (see Table 11). This setion also inludes some material obtained from the Better Commissioning LIN. Some of the ase study sites were high performing aording to national performane indiators; others were relatively poorly performing loal authorities and/or soial servies departments. Several of the sites had reently been suessful in applying for Partnerships for Older People Projets (POPPs) to develop new ways of delivering preventive servies in ollaboration with NHS and other loal partners. This setion does not reflet the full extent of the outomes-foused servie developments under way in eah site. Initial disussions with senior managers revealed that it was ommon for progress with outomes-foused approahes to be unevenly spread aross a loality s servies and/or ativities. The fieldwork therefore foused on those areas where most progress had been made, as these offered the greatest opportunities for learning. Setion below presents evidene on the 39

57 ADULTS SERVICES Table 11 Case study sites Site Ativity Servies Bradford Assessment, are Day are planning and review Cumbria County Counil Assessment and are planning; home are servies ontrats Intermediate are Dorset County Counil London Borough of Hillingdon North Linolnshire Counil Worestershire County Counil Developing, ommissioning and managing servies Commissioning and developing preventive servies Care management Commissioning; are management; ontrat speifiations for new preventive servies Prevention; ommunity-based rehabilitation; home are Home are; rehabilitation servies Residential are; home are Rehabilitation and reablement See Appendix 3 for further details of the ase study sites. benefits (and limitations) of these hanges from the perspetives of older servie users. Members of the User Advisory Group ommented in detail on the draft topi guides that were used during the ase study site visits and made many hanges to the wording to make this ompatible with the experienes and onerns of older people. They requested that a number of additional questions were asked of servie managers, inluding: Would you be happy if your mother was reeiving this servie? Are you working losely with voluntary organisations? 40

58 Pratie survey How far do soial servies share information with other relevant servies/departments? If an assessment identifies an outome that annot be met by soial servies, is a referral made to another statutory or voluntary organisation? Outomes-foused ativities Assessment and are planning The impat of SPRU s Outomes Researh Programme was apparent in the assessment and are planning douments used in several loalities. However, these sites all noted the diffiulties of inorporating an outomes fous into the SAP. Different solutions had been found: One site had drawn a lear distintion between assessment (understanding diffiulties and needs); and are planning (foused on desired outomes). Its are plan listed 10 quality of life (maintenane) outome domains and four rehabilitation (hange) outome domains; soial workers indiated against eah whether the aim was improvement or maintenane. In a seond site, outomes had been introdued into the are plan; are managers first identified the outome; then the type of support required to make it happen; finally they reorded the need in the SAP. This was desribed as doing it the other way round to what we used to do. A third site had adapted the EasyCare version of the SAP ontat assessment form. In the setion Planning your are, assessors were asked to seek users views on: > Outomes we an support you in ahieving > How these outomes might be ahieved (your are options) > Your preferred hoies from these options. The summary are plan, now part of the SAP ontat assessment paperwork, had also retained an outomes fous. Alongside detailing the help that had been arranged and who would provide it, assessors also ompleted a olumn headed By providing this support we hope you will be able to.... However, some managers 41

59 ADULTS SERVICES were disappointed not to have been able to retain a more expliit outomes fous. As part of its response to the postal survey, one soial servies department sent its Needs and Care Planning tool that was also used by other servies suh as ommunity nursing and the older people s mental health team. The tool inorporated FACS bandings as well as needs, ations and outomes. The department was keen to make this doument widely available as a Freeware tool; it had been posted on the Centre for Poliy on Ageing website ( Northumberland Care Trust had adapted its outomes approah to reflet FACS eligibility riteria; these were also inluded in their Community Care Charter Review Even though it may be diffiult to inorporate outomes into SAP doumentation, desired outomes an still form the basis for reviews. An example of an outomes-foused Review Assessment Form from one site is shown below; reviewers were asked to indiate hanges under the following headings: Outome domains review assessment Inreased physial abilities Quality of life maintained Higher morale Changes in behaviour Essential physial needs met Improved mental health Safer environment Have finanes in order Inreased onfidene or skills Cleaner environment More soial ontat Risk(s) redued/remove Staff in this site felt positive about the review proess. The paperwork keeps you in the right diretion it s prompting you all the way through. Of all the paperwork, the review form is the best beause you an look at what has been ahieved. Staff also had flexibility over when first reviews were onduted essential with older people reently disharged from hospital. 42

60 Pratie survey Commissioning Sites had made hanges to ommissioning and ontrating arrangements with both in-house and independent providers to enourage more flexible, person-entred and outomes-oriented servies. Commissioning for hange outomes in-house servies Refleting national poliy initiatives relating to hospital admission and disharge, all ase study sites had reently established intermediate are and reablement servies, inluding residential units funded and operated jointly with NHS partners; short-term extra are housing provision; and domiiliary reablement servies. The latter servies had involved reorganising soial servies departments in-house servies to provide short-term interventions, free of harge, to improve older people s mobility, independene and onfidene, with longer-term domiiliary support ommissioned from independent providers. One site had restrutured its in-house home are servie to provide short-term rehabilitation-oriented interventions for all new servie users. Following referral, the team, whih inluded an oupational therapist, identified a user s desired hange outomes; the older person reeived support for up to six weeks; and progress towards desired outomes was reviewed at weekly meetings. Front-line staff were enouraged to provide feedbak on the appropriateness of the are plan and also have some autonomy over how they delivered are on a daily basis. Another site had developed outomes-based ontrat speifiations for a new range of preventive servies. These inluded assessment and rehabilitation servies in residential and extra are housing settings; and a multidisiplinary ommunity reablement team working in older people s homes to promote independene, fousing on goals that were important to the individual, for up to eight weeks (although this ould be extended if neessary to ahieve individual goals). The servie was free of harge; staff onsidered that harges deterred take-up and were inappropriate for a servie that enouraged users to do things for themselves. 43

61 ADULTS SERVICES Commissioning for maintenane outomes independent providers Three study sites had hanged their ontrats with independent home are providers to failitate outomes-foused servies. These hanges involved a deliate balane between: flexibility to respond to users preditability in workloads, expenditure (by purhasers and servie users) and inome (for providers) audit and payment arrangements that were not unduly onerous and expensive. In one rural site, eah home are provider now worked in a speifi geographial zone. Although this redued the hoie of provider for servie users, there were distint gains for staff reruitment and retention and in ontinuity of relationships with users. Beause a given level of work ould be guaranteed for eah provider, invoiing was done on a four-week standing order-style arrangement, based on the estimated annual workload and adjusted periodially to aount for the atual time spent. This gave providers flexibility to deal with unexpeted situations without having first to ontat are managers. Another rural loality was also piloting a zoned approah. Providers were to work in the areas where they urrently had greatest presene; eah will have a blok ontrat with soial servies to provide a ore level of home are servies in that zone. Care managers were to speify in are plans the tasks users required help with and the probable number of hours of help required (this also provided the basis for the lient s finanial assessment). Providers would notify soial servies eah week of the atual hours they delivered against what was ordered. Users would not be billed for any extra help they reeived unless it beame regular, in whih ase it ould trigger a reassessment and a new order for the home are provider. This arrangement is expeted to reate some down time, when provider staff have spare hours. Soial workers will be asked to identify in advane older people who would benefit from pratial help (for example, with housework or going out) and down time will be used for this; again, users will not pay for this extra help. Providers expet this will enable them to employ staff on a shift basis; to guarantee a minimum amount 44

62 Pratie survey of work eah week; and to arrange staff training (inluding training on outomes) during any down time. Contributors to the Better Commissioning LIN suggested three models of outome-based ommissioning: Three models of outome-based ommissioning Following assessment of eligibility and identifiation of desired outomes: Care managers alloate bloks of hours to providers for a group of servie users; providers have autonomy to alloate these to individual users depending on their irumstanes and priorities. Care managers speify the number of hours normally to be reeived by eah servie user, but providers have flexibility to move hours between people aording to need. Care managers alloate a speified number of hours to eah servie user who has freedom to use these in whatever way s/he wishes. We ould find only one example (from the Better Commissioning LIN) of an outomes-based approah to ommissioning home are servies that had been evaluated. Outome-based home are ommissioning: evaluation of pilot projet In this pilot projet, are managers agreed outomes and an appropriate budget for eah home are servie user and let the provider negotiate the details with the user, with suffiient autonomy to respond flexibly to needs and preferenes. The are plan and assessment summary set out the outomes that the provider was expeted to ahieve. The servie user plan set out the ativities to be arried out to ahieve these 45

63 ADULTS SERVICES outomes and the estimated number of hours required. Seventy servie users were inluded in the pilot: 19 per ent reeived maintenane-based outomes servies and 81 per ent reeived hange outomes servies. Loal evaluation of the pilot found higher levels of user satisfation than in a reent national user experiene survey and inreased job satisfation was reported by front-line home are staff. Only eight per ent of are pakages exeeded the original budget. A number of learning points were identified, inluding: providers need an appropriate infrastruture to be able to onstrut, ost and adapt servie user plans as neessary are managers must be onfident that providers an math ativities to outomes and will monitor users regularly. Good ommuniation between providers and are managers was essential revisions to paperwork and finanial proesses were needed to improve ommuniation and redue paperwork new ontrats should inlude performane management frameworks defining the ounil s and provider s respetive responsibilities for monitoring; frameworks should inorporate key performane indiators. Case study sites involved in outomes-based ommissioning of independent home are servies agreed they involve transferring power and responsibility from ommissioners to providers and users. This required signifiant levels of trust between purhasers and providers; open ommuniation hannels; and appropriate administrative and finanial management systems. Although these new approahes to ommissioning ould result in less hoie of provider for servie users, members of the User Advisory Group did not onsider this a problem. They were onerned at the transfer of home are servies from in-house to independent agenies as they felt that this gave them less ontrol over the quality, reliability and osts of servies. The osts of home are servies were also pereived to be a barrier for some older people. Moreover, if home are servies were to be provided by independent agenies, Advisory Group members did 46

64 Pratie survey not want the responsibility of hoosing an ageny themselves; indeed, they onsidered hoie to be meaningless without aess to information and support. One ase study site had experiene of ommissioning low-level preventive servies from loal voluntary groups. In this loality, Age Conern was ontrated to organise a volunteer shopping and home delivery servie. Age Conern had enhaned its basi servie by produing lists of loal shops that will deliver and by offering advie on internet shopping. In another part of the loality, Age Conern provided a shortterm volunteer servie to fill gaps in statutory servies for older people at risk of hospital admission (for example, help with laundry and shopping or looking after pets) Outomes-foused servies Intermediate are and reablement servies Early disussions in several ase study sites led the researh team to fous on intermediate are and reablement servies, as staff thought these showed greatest progress in outomes-foused approahes. These servies have a very lear fous on hange outomes. Typially, reablement servies aim to promote independene by identifying and working towards outomes that were important to eah individual. Domiiliary reablement servies were thought to give added enouragement to a holisti approah. For example, initial referrals identified goals that users wished to ahieve and these are refined during an initial assessment visit from the team s oupational therapist. Goals might relate to personal are, daily living ativities suh as shopping or leisure interests We try to tailor things very muh to what the lient says. Subsequently a detailed piture of the user and her/his desired outomes was ompiled; this was shared with rehabilitation assistants who visited regularly. In one site, users ould request visits at times to fit their daily routines (the servie ould be offered seven days a week between 7am and 10pm). Visits were arranged a week in advane and a timetable sent to users every Friday so they know who to expet and when. Outomes ould inlude, for example, going shopping or attending art lasses. Helping to restore onfidene in whatever areas of life are important to users was entral. In one area, progress was measured using 47

65 ADULTS SERVICES the Canadian Oupational Performane Measure that is both personentred and outomes-foused. It asks about a user s lifestyle and what is important to them; identifies the top five things they want to do; asks how satisfied users are urrently with their ability to do these things; and then asks again after a period of intervention. Smiley faes an be used for people with ognitive impairments and interpreters for people who do not speak English Day are One loality was reviewing its output-based ontrats for voluntary setor day are servies, to see if new inentives to fous on user outomes ould be introdued. In another day entre for older people with mental health problems, a six-week assessment period allowed staff to identify users individual interests; eah user was then assigned a key worker who shared their interests, so the fous on outomes was as natural as possible. However, no examples were found of day servies that addressed outomes that ould be met other than by attendane at a day entre Residential and nursing home are A Quality Development Sheme (QDS) had been developed by one loality for its 40 nursing and residential homes, to enourage standards above the CSCI minimum. Homes reeiving the QDS Award reeived an additional payment for eah loal authority-funded resident and a marketing advantage as they were learly flagged up on the loal authority s website. In addition, residential are staff ould attend outomes training run by soial servies, although staffing onstraints restrited take-up Monitoring and evaluation The most frequent and systemati monitoring of user outomes appeared to our in relation to the hange outomes that were the fous of intermediate are and reablement servies. For example, linial outome tools were often used; weekly reviews and six-weekly reviews of users were routinely onduted; and questionnaires obtained feedbak from users at the end of their first week in a rehabilitation unit and again on disharge. 48

66 Pratie survey In ontrast, little evidene was found of routine monitoring of maintenane and prevention outomes among long-term users of home are servies. One authority was onsidering how to inlude user outomes in its new arrangements for monitoring home are providers, but had not yet done so. In another ase study site that had a long-standing ommitment to outomes-foused assessment and are management, information from outomes-foused assessment douments was not available eletronially and ould therefore not be aggregated and used as part of the monitoring and ontrating arrangements with independent providers. Managers here noted that as outomes were not a national priority or performane target, organisational resoures to develop appropriate omputer information systems were a low priority. However, in another authority entralised ontrating for independent home are servies enabled the feedbak from annual reviews of servie users to be inorporated into strategi planning. In relation to monitoring outomes in residential homes, managers identified multiple opportunities to obtain feedbak from users: Monitoring and evaluation in residential are settings Feedbak from residents monthly meetings Quality Cirles of resident, relative and staff representatives that met monthly to disuss performane and areas for improvement Routine questionnaires, for example about meals, privay Annual surveys of residents, relatives, staff and GPs Suggestion boxes Managers being easily aessible to residents Feedbak from routine audits (for example, kithens, aidents) Information from performane indiators 49

67 ADULTS SERVICES Impat of outomes-foused servies: the experienes of servie users This setion reports the views of older servie users who took part in interviews and fous groups in the ase study sites Change outomes These were partiularly evident in intermediate are and reablement servies. Many users reported hanges in their morale and outlook on life as well as their physial funtioning, thus supporting staff laims to take a holisti approah. Miss B had a fall and broke her hip. On leaving hospital her mobility was greatly redued, partly beause she laked onfidene to walk outside in ase she fell again. She was therefore unable to do her shopping and maintain her soial life. After referral to intermediate are, she reeived physiotherapy, equipment and support from a rehabilitation assistant to regain her onfidene. I wouldn t be where I am now mobile and with onfidene without it. One older person elebrated a small milestone in her rehabilitation being able to lean the toilet independently: I really enjoyed that! Mr F spent several weeks in a rehabilitation unit after a hospital stay. He said that staff in the unit had a very personal approah and understood what was important to him. One of my aims was to walk the dog, so they allowed him to ome and see me it was very helpful. It made all the differene in the world. I have a good quality of life and I know I an get better still. You need to look forward they kept stressing that and I m the living proof! 50

68 Pratie survey Staff working in reablement servies pointed out that, as older people regain their abilities and onfidene in relation to self-are and household ativities, desired outomes hange rapidly goals that originally seemed unattainable soon beome realisti. Regular reassessment was therefore important. They also pointed out that even where signifiant hange outomes had been ahieved, these were not always maintained when older people moved to longer-term home are servies: It gets so far then it s out of our hands and we an t follow it through Maintenane outomes It was harder to find examples of maintenane outomes. Some managers aknowledged this lak of evidene refleted servies ommissioned from independent home are agenies that prioritised physial maintenane rather than broader quality of life outomes. Interviews with older people onfirmed that some outomes that were important to them, suh as going out, partiipating in soial ativities and help with housework, were not being addressed by home are servies. However, older people did give examples of day and residential are servies that met desired maintenane outomes: Mrs R used to be very ative in her loal ommunity. After a hospital stay she reeived home are but, as she felt isolated and bored, she started attending a day entre. One of her desired outomes was to keep soially involved; she enjoyed the range of day entre ativities and appreiated the time staff spent finding out about her interests in theatre and musi so they ould math ativities to these. In one ombined residential and day are faility for Asian elders, users aknowledged the importane of the soial partiipation in maintaining morale: I think it s great you an sit down and have a hat and a giggle it s a hange. I didn t want to ome here at first but I m glad I did now it gives you something to look forward to. It s lonely in the flat you get ompany here. 51

69 ADULTS SERVICES Day entre users in another site appreiated the variety of ativities available There s something for everyone. They ould influene the ativities provided and onfirmed senior managers laims of an open ulture what one user desribed as a No serets poliy. Care home residents appreiated the hoie and ontrol they ould exerise: There s a elderly lady in here that said [about another home] one you ome out of your room you ve got to stay in the lounge, whereas here I go to [friend] s room, I go and sit and have a yarn with her Proess outomes These were more often noted by users of intermediate are and reablement servies, day are and residential are than by users of long-term home are servies. In one loality with a high proportion of minority ethni elders, Asian older people attending day entres valued having staff who spoke their languages: They make you feel good you re well looked after. They make you feel like one of the family, not a senior itizen. An older person attending another day entre praised the team spirit among staff, whih extended to the bus driver who took her into her living room and drew the urtains for her when he took her home on dark evenings. Care home residents refleted on their experiene of proess outomes: The senior arers are good, they listen, whih means a lot. They are aring and they understand. [The manager is] very warm, very onsiderate... involved every day in every way. A are home resident didn t sleep well. When she was awake during the night, staff looked in on her and brought a up of tea. 52

70 Pratie survey The next morning she was able to lie in and staff brought her breakfast to her room on a tray. Users of intermediate are servies reognised the importane of proess outomes, both for the aeptability of the servie and in underpinning hange outomes. One resident desribed her therapy timetable as fluid and flexible. You an do what you prefer. You have ontrol, you re not regimented and that all helps to regain your independene. Mrs S was disharged from hospital after a hip frature. She was relutant to aept intermediate are beause she didn t want to be taken over by strangers oming into the house. However, one bak home, a rehabilitation assistant worked with her to devise safe ways to do domesti tasks. Running her home was very important to Mrs S and the intermediate are team understood this: Some people say We want you to do this or that, but they weren t like that... They didn t intrude on your life like some do-gooders do. Mrs H spent four weeks in residential intermediate are following disharge from hospital. She refleted They [staff] taught me to stand on my own two feet I knew that was their aim. It wasn t just physial, it was emotional. They were really wonderful, they really listened, everything I mentioned they disussed. They got to know me and to understand what my aims were. The staff were never abrupt, you never felt I was in the way. I gradually started to feel better I started doing things for myself. Members of the User Advisory Group endorsed the importane for proess outomes of individualised, personalised approahes, underpinned by good staff training. 53

71 ADULTS SERVICES Servie-level outomes As in the postal survey, some managers and pratitioners also referred to outomes for servies, not just for users. A signifiant driver behind the development of outomes-foused intermediate are and reablement servies was to redue hospital and residential are admissions; staff therefore reported major gains in enabling older people to live independently. These sometimes also inluded a signifiant derease in residential are admissions that generated additional resoures for ommunity servies. A further impat reported by several sites was inreased staff satisfation and, onsequently, improved reruitment and retention, partiularly in relation to rehabilitation assistant posts that were more rewarding (both psyhologially and finanially) than are assistant posts. However, this had impliations for the staffing of long-term home are servies Constraints on the impat of outomes-foused approahes Staff and users both identified onstraints on the impat of outomesfoused initiatives. Mostly these related to the quality and range of home are servies, whih ould limit or even reverse hange outomes resulting from a period of intensive reablement. Intermediate are staff in one area tried to plan for hange outomes to be maintained when older people returned home, but found long-term servies ould not sustain the same personalised, enabling approah. Older people onfirmed that some desired outomes, suh as resuming soial ativities, were not being met. Day entre users in another site reported restritions in maintaining valued soial ativities outside the day entre as they ould not get out without help Fators failitating outomes approahes National poliies Case study interviewees onfirmed the findings of the postal survey, that outomes approahes were inreasingly ompatible with the national poliy environment. Relevant poliies inluded: 54

72 Pratie survey the NSF for older people poliy pressures and dediated resoures to redue hospital and residential are admissions; sometimes adverse CSCI inspetions of a loal authority s role in relation to delayed hospital disharges had prompted the development of new, in-house reablement servies the promotion of greater user hoie and ontrol through diret payments the Green Paper on adult soial are some interviewees also thought that CSCI inspetions of residential and home are servies had beome less paper-driven and more ompatible with outomes approahes. The development of intermediate are servies, both in partnership with NHS olleagues and in-house, were partiularly signifiant fators, as they involved dediated funding and the reation of new teams with a strong fous on hange outomes, underpinned by a person-entred ulture. The importane of ompatible performane indiators inevitably a big part of a manager s working life in promoting outomes approahes was emphasised several times. Several sites had been involved in SPRU s Outomes Network and this had provided important opportunities to share ideas with others. Other national networks that had helped inluded the Modernisation Ageny s Aelerated Development Programme and the Innovations Forum Loal vision, leadership and investment in hange management Leadership was essential. This needed to ome from senior managers who wanted, were in a position to and had time to devote to managing hange: You an t do it as part of your day job you need thinking time. Sometimes senior managers were new appointees who brought a new vision of person-entred servies; sometimes they were long-standing members of staff who identified new opportunities to introdue hange. In one or two instanes politial leadership was also noted as a signifiant enabling fator. A whole systems approah to managing hange was important, as were lear ommuniation hannels to take the staff with you so that we re all swimming the same way. Examples inluded: 55

73 ADULTS SERVICES regular meetings between ommissioning and are management teams and between all assessment and are management staff to keep them involved in hange proesses regular workshops for residential home staff to reinfore ultural hange formal staff training in using outomes-foused douments indution, training and on-going supervision for day entre staff bak to the floor sessions by senior managers who arried out home visits with staff having are plans signed off by senior and prinipal are managers who ould spot and talk through any mistakes. Sometimes a new are manager had a senior olleague working alongside to help embed an outomes approah when drawing up are plans Partnerships and whole systems working Close relationships with external partners were essential to implementing outomes approahes. Outomes-foused intermediate are and reablement servies required lose ollaboration with NHS partners. Other partners inluded voluntary organisations, partiularly in providing day are and low-level preventive servies; and independent home are providers, for suessful outomes-foused approahes to ontrating for domiiliary are. At operational levels, integrated servies improved aess to a wider range of skills and resoures to meet users outomes. The suess of this multidisiplinary approah was partiularly apparent in intermediate and day are servies. Ativities to promote interdisiplinary working inluded joint training, regular meetings, shared aommodation and staff seondments. However, outomes ould have different meanings for medial and soial are professionals and debates about medial versus soial models had impeded the development of integrated, outomes-foused day servies in one site. A whole systems approah also required appropriate administrative and omputerised information systems. Training in outomes-foused approahes was often linked to the introdution of new (eletroni or hard opy) doumentation. Members of the User Advisory Group also pointed to the support that other professionals and servies ould provide, inluding speialist NHS units for older people with mental health problems and ommunity nurs- 56

74 Pratie survey ing staff. For housebound older people, regular visits from ommunity nurses ould be as important for their soial as their linial funtions, as they addressed maintenane outomes relating to soial ontat. Although some loalities reported extensive multi-ageny working, it was not lear how this ontributed speifially to delivering outomesfoused servies. However, as noted above, partnerships with voluntary organisations suh as Age Conern to provide a range of low-level servies aimed at maintenane and prevention outomes were ommon What hinders outomes approahes? National poliies and performane indiators Although some loalities had adapted are planning and review douments to overome the needs fous of SAP, this was not entirely suessful. Keeping SAP foused on outomes was desribed as a onstant battle : home are servie managers thought it foused too muh on medial onditions; day entre staff desribed it as something to be endured rather than a proess that enhaned an outomes approah. Other poliies also impeded outomes-foused servies: CSCI inspetion regimes were thought still to be too paper based, as were registration requirements that did not value staff experiene suffiiently pressures to redue delayed hospital disharges had redued opportunities to identify and ahieve desired disharge outomes for some patients in poorly performing authorities, a preoupation with improving performane indiators detrated from developing outomes approahes Resoure onstraints These had a number of impats: resoures were not available for voluntary organisations to provide low-level preventive servies to address maintenane outomes 57

75 ADULTS SERVICES onstraints on NHS budgets threatened aess to servies like hiropody and physiotherapy that were vital in helping older people ahieve desired hange and maintenane outomes resoure panels that approved are managers reommendations ould prevent outomes-foused are plans from being fully implemented workload pressures redued are managers apaity to adopt a holisti and individualised approah resoure onstraints ould restrit outomes-foused ontrats with independent home are providers, espeially where these needed to be flexible and open-ended. These onstraints ould be exaerbated by poor relationships with home are providers resoure onstraints restrited home are providers in reruiting, training and retaining good quality staff Staff ulture and attitudes Previous resoure onstraints ould leave a legay on staff ulture and attitudes so that earlier, less flexible are planning praties were hard to hange Soial servies ommissioners reported some home are staff found it diffiult to keep up with rapid servie modernisation and move from doing everything for an older person to letting them deide on their priorities and working with them to ahieve these Problems with the attitudes and praties of other professional groups ould impede outomes approahes, again highlighting the importane of whole systems approahes. For example, some GPs were reported still to advise older people that residential are was the only option, although alloating soial servies staff to GP praties ould help hange this pratie. Some sheltered housing wardens also ontinued to assume that residential are was a preferred outome. Hospital staff involved in disharge planning also had diffiulty understanding onepts of outomes and prevention Users and arers attitudes Users and arers were sometimes resistant to outomes-foused approahes. Problems inluded deferene and a relutane to artiulate desired outomes for fear of appearing unrealisti. Managers explained 58

76 Pratie survey this as a legay of previous experienes of servies: Users find it hard to understand hoie they were so used to having servies shoved on them. Some older people were resistant to a reablement approah as they were said to be used to people oming and doing things. Other users resisted the withdrawal of time-limited home reablement servies, even if desired hange outomes had been ahieved. Users desired outomes ould onflit with those of arers, espeially when the latter plaed more emphasis on safety while the older person was prepared to aept a greater level of risk in order to maintain independene. Differenes in attitudes to risk had to be takled through good soial work, to reinfore the older person s preferenes while helping the family to distinguish between unonventional and dangerous behaviours Plans for (further) outomes-foused servie developments All the ase study sites had plans to build on or extend outomes approahes to other servies, ativities or loalities. These plans refleted loal priorities and irumstanes and inluded the following ativities Consolidating previous outomes work One ounty authority aimed to ahieve a onsistent outomes fous aross all its servies by revising its ommissioning strategy to inlude loser links with loal older people s organisations; promoting take-up of diret payments; and ontinuing to develop as many joint servies as possible with NHS partners. These objetives were aknowledged to be hallenging in the ontext of high workloads and staff shortages. A priority for loalities with high staff turnover was to relaunh outomes with a new series of training sessions. In other loalities, priorities inluded inreasing the volume of short-term reablement servies, and working with partner organisations (inluding hospital onsultants, independent providers and arers) to extend understanding of outomes. 59

77 ADULTS SERVICES Extending outomes approahes into new servies Some loalities planned to extend their outomes approahes by developing new speifiations and ontrats for servies suh as extra are housing, day are, residential are and dementia are that had hitherto not had an outomes fous. One loality planned to build on its relatively stable workfore and omparatively long tradition of outomes-foused approahes by inorporating outomes into the SAP; and by reviewing its ontrating and servie standards proesses to ensure they did not impede outomes approahes. New ontrats with independent home are providers were a priority for some sites. Proposed hanges inluded retendering for larger, loalitybased blok ontrats with a smaller number of providers; and ensuring that all new ontrats had flexible, outomes-foused speifiations Developing preventive servies Some loalities had identified a major gap in low-level servies that ould address the prevention and maintenane outomes valued by older people. Filling this gap was hallenging and involved identifying new soures of funding and labour. Two loalities had suessfully bid for POPPs. One of these loalities intended to promote ommunity development approahes to strengthen the role of loal neighbourhoods and ommunity organisations in supporting older people; older people themselves were expeted to play a key role in identifying, artiulating and addressing loal needs and onerns. Linked to this ambition were plans to seek EU funding to employ older people themselves as are staff to provide low-level support. Developing loal networks of older people was also intended to enable older people s perspetives on loal needs to inform servie ommissioners; indeed, it was planned that the latter would be aountable to the loality-wide POPP. Another loality planned to enable are managers to aess loal soures of help and support: 60

78 Pratie survey Bridging the gap between are managers and loal servies One loality was reloating all its are managers from a entral offie to ward level; eah would be given a laptop omputer and mobile phone. Loally based are managers were expeted to be able to make better links with loal ommunities and with the informal, neighbourhood and voluntary resoures in them; this would in turn provide aess to a wider range of support options for example, providing a taxi to a loal ommunity event rather than having to be transported to a distant day entre simply beause are managers did not know what else was available. It was also hoped that the new loal base would enourage are managers to proatively ase find older people who might benefit from low-level preventive work. 61

79

80 3 Conlusions During the past deade, disussion of outomes has beome ommon, as part of a wider servie modernisation disourse. As well as the SPRU Outomes Programme, other poliy initiatives have promoted outomes-foused servies. First, this pratie survey shows that targeted funding and performane indiators related to hospital disharge and intermediate are have produed signifiant developments in servies foused on hange outomes. Moreover, these are not restrited to NHS and soial servies intermediate are, rapid response and step-down servies; but are also inreasingly refleted in soial servies in-house home are servies that provide short-term reablement-oriented interventions. Seond, the poliy emphasis on prevention means that in some areas efforts are being made to develop low-level servies, often through partnerships with voluntary and ommunity organisations. These may ontribute to meeting valued maintenane outomes suh as domesti help and soial partiipation. These initiatives are likely to develop further as POPPs pilots get under way. Third, inspetion and quality indiators for residential and day are servies appear to have had an impat on proess outomes, at least aording to the servie users interviewed in this survey. Many of these proess outomes also feature strongly in older people s experienes of rehabilitation and reablement servies. Overall, it is inreasingly diffiult to identify a distintive soial are outomes fous. Many of the outomes desired by older people are likely to be addressed as the result of other poliies and servie developments. Thus in the ase study interviews, managers and front-line pratitioners did not always use the language of outomes but referred as well to goals, independene, prevention or person-entred servies. Members of the User Advisory Group also noted the ontributions of other organisations and servies, partiularly NHS staff and voluntary setor organisations, to desired outomes. However, there remain some signifiant gaps. The overall impression, even from ase study sites hosen for their outome-related approahes, is one of fragmentation. The outomes valued by older people were 63

81 ADULTS SERVICES most likely to be ahieved in servies with strong interprofessional teams and devolved resoures over whih they had ontrol. For example, in multidisiplinary reablement servies, day entres and residential are homes, staff had aess to a range of skills and resoures that they ould draw on flexibly in response to users priorities and to hanges in these. However, there appeared to be signifiant disjuntions between these examples of good pratie and servie users wider lives. For example, day entres ould provide exellent quality servies, with a high emphasis on proess outomes, for those who attended. However, support for users to maintain their own soial networks outside the day entre was non-existent. The most striking disjuntion, aknowledged by many managers and pratitioners, was between short-term reablement servies and longer-term home are servies. Here resoure onstraints and poor relationships with independent providers meant that home are servies were often inflexible, of poor quality and insuffiiently responsive to the outomes desired by older users. The new ontrating arrangements desribed in this knowledge review are in their very early stages and need areful monitoring and evaluation to ensure they deliver home are servies that address maintenane and proess outomes. As with any major organisational hange, introduing an outomes fous into soial are requires leadership and vision; the means to ommuniate effetively to all staff; and the apaity to underpin ultural hange with appropriate proedural and information management arrangements. For all the ase study sites in this pratie survey, the SAP onstituted a barrier rather than an enabling fator and managers had struggled to make it ompatible with outomes-foused approahes. The outomes desired by older people extend beyond the support urrently provided by soial servies departments. Partnerships with health, other loal authority servies suh as transport, and partiularly with voluntary setor organisations that appear inreasingly to be providing low-level preventive servies are therefore key to outomesfoused approahes. Members of the User Advisory Group also emphasised that many of the wider, life-enhaning outomes valued by older people extend beyond the sope of soial servies. Close relationships with voluntary organisations were onsidered to be key to filling some of these gaps. However, members stressed that voluntary organisations must have adequate funding and flexibility to play this role, rather than 64

82 Conlusions be onstrained by rigid ontrats with their loal authorities. Seurely funded advoay shemes were also onsidered essential in supporting older people to identify desired outomes and to aess the servies needed to fulfil these outomes. It is therefore important that the poliy priority and resoures alloated to intermediate are servies that promote hange and proess outomes do not elipse the ontinuing need for low-level servies that promote preventive and maintenane outomes. It is signifiant that managers and users interviewed in the pratie survey made very little mention of alternative forms of delivering support suh as diret payments or individual budgets. It is therefore likely that, for older people at least, a signifiant hallenge remains for soial servies departments to develop and sustain their different relationships with those voluntary and independent providers who an supply the outomes-related support that older people need. 65

83

84 Referenes 1 Leadbeater, C. (2004) Personalisation through partiipation: A new sript for publi servies, London: Demos. 2 Department of Health (2005) Independene, well-being and hoie: Our vision for the future of soial are in England, Cm 6499, London: DH. 3 Department for Work and Pensions (2005) Opportunity age, London: DWP. 4 Walker, A. and Hennessy, C. (2004) Growing older: Quality of life in old age, Maidenhead: Open University Press. 5 Parry, J., Vegeris, S., Hudson, M., Barnes, H. and Taylor, R. (2004) Independent living in later life, Researh Report 216, London: DWP. 6 Audit Commission (2004) Older people Independene and wellbeing. The hallenge for publi servies, London: Audit Commission. 7 Baldok, J.C. and Hadlow, J. (2001) How older people sustain their identities and preferenes in the fae of a limited physial ondition and the need to aept health and are servies, Growing Older Programme, Swindon: ESRC. 8 Bajekal, M., Blane, D., Grewal, I., Karlsen, S. and Nazroo, J. (2004) Ethni differenes in influenes on quality of life at older ages: a quantitative analysis, Ageing and Soiety, no 24, pp Ware, T., Matosevi, T., Hardy, B., Knapp, M., Kendall, J. and Forder, J. (2003) Commissioning are servies for older people in England: the view from are managers, users and arers, Ageing and Soiety, no 23, pp Parry-Jones, B. and Soulsby, J. (2001) Needs-led assessment: the hallenges and the reality, Health and Soial Care in the Community, no 9, pp Qureshi, H., Patmore, C., Niholas, E. and Bamford, C. (1998) Outomes in ommunity are pratie. Overview: Outomes of soial are for older people and arers, Report No 5, York: Soial Poliy Researh Unit, University of York. 12 Qureshi, H. and Henwood, M. (2000) Older people s definitions of quality servies, York: Joseph Rowntree Foundation. 13 Raynes, N. (1998) Involving residents in quality speifiation, Ageing and Soiety, no 18, pp

85 ADULTS SERVICES Gwyther, L. (1997) The perspetive of the person with Alzheimer disease: whih outomes matter in early to middle stage of dementia?, Alzheimer Disease and Related Disorders, no 11, pp Clark, H., Dyer, S. and Horwood, J. (1998) That bit of help : The high value of low level preventative servies for older people, Bristol: The Poliy Press. Joseph Rowntree Foundation (2003) Soial servie users own definitions of quality outomes, Report on Shaping Our Lives Projet, Ref 673 (available at June). Gabriel, Z. and Bowling, A. (2004) Quality of life from the perspetives of older people, Ageing and Soiety, no 24, pp Clark, H., Gough, H. and Mafarlane, A. (2004) It pays dividends : Diret payments and older people, Bristol/York: The Poliy Press/ Joseph Rowntree Foundation. Godfrey, M. and Callaghan, G. (2000) Exploring unmet need: The hallenge of a user-entred response, York: Joseph Rowntree Foundation. Wenger, C. (1992) Help in old age: Faing up to hange, Liverpool: Liverpool University Press. Coleman, P.G., Ivani-Chalian, C. and Robinson, M. (1998) The story ontinues: persistene of life themes in old age, Ageing and Soiety, no 18, pp Henwood, M., Lewis, H. and Waddington, E. (1998) Listening to users of domiiliary are servies, Leeds: Community Care Division, Nuffield Institute for Health, University of Leeds. 23 Bamford, C. and Brue, E. (2000) Defining the outomes of ommunity are: the perspetives of older people with dementia, Ageing and Soiety, no 20, pp Godlove Mozley, C., Sutliffe, C., Bagley, H., Cordingley, L., Huxley, P., Challis, D. and Burns, A. (2000) The quality of life study: outomes for older people in nursing and residential homes, Unpublished report presented to the NHS Exeutive, London: DH. 25 Cordingley, L., Hughes, J. and Challis, D. (2001) Unmet need and older people: Towards a synthesis of user and provider views, York: Joseph Rowntree Foundation. 68

86 Referenes 26 Patmore, C. (2003) Understanding home are providers: Live issues about management, quality and relationships with soial servies purhasers, Working Paper No DH 1963, York: Soial Poliy Researh Unit, University of York. 27 Beaumont, G. and Kenealy, P. (2004) Quality of life pereptions and soial omparisons in healthy old age, Ageing and Soiety, no 24, pp Audit Commission (1997) The oming of age: Improving are servies for older people, London: Audit Commission. 29 Joseph Rowntree Foundation (2004) Older people shaping poliy and pratie, Summary of 18 researh projets, Ref 044 (available at Otober). 30 Cordingley, L. (1999) Relationships between health, soial support and independene in older people: a study using the SF-36 and Q methodology, Unpublished PhD thesis, University of Manhester. 31 Tester, S., Hubbard, G., Downs, M., MaDonald, C. and Murphy, J. (2003) Exploring pereptions of quality of life of frail older people during and after their transition to institutional are, Researh Findings 24, Growing Older Programme, Swindon: ESRC. 32 Hayden, C., Boaz, A. and Taylor, F. (1999) Attitudes and aspirations of older people: A qualitative study, Researh Report 102, London: DWP. 33 Shaping Our Lives Projet (2003) Shaping Our Lives: From outset to outome: What people think of the soial are servies they use, York: Joseph Rowntree Foundation and the DH. 34 Franis, J. and Netten, A. (2004) Raising the quality of home are: a study of servie users views, Soial Poliy and Administration, no 38, pp Qureshi, H. (1999) Outomes of soial are for adults: attitudes towards olleting outome information in pratie, Health and Soial Care in the Community, no 7, pp Franis, J. and Netten, A. (2002) Homeare servies in one loal authority: Client and provider views, Rep 1795/3, London: Personal Soial Servies Researh Unit. 37 Boaz, A., Hayden, C. and Bernard, M. (1999) Attitudes and aspirations of older people: A review of the literature, Researh Report 101, London: DWP. 69

87 ADULTS SERVICES 38 Netten, A., Ryan, M., Smith, P., Skatun, D., Healey, A., Knapp, M. and Wykes, T. (2002) The development of a measure of soial are outome for older people, Rep PSSRU Disussion Paper 1690/2, University of Kent: Personal Soial Servies Researh Unit. 39 Willis, M., Douglas, G. and Pavey, S. (2005) Defining vision, Community Care, 7 13 July, pp Askham, J., Henshaw, L. and Tarpey, M. (1995) Soial and health authority servies for elderly people from blak and minority ethni ommunities, London: HMSO. 41 Mold, F., Fitzpatrik, J.M. and Roberts, J.D. (2005) Minority ethni elders in are homes: a review of the literature, Age and Ageing, vol 34, no 2, pp Butt, J. and Mirza, K. (1996) Soial are and blak ommunities, London: The Stationery Offie. 43 Allan, K. (2001) Communiation and onsultation: Exploring ways for staff to involve people with dementia in developing servies, Bristol: The Poliy Press. 44 Patel, N., Mirza, N., Linbland, P., Amstrup, K. and Samaoh, O. (1998) Dementia and minority ethni older people. Managing are in the UK, Denmark and Frane, Lyme Regis: Russell House Publishing. 45 Ramharan, P., Grant, G., Parry-Jones, B. and Robinson, C. (1999) The roles and tasks of are management pratitioners in Wales revisited, Managing Community Care, no 7, pp Challis, D., Weiner, K., Darton, R., Hughes, J. and Stewart, K. (2001) Emerging patterns of are management: arrangements for older people in England, Soial Poliy and Administration, no 35, pp Quinn, A., Snowling, A. and Deniolo, P. (2003) Older people s perspetives: Devising information, advie and advoay servies, York: Joseph Rowntree Foundation. 48 Baldok, J.C. and Hadlow, J. (2002) Self-talk versus needs-talk: an exploration of the priorities of housebound older people, Quality in Ageing: Poliy, Pratie and Researh, no 3, pp Godfrey, M. and Moore, J. (1996) Hospital disharge: User, arer and professional perspetives, Leeds: Nuffield Institute for Health, University of Leeds. 50 Clark, H., Dyer, S. and Hartman, L. (1996) Going home: Older people leaving hospital, Bristol: The Poliy Press. 70

88 Referenes 51 Age Conern (2006) The Age Agenda 2006: Publi poliy and older people, London: Age Conern. 52 Hardy, B., Young, R. and Wistow, G. (1999) Dimensions of hoie in the assessment and are management proess: the views of older people, arers and are managers, Health and Soial Care in the Community, no 7, pp Boneham, M.A., Williams, K.E. and Copeland, J.R.M. (1997) Elderly people from ethni minorities in Liverpool: mental illness, unmet need and barriers to servie use, Health and Soial Care in the Community, vol 5, no 3, pp Noon, A. and Qureshi, H. (1996) Outomes of ommunity are for servie users and arers: A soial servies perspetive, Report No 2, York: 55 Soial Poliy Researh Unit, University of York. Department of Health (2001) Soial servies performane assessment framework indiators , London: DH. 56 Sinlair, I., Gibbs, I. and Hiks, L. (2000) The management and effetiveness of the home are servie, York: Soial Work Researh and Development Unit, University of York. 57 Patmore, C. and MNulty, A. (2005) Making home are for older people more flexible and person-entred: Fators whih promote this, Working Paper No DH 2069, York: Soial Poliy Researh Unit, University of York. 58 Forder, J., Knapp, M., Hardy, B., Kendall, J., Matosevi, T. and Ware, P. (2004) Pries, ontrats and motivations: institutional arrangements in domiiliary are, Poliy & Politis, no 32, pp Knapp, M., Hardy, B. and Forder, J. (2001) Commissioning for quality: ten years of soial are markets, Journal of Soial Poliy, no 30, pp Matosevi, T., Ware, P., Forder, J., Hardy, B., Kendall, J., Knapp, M. and Wistow, G. (2000) Independent setor domiiliary setor providers in 1999, London: Personal Soial Servies Researh Unit, London Shool of Eonomis and Politial Siene. 61 Kendall, J., Matosevi, T., Forder, J., Knapp, M., Hardy, B. and Ware, P. (2003) The motivations of domiiliary are providers in England: new onepts, new findings, Journal of Soial Poliy, vol 32, no 4, pp

89 ADULTS SERVICES 62 Soial Servies Inspetorate (1999) Of primary importane: Inspetion of soial servies departments links with primary health servies, London: DH. 63 Health Advisory Servie (1997) Servies for people who are elderly: Addressing the balane, London: The Stationery Offie. 64 Banerjee, S. and Madonald, A. (1996) Mental disorder in an elderly home are population: assoiations with health and soial servies use, British Journal of Psyhiatry, vol 168, pp Shneider, J. (1997) Quality of are: Testing some measures in homes for elderly people, Disussion Paper 1245, Canterbury: Personal Soial Servies Researh Unit, University of Kent. 66 Alexopoulos, G. (1996) Editorial: geriatri depression in primary are, International Journal of Geriatri Psyhiatry, no 11, pp Patel, N. (1998) Blak and minority ethni elderly: perspetives on long-term are, in With respet to old age; Researh volume 1, Royal Commission on Long-term Care, London: The Stationery Offie. 68 Qureshi, H. (2001) Summarising intended outomes for older people at assessment, in H. Qureshi (ed) Outomes in soial are pratie, Report 7, York: Soial Poliy Researh Unit, University of York. 69 Raynes, R., Temple, B., Glenister, G. and Coulthard, L. (2001) Quality at home for older people: Involving servie users in defining home are speifiations, Bristol: The Poliy Press. 70 Evans, C. and Carmihael, A. (2002) Users best value: A guide to user involvement good pratie in best value reviews, York: Joseph Rowntree Foundation. 71 Niholas, E. (2001) Implementing an outomes approah in arer assessment and review, in H. Qureshi (ed) Outomes in soial are pratie, York: Soial Poliy Researh Unit, University of York, pp Niholas, E. (2003) An outomes fous in arer assessment and review: value and hallenge, British Journal of Soial Work, vol 33, no 1, pp Bamford, C. (2001) Using postal questionnaires to ollet information on outomes from users and arers, in H. Qureshi (ed) Outomes in soial are pratie, Report 7, York: Soial Poliy Researh Unit, University of York. 72

90 Referenes 74 Clark, H. (2006) It s meant that, well, I m living a life now : older people s experienes of diret payments, in J. Leee and J. Bornat (eds) Developments in diret payments, Bristol: The Poliy Press. 75 Patmore, C. (2001) Briefing sheet for home are staff: a method for fousing servie around eah individual user, in H. Qureshi (ed) Outomes in soial are pratie, Report 7, York: Soial Poliy Researh 76 Unit, University of York. Glendinning, C., Hardy, B., Hudson, B. and Young, R. (2002) National evaluation of notifiations for use of the Setion 31 partnership flexibilities in the 1999 Health At: Final projet report, Leeds/ Manhester: Nuffield Institute for Health/NPCRDC. 77 Dowling, B., Powell, M. and Glendinning, C. (2004) Coneptualising suessful partnerships, Health and Soial Care in the Community, vol 12, no 4, pp Department of Health (2006) Modernising adult soial are: Researh initiative Newsletter 2, London, DH, April. 79 Brue, E., Surr, C. and Tibbs, M.A. (nd) A speial kind of are: Improving well-being in people living with dementia, Bradford Dementia Group and MHA Care Group (available at aad/health/bdg/researh/methodist.php). 80 Makenzie, J. and Coates, D. (nd) Understanding and supporting South Asian and Eastern European family arers of people with dementia, Bradford Dementia Group (available at health/bdg/researh/supporting.php). 81 Hudson, B., Dearey, M. and Glendinning, C. (2004) A new vision for adult soial are: Soping servie users views, York: Soial Poliy Researh Unit, University of York. 73

91

92 Appendix 1 User involvement in the knowledge review The User Advisory Group In order to ensure that the knowledge review was informed by the views and experienes of older people themselves, an Advisory Group was reruited. The Advisory Group met three times during the knowledge review; eah meeting was held at a point at whih reent ativities ould be reported and immediate deisions and ourses of ation ould be disussed and modified in the light of group disussions. The advisory group was reruited through the Age Conern Consultation Servie (ACCS). Although this is a national servie, ACCS was asked to reruit up to six people from the loal area (to keep down travelling osts). Other speifiations were that members should be familiar with onsultation ativities; should have experiene of using soial are servies; should inlude both women and men; should inlude at least two people from minority ethni ommunities; and should inlude at least one older person with experiene of aring for someone with dementia. The atual members of the group inluded three women and three men, two minority ethni older people and one man whose wife had dementia and was living in a residential are home. The others all had personal experiene of using soial are and voluntary setor servies; some had been atively involved in a Better Government for Older People pilot projet; and some had taken part in previous researh onsultation groups. First meeting June 2005 The first meeting of the Advisory Group took plae in June 2005, after ompletion of the literature review and before the postal survey was onduted. The Group was given an outline of the projet; invited to disuss the onept of outomes with referene to their everyday experienes; presented with the main findings from the literature review; and 75

93 ADULTS SERVICES informed about the next stage of the projet (the postal survey). Members of the group made the following points. What do we mean by outomes? Not everyone finds it easy to think about what outomes they want or what is possible although skilled assessment an help with this. The outome someone wants may not always be what is best for them. Carers or professionals may seek different outomes. There has to be a proess of negotiation and people make trade-offs. Servie providers may redue independene by doing too muh. It is important to reognise individual needs and differenes it may be hard to meet these needs if they are relatively unusual (for example, speial dietary needs). Comments on the aims of the projet Human relationships are more important than poliy and paperwork. Servies sometimes fous too muh on the bureaurati proess of assessment rather than on outomes. There was onsiderable disussion about aess to servies. It was important to inlude people who do not/annot aess servies. Many older people do not ask for help even the name soial servies an be off-putting. Older people from minority ethni groups also have to overome language barriers they often have to rely on their hildren to interpret, but if their hildren have been born in England they may not speak the ommunity tongue. Soial servies ould improve aess by having loser links with the voluntary setor; groups suh as Age Conern are more approahable but loal authorities do not always provide adequate finanial support for suh groups. Servie users need ontat with someone who has an overall perspetive, who an disuss what outomes they might realistially expet in their individual situation. Home are staff (who are often in most frequent ontat with older people) are not usually able to perform this role. Health servies partiularly GPs have a role to play as they are in touh with many older people (ould the new ommunity matrons fill this gap for those with the most omplex needs?). But how losely are health and soial servies really working together? 76

94 Appendix 1 There was a general onsensus that agenies should share information as long as this is for the user s benefit and a suggestion that agenies should ask users permission to do this on a routine basis. What do we know already from the researh that has been done? There are some important tasks that soial servies do not help with, for example, leaning and gardening and taking someone shopping instead of doing their shopping for them. Clean and tidy homes and gardens are very important, espeially to older women and those who are housebound and if premises look unkempt there are also seurity risks. Going shopping an keep the mind alert, as an help to keep up hobbies and soial ontats. There was strong agreement about the importane of having hoie and ontrol over servies. Outomes of home are servies are influened by the alibre of are staff. Jobs are poorly paid and have low status, therefore there is high turnover. There is a need for more training and higher pay/status. The privatisation of many are servies has inreased ommuniation problems the person doing an assessment does not always ommuniate the desired outomes to the atual servie. In-house servies an be more reliable for this reason. Home are is also pereived as very ostly and osts an prevent people ahieving their desired outomes. Transport to servies is a real problem. GPs have a key role in helping older people aess soial are servies sometimes people feel they are passed from one person to another. Comments on the forthoming postal survey The advisory group asked how the researh team would know the answers obtained were aurate. It was explained that in some areas there would be more than one respondent, so answers ould be ross-heked. In the six ase study areas, the researh team would be talking to older people and arers as well as professionals; it would be 77

95 ADULTS SERVICES very important to find out if the outomes fous really works from the users perspetive. Group members were onerned the study should reah non-users of servies as many older people find it hard to get information about servies, espeially if they are house-bound, have language diffiulties or are no longer in touh with a wide range of ontats through work. Seond meeting September 2005 At this meeting, the onept of outomes was disussed again; the preliminary results of the postal survey were presented; and plans for the ase study site visits were disussed. Group members made the following points. Further disussion of outomes and servies Many older people have a hroni illness and would benefit from on-going ontat with a GP. However many GPs do not now visit people s homes routinely even though it an be diffiult for people to attend the surgery. If someone is under the are of a onsultant, some GPs an ignore their responsibility for the wider effets of the illness for example, on the patient s mental health and this an affet their desired outomes from soial are servies. Current trends mean it an be diffiult to get to see the same GP and shorter appointments add to the problem of having to start again eah time with a different GP. Lak of ontinuity is a potential problem for ahieving an outomes-foused approah, sine hanges in people s needs and desired outomes are not traked and disussed over time. Healthy eating advie and information is needed for older people to maintain their quality of life. With the right training, this ould be offered by home arers. Being supported to get out and about (for example to go shopping and other soial ontats) is important for maintaining quality of life. Without these sorts of ativities, older people an beome withdrawn and feel less onfident and positive about life. Voluntary setor shemes to help with mobility are important, suh as Dial-a-Ride; 78

96 Appendix 1 Age Conern also offer volunteers to help people who use wheelhairs get about town to do their shopping. Older people feel vulnerable when they need to depend on others, espeially if they do not deliver servies as expeted. Preliminary results from the postal survey The response rate was felt to be disappointing, although perhaps not surprising and possibly refleted the low priority given to outomes for older people. More servies need to be enouraged to involve older people and to monitor and evaluate their outomes-foused work, judging by the low number of organisations reporting that they urrently do so. Plans for the ase study site visits site seletion The seletion of loal authorities where there was good pratie was questioned why not inlude a loality where things are not going so well? It was explained that it was diffiult to learn anything from these sites to pass on to other areas; other bodies were responsible for identifying poorly performing loal authorities; and the researhers would be asking loal managers how they had overome any problems and barriers these lessons should help managers in other areas. The exlusion of a small unitary authority like York was questioned it was explained that this was beause none of these authorities who responded to the postal questionnaire had made suffiient progress with an outomes approah to be seleted as a ase study site. Plans for the ase study site visits interviews with servie users Group members made many pratial suggestions about the information that servie users taking part in the ase study interviews and disussions would need to know before agreeing to take part. This inluded: Why did you hoose me? What is the projet about? How muh time will it take? 79

97 ADULTS SERVICES How private is it will any staff be present? Can I have someone with me (for example, a friend or family member)? Is the information I give the researhers onfidential? Will what I say affet any servies I reeive? Will transport be provided to the interview venue? Will an interpreter be available if I want someone? What if I look after someone else? Can the researhers over the ost of their are while I am being interviewed? What feedbak will I get afterwards (for example, a summary of the loal ase study)? Plans for the ase study site visits questions to be asked of servie users and managers Members ommented in detail on the draft topi guides for the interviews and disussion groups with older people using servies in the ase study sites and made many suggestions about amending the wording to make this more onsistent with the experienes and onerns of older people. They suggested the following questions should be inluded in the interviews with servie managers: If it was your mother reeiving the servie, would you be happy? Are you working with voluntary organisations? To what extent do soial servies share information with other relevant servies or departments, for example, housing? How far do government poliies make a differene to what atually happens in pratie (not just what is on paper)? If an assessment identifies an outome that annot be met by soial are servies, how is that dealt with? Is it referred to another department, servie or voluntary organisation? Third meeting January 2006 The main fous of this meeting was the preliminary results from the ase study site interviews. The Advisory Group was reminded of the sites and servies involved and the range of staff and servie users who had been interviewed. The impat of outomes-foused servies in the six sites 80

98 Appendix 1 was illustrated through six vignettes of servie users who the researhers had met; these vignettes were intended to illustrate how different servies ould help people ahieve hange outomes, maintenane outomes and proess outomes. General points about outomes and loal servies Some Advisory Group members had reeived a letter from the ounil telling them there would be hanges in their home are servie but giving few onrete details. There was a rumour that all or most home are servies would soon be provided by private agenies this made people anxious, as they felt they would have less ontrol over quality, reliability and ost. Servie users were not sure if, or how, ageny staff are vetted and they felt safer with the in-house servie. They feel ageny staff an be too young and inexperiened, and there is less ontinuity. If they have to use a private ageny, they would prefer not to have to hoose whih one themselves. Older people an find it hard to be assertive, espeially if they are on their own. Choie an be meaningless in suh irumstanes to make it meaningful, people must have aess to support and information. There was disussion of the planned losure of the loal NHS Elderly Mentally Infirm unit. Older people were felt to have little ontrol over suh deisions, whih reflet an ivory tower syndrome in whih suh matters are deided behind losed doors. One advisory group member had reently reeived a lot of help from ommunity nurses he valued their ompany and the soial aspet of their visits. He explained that people who are house-bound suffer through lak of ontat with loal networks that an be an important soure of information. Another group member had been told that Housing Benefits would be paid differently in future. Again there was not muh information about this and it was making people anxious. 81

99 ADULTS SERVICES Comments on the ase study visits and vignettes of servie users When people are limited in what they an do, it an be very frustrating this an even affet their mental health. The osts of home are an be an extra barrier. Private agenies are pereived as less satisfatory than in-house are. There was disussion about the sope of soial are servies and whether these inluded wider life-enhaning outomes suh as soial and leisure opportunities. The advisory group thought that this is where hoie is important. It was pointed out that voluntary organisations are often able to fill these gaps, but they must have adequate funding and the flexibility to respond to individual outomes. It was felt that some voluntary groups are now too tightly ontrolled by rigid ontrats with their loal authority. The individual, personalised approah was really important to users, but staff attitudes depended a lot on good training. Advoay shemes and seure funding for these are essential in supporting older people to identify desired outomes. 82

100 Appendix 2 Methods used in the knowledge review Researh review The researh review did not involve a systemati searh for all known researh. Instead it drew on published outputs from a number of reent researh programmes in England and/or the UK that were known to be highly relevant to the topi. The review was restrited to the UK and to reent publiations beause of the diffiulties of generalising from other servie and poliy ontexts and the rapidly hanging poliy and pratie environment in the UK. Relevant researh inluded: Outputs relating to outomes and servies for older people and their arers derived from projets arried out under the Department of Health-funded Soial Poliy Resarh Unit (SPRU) Outomes Programme sine The Department of Health-ommissioned Outomes of Soial Care for Adults (OSCA) researh programme. The Eonomi and Soial Researh Counil s (ESRC s) Growing Older researh programme. Reent studies arried out by the Audit Commissions s Publi Setor researh programme. Studies arried out as part of the Joseph Rowntree Foundation s programme Older People Shaping Poliy and Pratie. Researh onduted as part of the Personal Soial Servies Researh Unit (PSSRU) and Nuffield Institute of Health s Mixed Eonomy of Care researh programme. Information olleted by SPRU from organisations representing adult soial are servie users as part of a sooping exerise on their vision for adult soial are. 81 This researh was supplemented by a limited amount of additional searhing, partiularly of itations at the end of artiles where these 83

101 ADULTS SERVICES related to groups of older people who were not well represented in mainstream literature. While this searh strategy was not systemati, we are nevertheless onfident that we have inluded all reent relevant published researh. Partiularly in relation to researh on the outomes desired by older people and their arers, there is a very high level of onsisteny between different studies, whih suggests that the risk of omitting researh that would signifiantly alter the findings of this review are relatively small. Postal survey Sampling framework The ontats who were sent the postal survey were identified from a database of individuals and organisations in the UK known to have an interest in developing outomes-foused soial are servies. The database was established and maintained by SPRU as part of an Outomes Network that was set up to failitate previous researh and development work funded by the Department of Health. The database provided a broad sampling framework for what was a highly targeted survey aimed at ontats who had developed or were urrently developing, outomesfoused approahes to servies for older people. In order to identify target respondents, the database was updated to ensure that only relevant and urrent ontats working with older people were inluded in the sample to be sent the survey. Of the 340 ontats, 99 were immediately exluded beause they were not in England or Wales, or were not relevant to the survey. The remaining 241 ontats were sent information about the study and a sreening questionnaire in order to update the database prior to the postal survey being mailed out. Respondents to the sreening questionnaire were also given the opportunity to identify other ontats, potentially unknown to the researh team, within or outside their organisation, who were also developing outomes-foused approahes to their older people s servies. A reminder to omplete the sreening questionnaire was sent by and/or post. Information from responses to the sreening questionnaire was used to update the database. In addition, all ontat details (name, address, job title et) of non-respondents to the postal survey were heked. The 84

102 Appendix 2 database was then used to identify the sample population for the pratie survey. Sixty three ontats were exluded beause they were not eligible, or beause they dupliated ontats from the same organisation, or they were from NHS organisations (see below). A total sample of 222 ontats (inluding all non-respondents to the postal survey) was identified, inluding 22 ontats from Wales. Development and ontent of the questionnaire A postal questionnaire was devised. The ontent was informed by the researh review and was designed to allow for the possibility that respondents would be engaged in a wide range of different outomesfoused servie developments, at different stages of development. A draft questionnaire was piloted with ontats in three (different) soial are organisations and minor revisions were made to the questionnaire. The questionnaire inluded a mix of losed and open-ended questions, with additional spae for respondents to expand on their answers if they wished. Most of the questions foused on outomes-foused work relating diretly to older people, although some questions related to arers of older people, refleting the balane of the researh brief. Respondents were also enouraged to submit any supporting douments relating to the outomes-foused ativities they desribed in the questionnaire. The questionnaire is inluded in Appendix 4. Condut of the postal survey A opy of the postal questionnaire together with a overing letter, information sheet about the projet and freepost return address label addressed to the researh team were sent to all potential respondents in July The questionnaires were pre-oded to enable respondents to be identified and not sent an unneessary reminder. Those who had not responded within three weeks were sent a reminder, inluding a seond opy of the questionnaire, by post. The deadline for responses was finally losed on 26 September Of the responses reeived, four were exluded beause the respondents did not work with older people. 85

103 ADULTS SERVICES Data analysis Quantitative and qualitative data from the questionnaires were entered onto an Aess database, heked and verified by two of the researhers. Quantitative data were transferred to SPSS for desriptive statistial analysis. Themati analysis of the qualitative data was arried out by the researhers, who together identified methods of ategorising the data. Where supporting douments were submitted, these were logged and examined as part of the in-depth ase studies (where appliable); some were also used as referene materials in subsequent work with the ase study sites. Case study sites Initial analysis of the postal survey revealed that only six organisations in Wales had responded (inluding two that replied after the deadline); these were all in the early stages of developing outomes-foused work with older people. Additional efforts were made by SCIE managers to hek that these responses refleted the urrent state of development in Wales; their efforts onfirmed the findings of the survey. As a result, the six ase studies seleted for more in-depth evaluation were all drawn from England on the basis that they offered the most potential for other organisations in England and Wales to learn from their experienes and pratie. Seletion of ase study sites Preliminary analysis of the quantitative and qualitative data from the postal survey was onduted to identify potential ase study sites. First, sites where outomes-foused work with older people had been established for the longest period of time were identified, on the grounds that these sites would have had the greatest range of experiene to draw on from whih lessons for other loal authorities ould be learned. Seven sites reported having had outomes-foused approahes established for more than three years. Another nine sites reported having had outomesfoused approahes for up to three years. The remainder of the sites responding to the postal survey were in the early stages of developing their outomes-foused work, for example, planning, rolling out, or 86

104 Appendix 2 piloting their work (inluding six Welsh sites that responded to the postal survey). The 16 sites where outomes-foused work had been established for longest were then examined in detail, together with one site from Wales that appeared to have made the most progress in developing outomesfoused work in order to omply with the SCIE study speifiations. Fators inluded in this analysis were: evidene of hanges in assessment, are planning and/or review; developments in ommissioning and/or servies; multiageny working; and older people s involvement in developing outomes-foused approahes. This analysis resulted in a long list of 10 potential ase study sites being identified. Among these, six sites appeared to have had an emphasis on outomes-foused assessment, are planning and review, with the remaining four onentrating on outomes-foused ommissioning and/or servie hange. From this list, six preferred ase study sites were seleted that inluded both types of outomes-foused ativities; a geographial spread; and a mix of different servies. The postal survey respondent for eah potential site was then ontated by the researh team, to larify their work to date and seek agreement in priniple to partiipate. Three potential sites (inluding the one in Wales) delined to take part owing to ompeting priorities. In an attempt to seure representation of a Welsh loal authority in the study, SCIE ed all heads of adult soial servies in Wales to request a volunteer replaement site, but none of those responding thought they had made suffiient progress with outomes-foused approahes to take part. Consequently, three replaement sites were sought from the long list and their agreement to take part seured. Defining the sope of the ase study fieldwork The researh team then disussed in more detail the sope of the fieldwork with eah of the six sites. In eah site we wished to gain both an overview of progress with outomes-foused servies for older people and to investigate a partiular type of servie in more depth. The latter would at as a vehile for examining how the loal outomes approah was working in pratie, inluding feedbak from servie users about the fit with their desired outomes. Resoures allowed around six fae-to-fae interviews with staff (slightly more if small group disussions proved 87

105 ADULTS SERVICES appropriate), and interviews with between 12 and 18 older servie users (again individually or in small groups) in eah site. Negotiating with individual sites about whih type of servie to fous on resulted in some hanges to our initial plans, whih in turn affeted the final mix of servies examined aross the sites in total. In partiular some sites were more keen for us to look at developments in intermediate are/rehabilitation servies (where they felt they had made most progress), and less keen for us to fous on mainstream servies suh as home are (where they felt they had made less progress, despite having indiated developments in their response to the postal survey). As the study aimed to learn from the experienes of ase study sites, eah site s assessment of the appropriate servie fous was taken seriously. In pratie, during the fieldwork staff and users spoke about a range of servies and so we did obtain data about other servies beyond the main fous of eah site visit. The six ase study sites and the main servie fous in eah were as follows (the names of the servies are those used by the site): Case study site City of Bradford Metropolitan Distrit Counil Cumbria County Counil Dorset County Counil London Borough of Hillingdon North Linolnshire Counil Worestershire County Counil Servie fous in fieldwork visit Day are Intermediate are Preventative servies Home are and rehabilitation Residential are Rehabilitation Further details of eah site are inluded in Appendix 3. Data olletion Data were olleted through site visits between the beginning of November and early Deember Fieldwork in eah site was onduted by two researhers, one of whom took the lead in liaising with the ontat person in eah site (details of staff and users who were 88

106 Appendix 2 interviewed are inluded in Appendix 3). To help ensure onsisteny between sites, a ommon topi guide was developed for users (Appendix 4) and another for staff (Appendix 4), whih ould be adapted to aommodate the range of postholders we enountered in eah site. Individual interviews with staff or users were arried out by a single researher, with both researhers present for any group disussions. All data olleted from staff were tape-reorded. Data olleted from servie users were reorded through a ombination of detailed note taking and tape-reording, depending on the irumstanes and individual preferenes of the users involved. Following agreement on the range and fous of the fieldwork with the lead ontat in eah site, s/he (or their nominee) took responsibility for reruiting appropriate staff and user respondents on our behalf. Separate projet information sheets were developed for staff and users. We asked that users be approahed by a member of staff who knew them to ask whether they would be willing to take part, making lear that they ould withdraw at any time. At this stage, users were asked for onsent for their ontat details to be passed on to the researh team. Staff also made appointments for the researhers either to visit a servie user individually, or to speak with him/her as part of a small group disussion. A reply form was returned to the researh team at this stage, with the user s ontat details, a note of any known soial are interventions and any needs to enable him or her to take part, for example transport. Users were asked for written onsent by the researher at the time of data olletion, again being reassured that they ould withdraw. In total aross the six ase study sites we worked with 153 respondents, 82 of whom were staff and 71 were servie users. Among the staff, the majority by far were employed by soial servies or working in joint health and soial are teams, with the remainder either employed by the NHS, the voluntary setor or the private setor. Data analysis One the fieldwork visits were omplete, the notes and taped material were typed in preparation for analysis. Initially the data were written up site by site, to provide a oherent loal aount. To ensure a onsistent approah, a template was drawn up with headings derived from the SCIE brief, whih the researhers used to organise their desription of eah 89

107 ADULTS SERVICES site s outomes-foused approahes and the key issues and themes arising in the data. A number of vignettes of typial users and experienes of servie use were inluded, to give a flavour of older people s situations, are servies and outomes. Ethial and researh governane issues Ethial approval for the pratie survey was obtained from the Assoiation of Diretors of Soial Servies (ADSS) researh group. Postal survey respondents were assured that individuals and organisations would not be identified in reports of the work without their expliit onsent. Potential interviewees in the ase study sites were asked for their onsent for their ontat details to be forwarded to the researh team and were again asked for written onsent before the start of eah interview/fous group disussion. The SPRU Outomes Network database of ontats inluded some people working in NHS organisations. However, it was not possible to inlude NHS staff and organisations in the postal survey beause this would have required NHS ethis and researh governane approval, whih it was not possible to obtain within the study timetable. However, responses to the postal survey revealed that a number of loal authorities were involved in joint outomes-foused servie developments together with loal NHS partners, for example, around hospital disharge and the Single Assessment Proess (SAP) (England)/Unified Assessment Proess (UAP) (Wales). Furthermore, in two of the six ase study sites, soial servies staff were working partiularly losely with olleagues in the NHS and felt it was important to obtain the latter s perspetives on the development of outomes-foused approahes. The nature of NHS staff involvement was somewhat unusual, in that they were not the subjets of the researh but rather were being asked for their perspetives on loal outomes-foused servie developments. The researh team therefore ontated the Central Offie of Researh Ethis Committees (COREC) to seek guidane on whether the projet needed NHS ethial approval. COREC advised that, given the nature of the projet, it did not need to be submitted to an NHS researh ethis ommittee. In both areas in whih NHS staff were involved in outomes-foused servies the researhers then ontated the loal NHS researh govern- 90

108 Appendix 2 ane oordinator and researh ethis ommittee oordinator to advise them about the projet and, following advie from COREC, to larify whether there were any loal proedures that should be followed. Both the loal researh ethis ommittee oordinators aepted the COREC advie and no further ation was needed. In one area the researh governane oordinator required an NHS researh and development appliation form to be ompleted so that they had a reord of the researh; in the other area the oordinator simply advised that management approval for staff involvement should be obtained from the NHS trust. In addition, three of the soial servies departments involved had their own loal researh governane proedures. In eah of these areas we ompleted the neessary forms and loal approval for the projet was given. 91

109

110 Appendix 3 Summary of ase study sites: servies and ativities This appendix ontains details of the six loalities inluded in the ase study visits. Dorset Dorset is a predominantly rural shire ounty with a population of almost 400,000 this is expeted to grow by some 35 per ent in the next 25 years. Besides the ounty ounil, there are six distrit/borough ounils and more than 20 large town and parish ounils. Bournemouth and Poole have unitary authorities, whih provide all servies in their respetive areas. Dorset has the highest elderly population in the ountry (approximately 93,700), as many people hoose to retire there and it also has high life expetany. However, funding for servies for older people in Dorset is the lowest in the ountry around 12 million below the average. The Audit Commission assessed the ounty ounil as an exellent authority in 2002, and the soial are and health diretorate (SC&H) is a two-star department. Dorset SC&H and its health partners have signed up to the innovations forum, in whih the government and toprated ounils an promote new ways of working. Dorset is also piloting a loal area agreement. Both initiatives are fousing on the redution of avoidable admissions to hospital for older people and the promotion of wellbeing. In its response to the postal survey, Dorset identified a number of areas in whih it was taking forward an outomes approah, inluding ommunity and residential servies, pre-and post-disharge support, day are and arers support. The ase study investigation in Dorset foused on its preventative and rehabilitation servies for older people; and on how servies have been ommissioned and developed. Servies disussed and/or visited inluded: low-level preventative servies, ommunity rehabilitation shemes, home from hospital shemes and day entres. 93

111 ADULTS SERVICES The ase study site visit had two main strands: interviews (single or paired) with staff involved in developing, ommissioning or managing outomes foused approahes in preventative or rehabilitation servies interviews and a group disussion with users of an integrated day servie. Those interviewed for the ase study were staff (n=14) from soial servies, NHS servies and voluntary organisations; servie users (n=10) from day entres and user forums. Cumbria Cumbria is a rural ounty, overing an area of around 2,600 square miles. It has a population of almost 500,000, of whih nearly 25 per ent are aged 60 or over. Servie provision to those in the most remote ommunities is a hallenge for both health and soial are servies. Cumbria Soial Servies works in three loalities West Cumbria, East Cumbria and South Lakeland whih reflet this spread of population. Cumbria County Counil had only one-star under omprehensive performane assessment (CPA) but is improving well. In 2005, the Commission for Soial are Inspetion (CSCI) gave Cumbria Soial Servies a one-star rating (in 2003 and 2004 it had no stars), so in reent years the department has had a strong fous on improving its performane indiators. Cumbria was hosen as a ase study partly beause of the work reported in the postal survey on outomes-foused assessment and are planning. However, in the ourse of the ase study visit it emerged that the department was about to pilot a number of signifiant hanges in its system for ontrating for home are servies, whih were designed to failitate a more outomes-foused approah. In addition, interviews with operational staff and servie users foused on intermediate are servies that have been developed jointly with NHS partners. Those interviewed for the ase study were: staff/managers (n=20) from soial servies and NHS servies;10 older people who had used 94

112 Appendix 3 intermediate are servies within the preeding two months. Two further interviews had been arranged but the older people onerned subsequently withdrew. Bradford The City of Bradford Metropolitan Distrit Counil overs Bradford, Bingley, Keighley and Shipley. It has a population of around 480,000 of whih approximately 16 per ent are aged 65 and over. The population is very mixed. In the 2001 Census, 19 per ent desribed themselves as Asian or Asian British and 1.5 per ent as of mixed heritage. In the Indies of Deprivation 2004, Bradford was ranked at 30 out of 354 loal authorities in England. For the last three years Bradford s adult servies have reeived a twostar rating; CSCI desribes its apaity for improvement as promising. In 2005 the department was suessful in its appliation for funding for a Partnerships for Older People Pilot (POPP) projet to develop integrated servies for older people with mental health problems. Bradford was one of the loal authorities involved in the original SPRU outomes researh. It was hosen as a ase study for the SCIE Pratie Review beause of its work on developing an outomes-foused approah to assessment, are planning and review, inluding hanges to doumentation. The ase study work also foused on Bradford s day are servies and two failities were visited. Both were ombined residential home and day entres. Those who took part in the study were: managers/staff (n=12) from soial servies; servie users (n=21), inluding users of day are and residential are servies. Hillingdon Hillingdon is one of the 33 London boroughs. Its population of almost a quarter of a million residents lives in about 100,000 households. Hillingdon is ranked 166 out of 354 authorities in the Indies of Deprivation 2004, but while several of its wards are among the least deprived in England, others are among the most deprived. Four fifths of 95

113 ADULTS SERVICES the population of Hillingdon are white; Asian (mainly Punjabi) residents make up the seond largest ethni group. The proportion of pensioner households varies aross the borough from less than one per ent to 16.2 per ent. Hillingdon urrently provides support to over 3,000 older people to help them live at home - above average for outer London boroughs. The 2002 joint SSI/Audit Commission Review and the 2004 CSCI inspetion identified the authority s approah as old-fashioned and alled for greater larity between the funtions of in-house and independent home are providers. The CSCI report stated that Although the range of servies was inreasing, and several were delivered on a joint basis, many of the servies for older people were traditional, delivered by a single ageny, laked fous on outomes for the servie user and reliant on residential and nursing home are. These reviews, together with the appointment of a new diretor of soial servies, were the atalyst for a major reorganisation of servies that have already resulted in a two-star rating (up one star) for Hillingdon s soial are servies for hildren and adults from CSCI in Deember Its apaity for improving its adult servies is now rated as promising, whereas previously it was rated as unertain. In its response to the postal survey, Hillingdon identified the following areas in whih it has been developing an outomes fous: home are; pre-disharge and post-disharge support; and day are. The ase study site visit foused primarily on the ommissioning and development of servies whih aim to (a) prevent admission to hospital or residential are or (b) rehabilitate people after hospital disharge. These inluded: rehabilitation servies provided in private are homes the reently modernised in-house home are servie an integrated, hospital-based (rapid response) servie soial servies ommunity rehabilitation team. Those interviewed for the ase study inluded: staff (n=17) from soial servies and rehabilitation servies; ten servie users, most of whom had used an intermediate are faility, and some who had used home are servies. 96

114 Appendix 3 Worestershire Worestershire County Counil overs a mixed urban/rural area inluding six distrit ounils. Aording to the 2001 Census, the proportion of older people was 19.1 per ent, around average for England and Wales (19 per ent). In the Deember 2005 CSCI assessment, Worestershire Soial Servies was awarded three stars. The ounil has also been suessful in bidding for a POPPs projet. Worestershire returned three questionnaires in the SPRU postal survey: on its reent development of a ommissioning strategy for older people s servies; on its urrent review of the are management proess for adults; and on the development of outomes-based ontrat speifiations for a range of new preventive servies. After initial disussions with staff, it was agreed that the ase study would fous on the reablement servie, sine this was where staff felt that they had made most progress with regard to an outomes-based approah and therefore where most learning ould be passed on. There were three elements to the reablement servie in north Worestershire, all of whih are time-limited: A next step rehabilitation unit: in a residential and resoure entre A residential intermediate are entre A ommunity reablement team. As well as the detailed fous on Worestershire s reablement servie, the site visit also obtained information about the development of the ommissioning strategy for older people s servies, the review of the are management proess, and outomes-based ontrat speifiations for new preventive Servies. While these outomes-foused developments shared some ommon drivers, the sense was of separate developments as opposed to an overarhing strategy for developing an outomes-based approah aross all servies. People interviewed: staff (n= 11) from soial servies, PCT and voluntary setor organisations; servie users (n=12) from reablement and intermediate are servies. 97

115 ADULTS SERVICES North Linolnshire North Linolnshire Counil is a unitary authority overing a mixed urban/rural area. Twenty per ent of residents are of pensionable age just over the average for England and Wales (19 per ent). At the time of the fieldwork, North Linolnshire had just been suessful in its bid for POPPs funding. North Linolnshire returned two questionnaires in the SPRU postal survey, both of whih referred to hanges in are management and one also drew attention to a loal quality development sheme for residential and nursing homes. After initial disussions with staff, it was agreed that the ase study would fous on residential are. We also obtained evidene about progress with other outomes-foused work, in partiular are management and home are. The study team visited three residential homes (one in-house and two privately owned). People interviewed: staff (n= 8) from soial servies and residential homes; servie users (n=8) from all three residential homes. 98

116 Appendix 4 Data olletion and projet douments Postal survey of outomes-foused servies for older people Soial Poliy Researh Unit, University of York Instrutions for ompleting questionnaire Please omplete as many questions as possible. There is spae at the end of the questionnaire for you to add any omments. We would be grateful for any douments (reports, plans, non-onfidential minutes) that you an send us that desribe outomes-foused initiatives or pratie in your organisation. All responses to the questionnaire will be treated in onfidene. Individuals and servies will not be identified in reports of the survey. However, we would like to identify a small number of loalities where we an look in detail at innovative outomes-foused approahes to older people s servies. We would therefore be grateful if you ould give us your ontat details. Names and/or loalities would only be identified with the permission of those onerned For the purposes of this survey, the terms below are defined as follows: Outomes the impat, effet or onsequene of help reeived from servies. Outomes-foused approahes ways of organising servies so that they an ahieve the outomes that servie users desire. Older people servie users aged 65+. Servies soial servies and their partner organisations/agenies (for example, health, voluntary servies) involved in outomes-foused work. 99

117 ADULTS SERVICES If you are not involved in any outomes-foused work with older people, please only omplete questions 1-3. If you have any queries or need any help ompleting the questionnaire, please ontat Janet Heaton tel: ) or Caroline Glendinning tel: ). Please return the questionnaire within two weeks using the FREEPOST label provided. Os dymunwh gael opi o r holiadur hwn yn Gymraeg wnewh hi roi gwybod i ni os gwelwh yn dda. If you would like a opy of this questionnaire in Welsh please let us know. 100

118 Appendix 4 Part A: You and your organisation 1. Please provide your name and ontat details Title: Mr Miss Ms Mrs Dr Other (please speify)... First name:... Surname:... Job title:... Name of organisation you work in: Address:... Postode:... Tel:

119 ADULTS SERVICES 2. What type of organisation(s) do you work in? (Please tik all that apply) Loal authority/soial servies PCT NHS trust Voluntary organisation Private servie provider Private onsultany Other (please state) 3. Whih of the following servie user groups does your job inlude? (Please tik all that apply) Older people aged 65+ Other If you answered only Other to Q3, there is no need to omplete any more questions. But please return the questionnaire in the envelope provided (so that we know how many people we ontated are not doing work with older people and their arers). Thank you. Part B: Involvement in outomes-foused work for older people 4. Are you involved in any of the following outomes-foused approahes to older people s servies? (Please tik all that apply) Planning servies that aim to identify and ahieve the outomes valued by older people Commissioning servies that aim to identify and ahieve the outomes valued by older people 102

120 Appendix 4 Providing servies that aim to identify and ahieve the outomes valued by older people Monitoring and evaluating effetiveness of outomes-foused servies for older people Involving older people in the design and development of outomes-foused servies Independent onsultany/development work with soial are servies Other type of outomes-foused work for older people Outomes-foused approahes to supporting arers of older people If you have answered No to ALL items in Q4, there is no need to omplete any more questions. But please return the questionnaire in the envelope provided (so that we know how many people we ontated are not doing work with older people). Thank you. 5. Please briefly desribe the nature of the outomes-foused approahes to older people s servies in your organisation. (Please supply any related douments desribing this work when you return the questionnaire.) 103

121 ADULTS SERVICES 6. Whih of the following best desribes the stage of development of the outomes-foused work you desribed in Q5? Established in pratie for more than three years Established in pratie for three years or less Currently being rolled-out Currently being piloted In planning stages Other (please desribe) Part C: Servie organisation and partnerships 7. Does the outomes-foused approah(es) you have desribed to older people s servies involve any other organisations? No, this department only (Please go to Q8) Yes If Yes, is this joint with : (Please tik all that apply) Loal authority/soial servies PCT NHS trust Voluntary organisation Private servie provider Private onsultany Other (please state)... If joint, whih is the lead ageny? (Please tik one only) Loal authority/soial servies PCT NHS trust Voluntary organisation Private servie provider Private onsultany Other (please state type of organisation)... No single lead ageny 104

122 Appendix 4 Part D: Older people 8. Please tell us whih of the following groups of older people are overed by your outomes-foused approah(es) to older people s servies. (Please tik all that apply) a) Older people living at home Yes No Don t know b) Older people living in residential are Yes No Don t know ) Older people in hospital prior to disharge Yes No Don t know d) Older people immediately after disharge from hospital Yes No Don t know e) Older people attending day are Yes No Don t know f) Older people with dementia Yes No Don t know g) Older people from blak and/or minority ethni groups Yes No Don t know h) Carers of older people Yes No Don t know 105

123 ADULTS SERVICES Part E: Approahes to outomes-foused work 9. Whih of the following ativities does your outomes-foused approah(es) to older people s servies involve? (Please tik all that apply) a) Identifying outomes desired by individual older people at assessment Yes urrently for most/all Yes urrently for some Yes still at planning stage No N/A Don t know b) A fous on outomes in are planning for older people Yes urrently for most/all Yes urrently for some Yes still at planning stage No N/A Don t know ) Reviewing whether outomes desired by individual older people at assessment are ahieved Yes urrently for most/all Yes urrently for some Yes still at planning stage No N/A Don t know 106

124 Appendix 4 d) Commissioning/developing brand new servies to better meet older people s needs and preferenes Yes urrently for most/all Yes urrently for some Yes still at planning stage No N/A Don t know e) Changing existing servies to better meet older people s needs and preferenes Yes urrently for most/all Yes urrently for some Yes still at planning stage No N/A Don t know f) Monitoring/evaluating servies to examine extent to whih servies are outomes-foused for older people Yes urrently for most/all Yes urrently for some Yes still at planning stage No N/A Don t know 10. To what extent have older people (servie users) been involved in planning the above approahes? Greatly Moderately A little Not at all Don t know N/A 107

125 ADULTS SERVICES 11. What have been the main ahievements or impat of your outomes-foused approah(es) to older people s servies? (Please rank these in order of importane, where 1 is the most important ahievement/impat.) Part F: What has helped and what has hindered you and your organisation make progress on outomesfoused approahes to older people s servies? 12. What three things have most helped you and your organisation progress outomes-foused approahes to older people s servies? (Please rank these in order of priority, where 1 is the most important fator.) Possible examples are: ommitment of managers, poliy developments, philosophy of staff, training of staff

126 Appendix What three things have most hindered you and your organisation in developing outomes-foused approahes to older people s servies? (Please rank these in order of priority, where 1 is the most important fator.) Possible examples are: targets, resoures, workload, training of staff Have you taken any measures to overome the barriers you mentioned in Q13? No Yes (Please desribe):

127 ADULTS SERVICES 15. If you answered Yes to Q14, were they suessful? Yes fully Yes partly No Too early to say Don t know Not appliable Please use the spae at the end of the questionnaire for any additional omments. Instrutions for returning questionnaire Please return the questionnaire using the FREEPOST label provided. Please remember to enlose any douments desribing the outomes projets or servie developments you are involved in. If you have any queries or need help ompleting the questionnaire, please ontat Janet Heaton ([email protected]; tel ) or Caroline Glendinning ([email protected]; tel ). What happens next We will analyse the responses to this questionnaire and write a report on the range of outomes-foused approahes to servies for older people. The report will be inluded in the knowledge review that SPRU will prepare for SCIE. We also wish to follow up a small number of loalities and investigate in more detail their outomes-foused approahes to older people s servies. We may therefore ontat you again to ask if your organisation would be willing to partiipate in this more detailed study, whih will take plae during the autumn

128 Appendix 4 Please use the spae below to add any additional omments you wish. Thank you for ompleting the questionnaire. 111

129 ADULTS SERVICES Pratie survey of outomes-foused servies for older people Soial Poliy Researh Unit, University of York with Aton Shapiro Case study sites Topi guide for servie users general 1. Introdutory questions What kind of servies are you using? How long have you been using them? In many areas, servies are quite restrited and an t neessarily take into aount the different lifestyles and preferenes of individual older people. What we are really interested in is finding out whether the servies you get help you to live the sort of life you want. That might be about helping you just to keep going, for example, helping you to keep lean and tidy and safe, or to keep in touh with other people. Or it ould be about helping things to hange or improve, for example, by beoming more independent. And it s also about how muh ontrol and hoie you feel you have about how things are done. 2. Your outomes Thinking about yourself, what is it that really matters to you in how you live your life? [prompt and probe against standard list of outomes valued by older people] Probes: Is there anything you might want to hange or improve? What about the emotional and soial aspets of your life, as well as the pratialities? 3. Your assessment How muh do you feel you have been enouraged to think and talk about what really matters to you when servies have been set up? Or were you just told what you ould have? 112

130 Appendix 4 How easy did you find it to do this? How easy do you think your assessor found it to talk in terms of your own priorities (rather than just about servies)? How often do you get the hane to talk about how well things are working or whether you would like something to hange? 4. Your servies On a day-to-day basis, do you feel the servies you are getting are helping you to live the kind of life you want? What s working well, what is not? How well do you feel your servies work together? How muh day-to-day hoie and ontrol do you feel you have over what servies you get and how they are delivered (for example, timing, what is done, who by) or are these restrited? Do you feel you are treated with respet? Do you have any ultural or religious preferenes relating to servies? If so, do servies take aount of these? Have you got anyone else helping you (family, neighbour?) If so, do servies try to fit in with what they do? Do you pay for any of your soial are servies? If so, do you feel they are good value for money? 5. General questions Overall, how good are servies at helping you live the life you want? Over time, have they been getting better at doing this? On refletion, do you think other areas an learn anything from how things are done here? 113

131 ADULTS SERVICES Outomes-foused soial servies for older people A review for the Soial Care Institute for Exellene (SCIE) Topi guide for servie users in are homes/other residential settings Name: Date: Interviewer: Age: Preliminaries 1. Show ID ard/ thanks for taking part/hek end time OK 2. Purpose of study: Aross England and Wales, soial servies departments are being enouraged to make sure that the servies they set up provide help with the things that older people themselves say are important to them. The overall aim of the projet is to see what progress is being made we are doing this in three ways: by looking at researh already arried out; by sending a questionnaire to soial servies departments aross England and Wales asking them to let us know what they are doing; and by visiting in person six loal ase study areas, inluding [loal ase study site], to learn from the progress you are making loally. The Soial Care Institute for Exellene has asked for the projet to be done to find out what lessons an be learned for everyone. We want to talk to staff and people like yourself who have been using servies, to ask about what is working well and what is diffiult in making sure that servies are helping with the things that are important for older people suh as yourself. We will write a report based on what you and other people and staff tell us, but no one s names will be mentioned what we disuss is private. 3. Area of speial servie interest One of the reasons we deided to ome to [loal ase study site] was to find out in partiular what has been happening in relation to [area 114

132 Appendix 4 of speial servie interest]. So we asked to speak to you in partiular beause you have had experiene of that servie. But we don t want to limit the disussion to that servie beause we are also interested in any other soial servies help you reeive (eg home are, day are et) beause what s important most of all is how servies together are helping you to live the life you want. Of ourse, as researhers, we an t ourselves influene the servies you get. But what you tell us an be used to help improve the way things are done here and in other areas. 4. Any questions? 5. Happy to take part? Ask person to omplete onsent form. 6. Seek agreement to take notes/tape-reord the interview 7. Don t have to answer any questions you don t want to, and an stop any time for whatever reason. QUESTIONS To begin: Can you tell me a little about your irumstanes at the moment. Are you a resident here, or using day are, intermediate are (rehab), respite, short stay (for example, for assessment) et? Residents: How long have you been here? How did you ome to this [home]? Did you have a hoie of other plaes? What made you hoose this plae? Does it suit you? Others: How did you ome to be getting [servie] here? How long have you been here for [servie]? Did you have an assessment before you ame? Were you getting any help from soial servies before you ame here? 115

133 ADULTS SERVICES 2. What matters to you 2.1 We re interested to find out how servies are helping you. So, thinking about yourself, what is it that really matters to you in how you live your life? Residents: How do you spend your time here? What do you like to do? Do you have any speial interests or hobbies? Do you like soialising or prefer your own ompany? Are you able to do these things as muh as you would like/live your life as you please? Others: How do you spend your time here? What do you want to get out of the servie while you re here? [for example, soial ontat with people; beome more independent; be able to take are of self so able to stay at home] 2.2 Is there anything you might want to hange or improve in your life? If so, what ould be done to enable that? 2.3 [if not mentioned] What about the emotional and soial aspets of your life, as well as the pratialities? 3. Servies/help What kind of servies are you using/ help are you getting? [for eah servie] how long has this been in plae? Residents: Do you need any help from people to get around or do things (eg look after yourself)? What kind of help do you need? Are you getting enough help with [ ]? Who provides that help (for example, the home, or outside servies for example, own GP)? Do you have a keyworker? If so, do you talk to her about your needs and preferenes? Others: What help are you getting while you re here? Do you need help with getting around or doing things (eg looking after yourself)? Are you getting enough help with [ ]? 116

134 Appendix 4 4. Your assessment How muh do you feel you have been enouraged to think and talk about what really matters to you while you ve been here/when your servies were set up? [Or were you just told what you ould have?] Residents: Has anyone enouraged you to think and talk about what matters to you and done something about it? Or were you just told what was on offer? [for example, food hoies, range of soial events/ativities on offer] Others: Has anyone enouraged you to think and talk about what matters to you while you ve been here? or before you ame here? [If yes] How easy did you find it to do this? [If appliable] How easy do you think your [keyworker]/assessor found it to talk in terms of your own wishes/priorities (rather than just about servies)? 5. Your servies We re interested to know, on a day-to-day basis, whether you feel the are and support [servies] you are getting is helping you to live the kind of life you want. What is working well? Can you give me an example of how the help you get here has made [or might make] a positive differene to your life? [Or an example from the help you ve had before?] What is not working so well? Is there any aspet of your life where you are not getting the help that you would like? If so, what ould be done to make that better? 117

135 ADULTS SERVICES How often do you get the hane to talk about how well things are working or whether you would like something to hange (for example, do you get a regular review)? What would you do if you were not happy about any aspet of your servie(s)? How well do you feel the are and support [servies] work together here? How muh day-to-day hoie and ontrol do you feel you have over what servies you get and how they are delivered [for example, timing, what is done, who by] or are these restrited? Do you feel you are treated with respet? Do you have any ultural or religious preferenes relating to servies? If so, do servies take aount of these? Have you got anyone else helping you (family, friends, neighbour?) If so, do servies try to fit in with what they do? Do you pay for any of your soial are servies? If so, do you feel they are good value for money? 6. General questions Overall, how good are servies at helping you live the life you want? Over time, have they been getting better at doing this? What do you think other parts of the ountry ould learn from how things are done here? 118

136 Appendix 4 Closure What happens next We will write up our notes from the six areas aross the ountry we are visiting in a report, along with the other aspets of the researh we have already done. No names will be used in the report so no one will know exatly who said what. Chek as appropriate that the person is happy for us to use all the material. Our report will be sent to the Soial Care Institute for Exellene, who will use it to write a pratial resoure guide next year to help all loal authorities. Any questions? Thanks. 119

137 ADULTS SERVICES Pratie survey of outomes-foused servies for older people Soial Poliy Researh Unit, University of York with Aton Shapiro Topi guide for managers (are managers, ommissioners, providers) Name: Date: Interviewer: Opening points for interviewer Thanks the interviewee for agreeing to take part in the review Explain how the material from the review will be used Reassure them about onfidentiality Ask if there is anything else they would like to know about the review Use the definition below if asked for one. NB: Outomes-foused approahes are those whih promote and develop servies designed to identify and ahieve the outomes (that is, lifestyle or quality of life) that older people desire. Setion 1: Introdutory questions *1.1 Can you briefly desribe your role? *1.2 What was the initial motivation behind developing an outomesbased approah? What speifi benefits were antiipated? [hek user benefits overed] *1.3 [for managers with a strategi overview] Can you briefly desribe how your loal outomes approah has been developed and implemented? Or [for those with knowledge of part of the proess] How have you been involved in developing an outomes-based approah loally? 120

138 Appendix 4 Prompt for: Any hallenges in relation to partiular servies Whih partner agenies have been involved and how this has helped/ hindered *1.4 What did you draw on to help you? [for example, SPRU pak; training; researh artiles; meetings with loal organisations; experienes from other areas] *1.5 To what extent have urrent poliy priorities and requirements helped or hindered the development of an outomes approah? [for example, NSF for older people, FACS, SAP, performane management regimes and targets, health flexibilities] *1.6 To what extent have older people and their arers been involved (at a olletive level) in developing your outomes approah? [Prompt for: what differene any involvement has made] Setion 2: Core Questions For some managers (for example, in servie management/provider roles) we will be asking them to think about a speifi area of work [agreed in advane with the ase study area]: home are day are intermediate are or rehabilitation servies residential are. Questions for ase study areas where the fous has been on assessment, are planning, are management and review *2.1 Can you tell us speifially what hanges have been made to implement an outomes approah [over the following separately: assessment, are planning, are management and review?] *2.2 What loal fators have helped or hindered your progress so far? 2.3 a) How easy has it been for you and your olleagues to think and talk to older people and arers in terms of outomes rather than servies? 121

139 ADULTS SERVICES b) What steps (if any) have been taken to ahieve the hange in ulture? [Prompt for: how effetive any initiatives have been; what as worked well/less well; what have been the most diffiult issues/areas to address?] 2.4 Do you feel you have been able to ahieve an holisti approah that is, one that inludes proess outomes and emotional andsoial outomes, as well as pratial ones 2.5 How muh freedom do are managers have to purhase/ oordinate the servies older people need to ahieve their outomes? [prompt for example of a hallenging one] 2.6 How have you and your olleagues addressed any tensions between risk management and outomes? 2.7 How have you managed to balane outomes for arers with those for users? 2.8 How easy have older people and arers found it to talk to you in terms of how they want to live their lives? 2.9 Have older people and their arers been involved (at an individual level) in key deisions about servies that are important to them (for example, about the hoie of provider)? 2.10 How muh ontrol do you feel older people have over their dayto-day servies and how these are delivered (for example, timing, what is done, who by)? 2.11 Have there been any partiular hallenges in identifying and addressing outomes for speifi individuals or user groups [for example, people with dementia; people from blak and minority ethni ommunities?] 2.12 Has the outomes approah in assessment and are planning been mathed by new ways of ommissioning, ontrating and developing servies? Questions for ase study areas where the fous has been on ommissioning, planning, servie development and provision *2.13 How you have ommissioned/developed servies to ahieve older people s outomes? 122

140 Appendix 4 Prompt for: Balane between hanges to existing servies and reation of new servies 2.14 How have partnerships hanged or developed? 2.15 What hanges have you made to your ontrats? 2.16 Have there been other hanges in the way ommissioners and providers relate to eah other (for example, ommuniation, payment methods)? *2.17 What loal fators have helped or hindered your progress so far? 2.18 How are you ensuring a ommon understanding of your outomes approah between ommissioners, are managers, provider agenies and front-line staff? 2.19 How are you ensuring that other agenies understand your outomes approah (for example, housing, leisure, health, voluntary organisations)? 2.20 Have providers needed to hange their organisational arrangements (for example, how they reruit, deploy and pay staff, what tasks they are allowed to do)? 2.21 Through your new ontrats, have you been able to support the relationship between older people and their front-line worker(s) (for example, through failitating time to soialise; ontinuity of staff)? 2.22 How muh ontrol do you feel older people have over their dayto-day servies and how these are delivered (for example, timing, what is done, who by)? 2.23 How have you and your olleagues addressed any tensions between risk management and outomes? 2.24 Do you feel you have been able to ahieve a holisti approah that is, one that inludes emotional and soial outomes, as well as pratial ones? 2.25 Has the outomes approah in ommissioning, ontrating and developing servies been mathed by new ways of assessment, are planning and review? 123

141 ADULTS SERVICES Setion 3: Training, monitoring and evaluation *3.1 Can you tell me about the training that has been delivered on outomes and any lessons learnt? Prompt for: whih staff groups/organisations have been involved in the training Whether the fous has been on ulture or proess *3.2 How is the implementation of your outomes approah being monitored? Prompt for: what measures have been used to monitor progress *3.3 How are you evaluating the impat on: (a) older people (b) arers () staff (d) resoures? *3.4 Have older people and their arers been involved in any way in evaluating the impat of your approah so far? Prompt for: how they have been involved What differene their involvement has made Setion 4: Overall refletions and thinking about the future *4.1 In summary, what have been the main hanges you have needed to make to the organisation and delivery of servies? *4.2 To what extent do you feel your aims have been realised? Have other benefits emerged? *4.3 [for sites in England] How do you intend to build on existing pratie to implement the proposals in the Green Paper on adult soial are? *4.4 Thinking about sustainability, what hallenges do you fae now in building on your initial ahievements with an outomes approah? [prompt to over sustainability both within a servie and in terms of broadening an outomes approah to other servies] 124

142 Appendix 4 Setion 5: Transferability *5.1 If you were talking to a group of managers from another area, what would your advie be to them in taking forward an outomes approah Prompt for: what the ritial suess fators have been explore these as fully as possible Essential dos and don ts *5.2 From your experiene, what lessons have been learned about suessful joint working? [for example, NHS, voluntary organisations, private setor hek whih lessons apply to whih] Closing points for interviewer Thank the interviewee for answering our questions Ask if there is anything they want to add Explain what will happen next, inluding likely timesales for our work and publiation of SCIE guidane 125

143

144 Appendix 5 Information about SPRU and Aton Shapiro Soial Poliy Researh Unit (SPRU) Sine its establishment in 1973 at the University of York, SPRU s researh has foused on hildren, young people and adults made vulnerable by poverty, ageing, disability or hroni illness. Most of SPRU s researh falls within the broad poliy areas of soial seurity, soial are and health are. SPRU has an international reputation for exellene in researh. SPRU s researh is underpinned by the following priniples: to reflet and ommuniate the experienes and views of the users of servies and benefiiaries of poliy interventions to reognise that people's lives do not divide into neat segments whih oinide with ageny and professional boundaries, and to ondut researh whih rosses these boundaries to make its researh influential in bringing about hange; to ommuniate findings effetively to key audienes; and to engage atively with poliy-makers and pratitioners More information about SPRU an be found at Aton Shapiro Aton Shapiro is an independent ompany based near York whih speialises in onsultany and researh in the fields of health and soial are. Its staff have experiene in healthare management, nursing, soial are, aademi researh and the voluntary setor; its projets utilise a portfolio of qualitative and quantitative tehniques. Aton Shapiro s ore areas of work are: applied researh, servie evaluations and reviews, inluding loal evaluation of national initiatives suh as the Partnerships for Older People Projet 127

145 ADULTS SERVICES supporting servie planning, innovation and hange, inluding developing outomes-foused approahes in soial are onsulting and involving, patients, arers, servie users and the publi. Aton Shapiro works with loal authorities, strategi health authorities, primary are trusts, individual GP praties, national and loal voluntary setor organisations and multi- and inter-ageny initiatives. In ollaboration with aademi partners, it has undertaken a number of projets for national researh bodies (for example, NHS Servie Delivery and Organisation R&D Programme and Joseph Rowntree Foundation) and national advisory/inspetion bodies (for example, Soial Care Institute for Exellene). Its fous is on finding pratial solutions that work for the teams, organisations or ommunities involved. More information about Aton Shapiro an be found at 128

146 Index A Aelerated Development Programme 55 ativity 4 5 Aton Shapiro Age Conern 23, 47, 57, 76 Age Conern Consultation Servie (ACCS) 75 alertness 4 5 Askham, J. 8 assessments ase studies x, 41 2 failitating outomes-foused servies vii, impeding outomes-foused servies vii, Assoiation of Diretors of Soial Servies (ADSS) 90 B Better Commissioning Learning and Information Network (LIN) 26, 27 outome-based ommissioning 39, 45 6 Bradford 40, 88, 95 Butt, J. 8 C Callaghan, G. 16 Canadian Oupational Performane Measure 48 are pakages miro-level ommissioning vii, 21 purhasing impeding outomesfoused servies are planning vii, x, 41 2 arers 58 9 ase studies x, 25, 26, onlusions 63 fators failitating outome approahes xii, 54 7 fators hindering outome approahes xii, 57 9 impat of outomes-foused servies 50 4 methods monitoring and evaluation xii, 48 9 outomes-foused ativities x xi, 41 7 outomes-foused servies xi xii, 47 8 plans for (further) outomesfoused servie developments summary of sites 93 8 User Advisory Group 79 80, 82 Central Offie of Researh Ethis Committees (COREC) 90 Centre for Poliy on Ageing 42 Change Agent Team 26, 37 hange management 55 6 hange outomes ommissioning ase studies x, 43 experienes of servie users 50 1 valued by older people vi, 3, 7 Commission for Soial Care Inspetion (CSCI) 129

147 ADULTS SERVICES failitating outome approahes 37, 39, 55 hindering outome approahes 37, 57 ommissioning viii, ase studies x xi, 43 7 miro-level vii, 21 ommuniation failitating outomes-foused servies 22 impeding outomes-foused servies ontrating viii, ase studies 43 7 ontrol 5 7 Cumbria County Counil 40, 88, 94 5 D day are ase studies xi, 48 onstraints on impat of outomes-foused approahes 54 maintenane outomes 51 2 proess outomes 52 3, 63 dementia 23 Department of Health 26, 84 diret payments 1 helping and hindering progress 21, 37, 39 diversity and barriers to outomesfoused servies 17 failitating outomes-foused servies 23 outomes valued by older people 8 9 Domiiliary Care Standards Regulations (2003) 11 Dorset County Counil 40, 88, 93 4 E environment 4 evaluation xii, 48 9 F Fair Aess to Care Servies (FACS) 1, 10 assessments 10 ase studies 42 purhasing of are pakages 12 reviews 20 Franis, J. 21 G Godfrey, M. 16 GPs 23, 58 Green Paper on adult soial are 25, 26 failitating outome approahes 39, 55 holisti perspetive 3 personalisation 2 H Hardy, B. 11 Health At 1999, Setion 31 1, 16, 22 health-soial are divide failitating outomes-foused servies 22 3 impeding outomes-foused servies Hillingdon 40, 88,

148 Index home are servies 9 10, 64 onstraints on impat of outomes-foused approahes 54 maintenane outomes 51 monitoring and evaluation 49 organisational arrangements failitating outomes-foused servies organisational arrangements impeding outomes-foused servies 9 17 I in-house servies 43 independene 2 independent providers see private servie providers Innovations Forum 55 intermediate are 63 ase studies x, xi, 47 8 hange outomes 50 1 failitating outome approahes 55 monitoring and evaluation 48 proess outomes 52 3 servie-level outomes 54 intermediate are servies, onstraints on impat of outomes-foused approahes 54 J joint working see partnerships L leadership 55 6 Linolnshire 40, 88, 98 loal authorities 28, 29 loal vision 55 6 London Borough of Hillingdon 40, 88, 95 6 M maintenane outomes ommissioning ase studies x xi, 44 7 experienes of servie users 51 2 plans for (further) developments 60 1 valued by older people vi, 4 6, 7 miro-level ommissioning vii, 21 Mirza, K. 8 Modernisation Ageny 55 Mold, F. 8 monitoring and evaluation xii, 48 9 multiageny working see partnerships N national poliies failitating outome approahes 37, 54 5 hindering outome approahes 37, 57 National Servie Framework (NSF) for older people 1, 55 assessments 10 helping and hindering progress 37, 39 Netten, A. 8, 21 NHS aute trusts 28, 29 Niholas, E

149 ADULTS SERVICES North Linolnshire Counil 40, 88, 98 Northumberland Care Trust 42 nursing homes 48 O older people outomes valued 3 9 see also User Advisory Group; users organisational arrangements failitating outomes-foused servies impeding outomes-foused servies 9 17 organisational hange and ulture 35 outomes definition v, 2 3 User Advisory Group 76 valued by older people v vi, 3 9, 24 outomes-foused ativities ase studies 41 7 groups overed 30, 31 older people s involvement in planning 31, 32 speifi 31, 32 stages 28, 29 types 28, 30 outomes-foused approahes 1 fators failitating xii, 54 7 fators hindering xii, 57 9 outomes-foused servies ahievements 33 7 ase studies xi xii, 47 8 onlusions xiii xv, 63 5 definition 2 experienes of servie users 50 4 fators failitating and inhibiting vii viii organisational arrangements failitating viii ix, 18 23, 24 organisational arrangements impeding 9 17, 24 plans for (further) developments see also pratie survey Outomes of Soial Care Researh and Development Programme 25 6 P partnerships 1, 34 failitating outome approahes 16, 22 3, 56 7, 64 5 postal survey 28, 29 Partnerships for Older People Projets (POPPs) 39 Patmore, C. 14, 21 2 performane indiators 57 personal safety 4 personalisation 2 physial needs 4 postal survey ix, 25, 26 ahievements and fators helping and hindering ahievements 33 7 aims 26 7 disussion 38 9 methods 27, 84 6, nature and range of outomes work 28, 29, 30 2 respondent harateristis 27 8 User Advisory Group 77 8,

150 Index pratie survey 25 6 onlusions 63 ethial and researh governane issues 90 see also ase studies; postal survey prevention outomes plans for (further) developments 60 1 valued by older people vi, 4 6, 7 primary are trusts 28, 29 private onsultany 28, 29 private servie providers ommissioning 44 7 postal survey 28, 29 proess outomes experienes of servie users 52 3 valued by older people vi, 6 7 provider-level fators vii failitating outomes-foused servies 21 2 impeding outomes-foused servies purhasing miro-level vii, 21 Q Quality Development Sheme (QDS) 48 quality of life 2 Qureshi, H. 3, R reablement servies 64 ase studies xi, 47 8 hange outomes 50 1 monitoring and evaluation 48 proess outomes 52 3 servie-level outomes 54 reording systems and tools 36 researh review 1, 83 4 onlusions 24 organisational arrangements failitating outomes-foused servies organisational arrangements impeding outomes-foused servies 9 17 outomes valued by older people 3 9 residential are 63 ase studies xi maintenane outomes 51 2 monitoring and evaluation 49 outomes-foused servies 48 proess outomes 52 3 servie-level outomes 54 resoures 36 onstraints 57 8 reviews ase studies x, 42 failitating outomes-foused servies fators failitating and inhibiting vii impeding outomes-foused servies S servie proess outomes see proess outomes servie users see users servie-level outomes

151 ADULTS SERVICES Single Assessment Proess (SAP) 1, 10, 16 ase studies 41 2 helping and hindering progress 37, 39 hindering outome approahes 57, 64 reviews 20 soial ontat 5 Soial Poliy Researh Unit (SPRU) 1, 18, 127 Outomes Network 25 6, 41, 55, 63, 84, 90 postal survey 27 soial servies 28, 29 staff attitudes 35, 58 T training 34 users attitudes hindering outome approahes 58 9 impat of outomes-foused servies xiii, 50 4 V voluntary organisations 64 5 postal survey 28, 29 W Ware, T. 16 whole systems working hange management 55 6 failitating outome approahes 56 7 Worestershire County Counil 40, 88, 97 U Unified Assessment Proess (UAP) 37, 90 User Advisory Group xiii, 26, ase studies 40 1 organisational arrangements failitating outomes-foused servies 23 organisational arrangements impeding outomes-foused servies 17 outome-based ommissioning 46 7 outomes valued by older people 9 partnerships 56 7 postal survey

152 Other knowledge reviews available from SCIE LEARNING AND TEACHING IN SOCIAL WORK EDUCATION: ASSESSMENT Beth R. Crisp, Mark R. Anderson, Joan Orme and Pam Green Lister ISBN November 2003 Ordering ode: KR01 THE ADOPTION OF LOOKED AFTER CHILDREN: A SCOPING REVIEW OF RESEARCH Alan Rushton ISBN November 2003 Ordering ode: KR02 TYPES AND QUALITY OF KNOWLEDGE IN SOCIAL CARE Ray Pawson, Annette Boaz, Lesley Grayson, Andrew Long and Colin Barnes ISBN November 2003 Ordering ode: KR03 INNOVATIVE, TRIED AND TESTED: A REVIEW OF GOOD PRACTICE IN FOSTERING Clive Sellik and Darren Howell ISBN November 2003 Ordering ode: KR04 FOSTERING SUCCESS: AN EXPLORATION OF THE RESEARCH LITERATURE IN FOSTER CARE Kate Wilson, Ian Sinlair, Claire Taylor, Andrew Pithouse and Clive Sellik ISBN X January 2004 Ordering ode: KR05 TEACHING AND LEARNING COMMUNICATION SKILLS IN SOCIAL WORK EDUCATION Pamela Trevithik, Sally Rihards, Gillian Ruh and Bernard Moss with Linda Lines and Oded Manor ISBN May 2004 Ordering ode: KR06 IMPROVING THE USE OF RESEARCH IN SOCIAL CARE PRACTICE Isabel Walter, Sandra Nutley, Janie Pery-Smith, Di MNeish and Sarah Frost ISBN June 2004 Ordering ode: KR07 TEACHING, LEARNING AND ASSESSMENT OF LAW IN SOCIAL WORK EDUCATION Suzy Braye and Mihael Preston-Shoot with Lesley-Ann Cull, Robert Johns and Jeremy Rohe ISBN April 2005 Ordering ode: KR08 LEARNING AND TEACHING IN SOCIAL WORK EDUCATION: TEXTBOOKS AND FRAMEWORKS ON ASSESSMENT Beth R. Crisp, Mark R. Anderson, Joan Orme and Pam Green Lister ISBN x April 2005 Ordering ode: KR09 THE LEARNING, TEACHING AND ASSESSMENT OF PARTNERSHIP IN SOCIAL WORK EDUCATION Imogen Taylor, Elaine Sharland, Judy Sebba and Pat Lerihe with Elaine Keep and David Orr ISBN June 2006 Ordering ode: KR10 TEACHING, LEARNING AND ASSESSING COMMUNICATION SKILLS WITH CHILDREN AND YOUNG PEOPLE IN SOCIAL WORK EDUCATION Barry Lukok, Mihelle Lefevre, David Orr, Mary Jones, Ruth Marhant and Karen Tanner ISBN Deember 2006 Ordering ode: KR12

153 DECEMBER 2006 KR13 Outomes-foused servies for older people This knowledge review onsists of a researh review and a pratie survey. The researh review aims to: summarise researh on the outomes that older people value and wish to ahieve from ontat with soial are servies identify fators that failitate or inhibit outomesfoused servies. The pratie survey aims to: identify features of the soial are poliy and pratie environments that support or inhibit the development of outomes-foused approahes in older people s servies identify examples of outomes-foused organisational arrangements and approahes that provide opportunities for wider learning. This publiation is available in an alternative format upon request. Soial Care Institute for Exellene Goldings House 2 Hay s Lane London SE1 2HB tel fax textphone