Deadline: 1pm, 24 March 2022
The UK has a rapidly ageing population with nearly 12 million people aged 65 years and above; 5.4 million are 75+ and 1.7 million are 85+ years. The 85+ year age group is projected to have nearly doubled to 3.1 million by mid-2045, representing 4.3% of the total UK population (ONS, 2020). Older people are sometimes affected by health problems and frailty which impacts their ability to live independently and this can place significant demands on health and social care services. Attempts to shift to community-based care have been a key part of health and social care policies and strategies. Most recently, in England, local authorities have a duty under the Care Act 2014 to prevent, reduce or delay needs for care and to provide support for all adults, including reablement as one part of interventions to prevent deterioration and reduce dependency on support from others.
Integrated services are seen as fundamental to successfully delivering this shift and legislation is set out in the white paper Working together to improve health and social care for all to support integration, within the NHS, local government, and other partners, for improved and more coordinated health and social care services. Each of the devolved administrations have separate legislation and guidance relating to care needs and preventative services (The Social Care (Self-direct Support) (Scotland) Act 2013 and Public Bodies (Joint Working) (Scotland) Act 2014; Social Services and Wellbeing (Wales) Act 2014; Health and Personal Social Services Act (Northern Ireland) 2001).
NICE guideline NG74 defines intermediate care as a multidisciplinary range of integrated services that supports people to be as independent as possible, based around the person’s strengths, needs, preferences and priorities. As one of the four service models of intermediate care described in NG74, reablement is delivered across the UK as a non-means-tested, time-limited intervention (usually up to six weeks) for people at risk of needing social care or an increased intensity of care. The approach aims to promote faster recovery from illness, prevent unnecessary admissions to hospital or longer-term care facilities, to support discharge from hospital, to maximise independent living and to reduce/remove the need for an ongoing care package.
A reablement approach aims to help people maintain, or regain, their capacity and confidence in being able to undertake ordinary daily activities and to continue to live as they wish. This approach supports people doing things for themselves, rather than a traditional home care model where tasks are completed by the visiting care worker. The Social Care Institute for Excellence (2020) notes that the terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ tend to be used interchangeably.
Services and responsibilities vary between localities and, as there are inconsistencies in terms used to describe services, there are difficulties in being able to compare these in relation to effectiveness and cost effectiveness. An ongoing NIHR study is investigating user and family member engagement with reablement and developing and evaluating a resource to support localities with intervention at ‘risk points’.
The “discharge to assess” or “home first” model works on the principle of ensuring that people do not stay in hospital for any longer than they need to and is designed to speed up the discharge of patients who no longer require acute hospital care but still require some level of support. Guidance on discharge to assess was published in 2016 and this model enables localities to adopt discharge processes that best meet local needs. Many hospitals introduced discharge to assess on a temporary basis during the COVID-19 pandemic because of the need to discharge all medically fit patients out of acute and community hospital beds. In order to achieve the aims of discharge to assess, most systems require a shift of assessment and therapy staff from the acute hospital to the community setting, so that these assessments are undertaken at the optimum time and in the appropriate setting. Driven by COVID-19, these new ways of working were adopted within the NHS and now localities are considering whether to continue these going forward, or to put in place alternative arrangements.
Section 91 of the Health and Care Act revoked procedural requirements in Schedule 3 to the Care Act 2014 which required local authorities to carry out long-term health and care needs assessments, in relevant circumstances, before a patient is discharged from hospital. Section 91 of the Act also introduced a duty for NHS trusts and foundation trusts to involve patients and carers in discharge planning, to be applied in situations where a person is likely to need care and support after their hospital discharge. From April 2022, updated DHSC guidance has been issued to inform planning and delivery of hospital discharge and community support that best meet the needs of the local population which could include the “discharge to assess/ home first ” approach.
Relevant NIHR Studies
Examples of some related studies, funded by the NIHR in this area, include:
- models of reablement evaluation: a mixed methods evaluation of a complex intervention (13/01/17);
- implementing the Care Act 2014: preventing, reducing or delaying needs for care and support in adult social care in England (PR-R14-1215-21005);
- developing a resource to support localities address user and family understanding of, and engagement with, reablement: a development and implementation study (P187 31/01/2024).