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The National Service Framework (NSF)
for Older People

The National Service Framework (NSF) for Older People was published by the Department of Health on March 27th 2001. It places carers at the centre of future health and social care strategies in England and has been warmly welcomed by CNA. Most older people who need care are looked after by a family member, partner or friend - and many older people are carers themselves.

The NSF focuses on rooting out age discrimination, providing person-centred care, promoting older people's health and independence and fitting services around people's needs. This briefing outlines the eight Standards in the Framework and the main interventions proposed, and highlights the main points of action and important milestones and indicators.

The 8 Standards in the NSF for Older People are:

  • rooting out age discrimination
  • person-centred care
  • intermediate care
  • general hospital care
  • stroke
  • falls
  • mental health in older people
  • the promotion of health and active life in older age

The standards apply across health and social services, whether an older person is being cared for at home, in a residential setting or in a hospital.

Carers and the NSF for Older People
The NSF recognises that some issues are integral to all standards and service models in this NSF. The Carers Group, established by the External Reference Group in the preparation of the NSF, emphasised that carers' needs should be considered as an integral part of the way in which services are provided for older people.
CNA welcomes the recognition that carers should be regarded as partners in the care of the family member or friend they are caring for. It is vital that it is also recognised that older people can often be carers in their own right.
The NSF Standards

Standard 1: Rooting out age discrimination
"NHS services will be provided, regardless of age, on the basis of clinical needs alone. Social care services will not use age in their eligibility criteria or policies, to restrict access to available services."

AIM: To ensure that older people are never unfairly discriminated against in accessing NHS or social care services as a result of their age.

The NSF states that older people will be represented across every organisation, including Modernisation Boards and Patients' Forums, Best Value programmes and in setting and monitoring standards within the framework of local Better Care, Higher Standards charters.

Every NHS organisation and council with social services responsibilities should:
· Establish local leadership for older people's services
· Establish a review, with service users and carers, of all relevant policies to ascertain whether they enable older people to access services on the basis of need or whether there are also age criteria which determine access
· Within the NHS, agree a rolling programme to tackle any areas of age discrimination which are identified including additional resources (both financial and human) where these are required
· Implement, for social services, guidance on Fair Access to Care Services (this has yet to be published)
· Involve staff in implementing this programme, providing additional training and support where necessary
· Communicate this programme of work to patients and carers, and to the local community.

October 2001 audits of all age-related policies to be completed with the outcomes to be reported in annual reports.
April 2002 councils to have reviewed their eligibility criteria for adult social care to ensure that they do not discriminate against older people.
October 2002 analysis of the levels and patterns of services for older people in order to facilitate comparisons across local authorities and establish best practice benchmarks based on health outcomes and needs.

Standard 2: Person-centred care
"NHS and social care services to treat older people as individuals and enable them to make choices about their own care. This is achieved through the single assessment process, integrated commissioning arrangements and integrated provision of services, including community equipment and continence services."

AIM: To ensure that older people are treated as individuals and they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries.

This standard goes on to state that "older people and their carers should receive person centred care and services which respect them as individuals and which are arranged around their needs. Older people and their carers have not, however, always been treated with respect or dignity nor have they always been enabled to make informed decisions through proper provision of information about care across care sectors."

Views of patients and carers
The views of patients and carers about their experiences will be sought systematically, and complaints will be monitored. CNA welcomes this recognition of the importance of listening to carers.

Information and involvement
Information should be provided at key points in care pathways, or stages of treatment so that the service user, and where appropriate, their carer can be involved in decisions about their own care.

Older people need information about:
· their own health - how they can improve their health through the promotion of health and well being and the prevention of illness
· assessment, investigation, diagnosis, treatment, rehabilitation and care
· any referral procedures or eligibility criteria
· range of local health and social services and housing services available, informing older people's choices.

Good information is also essential for carers
The NSF states that "subject to the consent of the older person, carers need information about the health or condition of the person they are caring for, what they can do to help and the services available. Good information enables carers to become partners in the provision of care, and supports them in best helping the person they are caring for. Conversely, without information, carers are more likely to suffer from stress and consequently be less able to continue to care."
CNA welcomes this recognition of the need for carers to have access to sufficient appropriate information, together with the statement that "good information enables carers to become partners in the provision of care".

Service improvements
The NSF states that the flexibilities available under the Health Act 1999 should be used to establish joint commissioning arrangements for older people's services. This should include the consideration of a lead commissioner and the use of pooled budgets.

In some cases, the NHS and councils have developed a more collaborative approach to commissioning and capacity building, based on shared information, open dialogue with independent providers, and informed by the views of users and carers. This good practice needs to become the norm.

Specific service improvements to be achieved as a priority include:
· a single assessment process in health and social care (April 2002)
· improved access to community equipment
· the establishment of integrated continence services.

Personal and professional behaviour
Service users and their carers should be able to expect that:
· staff are polite and courteous at all times
· procedures are in place to identify, and where possible, meet any particular needs and preferences relating to gender, personal appearance, communication, diet, race or culture, and religious and spiritual beliefs
· staff communicate in ways which meet the needs of all users and carers, including those with sensory impairment, physical or mental frailty, or learning disability or those whose first or preferred language is not English. Interpreting and translation services should be made available.
· personal hygiene needs, including toileting and bathing, are met sensitively, and other intimate interventions are also carried out in privacy.
· in hospital, if patients chose to wear their own clothes, they are enabled to do so, and (space and safety allowing) they are also able to have personal effects at their bedside
· staff support those with a long-term illness or disability to develop expertise in their own care, and to become partners in managing their continuing needs for health care - using the learning from the Expert Patient Programme.

The single assessment process: an NSF guide
· confirm and record current levels of help from carers, health services, social services, housing services and other services
· find out about the help that older people already receive. This should reveal whether family members or friends are acting as carers
· carers should be identified and offered the opportunity to be involved in the older person's assessment, or where it appears appropriate, informed of their right as part of a holistic assessment to an assessment in their own right under the Carers and Disabled Children Act 2000
· Guidance on carers' assessments can be found in the practice guidance on the Carers and Disabled Children Act, and the Practitioner's Guide to a Carers Assessment

Community Equipment Schemes
Community equipment services provide the majority of disability equipment needed by older people, but should also provide a well-informed gateway to other equipment services such as those provided by the NHS, councils and voluntary organisations. Key prinicples:
· identifying the need for equipment provision should be an integral part of any assessment, treatment or care plan, whether in hospital or community settings
· accountability should be clear with relevant professionals having specified responsibility for ensuring that older people and their carers know what is available and that they have a choice in the selection of equipment provided for them.
· services should take a preventative approach, recognising that effective equipment provision is likely to:
- resolve the frequently long delays which inhibit older people's discharge from hospital, or their safety and confidence in coping at home.
- support and better protect the health of carers

The NHS and councils should:
· agree at Board (NHS) and Committee (Social Services) level their core values for the care of older people, and how, in practice they intend to make sure that needs are best met
· communicate this to older people and their carers, and to the wider community
· involve staff, users and carers in reviewing the information provided for older people across the organisation - and where appropriate across the whole health and social care system
· agree a rolling programme to develop local information systems so that information is provided in appropriate format and languages, both for older people themselves and their carers. This should be in line with the Better Care, Higher Standards charters guidance published in March 2001.
· agree local arrangements for a single assessment process for older people. This process will cover both health and social care needs, including physical and mental health.
· implement the single assessment process
· ensure that, where appropriate, the carers of older people are offered their own assessment of their caring and health needs
· establish a single integrated community equipment service which meets key national targets
· implement integrated incontinence services

April 2002 single assessment process introduced
April 2003 systems to explore user and carer experience in place in all hospitals in all NHS and Personal Social Services organisations.
complaints procedure in place
April 2004 systems to explore user and carer experiences in PCTs
single integrated community equipment services in place

Standard 3: Intermediate care
"Older people will have access to a new range of intermediate care services at home or in designated care settings, to promote their independence by providing enhanced services from the NHS and councils to prevent unnecessary hospital admission and effective rehabilitation services to enable early discharge from hospital and to prevent premature or unnecessary admission to long-term residential care"

AIM: To provide integrated services to older people, to promote faster recovery from illness, prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living.

The NHS Implementation programme set early milestones, including, by 2001/02:
· To ensure that 25,000 more carers benefit from respite/breaks services in 2001/02 compared with 2000/01. Such services are of vital importance to people of all ages, including those with physical and learning disabilities.

By 2004:
· 50,000 more people will be enabled to live at home through additional home care and other support
· Carers' respite care services will be extended to benefit a further 75,000 carers and those they care for.

The NHS and councils should, in line with the national guidance:
· Agree a joint 3 year implementation plan for intermediate care, as part of the Local Action Plan and Joint Investment Plan, with arrangements for systematic monitoring and review focusing on:
1) Responding to or averting a crisis - including, for every Primary Care Team/Primary Care Group (PCT/PCG) area, a clear strategy for preventing avoidable acute hospital admissions
2) Rehabilitation and recovery - to include discharge/rehabilitation planning at the earliest possible opportunity during an acute hospital admission. Every PCT/G area to develop an appropriate range of services to meet local needs
3) Preventing unnecessary or premature admission to residential care - ensuring that early investment is targeted at service users at highest risk and that care plans clearly identify any potential for rehabilitation
(References for this: HSC 2001/01, LAC (2001)1 Intermediate Care)
· Ensure that the plan addresses the service, organisational and personal development needs of the new intermediate care teams.

July 2001 to have agreed the framework for patient/user and carer involvement
Jan 2002 local health and social care systems to have agreed the JIP (Joint Investment Plans) for 2002/03
Mar 2002 at least more than 1500 additional intermediate care beds compared with the 1999/2000 baseline
at least 40,000 additional people receiving intermediate care which prevents unnecessary hospital admission, compared with 1999/2000
Mar 2004 at least 5000 intermediate care beds and 1700 non-residential intermediate care places

Standard 4: General hospital care
"Older people's care in hospital is delivered through appropriate specialist care and by hospital staff who have the right set of skills to meet their needs."

AIM: To ensure that older people receive the specialist help they need in hospital and that they receive the maximum benefit from having been in hospital.

Discharge planning
· planning should start prior to admission for planned admissions and as soon as possible during the hospital stay for other admissions.
· a commitment in the NHS Plan that, by 2004, every NHS patient a discharge plan developed from the start of hospital admission
· The older person may be discharged to:
At Home
"The individual care plan will have identified what is needed to support the older person and their carers at home e.g. social care, primary health care, community support, housing". Arrangements should have been made to ensure that support is in place before discharge home.
Long-term care
Decisions about admission to long term care should follow from a multidisciplinary assessment and take account of the patients' (and carers') wishes.

Every NHS Trust which provides services for older people, working with the rest of the health and social care system, should:
· agree protocols between their specialist old age team and other departments within the hospital to ensure that all older people can benefit from the experience of the specialist team.
· recognise the risks which hospital admission can pose for older people, assess the risks for each individual and ensure that the risks are anticipated and minimised.
· identify Clinical Leaders (Modern Matrons) for Older People to oversee care of older people in wards
· ensure that discharge is planned from the point of admission

Standard 5: Stroke
"The NHS will take action to prevent strokes, working in partnership with other agencies where appropriate. People who are thought to have had a stroke have access to diagnostic services, are treated appropriately by a specialist stroke service, and subsequently, with their carers, participate in a multi-disciplinary programme of secondary prevention and rehabilitation."

AIM: To reduce the incidence of stroke in the population and ensure that those who have had stroke have prompt access to integrated stroke care services

Given the higher prevalence of stroke in some minority ethnic communities, this Standard states that integrated stroke services and stroke prevention advice should take into account the need for interpreting or advocacy support, especially for those patients and carers for whom English is not their first language.

This standard sets out 4 main components for the development of integrated stroke services:
· prevention: including the identification, treatment and follow-up of those at risk of stroke
· immediate care: including care from a specialist stroke team
· early and continuing rehabilitation
· long-term support, for the stroke patient and their carers.

Treatment and care: This should also include giving advice to patients and their carers to help manage the effects of the stroke on their lives and providing information and explanations about the treatment and care needed.

Early and continuing rehabilitation:
Patients and their carers should be involved in planning their care and safe discharge from hospital. This should identify an initial overview of needs likely on discharge, and pursue a fuller assessment of the issues that will impact on the patient's independence.

Assessment and services
An assessment should then result in a statement of need and an individual care plan which identifies proposed services, the responsibilities of various professionals providing those services and the aims and potential outcomes of the rehabilitation.

Every stroke patient will have a named stroke care co-ordinator, who will be responsible for:
· co-ordinating the assessment and individual care plans and ensuring arrangements for support and secondary prevention measures are in place prior to discharge
· ensuring the efficient flow of relevant information to community-based professionals
· ensuring a smooth transfer between care settings
· ensuring that the need for home adaptations, repairs and improvements are identified, and work completed pre-discharge.

Every health system should, in partnership with other agencies where appropriate review current arrangements, in primary care and elsewhere to identify those at greatest risk of stroke, and to intervene actively to reduce these risks; and agree local priorities to improve the rates of identification and effective intervention in stroke

April 2002 Every general hospital which cares for people with stroke, will have plans to introduce a specialised stroke service as described in the Stroke Service Model from 2004
April 2003 Every hospital which cares for older people with stroke will have established clinical audit systems to ensure delivery of the Royal College of Physicians clinical guidelines for stroke
April 2004 PCT/Gs will ensure that:
· every general practice can identify and treat patients identified as being at risk of a stroke because of high blood pressure, atrial fibrillation or other risk factors
· every general practice can identify people who have had a stroke and are treating them appropriately
· every general practice has established clinical audit systems for stroke
100% of all general hospitals which care for people with stroke to have a specialised stroke service, as described in the Stroke Service Model.

Standard 6: Falls
"The NHS, working in partnership with councils, takes action to prevent falls and reduce resultant fractures or other injuries in their populations of older people. Older people who have fallen receive effective treatment and, with their carers, receive advice on prevention through a specialised falls service."

Aim: To reduce the number of falls which result in serious injury and ensure effective treatment and rehab for those who have fallen.

Establish how the older person (and their carer) coped following any previous fall and if they have any strategies for coping with a fall in the future.

Hospital discharge
Prior to discharge, the needs of patients and their carers for care and support at home should be identified. The specialist falls service will be responsible for co-ordinating the assessment and individual care plan for discharge and ensuring that arrangements for support are in place prior to discharge. CNA welcomes this recognition in the NSF that discharge from hospital needs careful and early planning by multidisciplinary teams fully involving older people and their carers.

Every health system should, in partnership with councils:
· review the local system of services for falls, including the prevention of falls, identifying those at risk and minimising this risk, improving the care of those who have fallen, including rehabilitation and the continuing care for those whose falls have longer term consequences
· agree and implement local priorities to reduce the incidence of falls, and to reduce the impact which a fall can have on health, well-being and independence including appropriate interventions and advice to prevent osteoporotic fracture.

April 2003 local health care providers (health, social services and the independent sector) should have audited their procedures and put in place risk management procedures to reduce the risk of older people falling
April 2004 the HiMP (Health Improvement Plan), and other relevant local plans developed with local authority and independent sector partners, should include the development of an integrated falls service.
April 2005 all local health and social care systems should have established this service

Standard 7: Mental Health in Older People
"Older people who have mental health problems have access to integrated mental health services, provided by the NHS and councils to ensure effective diagnosis, treatment and support, for them and for their carers."

Aim: To promote good mental health in older people and to treat and support those older people with dementia and depression.

CNA welcomes the recognition that mental health problems among older people can exact a large social and economic toll on patients, their families and carers, and the statutory agencies. CNA also welcomes the link that is made to the NSF for Mental Health. The Framework also recognises the need for assessments to be accessible and culturally appropriate, "assessments may be culturally biased making it difficult for needs to be properly identified or assumptions may be made about the capacity and willingness of families to act as primary carers for their older relatives".

· Mental health services for older people should be community-orientated and provide seamless packages of care and support for older people and their carers.
· The hallmark of good mental health services is that they are: comprehensive, multidisciplinary, accessible, responsive, individualised, accountable and systematic.
· Carers of older people with mental health problems may also need information, advice and practical help to support them in caring for the older person.

Improving care of older people with depression and dementia depends on providing high quality evidence based care, within this broader framework.

Early recognition and management of mental health problems - Support for carers of people with mental health problems
Carers of older people with mental health problems often need support. They may have physical and mental health needs of their own. They also need information, advice and practical help to support them in caring for the older person.

If dementia is not diagnosed early, carers can become demoralised due to lack of support and having to cope with apparently unexplained behavioural changes. Providing support can be challenging as the impact of the condition upon those affected and their families can be devastating.

CNA welcomes the references to specific interventions for carers of people with dementia, for example counselling services or short breaks.

The NHS, and councils, should
· review the local system of mental health services for older people, including the arrangements for mental health promotion (Standard 8), early detection and diagnosis, assessment, care and treatment planning, and access to specialist services
· review current arrangements, in primary care and elsewhere, for the management of depression and dementia, and agree and implement local protocols across primary care and specialist services, including social care. In time, this should be extended to cover all mental health services for older people.
· review current arrangements, in primary care and elsewhere, for the management of dementia in younger people, and agree and implement a local protocol across primary care and specialist services, including social care.

April 2004 HimPs and other relevant local plans developed with local authority and independent sector partners, should have included the development of an integrated mental health service for older people, including mental health promotion

PCT/Gs will have ensured that every general practice is using a protocol agreed with local specialist services, health and social services, to diagnose, treat and care for patients with depression or dementia.

Health and social care systems should have agreed protocols in place for the care and management of older people with mental health problems.

Standard 8: The promotion of health and active life in older age
"The health and well-being of older people is promoted through a co-ordinated programme of action led by the NHS with support from councils."

Aim: To extend the healthy life expectancy of older people.

The NHS and local partners should refocus on helping and supporting older people to continue to live healthy and fulfilling lives.

Activities which can promote healthy active life for older people can include:
· access to mainstream health promotion and disease prevention programmes
· health promotion activities of specific benefit to older people, tailored where necessary to reflect cultural diversity
· wider initiatives involving a multi-sectoral approach to promoting health, independence and well-being in old age

CNA welcomes the references in the NSF for Older People to the Frameworks already in place for mental health and coronary heart disease, and the NHS Cancer Plan.

The NHS, with councils, should:
· assess the local priorities to promote both physical and mental health and well being among the older population groups
· ensure that older people have fair access to programmes of disease prevention and health promotion, including cancer screening, blood pressure management, smoking cessation, advice about lifestyle including nutrition and physical activity, and falls prevention. These should take account of the impact of cultural and religious beliefs and lifestyles.
· take stock of existing services (including the newer programmes for regeneration and neighbourhood renewal, as well as more traditional programmes such as housing, leisure and transport) which are relevant to health and well being; identify the broader opportunities to promote health and well being for older people; implemement a rolling programme.

April 2003 all relevant local plans should have included a programme to promote healthy ageing and to prevent disease in older people. They should reflect complimentary programmes to prevent cancer and coronary heart disease and to promote mental health, as well as well as the continuation of flu immunisation.

Plans should also include action specific to older people, utilising the range of local rescources, including those within regeneration programmes and reflecting wider partnership working.

April 2004 local health systems should be able to demonstrate year on year improvements in measures of health and well being among older people:
· flu immunisation
· smoking cessation
· blood pressure management

Local delivery (chapter 3)
Involving older people and their carers (p.114)
· The NSF states that older people and their carers should play their full part in local planning and implementation, advising on priorities, providing on progress and acting as a reality check.
· Older people and their carers should be represented across every organisation, the local Modernisation Board, the Patients' Forum, within the Best Value programme and in setting and monitoring standards within the framework of the Better Care, Higher Standards charters.
· Local arrangements should reflect the diversity of the community which is served - to ensure that local plans take full account of the specific needs and choices of black and ethnic minority groups. At the same time, they should identify and develop resources within the community to support older people and their carers.
· This engagement with older people and their carers as patients, service users and citizens should inform the whole system of care.

· Local arrangements for involving older people and their carers in implementing the NSF should be in place by 30 June 2001
· Local arrangements for implementing the NSF should be established by June 30 2001
· The elected member or non-executive director who will lead for older people in each organisation should be identified by 30 June 2001.
· The NHS modernisation review should include older people as a priority, and reflect this within the 3-5 year plan.

Ensuring progress (Chapter 4)
Performance is going to be assessed across the 6 domains of the NHS performance assessment framework (PAF). These are:
· health improvement
· fair access
· effective delivery of appropriate care
· efficiency
· patient/carer experience
· health outcomes of NHS care

The NSF states that numerical data should be complemented by regular surveys of users' and carers' views. From 2001, every NHS Trust and PCT will have to carry out annual surveys asking patients and carers about their experience of the services they have received.

The Taskforce for Older People
A national oversight will be provided through the Modernisation Board and the Taskforce for Older People, both established in 2000. Key roles of the Taskforce are to:
· track delivery of the NSF for Older People
· further develop proposals where required
· support local planning implementation through advice and
· communicate key messages throughout the NHS and Social Services


The Medicines Management Booklet, which also forms part of the NSF for Older People aims to ensure that older people:
· gain the maximum benefit from their medication to maintain or increase their quality and duration of life
· do not suffer unnecessarily from illness caused by excessive, inappropriate or inadequate consumption of medicines

Carers' potential contribution and needs are often not addressed
Carers are in a unique position to support older people in medicine taking but their potential contribution is under used. The NSF recognises this, and suggests that carers, together with those they care for "could be more involved in, and consulted about, treatment decisions. Their wealth of knowledge about the patient's health and any adverse changes is too often untapped. Carers want to know more about possible side effects of treatment, about which combinations of medicines should be avoided, and about reasons for changes in medication."

Education and training
· Programmes for carers on supporting medicines use have been provided in some parts of the country and should be replicated elsewhere.
· Patients and carers want more information about medicines. Sometimes this information needs to be interpreted.

The NSF reports that people are currently used to their doctor being the main source of information and decisions about medicines. A gradual culture change needs to occur for some older people to more readily accept advice from pharmacists and nurses. The role of patient and carer organisations will be important in supporting this change.

April 2002 all people over 75 years should normally have their medicines reviewed at least annually and those taking four or more medicines should have a review 6-monthly.

all hospitals should have 'one-stop dispensing/dispensing for discharge' schemes and, where appropriate, self administration schemes for medicines for older people

April 2004 every PCT or PCG will have schemes in place so that older people will get more help from pharmacists in using their medicines

What next?

The National Service Frameworks will be a very important lobbying tool locally. A number of very tough targets and deadlines have been set for health and social services. The DoH states that the NSF "represents an ambitious agenda for older people, applying the principles set out in the NHS Plan to their health and social care. This will drive up quality and tackle variations and inconsistencies in present services".

There is action you can take locally, either as a carers group, or as an individual.
As a group you could:
* discuss the NSF for Older People and how it will affect carers locally
* find out what action your local older people's organisation (Age Concern, Help the Aged etc.) is planning, and together ensure that older people who are carers are not left out of local frameworks
* make sure that carers of working age are also included in local implementation groups
* find out from your local NHS Trust or primary health care team whether they have seen a copy of the NSF and what action they are taking on it
* expect to be consulted on your local NSF - approach your LA/NSF Trust if they don't approach you
* check on the progress that your LA/NHS Trust is making
* ask to see the timetable for action

As an individual carer:
* ask to be involved in your local consultations around the NSF, using your personal experiences of caring
* become a lay member of your local PCT or PCG, or of your local Patients Forum in the future

Further Information
Copies of the NSF for Older People are available from: Department of Health, PO Box 777, London SE1 6XH. Fax: 0623 724524.
It is also available at the DoH's website:

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