Campaigners, policymakers and care sector leaders recently met at the Social Care Institute for Excellence to discuss how the prevention agenda should proceed
John Bolton: Since I started my career in 1971 there have been debates in social care about what prevention and early intervention are. There’s still confusion that I hope today we will get underneath and sort out. We’re going to start with three presentations setting the scene from Raj at the Department of Health, Clive from Age Concern and Ann from the disability movement.
Raj Kaur: Prevention and early intervention is at the heart of the vision in Our Health, Our Care, Our Say. There is a growing evidence base about the effectiveness of preventive interventions. We know that many councils find it difficult to invest in prevention and early intervention.
While some interventions will generate significant savings others will focus on improving well-being. It may be harder to track the financial benefit of the latter but in relation to higher satisfaction levels from older people in their daily lives this can make a big difference and is an important part of delivering social capital.
What is important is to be clear about what is being commissioned, and why, in order to deliver a balanced system which will make a real difference to the way individuals engage with services and so will make a real difference to their lives.
Clive Newton: The first point I want to pick up on is about outcomes and evidence: what are we aiming to prevent and how do we know when we are preventing it? Implicitly, or sometimes explicitly, savings, reduced demand on hospital bed and residential care bed usage is the gold standard measure of effectiveness in prevention. The problem with this is that it tends to favour the higher intensity types of prevention. While those are important we also need to have the lower intensity primary prevention the stuff that deals with loneliness, isolation, provides emotional support, provides low level practical support.
As far as I’m concerned, well-being and quality of life is an entirely valid outcome measure and we do know there will be a knock-on impact in terms of bed usage. The real killer of older people is loneliness. So we need to find a way to ensure that the sort of preventive work that provides social opportunities, emotional support and practical support is as fundable as the high intensity interventions.
Ann Macfarlane: What people want in their lives, based on research from the Older People’s Programme, is meaningful relationships personalised support and care personal identity and self esteem home with personal possessions authority and control and meaningful daily and community life. This will happen if people ask, listen, respond, act, report back and evaluate. Asking people and listening and sometimes hearing what is not spoken and getting back to them is terribly important. What we really need are “can do” approaches with a groundswell of grass roots action. We know what makes our lives good and we want to keep it that way.
John Bolton: Maybe the area we should first explore is the use of the words prevention and early intervention. I tend to distinguish between those services that save money and those services that promote the well-being of citizens and have equal value but you can’t always immediately track your savings. So what do we mean by “prevention” and “early intervention”?
Susanna White: I would ban the word unless we were specific because we all mean different things by it. I see the approach in three stages. One is what we will do for all citizens which isn’t preventing getting old but positively promoting a great old age. Then there’s the group of people who have particular issues that you might have specific interventions with, and then there’s the group who are getting reablement. If we use the word “prevention” we’ll get lost.
Emily Holzhausen: When you talk about family that changes the context again because families supporting older people play that prevention role. One part of the discussion is about those people who don’t have that family to provide that important role.
The second part is if families help on the prevention agenda, how can they be supported in a way that helps them and the third part is looking at those carers themselves in terms of prevention.
Annie Stevenson: It’s about a deeper issue than saving money because it’s a win-win for all of us if we can achieve that well-being so that we don’t need the services. So something about avoiding services all together? But maybe that’s going a bit far – but when we need them and they’re appropriate and person-centred.
Clive Newton: Primarily for me what we’re trying to prevent is older people leading lonely, boring, miserable and unrewarding lives. If people have fun they live more healthy lives, live longer and cost less. If we had one performance indicator for older people it would be the amount of fun in their lives.
Finbarr Martin: It’s worth deconstructing why this thing about preventing acute hospital admissions is so important. There are two areas, one is when people experience going into hospital, do they get things done that could not be done somewhere else? The second thing is it’s a major disjunction in someone’s life being in a hospital because of the complete loss of autonomy and we haven’t developed very good systems for dealing with that. In terms of the other side of why we want to reduce hospital admissions it is because it’s expensive. If we are talking about cost savings the gain is in reducing drastically the variants for people in hospital, it’s not about ending admissions. There are other good reasons for that but the cost one is a relatively weak one compared to what we could achieve through other types of intervention. Getting other things right will reduce hospital admissions.
David Colin-Thomé: The fitter you are when you go into hospital, even if you have an acute episode, the better equipped you are to come out earlier and lead a more fulfilling life. It isn’t just the packages of care we can give people it’s the sheer health. Those two agendas are quite aligned in lessening that need for hospital care.
John Bolton: We have to look at how we change the balance, particularly of admissions in residential care which has big variations across the country. I have identified evidence that seems to support that the right intervention leads to decreases in different aspects of health and social care. So the reablement and intermediate care services clearly now show that for older people you can reduce the number needing domiciliary care as well as residential care. We’re working with the Nuffield Trust to look at how, with predictor tools, you can target those people at risk. I was in Herefordshire two weeks ago where I saw the use of an IT system supporting people with dementia to stay in their own homes with good domiciliary 24-hour support getting better outcomes at a lower cost. There’s evidence on getting people’s housing right, health intervention and falls prevention.
Stephen Burke: I’m pleased you mentioned housing because if you look at where older people spend most of the time it’s in their home. There is a lot more we could do to make homes safer and more secure. What we still haven’t got a proper measure of is the impact on older people’s quality of life. We’ve got lots of examples of what could be done and we’ve got lots of evidence. So what’s the blockage? One is that this requires a holistic approach at a local level and we still haven’t got near the top of the list for local strategic partnerships and local area agreements in terms of making it happen. And second we’ve got an issue about the agency that invests doesn’t necessarily see the savings as a result of it. Until we get the NHS at a local level to put money in as well as save money then we are going to see quite a few blockages in the system.
Susanna White: It’s not just about the NHS putting money in locally. We know from the Popps programme in Southwark that across the whole system the rehabilitation programme was cost effective. The biggest gainers from that were our acute foundation trusts locally and the difficulty is that’s where the money is tied up in our local system. We need to find a way to get that money released to the whole system.
John Bolton: Brian, I’d like to ask you to talk about LinkAge Plus because that’s an important contribution to this.
Brian Keating: A couple of things have come out of LinkAge Plus, that citizenship is important and there is an education side to all this. We learn to be children, young adults, how to start a family, but we don’t have that education about the good positive bits about ageing. Some of those things tie in and that’s where you see the community come together within projects like LinkAge Plus where they used their own knowledge and their needs and aspirations to come up with the services they want. So how much can we let go to let people do what they want to do without having to always say it doesn’t fit our strategy or it’s not within the commissioning framework.
Carolyn Denne: I was reflecting on the discussion we’ve had so far in the context of this research from Community Care. It seemed to me there were some things that Community Care had given a positive spin to that I find a bit worrying, for instance on the contribution of the NHS to well-being. Of the sample 25% thought the NHS wasn’t contributing much. On safeguarding 25% thought that councils weren’t being very effective. Given the context of person-centred services, if that’s right it doesn’t seem to me that that’s good enough.
Guy Robertson: The experience from the evaluation so far of the Popps programme has highlighted the issue of savings accruing in one part of the system – acute healthcare – whereas most of the investment has come from another part of the system – social care. However, we have to realise that we are talking about very complex systems. It’s really unhelpful where people in social care talk in a rather adversarial way about – “so how do we get the savings out of health?” What’s really required to make the most of this prevention and early intervention agenda is the old chestnut of joint working. This needs to be approached in a mature way, recognising that there are things that health does that have a beneficial and negative impact on social care and vice versa. The self care agenda is one area where it’s often seen as something to do with health, but things like the Expert Carers Programme and peer support for people with dementia are of direct relevance to social care. These things don’t necessarily cost large amounts of money but can make big efficiencies particularly if we look at them as a whole system.
Imogen Martin: We are teaching people to practise their physical hygiene as then some will never reach hospital and to practise their well-being in their diet. People want education but there have been barriers because some of our people don’t speak our language and they don’t know what we’re saying and you have to show them with sign language. Some people stop their ways and some continue but even if they break down a little it still helps the health service because they don’t break down entirely so it doesn’t have to pick up the pieces.
Andrew Cozens: It’s inexcusable if the evidence is as robust as it is that local commissioners continue to choose to invest in things where the evidence is weak. That’s not the best use of public funds. If we’re confident about that infrastructure, then we must be brave enough to say that it will be in place irrespective of the personalisation of services so that people aren’t gambling on their personal budgets on whether or not a service is available locally or using their personal budget to prop up the deficiencies of local commissioning or the development of social capital. We’ve got a responsibility to use your evidence, John, to develop a better infrastructure first so that people do return to health quickly, have a high level of independence, have a sense of self care and support for carers. I think that’s a local leadership challenge.
Clive Newton: It’s important we don’t end up thinking you can sort everything out through individualisation and personal budgets. It’s important for older people’s well-being that they are able to go into town centres and they won’t if you’ve shut all the public loos and demolished all the seats. So we need to hang on to the idea of collective goods.
John Bolton: On that point, yesterday I was doing work on the social care capital strategy and one of the things I suggested as to why the Treasury might give money to councils was so they would support with capital money universal services, for example, ensuring there were toilets in public places. We’re on the same wavelength.
Allan Bowman: I was looking back at statistics which looked at the numbers of households that used to have domiciliary care in the early 1990s, I think 530,000 households and we’re now down to about 300,000. Against that, the numbers of hours per household was rising which suggested that home care had gone from cleaning, cooking, shopping to a personal care service which is a good thing. But what is difficult to identify is where are the services to do the cooking, cleaning and shopping coming from? If we go for what we know works in the sense of targeted prevention and we know it releases money then we come to the mechanism of the local area agreement which then should allow investment in the range of preventive services, like shopping. I think it’s a way of trying to encourage prevention and using what we know works as a lever to do that but then freeing up local authorities to use greater imagination.
Geraint Lewis: I wanted to offer a word of warning from research I did last year in the US where they are looking at how they can reduce costs in their system which is very much hospital based. They try to identify who is at high risk of emergency hospitalisation so they can offer preventive care. Another strategy they are pursuing is to look at the patients who they think are going to be least likely to co-operate with preventive care. It’s a roll call of the patients who we would want to target extra resources at, for example, people who have mental health problems, anyone who has an addiction, a single parent or somebody who doesn’t speak English or has learning disabilities. You can see if you’re a profit making company that might make sense but we need to recognise that this ability to predict things is going to come across the Atlantic and we need to think about flipping it on its head so we channel additional resources to these people who are going to be more challenging to work with in a preventive way.
Ann Macfarlane: I chair a patient participation group and through this we have done some focus groups around bereavement and older people. They wanted a local group where we could have a telephone service for each other – they didn’t want to go into full bereavement counselling, they wanted to just be able to say “I’m having a bad day who’s on the end of the phone”. Sometimes we take sledgehammers to crack nuts. If you listen to people the solutions are reasonable.
John Bolton: We’re all signed up to the agenda of the well-being of citizens. In the end the message is about creative collaboration between people. Where I hope we’ve got to is an image of a society where it’s good to grow old – that’s what we’re trying to create, making sure we get the right interventions to people at the right time.
Who are they?
John Bolton – director of strategic finance, Department of Health (chair)
Finbarr Martin – acting national clinical director for older people, Department of Health
Clive Newton – national development manager – health and social care, Age Concern England
David Colin-Thomé – national primary care director, Department of Health
Brian Keating – national project manager, LinkAge Plus, Department for Work and Pensions
Raj Kaur – national project manager, Partnerships for Older People Projects, Department of Health
Andrew Cozens – strategic adviser, adult services, Improvement and Development Agency
Susanna White – Southwark Council adult services director/Southwark PCT chief executive
Stephen Burke – chief executive, Counsel and Care
Annie Stevenson – head of older people’s services, Social Care Institute for Excellence
Emily Holzhausen – director of policy and public affairs, Carers UK
Ann Macfarlane – disability rights and equality consultant
Imogen Martin – service user
Geraint Lewis – visiting fellow, Nuffield Trust
Allan Bowman – chair, Social Care Institute for Excellence
Guy Robertson – prevention and early intervention programme, Department of Health
Carolyn Denne – interim policy support manager, Care Quality Commission