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Title: The Future Of Social Care for Older People:

Waltham Forest
  • The Future Of Social Care for Older People
  • A Case Study
  • National Council on Ageing
  • 30th Jan 2006
  • Sheena Scott Dunbar and Jorge Lagos

The Waltham Forest Model
  • Of
  • Early Detection,
  • Prevention
  • And
  • Healthy Ageing

  • Developed and framed by key national policies
  • NSF for Older People
  • Choosing Health
  • A Sure Start to Later Life
  • Opportunity Age
  • Admissions Avoidance
  • Link Age Plus
  • CSCI Leaving Hospital Revisited
  • Green Paper

It is about working collaboratively and
integrating services within an equal
opportunities framework across sectors across
health and social care but also across the wider
system of local services
Our Agenda
  • Supporting older adults stay safe, healthy,
    active and independent for as long as possible
  • Preventing ill health and social isolation but
    also promoting choice and control and quality of

  • We do this by
  • Offering services and information more
  • By identifying needs as they emerge and before
    crisis occurs
  • By basing our work on evidence as far as is
  • By collecting further evidence
  • Listening to older adults and carers

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Older Peoples Development Programme Waltham
Case Finding Single Assessment
Waltham Forest
The Project
The Waltham Forest Older Peoples Development
Programme (WFOPDP) was mainstreamed following a
successful pilot as part of the London Older
Peoples Development Programme. It was the only
pilot site out of 29 in London to be led by a
voluntary organisation (Age Concern Waltham
Forest). This highlighted the important role
that the voluntary sector can play in achieving
change and implementing innovative practice.
Working together The Partners
Age Concern Waltham Forest (and the Waltham
Forest Older Peoples Voluntary Sector
The London Borough of Waltham Forest Social
Services Department
Waltham Forest
The Waltham Forest Older Peoples Development
Programme is working in partnership with
Waltham Forest Primary Care Trust (previously
Chingford, Wanstead and Woodford Primary Care
Whipps Cross University Hospital NHS Trust
(North East London Mental Health Trust)
Total population of people aged 60 and over
living in Waltham Forest 33,930. All ages
218,341 15.54
Most OP aged 75 and above lives in Wards North of
the LBWF There is a significant concentration of
BME population south of WF
Life expectancy at birth over 75 years
50.20 of OP aged 60 have a Limiting Long-Term
Illness. The majority lives South LBWF rising to
77.3 of those aged 85 and over. Most of them
lives in precarious socio-economics
conditions. Waltham Forest has the highest
proportion of households with no central heating
in London (12.3), One in five aged 60 and above
did not have central heating, rising to nearly
one in three (28.8) of those aged 85 and above.
This group is particularly vulnerable to
hypothermia and therefore winter death. Winter
deaths in England and Wales 2004 28,700
Life expectancy at birth bellow 74 years
The Waltham Forest Older Peoples Development
A pro-active approach to identify older adults
who are not necessarily known to or in touch with
health and social services
Offers options, information, and control to older
Enables access to all services across sectors and
disciplines before a preventable deterioration,
accident or crisis occurs and/or to alleviate
social isolation
Uses holistic assessment (Overview Single
Case Finding Single Assessment Pathway
GPs involved in the programme identify patients
65 and make information available to the
Cardiff-Newport Q. Identifies for..
Mental Health
Functional Decline Emotional Social
Isolation Continence Depression Falls Memory Medic
Specialist Assessment
D. Nurses
Commissions Equipment
S Services
Referrals from SS WXH ACWF Self-referrals
Handy person Electrician
SA Starts here
ACWF-VSP (80 partners)
First Follow up After 6 weeks
Single Assessment Interview
Risk Assessment SA tool (services provided)
Known to services
Medicine Management
Discovery Interviews
District Nurse
Continence Service
Send appropriate information
Send appropriate information
Other ACWF Services
Healthy Ageing
Info Advocacy
Case Finding and Single Assessment Links with
other services
ACWF Services
WF Falls Collaborative
WF Older Peoples Collaborative
Voluntary Service Partnership
Equipment Commissioning
WF Social Services
Handyperson Service
Pension Services
Discovery Interviews
Medicine Management
Whipps Cross Hospital
Incontinence Service
District Nurse
Statistical returns May 2002 Sep 2005 Total
single and multiple referrals per risk factor of
OP not currently known in the system ()
Update 2002-2005 Total population of older people
aged 65 in Waltham Forest 25,528 (Census
2001) Questionnaire sent out May 2002 September
2005 4100 16.0 of all older people in Waltham
Forest have been sent questionnaires and above a
quarter of OP have been referred for Single
Over 600 older people received services through
Single Assessment, over 70 of these were
provided by Age Concern Waltham Forest and the
Falls 1 OP that have fallen Falls 2 OP at
risk of falls
Main reasons for the success of the project
1. The close participation and co-operation of
all agencies involved. 2. The commitment of
Senior Managers in all agencies 3. All agencies
involved meet on a regular basis to review
progress and plan future actions. 4. Responses
to clients needs are fast and tailor-made to the
individuals assessed needs older adults like
Quotes from Older People on Single Assessment
after the SA we now have a wheelchair for my
husband. It will make such a difference. My
husband will be able to go out in the chair and
meet neighbours he hasnt seen for years, or we
can just sit together in the sunshine on the
Such a good idea in principle. I will be very
pleased if the SA is on record if we need it in
the future....
.it was sensitively and intelligently done and
I enjoyed the meeting. I heartily endorse a
serious attempt to work out the needs both now
and in the future of the population and only hope
the findings are matched by practical, properly
funded solutions
Following on from your visit, recently I am
certain that you will be pleased to learn that I
feel so much better. Your kindness and patience
to me filled me with hope that life is worth
living and that not all people are unkind and
thoughtless. We all need to feel we are
worthwhile and you most certainly made me feel
Im so pleased, I didnt expect any help and am
pleased at how quickly it happened
Age Concern Waltham Forest
WF Voluntary Sector Partnership (VSP)
Social Inclusion
Waltham Forest
WF Older Peoples Voluntary Sector Partnership
  • part of the WF Older Peoples Service Development
  • administered by ACWF

ACWFs Statement to MembersMarch 2002
Age Concern Waltham Forest is committed to
working in partnership with members to develop a
Partnership that delivers for older people in the
borough and for their organisations/groups. We
wish to see Waltham Forest become the borough
leading the way in a whole system approach with
the voluntary sector as a fully integrated and
equal partner. The Partnership systems that we
develop must ensure that the smallest, least
resourced groups in the borough can participate
as well as the larger, better resourced groups.
  • WF OPVSP aims
  • To be a strong, vibrant and sustainable local
  • of voluntary sector organisations/groups/project
  • that
  • acts as a coordinating, support and development
    body for older peoples voluntary sector
    organisations / groups/ projects in Waltham
  • enables voluntary sector organisations / groups /
    projects working with older people and their
    carers to develop systems to work in partnership
    with each other and with the statutory sector to
    develop integrated services for older people

  • works in partnership with the Waltham Forest
    Healthy Ageing Programme.
  • increases the capacity of the voluntary sector to
    address the emotional, cultural and socialisation
    needs of older people.
  • provides a single point of access to voluntary
    sector services for older people and their
  • provides a single point of access for
    professional referrals to voluntary sector
    services for older people and their carers.
  • agrees, develops and maintains common referral,
    monitoring and feedback procedures with health
    and social care partners (PCT, Social Services,
    Whipps Cross University Hospital and NELMHT.

  • enables local groups and older people to come
    together to influence policy, to respond more
    effectively to consultations and to effect a
    stronger voice for older people across all local
    communities in the borough.
  • acts together to challenge ageism, racism and
    other forms of discrimination and to counter
    negative images of older people.
  • works to involve more people in community
    activity and to attract more older people to
    volunteer in the borough.
  • enhances shared learning across sectors.

Other initiatives for Members Fees paid for
participation Training Provided (IT, Human
Rights, Health and Safety, Manual Handling Elder
Abuse, First Aid) Access to ACWFs Small Grants
Scheme Administration of the Councils Health and
Social Care Grants Scheme
Forthcoming Local Developmentsin March 2006
  • Launch of Waltham Forests Older Peoples
    Corporate Strategy
  • Waltham Forest Older Peoples Community Council
  • Mayors Celebration of Older Volunteers

Referral System
The (VSP) receives referrals from Whipps
Cross University Hospital Trust General
Practitioners Self-referrals Community Social
Services Case Finding Age Concern Waltham Forest
Since 2002 the (VSP) has received over 500
referrals from Case Finding and 939 referrals
form the Welcome Home project at Whipps Cross
Hospital. Information distributed to partners and
older people since 2002 37,000
Voluntary Service Partnership (VSP) Members
Connaught Stroke Club Contact the
Elderly Creative Pastimes Arts and Crafts
Group CREST Disability Resource Centre WF
(DCR) Disabled Asian Women's Network WF ELOP
(East London Out Project) Emanuel Christian
Centre Evergreen Club 50 Elderly Asian
Club Friday Hill Community Association Good Life
Club Grange Park OAP Club Health Wellspring
Trust Higham Hill Common Allotments Highams Park
60 Club Islamic Association (WF) LBWF Retired
Pensioners Leyton Old Folks Social Club Leyton
Old People's Welfare Committee
African Caribbean Disablement
Association African Women Refugee Afro Caribbean
Elderly Women's Project Afro Caribbean Elders
Association Age Concern Waltham Forest All
Saint's Bridge Club Alzheimer's Society Waltham
Forest Branch Arabic Speaking Women's
Association Arthritis Care WF South Asia Link
Network Asian Community Centre Basantu Outreach
Project BME Alliance Waltham Forest Bridge Club
50 (Ross Wyld) Centre International Des
Compassions Chakwal PAK Welfare Association Chest
Clinic Amenities Fund Circle 33
Lloyd Park Tuesday Club London Quadrant Housing
Trust Mencap Multiple Sclerosis Society Muslim
Advice Community Welfare Council Muslim Women's
Welfare Association New Horizon Women's
Group New Testament Assembly Community
Project NHS Retirement Fellowship
(R_at_WF) Pakistani Women's Welfare
Association Parish of Walthamstow
Churches Parkinson's Disease Society Phoenix
Counseling Service Restore Hope Mission Roshni
Asian Women Association Senior Citizens Asian
Group Sikh Community Care Project Shopmobility
Waltham Forest Sidama Support Network St Andrew's
60 Club St Stephen's Church Friendship Club St.
Anne's Evening Women's Fellowship Starlighters
Musical Theatre
Tamil Welfare Assoc. UK The Amir Khusro
Society The Samaritans of Waltham Forest The
Seniors Tom Oakman Centre for the Elderly Waltham
Forest Blind Association Waltham Forest
Community Initiative Waltham Forest Crossroad -
Caring for Carers LTD Waltham Forest Disability
Action Walthamstow Social Centre for the
Blind Walthamstow Deaf Club Waltham Forest Stroke
Association Wesleyan Day Care Centre WF Asian
Disabled Association WF Asian Senior's Club WF
Gujerati Mandal 55 Whittingham Roots and Shoots
Gardening Club Wood Street Drop-in Centre Young
at Heart Young Ones Young Ones
VSP Links - Service Domains
Alzheimer Arthritis Lung Disease Disability Learni
ng Disabilities (MENCAP) Parkinson Blind
Association Stroke Stress
Support Groups for OP With particular conditions
Clubs, Education, Talks and walks Gardening Healt
hy Ageing
Social Physical Activities
Signposting Services
Shopping Befriending Outreach Equipment Supply
Access Mobility Info Advice BME services
BME Information/Advice Translation/Support Groups
Community Care
Befriending Outreach
Case Finding, Single Assessment and Falls
WFOPDP Falls Collaborative
Information Support Development
Social Isolation
Preventative Health
ACWF Healthy Ageing
Counselling, Bereavement, Depression
Education ACWF Silversurfers
ACWF Silversurfers
Mental Health
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The Waltham ForestHealthy Ageing Programme
  • Working Collaboratively
  • in Waltham Forest
  • Since 2002

Background Information
  • National Service Framework for Older People
    standard 8
  • Promoting health and active life in older age
    through a coordinated programme of action led by
    the NHS with support from councils

  • The Aim of the Programme
  • To tackle the many issues associated with the
    health and well being of older people by drawing
    on recent research undertaken across a number of
    disciplines and cultures to empower older people
    in Waltham Forest to live as full, independent,
    healthy and active a life as possible throughout
    their old age.

  • It is based on research carried out in Okinawa
  • over a third of the residents lived to be 100
    years or more.
  • they remained fit, active and happy throughout
    their older years
  • had the lowest incidence of coronary heart
    disease, stroke and cancer (the 3 leading killers
    in the West), than anywhere else in the world.
  • (This is now changing due to the Western
    influence on diet etc.)

  • Main components of the programme
  • Diet
  • Activity
  • Spirituality
  • Social networks
  • (Health Promotion)
  • The Okinawa Way by Bradley Willcox MD, Craig
    Willcox PhD and Makoto Suzuki MD

  • Programme Outline
  • To provide older adults with information on
    lifestyle choices for their health and well-being
  • To work with partners to establish services that
    support older people in achieving their health
    and lifestyle aims

  • Initiatives include
  • Healthy Ageing Partnership with the WFOPVSP
  • Private partnership to provide low-cost chiropody
  • Partnership with the John Ding School of Tai Chi
    Chuan to provide trainers for older peoples
  • Provision of Looking to the Future Groups
  • Production of a local Healthy Ageing Video

  • Message in a bottle scheme 8700 bottles
    distributed since 2004
  • Partnership with Falls Collaborative and PCT to
    provide Balance Classes 1000 older people have
    benefited this year
  • Partnership with Allotments Association and WF
    College to provide organic gardening classes to
    older people 37 older people have taken part
    thus far

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  • Participants have reported
  • Improved Balance
  • Improved breathing
  • More confidence in going out
  • Improved sleeping
  • General feeling of well-being

Older Peoples Development Programme Waltham
WF Falls Collaborative
Waltham Forest
THE WF Falls Collaborative Waltham Forest was
one of the twenty sites in England who together
formed the National Falls Collaborative. The WF
Falls collaborative has now been mainstreamed and
is working together with its partners in falls
reduction in Waltham Forest.
THE STANDARD 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
rehabilitation and with their carers, receive
advice on prevention through a specialised falls
service. National Service Framework for Older
People Standard Six, Falls.
  • Why falls prevention?
  • FACTS!
  • Falls are very common one in three adults aged
    65 living in the community fall each year
  • Every 5 hours an older person dies as a result
    of an accidental fall in the home
  • 40 of care home admissions are as a result of
    a fall
  • Fear of falling can inhibit peoples daily
  • 42 of fallers have at least an 18 reduction in
    activity after a fall
  • Hip fractures cost the NHS 1.7 billion per year

Local Statistics Location of Falls (AE Whipps
Cross Hospital)
Insufficient physical activity
Unsafe footwear
Medication Management
Risk Factors Falls in Older People
Underlying physical conditions
Changes in Balance and gait
Unsafe public environment
Vision deterioration
Unsafe home environment
What do we do?
Signpost OP to services available in the
borough What is on offer!
Information on falls to older people How to
prevent falls
Single Assessment interview if required and
referrals of OP to a professional-specialist (s)
for further assessment if needed
Refer OP to the ACWF Voluntary Service
Partnership (VSP)
Provide services on the spot Handyman
Electrician Commission Small equipments to
prevent further falls
We hold Sloppy Slippers Exchange events with
We held two Training Conferences on Falls
Prevention July-August 2005
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Age Concern Waltham Forest Presence At Whipps
Cross University Hospital Trust
Waltham Forest
A E Escorted Discharge
The AE Escorted Discharge Service provides a
service to older adults, who are being discharged
from A E and would go home with a relative, if
available. The service also settles the older
adult into his/her home surroundings and provide
shopping, pension collection and minor housework
tasks. A second visit can be initiated if there
is any concern about an older person. A contact
telephone number is always left with the older
Welcome Home Service
The Welcome Home Service provides a visit to
older adults on return home from hospital the
service provided is the same as the AE Escorted
The project aims to identify older adults
being discharged from hospital without a package
of care and to address any concerns about
discharge or coping at home thus making the
transition from hospital to home as safe and
comfortable as possible. As part of the
project, socially isolated older adults and
fallers are identified and referred to
appropriate services. ( March 2002 December
2003 939 referrals, 514 of which to
WFOPVSP) Information and a telephone number also
Discharge Lounge and Ward Project
Age Concern Waltham Forest
The Link-Up Project
Link-Up Support
Home visiting
Waltham Forest
The Link-Up Befriending Service
Befriending Service
  • Provides a voluntary weekly visitor for
    housebound and or isolated older adults living in
    the London Borough of Waltham Forest, in order to
    offer friendship and company to help.
  • alleviate social isolation
  • overcome the fear of loneliness
  • restore confidence
  • and encourage participation in social groups
    within the community.
  • This service is limited to a six month period.

Link-Up Teleconferencing
Telephone Chatting
Operates a telephone conference, this involves a
group of six people and a facilitator from Age
Concern Waltham Forest being linked together for
a chat and lively discussion. These sessions are
weekly for up to 8 weeks and are free of
charge. At the end of the eight weeks,a coffee
morning is held which is very popular.
The Link-Up - Volunteers
One example of a Befriending Visits being enjoyed
by Freda with her Volunteer Visitor, Normagene,
who has been part of the Link-Up Volunteer team
since June 2002
Quotes from Link-Up Service Users
such fun and lovely happy times well spent.
Many thanks. I enjoyed speaking to friends on the
phone club and link-Up, I hope many will enjoy
the pleasure it gave me.
I dont see many people so I did enjoy
telephone chatter, I felt that part of my week
was spent with friends on air. Thank you for
doing this for me.
Visits most welcome. I look forward to seeing
her, we do some shopping. The visits cheer me us,
and as a bonus make me laugh. Thank you Link-Up
As I cannot get out by myself, I love going for
a drive and doing some of my shopping.I am very
pleased with the service that Age Concern gives.
Thank you so much for all your help and support.
Its the company I enjoy. It makes you feel
Age Concern Waltham Forest
Older Peoples Safety Campaign A safer
community for older people
Waltham Forest
Community Safety
Age Concern Waltham Forest believes that older
people should be able to live safely and securely
in their own homes and community with out fear of
crime or harassment Security at home and in the
neighborhood plays a key role in the well being
of older people. The psychological and emotional
impact of crime is difficult to measure but can
have a high impact on the life of an individual.
Safety Campaign for Older People
In order to reduce and prevent crime against
older people, and following the example of Age
Concern Colchester which pioneered the scheme, a
Safety Campaign was launched in November 2004 in
Waltham Forest
Safety Campaign Partners
London Fire Brigade Metropolitan Police BQ
Chingford Net Community Safety Partnership HEET
Home Energy Efficiency Training The Home
Office London Energy Rotary Club Chingford and
Waltham Forest Thames Water Waltham Forest
Council Trading Standards Department Waltham
Forest Older People Voluntary Sector Partnership
What the Campaign provides
The campaign provides an information pack that
includes Home security remainder sticker Home
safety door reminder Energywatch (gas and
electricity) watchdog - Free services How to
recognize a scam Is your electric blanket
safe? Avoid Burglary, Protect Your Property How
to beat the bogus caller Protect your home from
fire Your guide to keeping control of doorstep
sales Useful telephone numbers Most utility
companies provide a password scheme to deter
bogus callers. These are featured in the pack
Since the start of the scheme more than 4,300
Bogus Packs have been distributed in Waltham
The scheme also provides safety equipment Since
November 2004, it has issued Net bags
7 Letterbox
cages 28 Smoke alarms
122 Personal alarms
36 Segment timers
41 Spy holes
3 Stairs lights
203 Door chains
86 Safe cans 48 Total
674 The scheme arranges fitting free of charge
where appropriate.
To reach older people, Special Events are held.
There is also a Referral System.
  • Single Assessment
  • Self referrals
  • Voluntary Sector Partnership
  • ACWF Services
  • Close working relationships with the London Fire
    Brigade and the London Metropolitan Police have
    developed and they now regularly refer older
    people to Age Concern Waltham Forest.

Age Concern Waltham Forest Information, Advice
and Advocacy Service
Integrated Working
  • Preventative services
  • Reaching all communities including BME
  • Income maximisation
  • Person-centred care
  • Links to case finding and hospital discharge

DWP Alternative Office
  • Went live on 22nd December 2004
  • First live in Waltham Forest
  • Second live in London

Good News for Older Adults
  • Claims process greatly simplified
  • Can verify clients documents
  • Easier to track progress of claim
  • More person centred approach
  • Clients made aware of all benefits they are
    entitled to claim

Claims Forwarded to DWP
  • Attendance Allowance 67
  • Disability Living Allowance 5
  • Carers Allowance 2
  • Total 74
  • (85 success rate)

The Future
  • Referrals from the DWP/Joint Visiting Team
    into ACWF and the Waltham Forest Older Peoples
    Voluntary Sector Partnership to increase
    preventative work and healthy ageing in WF?

Waltham Forest Older Peoples Information
Strategy (Public Stream)
  • Collaborative website
  • (25000 hits monthly)
  • ACWF website
  • (25000 hits monthly)
  • ACWF newsletter
  • Waltham Forest Council Newsletter
  • Events

(No Transcript)
Delivered in Waltham
Forest for and with older adults and their
The End j.lagos_at_ageconcernwf.