At a glance 52: Reablement: key issues for commissioners of adult social care

Published: March 2012

Key messages

Introduction

This At a glance briefing outlines research and practice evidence about reablement and describes what is required for successful implementation. It provides links to evidence and information freely available online and presents two case examples of the impact reablement can have on the population and on local authority budgets.

Reablement aims to help people do things for themselves rather than the conventional home care approach of others doing things for them.

The focus of reablement is on restoring independent functioning rather than resolving health care issues. It aims to help people do things for themselves rather than the conventional home care approach of others doing things for them. Reablement is welcomed by people receiving the service, and represents an investment that can produce savings.(1)

Research on reablement has examined whether it is a better approach to supporting people than conventional home care. Key questions are whether better outcomes can be achieved, and for whom, and whether savings can be made through investment in reablement.

Reablement aims to improve people’s confidence and independence and results in a reduction in social services’ spending on home care and other forms of support.

The findings are broadly positive. One study found that, compared with home care, reablement delivers improvements in physical functioning and reduces the need for ongoing support services.(2) Another concluded that reablement was significantly associated with better health-related quality of life and social care outcomes compared with conventional home care.(3) The same study also concluded that there is a high probability that reablement is more cost-effective in the long run than conventional home care and therefore worth investment.

Setting up a reablement service

Reablement works through an intensive short-term service leading to lasting savings. It aims to improve people’s confidence and independence and results in a reduction in social services’ spending on home care and other forms of support.

The implementation of reablement services is at different stages in councils with social services responsibilities (CSSRs) across England. Some CSSRs are still at the planning stage, some are piloting schemes and others have reablement services in place. A progress report published by Care Services Efficiency Delivery (CSED) in 2010 (4) shows that the majority of established schemes were in-house, although a small number of councils had outsourced their services. Over 80 per cent of councils were reportedly operating ‘intake and assessment’ (1) as opposed to hospital discharge schemes. Around a quarter of councils co-funded reablement with health and the remaining schemes were funded solely by the council.

The balance between jointly-funded and solely-funded schemes may shift now that the Government has announced targeted investment in reablement via health budgets. The government Spending Review and the 2011/12 NHS Operating Framework provided funding to primary care trusts (PCTs) for the financial years 2011/12 and 2012/13 to develop local reablement services in partnership with councils.(5) Commissioners should be working with their PCT counterparts to negotiate use of this funding.

Tips for commissioners

Performance monitoring needs to be robust to ensure that reablement is cost effective.

The following tips will be helpful to those setting up and monitoring a reablement service.

1. The first step is to baseline the current service in order to identify the impact of reablement. CSED provides some useful benchmarking formats and advice.(6)
2. When setting up or reviewing a reablement service, use a standard framework such as the toolkit published by CSED. This is based on local authorities who piloted the use of reablement across England. The toolkit is set out in eight sections describing the project steps that help lead to a successful reablement service. (7)
3. The connections with other community-based services, such as intermediate care, need to be reviewed, especially if they have been developed on a needs basis rather than planned. Bury NHS and Adult Care Services has an integrated model with the connections between many community services identified in its document on reablement. (8)
4. To ensure an efficient service it is essential to review the care pathway and the targets set at each stage. An example of a pathway can be found in the CSED toolkit. (7)
5. Performance monitoring needs to be robust to ensure that reablement is cost effective. Guidance on performance management systems is available in the CSED toolkit. (7)
6. Reduced spending on home care and other services should cover the investment in reablement. The break-even point or ‘payback period’ should give an idea of the effectiveness of the service. The Whole Systems Partnership provides support for developing your business model. (9)
7. Tools to monitor improvements for people using reablement should be used to assess the effectiveness of the service. One example is the East Midland Reablement Evaluation Tool (EMRET). (10) Another is the Adult Social Care Outcomes Toolkit (ASCOT), (11) which provides a well validated measure of the impact of a service (e.g. reablement) on a person’s quality of life.
8. The best available research evidence (3) demonstrates savings of 60 per cent on social care spend following a period of reablement. Although the report is inconclusive about an actual break-even point, the commentary by Gerald Pilkington (12) suggests it would be 32 weeks and highlights other issues likely to influence this time frame.
9. Many local authorities are optimistic about the savings to be achieved through reablement. For instance, Lewisham anticipates savings of £3 million per year once the service has matured (13) and the North East region reports potential savings of between £15 million and £30 million. (18)

The best available research evidence3 demonstrates savings of 60 per cent on social care spend following a period of reablement.

An efficient service: key considerations

Many local authorities have started reablement with an in-house service, to ensure that they have a good understanding of the costs before outsourcing, as this is a comparatively new area which is not yet fully understood.

Key issues to consider when determining the efficiency of the service include the following.

Pilot stage

The need for training, closer supervision of care workers and longer, more responsive and flexible visits all contribute to the greater upfront investment in reablement compared with conventional home care. As a result it is desirable to streamline the new service in order to make it as cost-effective as possible. A pilot stage will help to identify the most efficient ways of working.

When should the service end?

Many local authorities have started reablement with an in-house service, to ensure that they have a good understanding of the costs before outsourcing.

Delaying handover to another service, extending reablement to achieve a better result and providing the service to people who are too ill to participate will increase costs without necessarily improving outcomes. Consider setting a maximum period of reablement or a limit on the overall hours per individual to avoid this. However, it is also important to remain flexible on a case by case basis.

Research has identified the particular importance of occupational therapy skills in the delivery of reablement.

Allocation of costs

When evaluating the impact of a reablement service, be aware that transferred costs can make it appear more expensive than it actually is. For example, moving an already funded occupational therapist post from another team to carry out the same range of tasks in the new team results in no extra cost at all. Overheads should therefore only relate to increased costs caused by reablement, if any. Be wary of any conventions in your financial regulations that may distort the costs of a reablement scheme.

Skill mix

Care workers are the bedrock of the service. However, many reablement teams also include care managers, occupational therapists and physiotherapists. Research has identified the particular importance of occupational therapy skills in the delivery of reablement.

However, having occupational therapists as core team members is not the only way they can contribute. In some places they are external to the team but work collaboratively, sometimes being co-located with a reablement service to be on hand to give advice. Other reablement teams employ occupational therapists to deliver training to care workers, especially in the areas of assessment and goal-setting.

Providing training

In the UK, CSSRs designate NVQ Level 2 as the base qualification for reablement care workers.(14)

However, specific reablement training must complement qualifications so that care workers grasp the ‘reabling ethos’, which is distinct from the spirit of standard home care. A shift away from the old ‘doing for’ ethos needs to be supported by a training programme. There is currently no single, accredited training programme for reablement care workers, although individual councils have developed training manuals and programmes which they may be willing to share. In addition, the North East Improvement and Efficiency Partnership (NE IEP) has published a guide to reablement for frontline staff. (15)

Handover to other services

Where a person has benefited from reablement but has ongoing support needs being met by a conventional home care agency, the worry is that this traditional approach might undo the progress made during reablement. There are ways of addressing this and a number of teams are working to ensure that care providers delivering ongoing support understand the reabling ethos. In one team, reablement workers mentor home care workers when a person’s support needs have increased following handover. Another London borough is renegotiating home care contracts to reinforce the reabling message.

Outsourcing

Many reablement services were started in-house and consideration is now being given to outsourcing as the market matures. Issues concerning transition from an existing service are analysed in guides by Gerald Pilkington Associates (12) and Think Local, Act Personal (17) which examine the different options and their risks, costs and benefits.

Further information

• SCIE At a glance 46: Reablement: a key role for occupational therapists.(16)
• SCIE Research briefing 36: Reablement: a cost-effective route to better outcomes. (1)

A number of firms offer web-based support to establish, review and enhance reablement:

• Peter Fletcher Associates
• Whole Systems Partnership (WSP)
• Gerald Pilkington Associates
• Office for Public Management (OPM)

References

1. Francis, J., Fisher, M. and Rutter, D. (2011) Reablement: a cost-effective route to better outcomes, Research Briefing 36, London: SCIE.
2. Lewin, G. (2010) Submission to inquiry into caring for older Australians, Canberra: Caring for Older Australians Productivity Commission.
3. Glendinning, C. et al. (2010) Home care re-ablement services: investigating the longer-term impacts (prospective longitudinal study), York/Canterbury: SPRU, PSSRU.
4. Care Services Efficiency Delivery (CSED) (2010) Homecare re-ablement CSSR scheme directory, update November 2010, London: DH.
5. Department of Health (DH) (2010) The operating framework for the NHS in England 2011/12, London: DH.
6. Care Services Efficiency Delivery (CSED) (2010) Homecare re-ablement toolkit, 'Baselining your current service', [accessed 9 January 2012]
7. Care Services Efficiency Delivery (CSED) (2010) Homecare reablement toolkit, [accessed 14 November 2011]
8. Stringfellow, R. and Leeming, J. (2011) A business case for the reablement pathway, [accessed 9 January 2012]
9. Whole Systems Partnership (WSP) (2009) The case for reablement - a framework to support authorities in developing business cases for reablement services, [accessed 9 January 2012]
10. Lincolnshire County Council (2009) East Midland reablement evaluation tool (EMRET), [accessed 9 January 2012]
11. Netten, A. et al. (2011) Adult social care outcomes toolkit v2.1: main guidance, PSSRU discussion paper 2716/3, Canterbury: PSSRU.
12. Gerald Pilkington Associates (2011) The cost effectiveness of homecare re-ablement, [accessed 9 January 2012]
13. Whole Systems Partnership (WSP) (2010) The case for reablement - development of a modelfor reablement services in Lewisham, [accessed 9 January 2012]
14. Care Services Efficiency Delivery (CSED) (2007) Homecare re-ablement workstream: discussion document HRA 002, London: DH.
15. North East Improvement and Efficiency Partnership (NE IEP) (2011) Key products from the adult social care programme, [accessed 9 January 2012]
16. Social Care Institute for Excellence (SCIE) (2011) At a glance 46: reablement: a key role for occupational therapists, London: SCIE.
17. Think Local, Act Personal (2011) Outsourcing reablement services, [accessed 25 January 2012]
18. North East Improvement and Efficiency Partnership (2010) Reablement business case, [accessed 5 January 2012]