Using local evidence in service
design – Oxfordshire County
Council’s “Prevention Project”
Rachel Taylor, Research Officer
Sara Livadeas, Assistant Head of
Service, Strategy & Transformation
Summary of presentation
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Rationale for the project
Methods
Results
Service redesign
Questions and discussion
Rationale for undertaking the project
• Promoting independence agenda – preventing ill
health and avoiding or delaying the need for
costly services.
• Residential/nursing care per annum – 46m
• 58% spent on over 85s
• Predicted increase in 85+ - 2006-2031 143%
• Avoidance of unnecessary care home
admissions
• Evidence of what works required to justify
investment in preventative approaches
Methods 1
• Worked with Institute of Public Care,
Brookes University
• Literature review including past studies eg.
Northamptonshire’s work
• File audit of care home admissions in
Oxfordshire 2008-9 (25% of admissions)
• Interviews with 21 people – 7 older people,
8 carers and 8 care managers
Methods 2: Issues to do with file audit
• Electronic files very difficult to read
• People auditing did not have social work
background
• Only looked back 12 months
• Documents were the viewpoint of the care
staff
• Weighting of condition/circumstance
difficult to determine
• Health records not available
Methods 3: Issues to do with interviews
• Gave us the older person, carers and staff
perspective
• Recruitment was challenging
• Mental capacity issues – learning curve
• Difficult to get a clear sense of when
events occurred
• Perceived reluctance on part of older
person or carer to think that admission
may have been avoidable
Results - literature
• Falls: half of all older people who have had one fall will go on to
have further falls.
• Continence: Incontinence affects 25% of the older population, In
care homes these figures are considerably higher being 30-60%.
Incontinence may contribute to premature referral for care home
admission, as either the older person or their carers reach the point
of no longer being able to manage the situation. Evidence shows
that incontinence is often treatable in older people.
• Stroke: Approximately 110,000 people in England suffer from a
stroke each year. Caring for people who have had a stroke uses a
significant proportion of inpatient hospital beds and nursing homes
places. At present only around half of individuals who have
experienced a stroke receive the rehabilitation to meet their needs in
the first six months following discharge from hospital,
• Dementia: Carer capacity and skills to care have a strong influence
on the likelihood of someone being admitted to a care home early.
Results file audit 1
Variable
Oxfordshire
Northamptonshire
• Incontinence
39%
34.5%
• Dementia
40%
52%
• Depression
25%
23%
• Falls
40%
52%
• Hospital admissions
-in last 12/6m (OCC/NCC) 1 in 5
• Admitted from hospital
61%
Over half
Over half
Results file audit 2
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Bereavement (not always in last year)
Living alone (64%)
Female (71%)
Inappropriate housing (1 in 4-low estimate)
Carer death or breakdown (10% - low
estimate)
• Multiple health conditions (56%-under
recorded)
Interview findings 1
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Complexity of conditions/circumstances
Reflected the file audit
Mainstream services – mixed picture
Night care – importance in relation to continence
Isolation – key factor conveyed in interviews
Telecare – benefits unclear
Voluntary sector – very little involvement
Importance of carer – vital importance not shown
in the file audit
Interview findings 2- complexity of
conditions and circumstances
Eg: Living with consequences of health condition
from many years ago
• “He had the stroke in ’95. But that limited his
movement on his right side and you know I
suppose getting older as well, he struggled
getting around a bit more, then he got diagnosed
with prostate cancer…And he had to have a
catheter fitted and he gets quite prone to
infection and he had falls and things” Carer
Interview findings 3 – mainstream
services
• Varied picture – Social workers, PCT, hospitals
• Problems with service rather than needs-led
provision:
• “Yes, that was all I wanted, just come in,
concentrate on mum and had a 45 minute slot,
but what would happen is if they came in with
her and talk to her and that was as good as
anything else. But then we had a letter saying
they were cutting down her time because she
didn’t need any help with anything and they cut
her down to a 15 minute slot” Carer
Interview findings 4 - incontinence
• In a lot of cases, when clients come from
hospital to nursing homes, they come with
catheters and all sorts of things that they quite
possibly don’t really need, but quite often they
are given them at hospital because it’s easier.
Maybe I shouldn’t say that but the general
feeling is that it’s easier to manage so they are
given catheters and all sorts of things that take
away their independence, take away their dignity
and most of them don’t want and don’t actually
need. Care Manager 7
Interview findings 5 - isolation
• The other big one that I find that people tend to go into
long-term care that aren’t hospital admissions, a lot of it
is isolation, is loneliness, is feeling vulnerable and at risk
and especially during the winter months. Care Manager
• ‘He wouldn’t go out. He was frightened and so he got
very isolated and although they had a community room
at [sheltered housing scheme], because of the dark
nights and that, he wasn’t going to go; you know he
didn’t go so most days the only person he saw would be
the warden, the lady who came to put him to bed, the
one who came in the morning. So that was the only
people he ever spoke to.’ Carer of ES
Service design
• Continence
• “Turnaround” – what it is and where
we are at with it.
• Support for carers of people with
dementia
Continence redesign
• DH funding for joint PCT/SCS project to
redesign project
• Aiming for a fully integrated service which will
move towards prevention and rehabilitation and
away management / containment of the problem
to include:
– Pathway redesign
– A Workforce Strategy to deliver an appropriately led,
trained workforce in bladder and bowel dysfunction
– Great emphasis on educational awareness for self
care, drawing on user experience and involvement, to
promote universal bladder and bowel.
“Turnaround” 1
Health
and
Well
Death of a spouse
First fall
Being
Increasing age
17
“Turnaround” 2
Health
and
Well
Being
Reablement or
restorative interventions
Increasing age
18
The “Turnaround” approach
Interventions need to be:
Health
and
Well
Being
•Focussed on most opportune
moment for change.
•Open ended in terms of
time commitment .
•Delivered on the basis of
evidence based outcomes.
Increasing age
19
Key factors in making it happen
Local, national and anecdotal evidence all
coming together
Good partnership working already in place
Right people willing to engage
Opportunity with TASC money
……
Still a long way to go
Key messages
• Use of evidence to provide knowledge based
commissioning.
• Literature review indicated what the issues were.
• Used our own data to see what was really
happening in Oxfordshire.
• Strong relationship between the literature and
our own findings.
• Service response based on 2 or 3 factors that
would make a difference.
• Needs ongoing evaluation.