Older people with social care needs and multiple long‑term conditions implementation: getting started

This section highlights 3 areas of the older people with social care needs and multiple long‑term conditions guideline that could have a big impact on practice and be challenging to implement, along with the reasons why change is happening in these areas (given in the box at the start of each area). We identified these with the help of stakeholders and Guideline Committee members (see section 9.4 of the manual). The section also gives information on resources to help with implementation.

The challenge: empowering older people with social care needs and multiple long‑term conditions and their carers to choose and manage their own support

See recommendations 1.1.3, 1.2.5 and 1.2.10.

A person‑centred assessment, focused on ensuring a person has choice and control over their care and support, can:

  • result in a care and support plan that better meets the person's needs, helps them to maintain their independence for longer and may delay the need for higher levels of care

  • contribute to the person's sense of wellbeing and improve their quality of life, which is consistent with the principles of the Care Act 2014 and the desire of older people to live a 'normal' life as described in published research.

Changing perceptions

As a result of pressures within the social care system, managers and practitioners often prioritise meeting older people's essential personal care needs over their wish to live a 'normal' life. This approach needs to change to reflect a much wider understanding of the role and contribution of social care.

To do this, social care managers and practitioners could:

  • Work in partnership with focus groups, care providers or existing local forums to review their provision of information and advice, and ensure it covers all aspects needed to enable people to choose and manage their own care and support. The Care Act Statutory Guidance provides some helpful points to consider. The SCIE guide on co-production in social care provides some helpful pointers and practice examples about reviewing services in partnership with those who use them.

  • Draw on information and examples, such as those found in SCIE's Prevention Library or as part of the Campaign to End Loneliness, to develop an awareness and understanding of the impact of social isolation. They should also consider the contribution that person‑centred assessment and support planning can make to reduce social isolation, including through access‑to‑peer support.

  • Work with older people locally who are already using personal budgets, continuing healthcare budgets, individual service funds and direct payments, to review the support they need.

The challenge: empowering practitioners to deliver person‑centred care

See recommendations 1.2.5, 1.5.1 and 1.7.1–3.

Knowledgeable, confident and well‑supported practitioners can deliver:

Skills and knowledge development

To support older people with social care needs and multiple long‑term conditions, health and social care practitioners need to have skills and knowledge about a range of conditions, care needs, support options and legislation. Managers also need to understand their role in supporting this.

To do this, managers could:

  • Use this guideline and local forums to review the knowledge, skills and qualifications practitioners need to provide person‑centred care and support to older people with social care needs and multiple long‑term conditions, and to identify any gaps.

  • Use resources (such as the SCIE guide to effective supervision in a variety of settings) that highlight the importance of supervision, coaching, training and development plans, and regularly review progress and performance in partnership with practitioners.

  • Use the Care Quality Commission's provider handbook for community community adult social care services (Appendix B: Characteristics of each rating level) to understand the characteristics of a well‑led service and review the current approach using this as a benchmark.

  • Use resources such as those developed by Skills for Care to review and identify the personal support managers need, including from their peers, to provide effective and supportive management and leadership.

The challenge: integrating different care and support options to enable person‑centred care

See recommendations 1.2.1, 1.4.1 and 1.4.2.

Joined‑up care and support helps to deliver better experiences and outcomes for older people with social care needs and multiple long‑term conditions and their carers, who are known to value coordinated care with good links to the wider health and social care system. It also saves time and money across the health and social care system through avoiding duplication.

Working across boundaries

Traditionally, health and social care services that support older people with social care needs and multiple long‑term conditions focus on managing separate health conditions, and the system is complex to navigate. Systems and structures may need to change to help professionals to work across service boundaries and specialisms.

To do this, managers and commissioners could:

  • Establish named care coordinators locally and ensure they have the authority to provide continuity of support and amend care and support plans as needed. Share information about their role and responsibilities widely to make sure it is fully understood.

  • Provide care coordinators with the necessary training and support based on a clear understanding of their role, and the skills and knowledge they need.

  • Review local relationships across health, social care and the voluntary sector and identify where more support is needed to work across service boundaries and professions. Resources such as The How to… guides produced to support the Better Care Fund can help with this.

Need more help?

Further resources are available from NICE that may help to support implementation.

  • NICE produces indicators annually for use in the Quality and Outcomes Framework (QOF) for the UK. The process for this and the NICE menu can be found here.

  • Uptake data about guideline recommendations and quality standard measures are available on the NICE website.

  • National Institute for Health and Care Excellence (NICE)