Good practice in strategic development

It is important to examine the potential for development at the more strategic levels of the new PCTs, SHAs and the Department of Health itself.

The role of PCTs – the GP contract

The national GMS (General Medical Services) GP contract, gives three points (management indicator nine), out of 1050, in the Quality and Outcomes Framework (QOF) for the establishment of a system to identify carers and refer them to the Local Authority for an assessment. Although this is a disappointingly low number of points, the number of practices taking up this option has been very high.

There do however appear to be two other problems:

1. Because the points available are relatively low, this indicator has probably not been audited as robustly as some others; and
2. It refers to a process, not an outcome.

As shown in the section on the demonstration projects (section four), it is possible to gain the points for this whilst still only identifying a small proportion of carers. It should be audited against the number of carers identified compared with the expected number.

Some areas have however taken welcome initiatives in this area.

In Greenwich, Neighbourhood Renewal Funding (NRF) has been used to support a pilot project around the Greenwich protocol which enables carer support to be delivered in three phases: basic support, intermediate support and intensive support. Two practices are working at each level, and targets have been set to measure the outcomes. The NRF funding has also been used to provide publicity in all surgeries.

Worcester PCT have included the use of a GP registration card provided by the Carers’ Centre in their monitoring of GP practices against QOF management standard 9.

There are other opportunities to encourage progress in this area. Some practices have locally-negotiated Personal Medical Services (PMS) contracts. It is open to PCTs to negotiate with those GPs for the inclusion of systems and services to improve the level and quality of support given to carers. Similarly, the new GMS contract has within it the option of payments for locally or nationally determined ‘enhanced services’. This should be one focus for local discussions with PCTs and Strategic Health Authorities about how to improve primary care support and services for carers.

The Scottish Executive have produced a framework for ‘Enhanced Services - services for carers’ which comprises the following specifications:

a. Produce and maintain a register of people who are carers. In addition medical notes will include a flag to indicate that this person is a carer; and
b. Effectively liaise with relevant outside local carer agencies and social work services. This will involve each participating GP practice:

i. Identifying one person from within the practice team to act as an appropriate liaison officer for the practice with relevant local carer agencies and social work services; and
ii. Agreeing a referral process for referring carers from the practice to relevant outside carer agencies and social work services, to ensure carers can access appropriate information and support from these agencies/services at an early stage in their caring role. This will include co-operating with relevant outside local care agencies in any initiative designed to alert carers to the support they offer.

The role of PCTs – service development

PCTs are responsible for establishing clinical governance protocols for the delivery of services by GPs. These should address the extent and manner in which the role of carers is recognised and supported. In other words, the principles which have been incorporated, for example, into the National Service Framework for Mental Health should be included in other clinical areas. Similarly, arrangements for appraisal of GP practices could include elements relating to this area.

PCTs provide training programmes for practice staff. This training should include carer awareness, how to establish carers’ registers at practice level, and how to support carers and improve the range and quality of service offered.

PCTs have discretion in the financial allocations they make and the types of service development that they support. PCTs should recognise the relevance of such projects to NHS objectives and the value of supporting them, financially and with longer-term contracts. PCTs can also assist in other ways. For example, they can organise local conferences or listening events to give local carers an opportunity to contribute their views and experience to debates on service improvements.

The old star rating system has been replaced by a new system of Core Standards based on self-assessment which the Board has to sign up to. Two of those are as follows:

• Standard C14c – Healthcare organisations have systems in place to ensure that patients, their relatives and carers are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery; and
• Standard C17 – The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services.

There are examples of PCTs adopting good and innovative approaches in this area some of which would contribute to meeting these standards:

The Commission for Healthcare Improvement (as was) in its report on Airedale Primary Care Trust, identified the PCT’s work with carers as an area of ‘notable practice’, describing it as follows: ‘This innovative project works in conjunction with Social Services to map and explore how carers are supported and needs are met. This encourages practices to record carers’ details on patients’ records’.

Carers In Herts undertook a ‘carers challenge audit’ of the eight PCTs in their area using a quality assurance tool, and produced a report back to each PCT. It developed a Red/Amber/Green categorisation for PCTs.
Wandsworth PCT has employed a carers development worker. That worker was able to ensure that the role of carers was championed and recognised in the development of a Long Term Conditions Strategy which included five cross-cutting recommendations to improve support to carers which will apply to a range of organisations and providers.

Redbridge PCT have supported a Carers’ Centre project called ‘Carers Choosing Health’ aimed, as its name implies, at improving carers’ health.

Swindon PCT has developed a generic set of five standards for support for carers to be applied to all services provided and commissioned by the PCT. These cover information, staff training, record keeping, carers ‘leads’ and ‘champions’ attending meetings at the Carers’ Centre, appointment systems, carer health checks, carer involvement in service development and evaluation, and carers support groups.

Leeds Carers’ Centre Health Project, working with five PCTs in Leeds, has run a Carers Conference, three mini conferences and seven listening events as part of the project’s strategic work on raising awareness of carers issues and providing training for primary care staff to enable them to identify and support carers.

Carers training

The National Strategy for Carers made clear that “the NHS must help carers to learn the necessary skills so that they can care without risk of injury to themselves”. The strategy also noted that this can be particularly important at the start of caring. Untrained new carers are sometimes thrown into a situation that would never be allowed for paid care staff. The Carers Speak Out survey found that as many as six out of ten carers did not have sufficient information, help or support with the tasks of moving, lifting and handling the person cared-for. National statistics on health symptoms among carers also reveal that one in four carers who were caring more than 50 hours a week suffered physical strain. However, it is about much more than moving and handling.

We are very pleased that Our health, our care, our say has accepted the recommendation in Primary Carers that an Expert Carers Programme (ECP) should be introduced, building on the model of the Expert Patients Programme. It is appropriate to identify some good practice about how this should be implemented, which emerged from a mapping exercise of 266 organisations involved with carers training, which The Princess Royal Trust for Carers recently undertook on behalf of The Department of Health:

• Carers should be involved in decisions about the content and delivery styles of any programmes;
• The programme should include the concept of the carer exercising choice about the amount of caring which is undertaken;
• Drawing from the Expert Patients Programme the concept of carers themselves doing the training, and being trained as trainers, is important;
• Whilst the similarities with the Expert Patients Programme are acknowledged, it is also important to recognise the differences for carers training. The former is about caring for oneself, whilst the latter is both about that and caring for someone else;
• It is important that it should not be too health focused, or be seen to mainly aimed at reducing the demands on the NHS (even though effective support for carers will undoubtedly do that). Some carers have already expressed suspicion of this;

1. ‘Carers’ should not be seen as an homogenous group. There are great differences in carers needs, based on their personal situations, and the longevity and nature of the caring need, which should affect both the content and delivery style of training provided; and
2. The special circumstances of young carers, in particular, should be recognised.

The mapping exercise revealed a wide range of possible areas for inclusion in the ECP:

• Moving and handling;
• Carers’ rights;
• Coping with stress/coping strategies;
• Services for carers;
• Information for carers;
• Communication skills;
• Looking after yourself;
• Advocacy;
• First Aid;
• Medication;
• The effect of caring on other relationships of the carer;
• The changed relationship with the cared for;
• Bereavement counselling;
• Training for life after caring including new skills or refresher courses;
• Influencing local decision making/influencing public perception/acting as a carers’ representative;
• Starting/running a local carers group; and
• Palliative care.

Many Carers’ Centres are already involved in the training of carers, covering a wide range of areas often with the support of their PCTs.

Brent Carers Centre held information and support events for carers, covering a wide range of areas including specific advice on caring for people with particular conditions; lifting and handling; first aid; nutrition; managing stress; exercise and relaxation.

These courses were either held on one day or once a week in the afternoon over three weeks. Carers Resource (Harrogate & Craven) holds contracts with its PCT for memory clinics and palliative care training.

Wandsworth Carers’ Centre is involved with a local back care project.

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