Maximising the potential of reablement

The required culture change: People involved in planning and referring to reablement services

This section looks at changes in the way people need to work when they are planning, establishing or procuring a reablement service. In some places, they may be known as ‘commissioners’ where other local authorities have ‘procurement teams’.

Recommendation

Reablement requires a move away from commissioning on the basis of time and tasks. Instead, it should be commissioned on the basis of the outcomes that the service will support the individual to achieve.

This greater flexibility and focus on outcomes can be emphasised in service contracts. For example, in one borough, the reablement provider is paid a lump sum to use in whatever way is necessary to support a person in achieving desired outcomes. This gives the provider flexibility to deliver intensive support at the beginning of a service and then adjust input according to the person’s changing abilities and confidence. It is therefore implied that the commissioning authority is paying the provider to achieve certain outcomes as opposed to performing certain tasks during set visiting times.

In this context, the importance of maintaining good, honest relationships between commissioning authorities and reablement providers cannot be exaggerated. Commissioning on the basis of outcomes achieved rather than hours provided is a clear departure from traditional commissioning arrangements and requires trust and transparency from both commissioner and provider. This will help ensure reablement is seen as an opportunity rather than a threat.

Recommendation

In order to encourage a focus on outcomes in the provision of reablement, commissioners should consider offering incentives to providers (based on these outcomes). At the same time, perverse incentives to extend the reablement period should be minimised.

Case study: commissioning for results

One county council has a payment model for reablement that is based on providers achieving ‘no further action’ (NFA). Providers are given a basic amount of money for each person referred to them and have to ensure a certain proportion of their service users are NFAs in order to receive a top-up payment. NFA means that for a 90-day period the individual does not require support from any formal health or social care services such as hospital admission or home care services. If they fall below the designated proportion of NFAs the provider loses money.

Recommendation

Where incentives based on outcomes are offered, commissioners should ensure the outcomes are measured in relative terms against service users’ baseline needs. This is important because the basis for including or excluding people with certain needs or conditions varies significantly between reablement services.
The model for the employment of reablement care workers should be assessed to ensure it is fit for this new means of commissioning.

The ‘zero hours’ contracts held by many care workers may be too inflexible for the purposes of reablement. The risk of this type of contract is that it does not provide an incentive for the reablement worker to reduce the amount of support a person needs, as they would be reducing potential earnings. Employing reablement workers on ‘set contracted hours’ may offer a better alternative and greater stability for the worker, although from a commissioner’s perspective, it will be more costly.

Recommendations

The same flexibility should be possible in the independent sector. Where reablement is outsourced, the commissioning authority should procure services in a way that enables private providers to employ reablement workers on the same flexible contracts as their in-house counterparts. This includes paying for travel time and for time spent in training.
On the whole, there should be clear communication between the commissioning authority and local providers, beginning at the initial development phase, so that commissioners can be sure their procurement plans will attract tenders to support the roll-out of reablement.
Those planning and procuring reablement need to be realistic about the pattern of investment and savings they can expect. The need for training, closer supervision of care workers and more responsive, flexible visits all contribute to a greater upfront investment in reablement compared with conventional home care. However, research demonstrates savings of 60 per cent on social care spend following a period of reablement [7-8] and in practice local authorities have reported even greater savings.

Referrals to reablement services

Research on the effectiveness of reablement tends to focus on the role of reablement managers and frontline workers where research and advice on planning and investing in reablement addresses the role of commissioners. Far less research centres on the task of referring to reablement, normally undertaken by social workers, whether in hospital or the community. This recommendation is therefore based on what is known about the importance of people having a clear understanding of reablement and working toward goals that are relevant to them:

Recommendation

Those referring to reablement should ensure that:

they know how reablement fits within the context of other local health, social care, housing or equipment services
they know any referral requirements for the reablement service (e.g. whether they are limited to referrals from the community or from hospitals or whether they exclude referrals on the basis of particular criteria)
they include in their assessments a holistic understanding of the person’s strengths
they know enough to describe reablement, including its role in maximising independence and its time-limited nature (usually a maximum of six weeks)
they have sufficient information about the outcomes of reablement to be able to convey hope about improving physical, social and/or psychological wellbeing
they encourage independent sector care providers to deliver any ongoing support in a way that maintains the progress a person has made during a period of reablement
they encourage all providers of adult social care to deliver support in a way that maximises people's control over their own lives and ability to do things for themselves.