Health and Social Care in the Community 13(2), 136–144
The feasibility and acceptability of a specialist health and social care team for the
Blackwell Publishing, Ltd.
promotion of health and independence in ‘at risk’ older adults
Vari Drennan1, Steve Iliffe2, Deborah Haworth3, Sharon S. Tai4, Penny Lenihan5 and Toity Deave6
1
Senior Lecturer In Primary Care, 2Reader In General Practice, 3Research Fellow, 4Senior Research Fellow In Quantitative
Methods and Analysis, 5Lecturer In Primary Care and Old Age, 6Research Fellow, Primary Care Nursing Research Unit,
Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College
London, Archway Campus, Highgate Hill, London
Correspondence
Abstract
Vari Drennan
Department of Primary Care and
Population Sciences
Royal Free and University College
Medical School
University College London
Archway Campus
Highgate Hill
London N19 5LW
UK
E-mail: v.drennan@pcps.ucl.ac.uk
Population ageing, escalating costs in pensions, health-care and long-term
care have prompted a new policy agenda for active ageing and quality of life
in old age across the European Union and other developed countries.
In England, the National Service Framework for Older People (NSF OP)
explicitly demands for the first time that the NHS and local authorities, in
partnership, agree programmes to promote health ageing and to prevent
disease in older people. These programmes are expected to improve access
for older people to mainstream health promotion services and also to
develop multiagency initiatives to promote health, independence and
well-being in old age. This paper describes the evaluation of one interagency
project team established to test out mechanisms for addressing health
promotion for older people through primary care. A mixed methodology
was used to understand the processes of service development, the impact of
the team’s intervention, and the primary and secondary outcomes for older
people. The project demonstrated that multi-agency partnerships have the
potential to improve the quality of the lives of older people deemed ‘at risk’
by their general practitioners, particularly through income generation but
also in the identification of medical problems such as unrecognised
hypertension, hearing loss and visual loss. It also offered some key learning
points for other multi-agency groups developing similar services.
Keywords: assessment, health promotion, multidisciplinary, older people,
primary care, welfare
Accepted for publication 13 September 2004
Introduction
Healthy ageing as a policy objective
Population ageing, escalating costs in pensions, healthcare and long-term care have prompted a new policy
agenda for active ageing and quality of life in old age
across the European Union and other developed countries (European Commission 1999, Cabinet Office 2000,
Health Canada 1996). In England, the government has
made a commitment to improve services for older
people through combating age discrimination, engaging
136
with older people, better decision making for services
for older people, better meeting of older peoples’ needs
and promoting a strategic and joined up approach
(Department of Work & Pensions 2000). These objectives
are pursued throughout its current reform agenda,
from an integrated transport policy, through age diversity in employment to reconfiguration of health and
social care services. The National Service Framework
for Older People (NSF OP) explicitly demands for the
first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing
and to prevent disease in older people (Department of
© 2005 Blackwell Publishing Ltd
Promoting health and independence in ‘at risk’ older adults
Health 2001: NSF OP Standard 8 p. 113). These programmes were expected to improve access for older
people to ‘mainstream’ health promotion services and
also develop ‘wider initiatives involving a multisectoral
approach to promoting health, independence and
well-being in old age’ (Department of Health 2001:
section 8.4).
Promoting health, independence and well-being in
old age
Policy makers, researchers and practitioners have
neglected health promotion and illness prevention for
older people (Victor & House 2000, Iliffe & Drennan
2000). Consequently, the evidence base for preventive
services and anticipatory care is small and inconclusive
(Victor & House 2000, Beales & Tulloch 1998), a key factor in the piecemeal and unenthusiastic implementation
of the over 75 checks specified in the 1990 GP contract
(Brown et al. 1992, Harris 1992). A recent meta-analysis
of home-based visiting programmes that offered health
promotion and preventative care to older people suggested that they were associated with a reduction in
mortality and admission to institutional care (Elkan
et al. 2001). However, it was uncertain which components of the home-visiting activity were beneficial or
which populations were most likely to benefit (Egger
2001).
It has been suggested that targeted screening and
health promotion activities combined with techniques
of case management may be an effective way forward
(Iliffe & Drennan 2000). Case management techniques
have been reported to be beneficial in improved access
to health and social care services (Pacala et al. 1995, Ross
& Tissier 1994), enhanced quality of life (Challis &
Davies 1986, Marshall et al. 1999) and the reduction
in admission to institutions (Stuck et al. 1995, Bernabei
et al. 1998).
In the UK, an MRC-funded trial is currently comparing universal vs. targeted assessments and management by primary care teams vs. a multidisciplinary
geriatric assessment team in order to strengthen the evidence base (Fletcher et al. 2002). Meanwhile, across the
country, Primary Care Trusts are setting up small partnership projects to promote health in older people using
case-finding and case-management strategies (see e.g.
Jones 2003).
This paper describes the development of a specialist
health and social care team for promoting the health of
older people perceived as ‘at risk’ by their general practitioners, utilising elements of case finding and case
management models. The impact and outcomes of the
team’s intervention in an inner-city area are described,
and lessons drawn for those implementing the policies
of active ageing and improved quality of life for older
people.
Background
Team formation and development
The specialist health and social care multidisciplinary
team was commissioned by an inner city London
Borough and its corresponding Primary Care Groups in
January 2001 for 18 months. The aim of the team was to
reduce isolation amongst older people, enable mainstream services to more effectively focus their delivery
to older people, and foster self-help for older people in
order to promote quality of life. The six team members
were seconded from the community nursing services
and from the social welfare service of Age Concern. A
multi-agency group, from the partnership organisations,
steered the work of the team.
The impetus for this particular team came from two
different sources. From the Local Authority perspective, it was the latest in a number of initiatives set up in
the wake of the discovery of the body of an elderly
council tenant some months after death in 1994. From
the Primary Care Groups’ perspective, it was the latest
in a number of initiatives to find ways of addressing
health promotion and prevention with people aged
over 75 in recognition of the uneven delivery of service
to this group by general practice (Camden & Islington
Health Authority 1999). The Health Authority had
decommissioned a health visiting and nurse advisor
service to elderly people in 1995.
The intervention
The brief of the team was to work in pairs (from the two
different backgrounds) proactively contacting people
aged over 75 deemed ‘at risk’ by general practitioners
(Box 1). These people were offered a joint health and
social care assessment (Box 2) followed by information
giving, support and short-term case management
activities as appropriate.
Box 1
Criteria for client access to the specialist health and
social care team
A call for a routine health check has already been made by
the general practice, and there has been no response
Person lives alone/has no telephone
The person has not contacted the practice in the last year
The practice is already concerned about the person
© 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 136–144
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V. Drennan et al.
Box 2
The assessment process
This covered all domains of physical, emotional, social, and
mental well-being. It included assessment tools,
assessment activities and questions regarded as important
in discussion with the Partnership members including:
The Camberwell Assessment of Unmet Need in the Elderly
(CANE), assessment tool amended by the Well-Being team
15 item Geriatric Depression Scale (GDS15)
Abbreviated Mental Test Score (AMTS)
Hearing handicap inventory
Visual impairment assessment
Blood pressure measurement
A medication review
SF-8tm health survey
The person’s stated goals
The core component of the assessment was the
Camberwell Assessment of Need in the Elderly (CANE),
which was identified at the time as one of the tools that
could be used in the introduction of the single assessment
process in England (Department of Health 2002). This
tool explores needs from patient, carer and professional
perspectives, in a hierarchy of questions from general to
specific across 24 domains of need (Reynolds et al. 2000)
and has been validated in primary care and noninstitutional settings (Walter et al. 2000). The team also
asked the older person if there was something that
they specifically wanted to achieve, i.e. a personal goal.
Each older person was then revisited 3 months after the
previous contact to review whether the agreed actions
had been effective and identify any new issues that
had arisen in the intervening period.
conducted with a sample of 13 older people representative of the range of people who had received the service,
six GPs representative of different types of practice,
nine managers (across the local authority, community
health services, Age Concern and general practice), and
all the team members.
A representative sample of service users who indicated to the service team that they were willing to talk
to a member of the evaluation team were approached
in writing with a request for an interview. A stamped
addressed envelope and reply slip were included. Service users were interviewed in their own homes, service
providers in their place of work. Written consent to
participate was obtained from all informants. Qualitative
data were transcribed and managed through word
processing and spreadsheet software (Burnard 1998).
Two members of the team, independent of each
other, undertook thematic analysis utilising a template
method of coding (Ritchie & Spencer 1994). Clinical
record entries of the assessments were coded and entered
into an Excel database. Specific written consent was
obtained for the inclusion of the older person’s anonymous data in the evaluation. The anonymous coded
data were exported and analysed using SPSS.
The primary quantitative outcome measures were:
(1) numbers of unmet health and social needs as documented using CANE; (2) unmet financial needs, as
identified by the team; (3) caseness on the depression
and cognitive function scales. The secondary quantitative outcome was the number and range of referrals
made by the team. The Local Research Ethics Committee approved the evaluation methods.
Findings
The evaluation method
The evaluation addressed the question: ‘Is a comprehensive joint health and social review feasible, acceptable
and effective in solving problems for older individuals
judged to be “at-risk”’?
A realistic evaluation framework (Pawson & Tilley
1997) was used, underpinned by Maxwell’s dimensions
for judging health and social care (Maxwell 1992), which
form the current public sector framework for assessing
performance (Department of Health 1999). Multiple methods of data collection were used across the evaluation.
Data were obtained through observation (May 1997) at
management and team meetings in order to describe and
understand the processes of team development and the
intervention itself. These data were recorded through
minutes of meetings and the evaluators’ field notes.
To address questions of feasibility and acceptability,
and to assess secondary outcomes like perceived
benefit, semi-structured interviews (Robson 1993) were
138
Team development: working in partnership at
organisation and service delivery levels
The senior managers of the partner organisations
expressed commitment and enthusiasm to the idea of
the team. The general practitioners (GPs) generally
viewed the work of the team favourably, sometimes
seeing it as a replacement for services that had been
decommissioned. They were however, concerned about
some aspects of working with an outside health and
social care team, such as the maintenance of patient
confidentiality and the centrally determined modus
operandi (exemplar 1).
Exemplar 1
‘I suppose there are always several risks attached; one of
course is confidentiality, although I trust them implicitly, but
because of course who they are they are automatically covered
© 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 136–144
Promoting health and independence in ‘at risk’ older adults
by confidentiality agreements. But even so you worry. There is
also the risk of duplication and there is the risk of failure of communication between them and the practice, and the patients
and the practice, and they might be asking patients to do
things that have either been done, about to be done, or done in
different ways’. GP 4
‘I believe I was selected as a pilot practice or something. Well,
it wasn’t quite with my agreement. It was sort of a slight
imposition that we are doing this’. GP 5
All the steering group and team members described the
establishment of the team as ‘slow’ and ‘very frustrating’. It was apparent that there were different visions
for the service, which had implications for every aspect
of the team’s activity. The disparate views became
apparent in the discussions about the nature of the
contact with the older people. There were at least two
views: one argued for a general, holistic conversation
which would lead to connecting that older person
more widely to services and local communities at some
point; the other argued for a more structured approach
to identifying people at risk and/or unmet needs
(Exemplar 2).
Exemplar 2
‘I had a thing about not assessing people, but that we were
wishing to say that “there are possibilities out there, you may
or may not wish to take advantage of them but our purpose is
to ensure that you’re aware of them and assist you to make
those decisions”. So I wasn’t particularly keen on it being case
finding although some people were interested in that.’ Steering Group Member A
The reconciliation of these different objectives and cultural inclinations in the partnership organisations was
problematic. It was compounded by a lack of clarity as
to where the responsibility and authority for different
types of decision-making actually lay between the partnership organisations. In this vacuum it became apparent that there were ‘issues of strong and weak partners’
(Steering group Member F), where the strong were able
to shape the decisions that were made (Exemplar 3).
Exemplar 3
‘The Partnership working didn’t go to well because, you
know, you’d go to one meeting and you’d agree whatever.
You’d go back to another meeting and something else had
been done. The decisions were made but the discussions
didn’t happen, so there wasn’t agreements … you could physically see people withdrawing in many respects.’ Steering
Group Member B
Cultural differences between the organisations in the
Partnership were also an issue, but usually only recog-
Box 3
Key lessons that Steering Group and team members
identified for Partnership projects between agencies were:
The importance of clear terms of reference and
membership criteria for all Partnership project steering and
management groups
The unification of Partnership finance into one budgetary
source
The identification of a senior project manager with sufficient
dedicated time
Agreement of a project development and operational plan
before staff are employed
Explicitly locate the project in the whole system of services
for older people
nised in retrospect after a major problem for the team.
Examples of this included:
• Misunderstandings about the nature of supervision
activities offered to staff in nursing and social care
roles in different organisations, leading to omissions
and duplications.
• Misunderstandings as to the feasibility and acceptability
of sharing patient information electronically between
general practices and the team. This led to significant
delays in establishing the team and addressing its IT
needs.
The steering group members and team members
suggested a number of learning points they had identified in Partnership working (Box 3).
At the level of providing service to older people, the
expectation was a team partnership through joint home
visiting and joint undertaking of the assessment by
the community nurse and the social welfare officer. One
general practice refused the service in this form, arguing that the presence of the community nurse would
only duplicate the work already undertaken by the
practice nurse with practice patients.
The community nurses and social welfare officers
undertook the majority of first visits and assessments
together. They reported that during the initial phase
they learned new knowledge from observing each other.
However, they did not believe that this was an efficient
way of offering the service. The community nurses in
particular believed that they could undertake this type
of assessment and case management work alone, having substantially increased their knowledge about the
financial aspects, local authority services and the wider
community resources from the early co-working.
The intervention
The team worked with 18 general practices ranging in
size from single practitioners with under 2000 patients
© 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 136–144
139
V. Drennan et al.
Figure 1 Flow diagram of the passage of
older people contacted by the team.
to six-partner practices with a list size greater than
12 000. They sent letters offering their service to 1271
people identified through general practice lists. However, 47% of these people were not found at that address
(see Figure 1).
Thirteen per cent (n = 88) of older people who were
offered the service, declined it. Some GPs reported that
they were aware of older people who did not consider
the idea of the project as acceptable. Some older people
clearly perceived the project service as acceptable because
the general practitioner had offered it (Exemplar 4).
relationship with the older people, and found trying to
use palmtop computers to record assessment information in the person’s home counter-productive to this
process. The time range for a first visit was between 30
and 150 minutes.
The team provided assessment and short-term casework service to 481 people (Figure 1); 327 consented to
inclusion in the evaluation, of whom 70% were women,
34% were aged over 85, 38% identified their ethnic
origin as other than white UK and 32% had informal
carers.
Exemplar 4
Outcomes: identifying unmet need
‘I knew exactly where they [the team] came from, under the
auspices of my doctor and his group and I felt very safe and
secure.’ Older person 7
Seventy-one per cent of people (n = 226) had no unmet
needs recorded on the amended CANE Assessment
tool. The most frequently recorded unmet needs were
concerned with problems of mobility. Only 9 people out
of the 320 were identified as having unmet problems
with maintaining social relationships. Further details of
the CANE findings are reported in a separate publication (Drennan et al. 2003). In addition, the team had
used the 15-item Geriatric Depression Scale with 247
people and recorded that 7% (n = 23) of people scored 6
and above, an indicator of clinical depression (Osborn
et al. 2002). This is lower than would be expected from
a community sample in the same locality (Iliffe et al.
1991). They had also used the Abbreviated Mental Test
Score (AMTS) with 264 people and reported that 20%
(n = 44) of people had a score of 7 or less, indicating
problems with cognition (Hodginkson 1972), a prevalence higher than would be expected from a community
sample from the same locality (Livingstone et al. 1990).
‘What I find works well is that often the community nurses are
the foot in the door without a doubt, and so once she’s done
her bit then I can easily step in because it’s almost like she’s my
reference, sort of thing.’ Social welfare officer team member
Team members agreed that offering the service from the
health service made it acceptable to older people. A
social welfare officer and a nurse undertook the first
visit together. Any subsequent visits to complete the
assessment or undertake further short-term casework
were undertaken by only one member of the team.
Older people reported that the presence of two people
in that first visit was acceptable because they knew in
advance that two people were coming.
The team members emphasised that as an unsolicited
outreach service, they had to spend time establishing a
140
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Promoting health and independence in ‘at risk’ older adults
Many older people were unable to suggest specific
personal goals, while some aimed for the global as in
‘world peace’. The most frequently reported personal
goals of older people were to move home, to undertake
repairs or decoration in the home, to go outside the
home more, and to have improved health.
A team member returned to each person 3 months
after his or her last contact; 14% (n = 45) were no longer
at the same address (Figure 1). For those they could
review, there were no new problems or unmet needs
identified at this point.
Responding to unmet needs
Older people are not a homogeneous group. Responses
to the information and advice offered from the team
were likewise varied (Exemplar 5).
Exemplar 5
‘Well, I got leaflets from X [the team member] about security,
you know things on the door. I’ve still got them somewhere,
and whether I needed anyone to speak to, you know. Of
course, I live with me cats. Well, that’s all right. I can’t got out
for meeting somebody on the street and sometimes we stand
there gassing for half an hour, you know. And as for having a
spy hole in the door and different locks, I could get that but I’m
not bothered, that’s the thing.’ Older person 6
‘Having worked for the CAB [Citizens Advice Bureau] I’m
pretty well clued up.’ Older person 7
‘I did get some information from X [local team member] about
help to give up smoking, which I haven’t done. And also some
information about the, what’s it called, the prostate something
or other, which is an organisation for people with prostate
cancer, you know … yes, it was helpful because I got in touch
with them and I got some information from them which was
quite useful.’ Older person 5
The team referred people to 27 services across the
spectrum of health, social service, housing, leisure,
voluntary sector services, and transport services. The most
frequent category of referrals was to the GP (Table 1).
The three most common reasons were for people with
Table 1 Referrals to services
GP
Occupational therapy
Housing
Social services
Domiciliary optician
Community dentist
Number of
people referred
Percentage of
total referrals
to all services
114
66
53
31
30
21
36
21
17
10
10
6
multiple physical, mental and emotional problems,
hearing problems only, and raised blood pressure only.
The GPs were clear that the referrals to them were
appropriate, had not increased the workload of the
practice and many considered many were likely to avert
a crisis contact at a future point.
The team members reported the reluctance many
people expressed to approach new services or trust the
team to help deal with apparent needs (Exemplar 6).
Exemplar 6
‘This was a client who the GP identified because they hadn’t
seen him in a year. Now he is a classic example of a client who
declined everything under the sun when he clearly did need
some support, right up until three visits ago when I did this
one thing for him and I gained his trust. Since that time he has
let me phone the housing department to contact him because
he was paying too much rent, and as it happened he doesn’t
have to pay rent for the next three months and that makes a
great difference to him. That gave him the confidence to trust
me to do some other things, so for example attendance allowance is one of the things that I’ve just done for him recently’.
Team member
Despite only 2% of people (n = 4) reporting unmet
financial needs that were then recorded on the CANE
assessment, the team helped 38% of people (n = 122) to
apply to 15 sources of additional finance, and 87 people
had their monthly income improved as a result. The total
amount of money raised on behalf of the service users
was £145 522 of which £95 370 was attendance allowance for 39 people. The explanation for this discrepancy
appeared to be that the team members were very
proactive in using their knowledge of eligibility criteria
to encourage the older people to apply for financial
benefits. They met significant reluctance from many
older people to pursue sources of financial assistance
(Exemplar 7).
Exemplar 7
‘They seemed [the team] very eager to get me everything I
wanted, that’s what I felt! I feel guilty because, I don’t know,
it’s very difficult to say. I still have for instance an application
form for [a source of financial assistance] which X gave me.
But I won’t sign it because I live scantily, but there’s nothing I
really need, I’m not hungry, and when I think of the thousands
of people who need it, it’s greedy and I don’t want to ask them
[the source of financial assistance].’ Older person 2
Acceptability
All the older people interviewed in the evaluation were
very positive about the service that had been offered by
the team. However, there were differences in perceptions
© 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 136–144
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V. Drennan et al.
as to the value of the service. Those people whom the
team had helped access a number of services acknowledged the difference the service had made to them and
the quality of their lives. In contrast, people to whom
the team had only been able to offer general local information but had no further involvement, perceived the
value of the service for people with multiple problems
but not themselves (Exemplar 8).
Exemplar 8
‘I think it’s [the team service] excellent; it’s been a lifesaver for
me. It’s opened up so many vistas for me. They’ve helped me
enormously, they’re both so kind. I’m most grateful to them
both.’ Older person 11, who had been referred to five different
health and social care services.
‘There was nothing wrong with me and I didn’t need any
social work or anything like that you know, and she could see
I was living a nice pleasant life you know.... Well, I think it’s a
good idea because some much younger than I am are in a state
of some kind, you know, and they don’t know what to do and
they can’t be bothered sort of thing. So I do think its good idea
all together.’ Older person 8
Discussion and Conclusions
The experience of this specialist health and social care
team illustrates the many challenges in implementing
a public service policy that advocates collaboration
between sectors to address both broad quality of life
issues as well as prevention of ill health. The complexities of health and social care partnership working at an
organisational level are well documented (Audit
Commission 1998, Balloch & Taylor 2001), as are those
at the service delivery level (Dalley 1989, Øvretveit
1997, Hudson 2002, Manthorpe & Iliffe 2003).
The members of the steering group and the team
expressed initial enthusiasm and commitment to
Partnership working to support residents in healthy
ageing, but did not anticipate the complexity of turning
divergent agendas, aspirations and knowledge into
operational reality. The lack of a shared vision, shared
operational and local knowledge between the GPs, the
health service managers, the local authority managers
and the voluntary organisation managers meant that
the team faced prolonged and recurrent problems.
Expertise in the promotion and management of collaborative working between diverse professional groups
appears to be lacking, and correction of this deficit may
be more important than enthusiasm for cross-agency
initiatives, if innovations are to succeed.
Despite these problems, the team were able to proactively contact older people aged over 75 through GP
patient lists. The case example of this joint health and
142
social care team offers an example of optimism set
against what has been described as the ‘pessimistic tradition’ (Hudson 2002: 7) of considering inter-professional
working. The feasibility and acceptability of a joint
health and social care assessment was demonstrated
and the team did identify unmet needs in approximately one third of the target ‘at risk’ group, more than
found in an earlier study on a less selected population
(Walters et al. 2000). Most of these needs led to referral
back to the general practitioner, raising the question
whether they would have come to the attention of primary care professionals in the normal course of service
use and clinical enquiry, without the team’s intervention. The extent to which financial resources can be
mobilised confirms the findings from a smaller, practicebased study in the same area (Toeg et al. 2003) and
underlines the importance of benefits advice for the
older population. What was not demonstrated was
that these joint, outreach methods using broad-based
selection criteria with little evidence base were the most
efficient way of achieving their intended aims, but
neither the pilot nor its evaluation were designed for
this purpose.
The selection criteria for providing this outreach
service did not reveal a large number of people aged
over 75 who were socially isolated or who had multiple
unmet health and social care needs. In this, they confirmed again the findings of previous local outreach
projects (London Borough of Camden 1998), local
neighbourhood population studies (Livingston et al.
1990), local practice population studies (Iliffe et al. 1992)
and nationally available data (Tinker 1997).
Commissioners and providers should note that the
identification of older people with multiple unmet
needs through general practice registration in the inner
city remains problematic. It is recognised that general
practice patient registration lists are inaccurate compared to resident populations across the UK and particularly in Inner London (Select Committee on Public
Accounts 1998). The fact that the team was unable to
find 14% of the people at the same address 3 months
after they had worked with them there gives some
indication of population mobility in this age group in
Inner London. The mobility of this age group is undocumented, but the experience of the team indicates that
it is considerable.
The evaluation of this multifaceted innovation has
limitations in that it did not include an economic analysis. Additional aspects of feasibility with regard to cost
would need further study. For example, the nurse team
members’ suggestion that they could undertake the
assessments alone as effectively as with a social care
partner requires additional study. Other limitations
of the study centre on the fact that it addressed one
© 2005 Blackwell Publishing Ltd, Health and Social Care in the Community 13(2), 136–144
Promoting health and independence in ‘at risk’ older adults
service-led development in one geographical area.
However, it does provide a case study of key issues in
the implementation of health and social care service
improvements for older people. These issues become
more pertinent as the policy agendas in the UK, Europe
and beyond promote mechanisms to support both active
ageing and the proactive management of long-term
conditions (see for example Department of Health 2001).
Future research should examine longitudinally the
effects of such interventions on both quality of life, use
of services and morbidity. Joint working across different organisations is, and will continue to be, complex
and will not flourish without well-grounded development and management. If this project is anything other
than unique, the first challenge is to learn from experience and not relearn past lessons. The second challenge
is to take those elements that achieved demonstrable
outcomes for some older people, such as the promotion
of financial eligibility, and provide them in ways that
increase their acceptability to older people and their
efficiency in resource utilisation.
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