Reablement delivers better outcomes and savings

Reablement services save councils money by helping service users regain independence. But, as public finances tighten, will authorities be able to find the investment required to make them work? Natalie Valios reports

Reablement services save councils money by helping service users regain independence. But, as public finances tighten, will authorities be able to find the investment required to make them work? Natalie Valios reports

An excellent local authority will achieve efficiencies “through a system focused on early intervention, prevention and reablement”, according to a Department of Health report last year on the use of resources in adult care.

The statement reflected the positive results demonstrated by reablement. Providing personal care, help with daily living activities and other practical tasks, usually for up to six weeks, reablement encourages service users to develop the confidence and skills to carry out these activities themselves and continue to live at home.

A 2007 study for the DH’s care services efficiency delivery (CSED) network found that up to 68% of people no longer needed a home care package after a period of reablement, and up to 48% continued not to need home care two years later.

As with all preventive services, reablement entails up-front investment, but these costs appear to be outweighed by reductions in the use of home care and a delay in requiring more intensive services in the future. As changing demographics put an increasing strain on local authorities, Gerald Pilkington, CSED programme lead for home care reablement, believes the money they are saving through reablement is being used to help them manage this demand.

“They are better off than they would have been because, if demand goes up and they don’t have the budget, they have one option – to continue raising Fair Access to Care Services eligibility criteria,” says Pilkington.

How those benefits in outcomes and savings are maximised is the subject of a study being carried out for the CSED. It aims to identify the factors that affect the level and duration of benefits to users and any impact on and savings in the use of social care and other services from reablement. The final report is due in October, but the interim report showed reablement brought significant improvements in social outcomes, quality of life, health and levels of dependency.

A good reablement service needs to be flexible so it can spend longer with people if necessary, so a better resourced service might achieve better outcomes, says Jon Glasby, professor of health and social care at Birmingham University.

“This is about investing to save, so reablement might be more expensive but have longer-term benefits. The difficulty is in the current and future financial climate can we protect enough resource to invest in prevention in the hope that it will save money further down the line? That, literally, is the billion dollar question.”

As the former director of strategic finance at the DH, John Bolton has had to grapple with plenty of billion dollar – or at least billion pound – questions. Now interim director of adult services at Warwickshire Council, he says: “The evidence is quite compelling of significant sums of money saved [through reablement] and good outcomes, so it’s win-win.

“Of the 3% efficiencies in 2009-11 that local authorities were going to have to find, we [at the DH] were confident that one third of social care’s contribution to those efficiencies could come from reablement.”

However, although 148 of 152 councils in England have told CSED that they are planning, implementing or running a reablement service, there is no data on what stage they have reached.

This potential for variation leads Bolton to warn: “When I was at the DH we put reablement into this round of efficiencies. It had nothing to do with the next spending review [from 2011-14].

“Those who are ahead of the game can’t make those efficiencies again, so it would be unfair if all councils were expected to make efficiencies through reablement. There’s a risk of double-counting and a risk if the government thinks this is the solution because, in a sense, it was yesterday’s solution.”

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Savings for Leicestershire and independence for clients

When 91-year-old Nellie Williams fell and fractured a small bone in her back in January, she knew she could rely on Leicestershire Council’s home care assessment and reablement team (Hart) because she had already used them twice before, after a hip replacement operation and another fall.

“They came in three times a day for a while: in the morning to get me out of bed, washed and dressed, at lunchtime and in the evening,” says Williams, who no longer needs the service. “They didn’t put me to bed, but they got me ready for bed. They help you do things for yourself again rather than doing it all for you.

“They are a marvellous team. I wouldn’t be a bit surprised if I had ended up in residential care if Hart wasn’t available.”

Hart started as a pilot 10 years ago. It is a social care model of reablement. Although it does work alongside health partners, the staff are employed by the council. There are 184 home care assistants and 22 supervisory and management staff organised into 12 teams in six localities. Hart doesn’t have an occupational therapist attached to it but has access to one in adult social care.

The service is available to all adults aged 18 and older, including those receiving long-term care and people with dementia. Only a few are excluded, such as those receiving end-of-life care and people with complex mental health needs. After referral, commissioning staff assess an individual’s needs and, if they meet Fair Access to Care Services criteria (moderate and above) and require home care, Hart goes in first for up to six weeks. The first two days are free and then there is a charge: from October 2010 this will be £13 an hour, though this is means-tested.

Service manager for provider services Jane Dabrowska says: “On the first two days we carry out observations and identify what people are doing for themselves and discuss their goals and arrange a support plan around that.”

Staff can also assess clients’ needs for basic aids for daily living and order them directly: for example, Williams now has a bath seat, toilet seat and perching stools in the bathroom and kitchen.

“In 2007-8 and 2008-9, in 58% of cases clients no longer needed ongoing home care support [following reablement],” says Dabrowska. “For the remaining 42%, ongoing support is commissioned from independent home care providers or clients are offered a direct payment.”

The evidence is that this is saving the council a great deal of money. Currently 80% of new referrals are passed through the team (the other 20% go straight to the independent sector because Hart doesn’t have the capacity to take them on), saving the council about £8.7m a year in independent home care costs. The council is trying to create capacity for the remaining 20% of cases to be passed through Hart which could create additional annual savings of £1.3m.

Meanwhile, making the correlation between reablement and reduced use of residential care is difficult, says Dabrowska, “but the number going into residential care continues to decrease and we say part of the reason is that we are keeping people at home much longer”.

Published in the 3 June 2010 issue of Community Care under the heading ‘It’s about investing to save’

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