Introduction

In this article, I describe the background to the development of the National Service Framework (NSF) for Older People in England (Philp, 2001), its implementation in the seven years since its publication in 2001, the main achievements to date and my views about what remains to be done in the last three years of its life as a ten year programme for reforming the culture and system of health and social care for older people.

In 1998, I was asked by Frank Dobson when he was Secretary of State for Health, to co-chair the External Reference Group for the development of the National Service Framework (NSF) for Older People, and, in 2000, was appointed by his successor, Alan Milburn, as National Clinical Director for Older people to lead its completion and implementation.

The NSF for Older People was the first NSF to apply to social care as well as health. It followed NSF’s in Coronary Heart Disease, Mental Health and the NHS Cancer Plan. Concurrently, quality standards and requirements were being set for the care home sector, so the NSF focussed particularly on domiciliary social care, the NHS, and the interface between health and care services.

The breadth of the NSF for Older People created an implementation challenge which was different from other NSF’s. There was not only the challenge of including health and care systems, but also about addressing the wide range of needs of people aged 50 plus, and adults with old age-related conditions. These included the general population of people aged 50 plus, for whom the NSF set standards for disease prevention and for promoting health, independence and well-being. At the other extreme, the NSF set standards for people with multiple conditions requiring complex service interventions, at high risk of death, hospitalisation or care home placement, whose carers often had high levels of need.

The NSF also covered some major old age-related conditions such as stroke, falls and fractures and dementia, setting standards for all adults with these conditions. Each of these conditions is associated with very high costs of care and considerable impact on people’s lives, and each could have warranted an NSF in their own right.

The NSF also addressed the needs of a group in the population who sit between the general population of older people and those with established complex needs. This “at risk” group, set a challenge for primary health and care services to improve early identification and response to needs: including addressing issues which older people’s advocacy groups identified as important to older people and their families; vision, hearing, oral health, foot-care, continence, depression and social isolation. The needs of family carers, and the specific needs of some black and minority ethnic groups were embedded in each of the NSF standards.

The NSF for Mental Health had been developed for adults age 16-65, so the NSF for Older People was expected to set standards for mental health for older adults. This split caused some difficulties in ensuring equitable investment in services for older and younger adults and in ensuing access to services was determined by need, without age as a barrier to receiving care. This was addressed later by developing a vision for adult mental health (Philp & Appleby, 2005), which emphasised the need to invest in services for old-age related mental health needs, but ensure that age was not a barrier in accessing mental health services. The vision also aligned investment in underpinning programmes including information systems for benchmarking, workforce development and support for service improvement.

NSF Development

I have previously reported in this Journal how we developed the NSF for Older People (Philp, 2003). It was organised around three themes, which I think are still valid and relevant:

• culture change
• system change
• promoting healthy ageing

Culture Change

Politicians recognised the need for culture change and wanted to respond to public concerns about age discrimination and lack of respect for the dignity of older people receiving care. These concerns are felt most amongst the middle aged children and grandchildren of older people, many of whom could report a negative experience of care amongst their older relatives.

System Change

System change was required to improve efficiency and effectiveness of health and care services for people with old age-related conditions. This was directed particularly to reducing the unnecessary use of acute hospital care through avoiding inappropriate admission and reducing delayed discharge.

Promoting Healthy Ageing

Older people were most concerned to maintain their health, independence and well-being, and not be a burden to their families, so the political offer to older people was to increase access to services which help promote healthy ageing.

NSF Implementation

During the early phase of implementation, the NSF was a top national policy priority, with a strong infrastructure for supporting implementation, which included local champions, implementation teams and change agents, regional task forces, a national task force, a national older people’s and carer’s reference group, and a large policy team. Ring-fenced money was available to pump-prime investment in intermediate care services which bridge the gap between hospital and home. A lot of early progress was made in removing age-based barriers for NHS preventative and treatment services and in developing intermediate care services.

In 2003, the Department narrowed its top priorities to improving access to primary care services, elective hospital care and waiting times during emergency response, and improving standards of care in Coronary Heart Disease and Cancer. At the same time, the NHS underwent a major structural reorganisation. Many regional and local NSF implementation teams were disbanded.

It became imperative to regain national priority for the NSF for Older People. It was important to demonstrate to Ministers that it was possible to improve older people’s care, and that the Government could take pride in such success as we had had in the early implementation of the NSF. I concentrated policy support on reviewing progress and identifying gaps. Our findings were reported in “Better Health in Old Age” (Philp, 2004) which caught the attention of the Permanent Secretary in the Department of Health, Nigel Crisp, and the Prime Minister. Tony Blair launched the Report. Following this, the status of the NSF was raised within the Department and with the service.

In order to strengthen levers for system reform in the care of frail older people and for people with old age-related conditions, we developed alliances with other National Clinical Directors and their policy teams. Roger Boyle and the vascular team put their weight behind improving services for people with stroke. Mike Richards and the cancer team did so for extending best practice in end of life care from cancer to other groups, particularly for frail older people dying in general hospitals and care homes. Louis Appleby and the mental health team did so for older adult mental health, particularly for people with dementia. George Alberti and the emergency reform team worked with us to produce guidance for emergency response for older people with falls, fractures and confusional states. The Chief Nursing Officer, Chris Beesley, committed resources from her team to promote dignity in care. These powerful alliances helped drive reforms which could not have been accomplished by the older people’s team alone.

Progress

We have seen a number of improvements in older people's health and care since 2001. Age-based barriers in access to treatments and services in much of the NHS have been removed. Ensuring dignity in care is now a top priority in performance management, inspection and regulation in health and care settings, as well as being widely discussed in the media. Older people and their carers are becoming more empowered through greater use of direct payments and personalised budgets.

Improvements to community health and care services are supporting many more older people to live at home who would otherwise require long-term institutional care, and have helped reduce delayed discharge from hospital. All hospitals treating people with strokes now have dedicated stroke units, and early death from stroke in England is now amongst the lowest in the world. Further improvements will be made following the implementation of the National Stroke Strategy.

We should also see a step-change in dementia care with the publication and implementation of the National Dementia Strategy. End of life care for older people has been improved through the use of tools, adapted from cancer care and now widely used to support best practice in end of life care for older people in hospitals and care homes.

Some of the biggest improvements in disease prevention have been amongst older people in areas such as vaccination programmes, smoking cessation, blood pressure control, and cancer screening. Current and future generations of older people will benefit from changes to diet, exercise, and alcohol and tobacco consumption if our work with consumer media to encourage behavioural change in middle life is successful.

These changes were made possible through partnership working at all levels in the system.

The Next Three Years

In the next and last phase of NSF implementation, some priorities are well established. These include empowerment of service users and families through greater use of personalised budgets and direct payments, and improved dementia care with a National Dementia Strategy and Implementation Plan to be published in late 2008.

We are three years into our five year programme to promote dignity in care. Foundations are in place through increased awareness and championing, and stronger inspection and regulation. More will be needed to strengthen user and carer feedback systems to drive quality improvement at local levels, and to support workforce development (particularly early work experience) for all staff groups involved in the care of older people.

In “A Recipe for Care” (Philp, 2007) we described some of the actions needed for system reform in the next few years:

a) Early response to old age related conditions relating to: vision, hearing, continence, foot care, oral health, mobility and mental health (depression, anxiety, loneliness, bereavement, alcohol abuse).

b) Emergency response with streaming to specialist care for older people with falls, fragility fractures and confusion/delirium.

c) Better in-hospital care for older people with complex needs, with simple rules for risk management and specialist involvement, especially for older people with mental health problems in general acute hospitals, or physical health problems in mental health hospitals.

d) Early supported discharge in the community, including use of intermediate care services to undertake comprehensive assessment and care-planning prior to care home placement or continuing support to live at home.

e) Spreading best practice in partnership and integrated working.

Now that the NHS has settled into its new structures with better alignment with local government, there is an opportunity to develop and implement local strategies to promote the health and well-being of all older people and to reach out to marginalised groups of older people, (including those who are isolated, poor, those with mental, physical or sensory deprivation, and some black and minority ethnic groups). This work should be led by local government with support from the independent sector, the NHS and older people’s groups.

Conclusion

It has been an extraordinary privilege, and a big challenge, to provide national leadership to help improve the health and care of older people. I hope my approach has helped move policy and practice from the margin to the mainstream and raised priority and attention to the needs of older people and their carers.

We have been fortunate to have had a prolonged period of national attention to older people’s needs using the organising framework of the NSF. The programme will need ongoing leadership and refreshment as the challenge of responding best to an ageing population will only increase as we live longer.

References

Philp, I. (2001). National service framework for older people. London: Department of Health.

Philp, I. (2003). The development and implementation of the national service framework for older people’s services. Generations Review, 13, 24-25.

Philp, I. (2004). Better health in old age. London: Department of Health.

Philp, I. (2007). A recipe for care – Not a singe ingredient. London: Department of Health.

Philp, I., & Appleby, L. (2005). Securing better mental health for older adults. London: Department of Health.