VOL: 98, ISSUE: 48, PAGE NO: 48
Ruth Williams, MSc, RGN, DipN, head of practice development, Royal West Sussex NHS Trust
Jonathan Webster, MSc, BA, DPS(N), RGN, nurse consultant, Royal West Sussex NHS Trust
Older people are the main users of health and social care services, but services have not always adequately addressed need (Department of Health, 2001). The past 50 years have witnessed many changes and reforms in health and the social welfare state that have directly affected older people and the level and type of help and support they can expect from the state. Nurses need to understand these changes, as the implications of policy development will have a direct impact on the people we are working with. Nurses also have a part to play in shaping and informing policy development.
The 1990s The NHS and Community Care Act 1990 and subsequent reforms during the early 1990s marked a huge change in how long-term care was provided. Before 1983 historically most publicly funded care was provided directly by the public sector - NHS or local authorities. The change in how funding was organised meant that private and voluntary sector residential and nursing homes were able to access social security payments for anyone qualifying for means-tested supplementary benefit, irrespective of need (Audit Commission, 1997). The responsibility for providing this service had passed from the NHS to the independent sector, and this would subsequently lead to, and fuel, the debate on the provision and funding of long-term care and the potential limited choices available to older people.
These reforms resulted in many examples of innovative ways of working which aim to maintain independence and dignity in older age. However, it became clear that health and social services were not always good or consistent at helping older people and their carers (especially those with complex or continuing needs) to live a ‘normal’ life (Roberts, 2000).
Demographic changes Between 1995 and 2025 the number of people over the age of 80 is set to increase by almost half, and the number of people over 90 will double (Department of Health, 2001). Older age does not necessarily mean increased dependency or reliance on others. However, as part of the ageing process some older people can have a multiplicity of age-related physical, psychological and social needs (Webster, 2002). When this is the case the need for services that are responsive and timely, that enable choice and independence and promote person-centred ways of working become even more important.
The move to integrated care An overdue change has occurred in which writing elderly people off has given way to a belief and demand that older people should have their individual needs acknowledged and that living longer is something to celebrate (Department of Health, 2001).
The New NHS, Modern, Dependable (Department of Health, 1997) identified a change in focus and policy in which the internal market was to be replaced with integrated care. This white paper marked a turning point for the NHS in which government policy aimed to combine ‘efficiency and quality with a belief in fairness and partnership’, based on the principles that dependable, high-quality care should be based on individual need, not on the ability to pay. It was also recognised that quality and efficiency should go hand in hand and that evidence-based national service frameworks (NSFs) would be developed to ensure consistent access to services and quality of care right across the country (Department of Health, 1997).
The NHS Plan (Department of Health, 2000) set out a series of changes and reforms that needed to happen in the future for a system of care which older people can trust. Care should be:
- Organised around the patient’s own needs and preferences;
- Easy to access and quick to respond;
- Reliable, consistent and stable, so the patient knows what is expected;
- Fairly funded;
- Designed with the incentives for every agency to work together in the interests of older people.
The NHS Plan (Department of Health, 2000) identified that the complex causes of ill health that are rooted in individuals’ life-styles and in the wider community and economic issues needed to be addressed. It was acknowledged that in the past systems of care were confusing, unfair and unresponsive to people’s needs (Department of Health, 2000).
Documents such as The Way to Go Home (Audit Commission, 2000) and The National Beds Inquiry (Department of Health, 1998) highlighted the challenges facing older people accessing both health and social care. This identified the increasing, unsustainable demand on services - the revolving-door syndrome and vicious circle in which some older people were not able to break free from a cycle that was both disempowering and did little to promote choice and individuality.
The National Service Framework for Older People is a key vehicle for ensuring that the needs of older people are at the heart of the reform programme for health and social services. The reform programme will be taken forward through six key areas (Box 1). The four themes in the NSF are:
- Respecting the individual;
- Intermediate care;
- Providing evidence-based specialist care;
- Promoting an active, healthy life.
Other policy initiatives The policy initiatives impacting on the care of older people are not just focussed on the NSF for Older People. A New NHS: Modern, Dependable (Department of Health, 1997) also outlines a clear statutory responsibility of NHS trust chairs and chief executives for quality of care. Previously the statutory responsibility was only for financial acuity. This makes quality of care the business of each trust board.
Nursing initiatives affecting patient care were also acknowledged. In 1999, Making a Difference (Department of Health, 1999) was published. This document outlined changes, such as advanced practice and expanded roles, as well as nurse education and regulation; within the context of this a national central commitment to The Essence of Care was made. (Department of Health, 2001).
Essence of care The Essence of Care is based on a benchmarking process and identifies eight initial areas for attention - self-care, hygiene, nutrition, continence, pressure ulcers, safety, record-keeping, privacy and dignity (Department of Health, 1999).
These had been identified in Making a Difference (Department of Health, 1999) as being areas of care that patients, carers and the ombudsman were concerned about.
The elements of The Essence of Care echo the policy initiatives in the NSF. Privacy and dignity underpins the theme of respecting the individual. The Essence of Care identifies seven factors for privacy and dignity and the best-practice benchmark (Box 2).
A good example of how both NSF for Older People and The Essence of Care policy initiatives have made a difference to the provision of care has been published by Richmond et al (2001). They describe how they have applied the benchmarks and the method they used for this.
The Essence of Care has appeared to support nurses in the business of caring. The fundamentals have been given policy weight, and a recognition that these areas of care are important has allowed nurses to reaffirm the importance of essential nursing care.
Understanding and defining how policy impacts on older people can be seen as challenging, particularly in view of the pace of change in the past 10 years. A key challenge in implementing policy is the need to engage older people in the process by putting their real needs at the centre of policy development while enabling practitioners to feel that they have a vital part to play in influencing and interpreting policy by making it a dynamic reality in gerontological practice.