Modernisation of older people’s services in Birmingham

Why was this example implemented?

Over time in England a number of local Councils have sought to close or contract out their residential care homes. This has been a longstanding trend, but acquired increased impetus following the introduction of new care standards from 2001 onwards which meant that the cost of refurbishing often dilapidated local authorioty care homes was too great and these services tended to be closed and/or contracted out to voluntary or private providers. While the unit costs for private care homes tend to be lower, this seems to have been generated by a mix of motives – through a desire to lower cost, increase quality and improve the quality of the built environment (if possible).

After detailed consultation (including with older people and their families), Birmingham decided to close its local authority care homes (and any attached day centres) and to build new special care centres (built to a much higher quality design and providing a mix of support for people with dementia and short-term rehabilitation/reablement). Additional places were also purchased in the private sector and in extra care sheltered housing schemes.  This was justified by the need to create more modern and higher quality services and buildings more in keeping with public expectations.

Description

This practice example focuses on the techniques adopted in Birmingham to engage older people and their families in the process and to ensure a user-centred approach. In particular, the Birmingham example involved:

• A formal public consultation and a public decision by elected local councillors
• A commitment to regular and honest communication with all staff and service users involved in the process
• The creation of a well organised, dedicated and skilled assessment team, based in the care homes concerned so as to get to know people well and carry out holistic assessments of their needs
• A commitment to working at the pace of the individual and giving as much time and space to explore future arrangements as possible (for example, visiting potential new services as often as they wanted)
• Helping residents and key members of care staff to stay together if possible
• Ensuring independent advocacy was available for people with specific needs (for example, if a person with dementia needed extra support)
• Staying in touch with people after the move and assessing the longer-term impact of resettlement (for at least one year afterwards)
• Commissioning an independent evaluation of the project based around the literature on what older people say they value about social care services
• Making these results available nationally so that lessons could be shared with others

What are/were the effects?

An independent research study carried out interviews with 49 older people, carers, care staff and assessors, and explored outcomes for 74 older people collected when their social worker first assessed their needs. This took place when their new care package was reviewed after 28 days and when their care was reviewed after 12 months.  It was based on outcomes from social care services that older people say are important to them and on an easy to complete but internationally recognised measure known as the EQ-5D (a simple, but well tested and frequently used measure of health and quality of life). 

While older people and their families felt very unsettled and distressed as the closures were taking place, outcome data after 12 months suggests that the older people who took part were relatively satisfied with their services and with their lives throughout the study.  Overall, most people said that things had either stayed the same or got better.  While full details of the research are provided via the references at the end of this practice example, key changes included:

• The majority of respondents suggested they felt valued and were happy with the control they had over their life at all stages of the study (at initial assessment, after 28 days in a new service and after one year in a new service).
• 42 per cent of respondents suggested that life had got better following the resettlement programme and a further 35 per cent suggested life had stayed the same.
• Of the 19 per cent who suggested life had got worse following changes, around half of these respondents suggested this was due to deterioration in their actual health rather than due to the services at their current care home.

While the small number of older people taking part means that such figures need to be interpreted carefully, the results are nevertheless much more positive than the literature on care home closures might typically suggest.

What are the strengths and limitations?

Overall, quantitative data and interviews with older people, their families, care staff and assessors identified four key factors in achieving these outcomes (which have implications for the management of change in long-term care more generally):

• Strategy and preparation: having a clear strategy and policy that could be easily articulated to stakeholder groups was seen as important. This aided subsequent communication and enabled the closure programme to take place on a phased basis (which prevented rushed decisions and overloading care staff and assessors).  Being forewarned of potential risks and negatives was also seen as important, so that every possible step could be taken to overcome these (or at least acknowledge them and support people through the process):
• Engagement and involvement: engagement and involvement of all relevant stakeholders was seen as crucial.  Involving key people (especially older people themselves) upfront in initial decisions about services also seemed important, as did ensuring a user-centred approach (see above for a summary).  Anxiety and stress is often increased when service users are facing a perceived loss or change to services, especially if they do not feel they have any control over the subsequent process.  Providing as much certainty as is feasible by being honest and clear with people as soon as possible about where they may be going in the future helped to reassure service users and their families.
• Implementation and operational capacity: assessment provides the primary mechanism by which new services are determined and getting this right is crucial to the health and well-being of service users, both short- and long-term.  A key strength of the Birmingham process suggested by participants was a dedicated group of assessors who were able to take the time to get to know people well, meet families, work alongside care staff and carry out holistic assessments. 
• Working with care staff: a further key ingredient is the role of care staff in homes that are closing, who can be well placed to provide help and support to older people and their families (but who may be feeling just as worried about the changes as service users).  Supporting care staff through such closures through regular communication, additional job training etc, providing them with up-to-date information and treating them as partners in the process seems key.

Credits

External Links and References

• Birmingham City Council (2007) Changing care, meeting needs: Birmingham’s plan for the future of older people’s services.  Birmingham, Birmingham City Council.
• Glasby, J., Robinson, S. and Allen, K. (2011) Achieiving closure: good practice in supporting older people during residential care home closures.  Birmingham, Health Services Management Centre (on behalf of the Assocviation of Directors of Adult Social Services and in association with the Social Care Institute for Excellence).
• Glasby, J., Robinson, S. and Allen, K. (2011) An evaluation of the modernisation of older people’s services in Birmingham – final report.  Birmingham, Health Services Management Centre (forthcoming).