Memorandum by the Lancashire Care Association
1.1 The LCA is the representative body of
independent Nursing, Residential and Domiciliary providers in
Lancashire. It is established as a limited company and has a board
of directors, who are homeowners and domiciliary care providers,
representing all areas of the County. Its aim is to provide advice
and support to its 400 members, to represent its members at National,
Regional and Local levels in political and officer forums. Its
members currently provide over 7,000 beds in residential and nursing
homes in Lancashire.
1.2 The LCA members are committed to ensuring
Older People and other Vulnerable Adults are provided with the
highest standard of services to meet their needs. To this end
it has promoted training for staff in the sector by accessing
£2 million in European Funding over the last two years.
1.3 The LCA is heavily involved across health
communities in Lancashire in National Services Framework for Older
People, Local Implementation Groups, Capacity Planning Groups
and Intermediate Care planning groups.
1.4 The experience of the LCA's officers
and Board is considerable. The LCA's full time Chief Executive
has 12 years experience working as Chief Officer for a local Age
Concern Group and who has also worked on secondment to the Social
Services Inspectorate and recently the Regional Health Authority
"Change Agent" and older people's NSF Monitoring Team.
2. OUR EVIDENCE
2.1 The LCA welcomes the opportunity to
comment on the area of delayed discharge from hospital. Our evidence
will focus on what are some of the reasons why this is such a
problem. Our views are the product of many years direct experience
in and involvement in the Health and Social Care Sector, background
documents such as the National Beds Inquiry, Audit Commission
and Social Services Inspectorate Reports, Research Papers and
reports of academic bodies such as Rowntree Foundation.
2.2 In the time available we have only been
able to raise what we see as the broad reasons behind the problems
of delayed discharge. Much can be validated by detailed statistical
and academic references that we are sure the Select Committee
will have access to. We would be happy to elaborate on this evidence
via direct questioning if the Select Committee so wished. We have
shared this paper with the Independent Healthcare Association,
Registered Nursing Homes Association and the National Care Homes
Association and the British Medical Association.
2.3 In order to understand the problem of
delayed discharge we believe you have to take a historical perspective,
over at least the last 20 years, and look at many factors, including
socio-economic and demographic, that have culminated in what is
seen as the problem of "delayed discharge". This includes
the reasons why so many elderly people are admitted into hospital
in the first place and what can be done to prevent this.
2.4 Our evidence will focus largely on the
problems of older people as the National Bed Inquiry indicated
that this was the biggest group of consumers occupying acute hospital
beds. It is the over 75s that have until recently, been counted
as delayed discharges in the CITREP reports.
2.5 There is no one reason but many inter-related
factors that culminate in the problem of "delayed discharge"
and significant pressure on acute beds in NHS hospitals.
3.1 The Department of Health definition
is "a person is delayed in discharge when they are medically
fit to move from an acute bed". Reasons for delay can be
Delays in assessment by social services,
allied health professionals or nurses.
Delays in decision-making on commissioning
community based or intermediate care services. (There are perverse
incentives for Local Authorities to delay as many cases as possible
to save money on their budgets).
Budget blocks from local authoritiesperson
stays in hospital because they are considered by the local authority
to be "safe" and therefore not a priority case.
3.2 It must be recognised that the numbers
of delayed discharges as measured by the SITREP statistics are
not an accurate reflection of when someone is fit for discharge.
3.3 The point when someone is medically
fit and do not need an acute bed will depend on the views of the
clinician. Following this, the next question that needs to be
asked is "what services are available to meet the patient's
needs"? For example, if there is a good network of intermediate
care facilities in the locality, that the secondary and primary
care staff have confidence in, then a patient could be discharged
much earlier than if no such facilities exist, or bureaucratic
or professional barriers delay such action. This is the thinking
that underpins the Government's strategy to manage the supply
of beds by developing intermediate care service.
3.4 There are also problems of delayed transfer
that regional specialities face. They take a patient into a regional
speciality, treat the patient to the point that they can be transferred
to their nearest host hospital but that hospital has no bed for
themmore often because they are blocked with older people
who, as research has shown, simply do not need to be there.
Delayed Discharge and Acute Sector Capacity
is a relatively new phenomena. Prior to 1993, when hospitals had
direct access to residential and nursing home care, there were
not any problems with capacity and delayed discharge.
The previous time in recent history was the
1970s, before the significant investment by the independent sector
in the 1980s, when the main providers of residential care were
Social Services departments. In those days swap systems often
operated between geriatric beds as they were then and Local Authority
This evidence will concentrate on a wide range
of factors which impact on delayed discharges and capacity problems
in the acute NHS:
Demographic and Social Change.
NHS withdrawal from long term care.
The care in Community Agenda as implemented
paying un-economical fee levels for residential and nursing home
Over Stretched Primary Care Services.
Differential priorities between Social
Services and Health.
Limited effective partnerships with
Health, Social Services and Independent Sector.
Failure of Social Services and Health
to think laterally.
The Assessment and Care Management
The solutions are seen to revolve in many areas
Developing Care Trusts for Older
Developing effective strategic partnerships
with quality Independent Sector providers.
Paying realistic fees to residential
and nursing home providers and managing the market more effectively.
Streamline the assessment process.
5. REASONS FOR
5.1 Demographic and Social Changes
5.1.1 It is a fact that the proportion of
elderly in the population has risen significantly including the
over 85s who tend to be in poorer health and have a wide range
of disabilities and who require help to have their everyday needs
for food, washing, dressing and cleaning met by informal or formal
5.1.2 Advances in medical care have led
to people living longer.
5.1.3 Family living patterns have changed
over the last 50 years. There is greater mobility and fragmentation
of families leaving many elderly people isolated.
5.1.4 If they have sons or daughters they
can often be in there 60s or 70s caring for an 80 or 90 year old
5.1.5 Family carers tend to be women. Changes
have occurred in the workforce with over 50 per cent of women
now working. These are often the main or a vital part of economic
stability of a household. This leads to inability to care for
family members or greater stress trying to juggle family and childcare,
work and caring roles.
5.1.6 In the last 30 years the role of organised
care, via Local Authority Social Services Departments, has developed
to try and fill some of the gaps created by social, economic and
5.1.7 The percentage of over 85s is set
to rise significantly over the next 30 years and if medical and
nursing care continues to prolong life the number of over 90 year
olds is likely to increase even more significantly.
5.1.8 The focus of local authorities upon
higher dependency needs people has caused the removal of many
low level services which were supporting people at home.
5.1.9 The trend to persuade more and more
people that they can be cared for despite increasing dependencies
at home has lead to a "revolving door" effect of older
people going in and out of hospital on a regular basis.
5.1.10 The effective removal in 1993 of
the GP's option to transfer someone from their own home to a nursing
home effectively means he/she has no option other than to refer
to hospital any older person who needs a period of 24 hour care,
ie, someone with a chest infection. This effectively soaks up
masses of unnecessary NHS resource.
5.2 NHS Withdrawal From Long Term Care of
5.2.1 The Social Security changes in the
early 1980s led to a major expansion of the independent sector
residential and nursing home sector. Many NHS managers actively
worked to close, often out dated and poor long stay wards or hospitals
for elderly people. New people who required longer-term care were
referred to the independent sector and their care was funded by
Social Security benefits for those who met the income and capital
5.2.2 The growth in social security payments
for people in long-term care grew exponentially during the 1980s
from a few million to over £2 billion when Sir Roy Griffiths
produced his Care in the Community Report in 1988.
5.2.3 The resources released within the
NHS were diverted to mange the wide range of new treatments, demands
and cost pressures it was facing.
5.3 The Care in Community Policy Agenda
5.3.1 The Griffith's Report published in
the late 1980s heralded a shift from an over reliance on residential
care to a more balanced policy of providing a range of options
including more capacity to enable people to live at home. The
ensuing Government response in the form of the Community Care
Act 1990, gave Local Authority Social Services Departments the
funds, currently in the Social Security budget, and the responsibility
to assess and commission appropriate services including domiciliary,
residential and nursing home care.
5.3.2 Whilst the Care in the Community Policy
agenda was initially driven by the Treasury's wish to cap the
Social Security budget spend on residential and nursing home care
it was broadly welcomed by Local Authorities. Social Services
professionals, driven on by the Audit Commission and Social Services
Inspectorate, have actively kept more frail and elderly people
in their own homes. There is in reality a paucity of research
based evidence to suggest that this is always in the service users
best interests. Certainly isolation and other issues are given
scant regard in the information put forward. It should be remembered
that there was no real delayed discharge and capacity issues prior
to 1993 when Social Services became the gatekeeper of the cash
5.3.3 Local Social Services, over the last
eight years, have to a greater or lesser extent seen, a placement
of an elderly person in residential and nursing care as a failure
and have worked very hard to keep people at home. This is in stark
contrast to what the vast majority of people and their families
actually say about their experiences in care homes. They frequently
report how their lives were transformed by the experience, how
safe and inclusive they feel etc, etc. The comments are often
in stark contrast to the fear and isolation experienced by many
persuaded to stay at home (See Age Concern's research in this
area). Despite academic and social workers fashionable spin on
residential care, the verifiable reality is that for the vast
majority of the millions of people cared for over the last 20
years or so and for the ½ million currently in care, the
move to residential care has been a very positive experience indeed.
Yet ironically nothing has been done to seek these positive views
from the service users or their families, why?
5.3.4 Whilst not decrying that many people
want to stay at home for as long as they can it is the LCA's view
based on experience of members who provide domiciliary and residential
services to thousands of people, that a great many people are
coerced into staying at home when they would prefer (and be far
better cared for) to move to residential or nursing care.
5.3.5 Social Services, for budgetary reasons,
have set assessment criteria so that only a very small number
of the most needy people qualify for full nursing care. The Department
of Health and Laing and Buision statistics confirm that the placement
rate in nursing homes has declined faster than residential and
that the closure rate of Nursing Homes has been higher than residential
care homes. Many Nursing Homes have also had to dual register
and accept older people as residential customers just to survive.
5.3.6 The policy of raising the threshold
of who can enter a nursing homein Lancashire they have
to require more than five hours nursing care a day before they
can enter a nursing homemeans that many frail elderly are
not having the specialist 24 hour nursing care that prevents many
health problems occurring. (One does not receive five hours of
nursing care on an acute medical ward). It has also placed greater
demands on the GP and Primary Care Services. Are we surprised
the knock on effect is being felt within the NHS?
5.3.7 The policy of keeping more very frail
elderly people in their own homes, often with limited domiciliary
and health services support, has had an even greater impact. The
fact that the commissioning agency (Social Services) only picks
up part of the bill, Primary Health and Housing Benefit being
the other components makes it superficially attractive. The elderly
person's overall health is more unstable and they are vulnerable
to illness and hence it is a very high-risk strategy in terms
of admissions to hospital. For many, the real experience of domiciliary
care amounts to an unpredictable service by definition. How can
this possibly compare to the holistic experience in residential
care of someone on hand 24 hours to attend to your every need?
5.3.8 When frail elderly people do become
ill the only option is for them to be admitted to an acute hospital.
Their conditionsoften multiple medical conditions exacerbated
by dehydration, malnutrition and depression, in older people living
on their own created through loneliness, all lead to longer admission
times. Discharge home requires the starting or restarting of complex
packages of care which takes Social Services more time to assess
and commission. The "revolving door" effect of admission,
home, readmission is a sad fact of life for substantial numbers
of older people in England today. Simply because the right care
is not being effectively accessed at the right place at the right
5.4 Over stretched Primary Care services
5.4.1 The reduction in length of stay across
all specialists in acute hospitals, the reduction in acute NHS
beds and the Care in Community policy have all placed additional
pressures and demands on GPs and the Primary Care Service.
5.4.2 There is now an emerging crisis in
Primary Care with increasing difficulty in training and recruiting
GPs to replace those retiring or to meet increased demands. The
shortage of District Nurses and Allied Health Professionals working
in the community all add to pressures and patients not getting
an adequate service.
5.4.3 Intermediate Careone of the
key Government strategies to manage the capacity problem in the
NHSwill also place additional pressure on GPs unless additional
resources are invested here.
5.4.4. Given their inability to directly
access nursing or residential home beds since 1993, the impact
of the Care in the Community Policy, an increasingly elderly population
on their lists, limited community care support services and the
general frailty and complex mix of health problems presented,
it is not surprising, that GPs seek a hospital admission when
faced with a vulnerable and perhaps poorly supported elderly person
in a home setting.
5.4.5. There are some indications that the
compensation culture which has developed in Britain in the last
10 years may also impact on GPs decision making about whether
to admit someone to hospital. The issues around defensive medicine
clearly need greater exploration with the representatives of the
5.4.6 The bureaucracy and red tape which
binds and ensnares all and costs professionals in this arena adds
significantly to delays, frustrating GPs and de-motivating service
providers at every level. The effect of this should not be under-estimated.
5.5 Policy agendas of Health and Social Services
5.5.1 It is only relatively recently (circa
last three years) that the Health and Social Services Policy agenda
has been looked at in a combined manner. Only in the last year
have the two arms of the Department of Health been integrated.
5.5.2 The focus of the National Services
Frameworks, "whole systems" thinking and planning, Health
Promotion and linking health to the wider community agenda of
housing, income, employment etc has brought the NHS and Local
Government closer together.
5.5.3 "Working together" and "developing
strategic partnerships" is still rather embryonic in many
areas and is a process that will take considerable time and effort
to ensure it happens. In particular, whilst some of the barriers
between public and private sector partnerships have been broken
down, attitudes and the lack of positive incentives are preventing
this rolling out across the Country in the way the Government
might wish. Without a fundamental reform, the whole policy shift
runs a high risk of stagnation.
5.5.4 Meanwhile it should not be assumed
that the implementation of Government Policy on, for example,
minimising delayed discharges will be given the same priority
by Local Authority Social Services Departments as the NHS.
5.5.5 It will not work if Local Authorities
cap budgets and only allow so many placements in residential and
nursing homes (two-out one-in schemes, etc) or very limited domiciliary
packages of care a week or month.
5.5.6 The Government realised the problems
of under-funding when it announced the £300 million Building
Capacity money in October 2001. This had two objectives1)
to stabilise the residential and nursing home sector by increasing
placements and starting to address the problems of grossly inadequate
fee rates and 2) eliminate delayed discharges by 2004. The response
to this by Local Authorities has at best been patchy and inconsistent.
5.5.7 Local authorities are struggling to
cope with the demands of people already at home, as well as other
budget pressures on child care services, so when someone is in
hospital it actually relieves pressure on staff and budgets.
5.6 Limited effective partnerships between
Local Government, the NHS and Independent Sector
5.6.1 Whilst there has been exhortation
at a Government Policy level for Health and Social Services to
plan and work together for 30 years the results have been patchy
and broadly at the margin of each organisation's main independent
5.6.2 Joint planning and joint finance was
introduced in the early 1970s. However, evidence suggests that
real joint working only developed in areas where there were champions
willing and wishing to work closely together. In 90 per cent of
the country what joint working there was, centred on the relatively
marginal activity of spending "Joint Finance" monies.
5.6.3 The Community Care Act 1990 was supposed
to see greater joint working between health and social services
but the results have again at best been tentative. Indeed cost
shunting (deliberate or un-intended) still occurs between health
and social services. Local Authority policies of placing increasing
proportions of people in residential care has cost the District
Nursing service dearly as they have to visit to assess and provide
nursing care to an increasingly dependent group of residents.
5.6.4 The policy of keeping severely disabled
elderly people in their own homes, even sometimes against their
wishes, has cost the NHS dearly.
5.6.5 Bizarrely nurses in dual registered
nursing homes have had to stand by waiting and watching a District
Nurse give an injection or change a dressing as it is not legal
for them to undertake this task on residential clients. This may
change with the implementation of the single Care Home under the
Care Standards Act from 2002 but only if realistic and sustainable
fees are paid to such homes.
5.6.6 It is only in the last two years that
a new attempt has been made to promote partnership working between
Health and Social Services. Apart from PFI initiates, using private
sector resources to build hospitals, the independent sector has
only featured in policy guidance from the Department of Health
in the last year or so.
5.6.7 The political debate about the role
of the independent sector in the NHS has not helped develop effective
partnerships although Concordat 1 and 2 has helped the process
in the last 18 months. Actual evidence of new contracts is however
extremely sparse in percentage terms.
5.6.8 Two to three years ago Members of
the LCA were knocking on doors of both NHS Commissioners and Trusts
offering partnership proposals only to be told they were not interested.
Even now, relatively few partnership schemes exist, why? One of
our members in 1997 built a six-bedded extension to specification
having been selected as the "preferred provider". The
trust prevaricated and the home still awaits its first "continuing
5.7 Failure of Social Services or Health Authorities
to think laterally or use expertise in Independent Sector
5.7.1 It is clear that the National Beds
Inquiry, the NHS Plan and the Modernisation agenda have started
to focus manager's minds in both Health and Social Services. There
is embryonic broadening of thinking and whole system approaches,
but it is thinly spread and significantly hampered by the massive
organisational changes affecting the NHS at the moment.
5.7.2 Until recently there has been a paucity
of imagination in much of local government and health service
planning. Whilst some local partnerships have developed between
health and social services or with the independent sector they
are the limited in number and scope.
5.7.3 Many managers and clinicians have
not been brought up in a culture of thinking "out of the
box". Hence the majority of solutions to problems have been
limited to the tried and tested with the inordinate request for
new money rather than any thinking laterally and analysing whether
existing resources can be re-engineered or used more appropriately.
A good example has been how local authorities like Lancashire
have held onto their stock of Old People's homes (some 48 of them)
when many are well past modern standards and are significantly
more costly to run than services provided in the independent sector
and run at low occupancy.
5.8 Failure by Social Services to Properly
Understand and Manage the Independent Residential and Nursing
5.8.1 Social Services were handed a poisoned
chalice in 1993; they had to cash limit the out-of-control social
security budget and develop new ways of commissioning services
rather than providing them. Very few had any experience of working
in business; few had knowledge or any interest in the economics
of business including rates of return. There was not a culture
of planning based on aggregating assessed needs and setting out
clearly what the new commissioners of services wanted. The culture
had been built up around largely managing and protecting in house
5.8.2 Social Services in many areas of the
country have singularly failed to work effectively with the large
residential and nursing home market. (Remember there are still
more beds379,200 beds for older peoplein the independent
sector than the whole of the NHS).
5.8.3 Social Services have suppressed fees
and restricted placements to the point were many homes have become
un-viable. Little building is going on to replace the old converted
stock to achieve the standards that are set out under the Care
Standards Act 2000. The economics of a new build home, on the
majority of fee rates paid by local authorities, are simply not
viable nor sustainablebanks will not lend! Exceptions to
this are occurring around the London area where fees are being
set at a level where operators will build and run homes.
5.8.4 The result is that many homeowners
have shut their doors and sold for the price of the land or building
to be used for alternatives. In areas of the South East, South
Coast and the North there are now insufficient places for the
5.8.5 Social Services, whilst stimulating
the Domiciliary Market (to some extent artificially), have again
tried to force providers to accept fees that do not enable providers
to meet the challenge of providing quality training and the infrastructure
to develop effective care services.
5.8.6 The LCA is of the view that some of
this has been created by mismanagement of social services budgets
but it must also be recognised that demand has grown far in excess
of any real increase in their base budgets.
5.8.7 Other pressures on social services
in particular on their child care budgets has led to cross subsiding
of children's services from monies allocated in the SSA process
to elderly services. The reluctance of Local Authorities to have
ring-fenced budgets enables this to occur.
5.9 Manpower crisis
5.9.1 There is a national shortage in qualified
nurses that is well documented. The Government projections for
the numbers of new nurses are woefully inadequate given the expansion
of the NHS currently underway. Currently each new initiativeNHS
Direct, Intermediate Care, Intensive Care Beds, Improvements to
A&E all lead to existing nurses moving to new jobs and their
existing wards or community posts denuded.
5.9.2 Whilst the LCA do not like the use
of agency nurses, not least because of the cost but more importantly
because of the effect on quality and continuity of care, even
the agencies are struggling to supply the NHS and Independent
5.9.3 Whilst the LCA welcomes the general
health of the economy it is clear that both the NHS and residential
and domiciliary services are struggling to find sufficient care
assistant staff who wish to work in such demanding and yet relatively
poorly paid jobs.
5.9.4 Few Local or Health Authorities have
undertaken a detailed manpower projection of the impact of their
Care in Community policies. However, given the projected rise
in very frail elderly who will require significant amounts of
care it is expected that there will need to be a significant increase
in the numbers of paid carer workers.
5.9.5 There are many examples locally of
an inability to recruit care staff to work in the community or
residential homes. In other areas with a more buoyant economy
the problems are more intense. Whilst some of this could be remedied
by local authorities paying more realistic fees, thus enabling
providers to pay more competitive rates this alone will not solve
5.9.6 The LCA believe that the shift in
demographics and the rise in the 85 years plus population coupled
with near full employment will mean that the overall policy of
keeping very highly dependent people at home will have to be reviewed.
The challenge faced by politicians is, will this be done sooner
5.9.7 The National Statistics Office have
recently published a report that suggests that to meet the needs
of the rapidly increasing over 85s in the next 30 years some 65
per cent more beds in residential and nursing homes will be required!
This is a significantly more cost effective and less staff intensive
solution. If the solution is to keep them at home or in extra
care housing schemes, then this will be both more costly and more
staff intensive and probably unsustainable. Moreover, it is far
from proven that this is what people actually want.
5.9.8 Whilst the NHS and independent sector
are currently recruiting qualified nurses to fill vacancies, it
may be, given the balance of our population, that we have to look
to recruit care assistants from abroad to fill the labour gap.
5.10 The care assessment and commissioning
5.10.1 The joint assessment procedures recommended
to implement the Care in Community legislation have in the main
not been implemented. Indeed the Department of Health's NHS Plan
has focussed again on a "Single Assessment Process"
which has to be in place by 2004.
5.10.2 The community care assessment and
commissioning process can be overly complex, not started soon
enough when someone enters hospital or is close to discharge.
If assessments only start when a doctor says someone is fit for
discharge then by definition delayed discharges will occur however
speedy the subsequent assessment.
5.10.3 Allocation panels can be used as
a means of slowing down the commissioning of a community or residential
package. If panels sit weekly and papers miss the deadline for
consideration then another week goes by with the patient taking
up an acute bed when they do not need it.
5.10.4 Rigid budget setting by Local Authorities
which bear no relation to demand create delays. In an area which
borders Lancashire but affects Lancashire hospitals there are
around 140 delayed discharges some of whom are waiting months
for a community placement. The mismanagement of the care market
in Cumbria has led to a contraction of the market and now money
has been released through Building Capacity Grant there are not
the places available to purchase. The fees are still too low for
providers to start building and there is no surety that the Local
Authority will purchase beds on a longer-term basis if they are
6. THE SOLUTIONS
6.1 Given the experience of the failure
in Lancashire, and many other areas, to develop effective strategic
partnerships and any semblance of pooled budgets the LCA would
like to see urgent direction by the Secretary of State for Health
to create "Care Trusts" for Older People.
6.2 This would create one organisation,
under the leadership of the NHS with an accountable Chief Executive,
with one agenda and the ability to make things happen. This would
reduce duplication and waste and lead to more innovative solutions
being developed more quickly. Currently the blame culture can
shift responsibility between health and social services, and local
politicians can also blame central government for not funding
their budget adequately. Arguments abound about the real year
on year increases provided to local authorities with the Government
telling us that there has been a 3-4 per cent real increase in
funds and the local authority saying they have lost money. The
outcome has been eight years of the care sector suffering major
cost pressures that have simply not been recognised by appropriate
fee increases. The current agenda is not totally sharedthe
emphasis still varies between health and social services.
6.3 Develop strategic partnerships with
Independent Sector with significant block contracts over a minimum
of three years for new Intermediate Care services at prices that
are independently shown to be economically viable.
6.4 Raise fees for domiciliary, residential
and nursing home care to rates which are viable and enables providers
to attract staff and retain them. The National Care Coalition
estimated that the residential and nursing home sector needed
an injection of £1.5 billion in 2002-03. In 2001 the Rowntree
Foundation estimated the social care sector needed £700 million
just to stem the crisis in social care provision.
6.5 Develop strategies and plans based on
clear understanding of need and projected increase in demand,
which are sustainable both financially and in terms of manpower.
6.6 NHS Trusts to charge Social Services
or other Trusts when awaiting a transfer back to a hospital of
origin, the actual cost of the acute bed when a patient is delayed
more than one week after a decision is made that they are fit
for discharge or transfer. (It is understood that a hospital trust
in Bristol is about to implement such a policy due to frustrations
over social services delayed discharges).
6.7 The recently established Change Agent
Team be enabled to impose on Health & Social Care systems
with significant problems of delayed discharge the solutions they
must follow. Failure to achieve target reductions be utilised
as a trigger to establish a Care Trust or replace NHS managers
who have failed to implement changes.
6.8 Streamline the assessment commissioning
process and abolish allocation panels. Delegate decisions to front
line managers to commission services quickly and efficiently.
6.9 Implementation of Best Value within
6.10 Creation of real incentives towards
the achievement of joint working.
6.11 Transparent and wider publishing of
areas of good practice and those poorly performing in terms of
partnership working, with far greater use of internet technology
for these purposes.
6.12 Finally, the older people we serve,
deserve the development of a system that will brush aside the
old excuses for inaction and facilitate real action in time for
them to enjoy better and more integrated services now.
18 January 2001