Barriers to early intervention and prevention

Prevention and early intervention form the cornerstone of more personalised services for older people, but what needs to be done to make them more than ideals? Mark Hunter reports

The case for early intervention and preventive services for older people ought to be a no-brainer. Logic dictates that if low-level needs can be prevented from turning into acute needs, or at least their progress slowed down, then everybody wins. Service users retain their independence for longer and receive the kind of care they actually want, while care providers save resources on expensive acute services.

It is an argument that has been put repeatedly in policy documents, ranging from 2005’s Opportunity Age in which the government set out to “end the perception of older people as dependent”, to 2007’s Putting People First concordat in which central and local government agreed to transform the provision of adult social care. Additionally, prevention is a vital ingredient for all the other strategies that affect older people, such as those for dementia and carers.

More recently the publication of preliminary findings from the Partnerships for Older People Projects (Popps) showed that the benefits of early intervention go beyond mere theory. In 470 projects involving nearly 100,000 older people, the Popps pilots improved people’s quality of life, reduced their dependence on acute hospital services and demonstrated that for every £1 spent on preventive schemes there is an average £1.73 benefit to the health and social care economy.

According to John Bolton, director of strategic finance at the Department of Health, many local authorities are already making progress towards the early intervention that will provide the cornerstone of more personalised health and social care services.

“Early intervention is a really significant part of the Putting People First agenda so we are obviously keen to support the whole health and social care sector in doing this,” he says. “There’s growing evidence of interventions that are particularly effective in reducing long-term demands on social care and increasing service capacity.”

Enablement programmes

Bolton cites schemes such as home-based enablement programmes that can reduce both admissions to care homes and the demand for domiciliary care. High-tech interventions such as remote monitoring and telecare, the use of predictive tools to identify people most at risk, and better healthcare and housing options for older people can also reduce the demand on acute care and save resources.

“These are all areas where the evidence is strong that if you do this you will save money in the long run,” says Bolton.

Not that financial rewards are the only reason for investing in preventive services. Bolton points to initiatives such as peer support and befriending schemes, housing repair services and gardening projects that can all improve people’s quality of life at little extra cost.

“There are a number of what I call ‘well-being services’ where it may be harder to track the financial rewards but which appear to add value to the quality of people’s lives.”

Bolton is clearly optimistic at the way in which local authorities are introducing preventive services. However, a recent report by the Audit Commission suggests that a number of councils are struggling to provide for their ageing populations.

Age-proof services

Don’t Stop Me Now concluded that only one in three local authorities had put sufficient provision in place. Moreover, those councils with the highest populations of older people were often those who had fallen the furthest behind.

“The reasons why some areas are lagging behind others are very difficult and complex,” says Natalie Penrose, senior manager in the Audit Commission’s policy, research and studies directorate, and one of the authors of the report.

“Some say they are only just managing to keep their heads above water, but there doesn’t seem to be any correlation between how well prepared a council is and how many older people they have.”

Nor is it the case that ‘good’ councils are better prepared than ‘bad’ ones. Many three and four-star councils were dragging their heels just as much as those with poor comprehensive performance assessments.

Penrose emphasises that local authorities need to age proof their services right across the board, not just in social care. “Councils need to understand their own demographics and age-proofing means building in provision for the over-50s when you are planning your services, not trying to add it on at a later stage.”

Voluntary sector

One way of involving local people in the delivery of services is to make efficient use of the voluntary sector. This not only helps ensure that the services remain relevant to local people’s needs, but may also be of considerable benefit to the volunteers themselves.

“The volunteers are often older people so it’s an excellent way of keeping people engaged in their local communities,” says Sarah Stone, deputy commissioner at the Older People’s Commission for Wales. “It’s a win-win situation.”

Using volunteers can be a way of bringing fragmented communities together, and if they are older people, may help tackle age discrimination. This is essential to the prevention agenda if we are to change poor attitudes to older people.

Stone believes that the argument for early intervention was won long ago and expresses frustration at how slowly it appears to be taking place.

“There is a general agreement on this now but there do seem to be some practical difficulties in actually making it happen. There is a lot of good practice out there but at the same time we’ve seen eligibility criteria becoming much tighter. So you really do need to have quite a sizeable level of need now before you can access any services at all.”

Early benefits

But James Reilly, director of community services at the London Borough of Hammersmith & Fulham, points out that older people can benefit from preventive services long before they have even entered the care system.

“It’s important to make use of the contacts that the council, whether through social services, housing or any other department, already has with people who do not currently meet eligibility criteria but who may be at risk,” he says.

For instance, the borough has recently used the preventive technology grant to support the team that manages its care alarm system, which is used by people not yet in the care system.

Other ways in which councils can introduce early intervention measures include using the Supporting People programme, which offers housing-related services to vulnerable people.

“We’ve re-energised the way that housing support is provided by using floating support models and extra care supported housing,” says Reilly. “This has assisted us in helping disabled people regain and retain their independence.

“When you help people to achieve that you often find that they grow in confidence, improve their mental well-being and so they become much more resilient in any crisis that may occur later on.”

Another measure being introduced by a growing number of councils is reablement homecare, which helps people recently discharged from hospital to increase their skills and confidence.

“In many ways this is the biggest preventive show in town,” says Reilly. “It has the potential to help a large number of service users. But there is a skills issue and there is a need for cultural change towards a more dynamic model of rehabilitation.”

It may be that barriers such as these are slowing down the development of early intervention.

Nevertheless, with the nation’s over-50s population set to increase by a quarter over the next 20 years, and with mounting evidence that properly implemented preventive initiatives can improve people’s lives while saving resources across the health and social care sector, there is no doubt that early intervention is here to stay and that nobody working in social care can afford to ignore it.

Survey reveals local prevention progress

Community Care’s survey of social care professionals working with adults – two-thirds of whom were from local authorities – paints a positive picture of local progress with prevention and early intervention strategies to help older people live independently for longer.

Sponsored by the Department of Health and the Social Care Institute for Excellence, the survey found that two-thirds of the 692 social care professionals who responded thought that their local authorities had a prevention and early intervention strategy in place.

Roughly the same proportion said the strategy was effective, although most were slightly lukewarm – 60% said it was quite effective, and just 8% thought it was very effective. However, 16% of respondents said their local authority lacked a strategy, while a little over a fifth (22%) said their strategy was not very effective.

When it came to the involvement of council departments other than social care in promoting the well-being of older people, housing performed particularly well, with 63% of respondents saying housing was involved in the strategy. Transport scored second highest (49%), followed by leisure (45%) and community regeneration (37%).

Asked about the involvement of agencies outside the council in promoting the well-being of older people locally, respondents predictably ranked the voluntary sector first, 41% saying it was very involved and 48% quite involved.

The NHS also did well, nearly three-quarters of respondents said it was involved. But only about half said the NHS and their local authority would work together effectively in the future to implement early intervention.

The survey indicates that delayed discharge is far from the only trigger for planning older people’s long-term care needs. Just over two-thirds of respondents said that their local authority had systems in place to enable decisions about these needs to be made outside of hospital.

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