Edinburgh To Tackle Demand On Homecare Services

Homecare re-ablement is a concept that may be unfamiliar to many in Scotland.  But, in Edinburgh at least, it is about to become better known.

Edinburgh City Council is to introduce re-ablement in 2008 as a way of tackling the demand on homecare services caused by the rising number of elderly people and those with higher dependencies living at home.

The Department of Health (DH) definition is: services for people with poor physical or mental health to help them accommodate their illness by learning or re-learning the skills necessary for daily living.

A spokesperson for the department of health and social care of Edinburgh City Council puts it another way:  ‘The key re-ablement is helping people ‘to do’ rather than ‘doing to or for’ people.’

The council will provide intensive support for up to six weeks to people with a homecare need following injury or illness.  Referrals will come from hospital and the community.  During re-ablement, patients will receive care and support to learn new skills or re-learn old ones in order to maximise their independence. 

Re-ablement could mean a better use of resources at a time when the aging population is pushing up demand for home care. 

The hope is that by supporting people to be as self-sufficient as possible, money will be saved on care services. 

Edinburgh is aiming for a 20 per cent reduction on care hour costs over four years.

The council spokesperson describes this as ‘cautious’ compared to savings made by re-ablement elsewhere.

‘The evidence from England indicates that following re-ablement, there is between 28 per cent and 50 per cent reduction in care hours for the service.’ 

As well as reducing the number of homecare hours required by individuals after re-ablement, the council hopes to prevent people going into hospital and care homes, thereby saving more money. 

The council is quick to point out that it is not all about costs. 

‘It maximises people’s long term independence, choice and quality of life,’ says the spokesperson.

Anne Bailey, principle manager of homecare re-ablement at Wirral Borough Council, can vouch for that. 

Wirral has had re-ablement in one form or another since October 2003 when the initiative was piloted.  It was first introduced as a hospital discharge service when the team worked to a very strict criteria, only taking referrals from hospital occupational therapists who identified patients most likely to benefit from re-ablement.

Last August, the team expanded to take referrals from the community too.  The number of carers has swelled from 16 to 85 with another 65 in training.

Ms Bailey describes re-ablement as a ‘win, win’ arrangement.  As well as being cost-effective, it helps adults of all ages regain lost skills.

‘The service users like it because they like the opportunity to become more independent,’ she says. 

‘It’s simple things like they don’t have to wait for someone to come and make them a cup of tea.  Little things like that are really empowering.’

As the Wirral example suggests, re-ablement is better established and more common in England than in Scotland.

Dr Hilary Arksey, senior research fellow of the social policy research unit at the University of York, estimates that it began to be piloted down south about ten years ago.
The scene was set for re-ablement when England’s NHS Plan introduced intermediate care services in 2000.  Its aims were to free up hospital beds and address delayed discharge by promoting independence through active recovery.  This was then reinforced with the National Service Framework for Older People in 2001.

Money followed the policy in England.

The DH put £900million into implementing intermediate care in all its forms, which include hospital beds, care homes and people’s own homes. 

In April 2004, the Community Care (Delayed Discharges) Act came into full force, which imposed a system of fines on English local authorities where delayed transfers of care were caused by a time lapse in providing appropriate care in the community.  

Since then, the DH has set up a Care Services Efficiency Delivery, which included a homecare re-ablement work stream, to support councils in meeting efficiency targets in adult social care.

Dr Arksey says that by the end of 2006, 60 councils with adult social services responsibility had a homecare re-ablement service of some kind.  That figure is certain to have risen in the past year, she says.

‘Things are moving really quickly.  The bottom line is that resources are so tight and local authorities looking to spread them more widely and this is one way of doing that.’

Last November, the University of York published research into the effectiveness of re-ablement based on four councils’ experience.

The report Homecare Re-ablement:  Retrospective Longitudinal Study found that there are significant reductions in the use of homecare services following discharge from a re-ablement scheme compared with the assessed need on entry to the service. 

Between half and a third (53- 68 per cent) of people left re-ablement requiring no immediate homecare package.  And, of those that did need a homecare package within two years of being through re-ablement, between 34 and 54 per cent had maintained or reduced their needs.

Ms Bailey of Wirral Borough Council explains the impact this can have on cost.

‘Even a small care package of two half-hour calls per day at £13 an hour mounts up when you cost it over weeks, months and years.   You’re talking about thousands of pounds. And when you multiply that by hundreds of service users, the costs soar,’ she says.

Re-ablement is not only for the elderly.  It is offered to adults of any age with a wide range of health problems.

Patients may have suffered a fall and broken or fractured a limb. Or they might be recovering from a mild stroke or even heart surgery. 
Whatever the problem, service users are assessed and a care plan is set.  After that, carers visit the individual each day to support them in becoming self-sufficient. 

Carers will teach individuals new ways to perform tasks to accommodate their particular problem.  They may also provide gadgets.  Common help surrounds actions such as dressing, washing, preparing a meal, making drinks or moving around the home.

The benefits for the individual go beyond the physical.  It also helps them psychologically because they develop stamina and build confidence in becoming more independent.

Ms Bailey describes the help given to a woman who had not used her bedroom or bathroom for two years because she was unable to climb the stairs to the first floor in her house.  Her family had installed a stair lift, but she was afraid of using it, so she was confined to the ground floor of her home.  She required carers to come in and strip-wash her on a regular basis.

Re-ablement taught her how to use the stair lift which meant she could access her specially-adapted shower.  Once she had built the skills and confidence to do this, she no longer needed any homecare.

‘It opens up a whole new world,’ says Ms Bailey.

However, there is a downside to re-ablement, especially when it comes to the elderly.

Annie Stevenson, senior policy officer for health and social care at Help the Aged, says that it can take older people longer to recover from a time in hospital or injury than younger patients. 

‘Service provision is limited.  Six weeks – the standard length of time that services are available – is simply not long enough for many people,’ she says.

The research from York concluded that the best re-ablement schemes are flexible to individual need.  Whilst programmes have to be time-limited, says the report, it is unhelpful to adhere to a strict number of weeks. 

It also identified other potential barriers to successful re-ablement.

One is the interface between a re-ablement team and long term care service. 

For example, if the independent sector is providing long term homecare then it may not understand the importance of maintaining the level of independence achieved.

Dr Arksey says: ‘Just as it’s easier to tie a child’s shoe yourself than watch them struggle, it’s quicker to do something for an elderly person. But re-ablement is about taking the time to help someone do things for themselves.’

This has been an issue in Salford City Council.

It may also become one in Edinburgh as the council has said that long term maintenance packages for homecare will be commissioned from 35 independent providers in the city.

Janet Senior, team manager for the intermediate homecare service at Salford City Council, says work is in progress to address the issue of the independent sector undermining re-ablement (see case study). 

It is also setting up a new commissioning group to look at medium to long term domiciliary care. 

Having a contracting arrangement that is focussed on outcomes rather than tasks is one way of ensuring a common ethos.

Another factor that influences the success of re-ablement is communication.

If a service user and their family do not understand the thinking behind re-ablement, they may feel short-changed.

Ms Senior says social workers in Salford have become better at explaining about the purpose of the re-ablement service. 

She says it is about changing attitudes of some people who may not realise that it is in their interest to stay self-sufficient.

‘You get people saying, “I’m 89 years old.  What do you mean I have to make my own cup of tea?”’ she says.

But if a service user opts not to use the re-ablement service then the team withdraws.

‘We’re not forcing people.  If people don’t want to work with us, it’s pointless for us to go in,’ says Ms Senior.

‘But I can’t remember the last time that happened.’

Case Study

Salford City Council has had a re-ablement service since November 2003.  The number of service users has doubled from about 620 in 2004/5 to about 1,200 in 2006/7. 

Assessment is carried out by dedicated assessment officers.  If the referral involves hospital discharge, they will visit the hospital and are involved in discharge planning.  Otherwise, they visit the patient’s home.  

A care plan is put together to meet the needs of the service user.

Janet Senior, team manager for the intermediate homecare service, says the focus is on reducing the level of care needed and promoting independence.

‘It used to be that people would come out of hospital and a care package from day one and it’s still in place three years later because they become dependent on it.  It becomes counter effective.’

Home support is provided for up to six weeks but is flexible in individual cases.

Ms Senior says: ‘There are situations where it’s clear that, if we kept them another week or, at maximum, two weeks, the person would not need long term care.’ 

At the end of re-ablement, another assessment determines whether a long term package of care is required. 

If it is, the team commission direct from the independent sector.  There are about 15 independent providers that are organised into geographical areas, with each bit of the city dealing with five or six providers. 

Sometimes the independent provider will shadow the re-ablement team before taking over care.

‘They would come in alongside us for a few days to look at why we’re doing things so they know exactly what they’re doing.’