How payment by results can improve reablement services

In 2009, after a successful pilot, Hertfordshire decided to explore the option of delivering a countywide reablement service (known as ‘enablement’ locally) for all people who came into adult care, either via hospital or community referrals.  After much research and planning the enablement service was rolled out across the county between August 2010 and July 2011.

The service was established to:

• Work in partnership with a single external countywide provider to ensure a rapid response to all referrals;
• Be co-located with our social work teams to ensure good communication and co-ordination and effectively planned and delivered services;
• Provide services to at least 80% of those referred by using a deselection model, where all those referred are eligible unless there is a good reason for them not to be;
• Provide a mixture of community and bed-based provision, with agreed service user pathways to ensure consistency and throughput;
• Ensure assessment, care co-ordination and enablement delivery is provided by an integrated team to maximise outcomes for service users;
• Achieve a 40% reduction in ongoing care packages, based upon national research and performance of other authorities.

Within the first full year, nearly 70% of all referrals, both community and hospital, were going through the enablement service with 50% of people coming out with no ongoing needs.  However, the cost of delivering the service (per hour) was high as the amount of contact time per worker was relatively low.

Last year a review of the enablement service identified a number of areas where further improvements could be made. These included streamlining the referral pathway, including by giving the provider access to our computer systems; redesigning paperwork, to ensure outcomes are clear; and updating the service specification, with key performance indicators, tied to payment by results, to ensure cost per hour improved along with the amount of contact time each worker delivers.

The payment by results indicators were that half of enablement support workers’ working time should be spent engaged in direct service user contact, equating to 17.5 hours of a 35-hour contract, and an hourly cost of less than £33 for the service.

The provider can gain extra funds, over and above that agreed in the contract, if it performs above the expected service level. However, if it does not perform to the expected levels, the council will be able to take funds away.

These improvements were rolled out over the last year, along with investment in a new electronic monitoring system, which has aided with rotaring and therefore enablement delivery. Currently 68% of all referrals, both community and hospital, are going through the enablement service with 65% of people coming out with no ongoing needs. The current hourly cost of the service is aboit £45 per hour, which has come down from £70 at the start of the year.

And service users are welcoming what we are doing. As one commented:

“I can’t begin to thank you and your wonderful team for all you have done for me. I’m sure that had I been left alone I would have floundered around, but with all your gentle encouragement I really am so much better. I shall miss the care workers but I will remember all the little tips they gave me. I appreciate all the equipment to make my life easier. I have no way of repaying you except to try to improve every day as you have shown me.”

Iain MacBeath is deputy director, health and community services, at Hertfordshire Council

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How reablement can be good for care staff as well as service users 

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