1 Background and Introduction
1.1 This evaluation is set within an overall policy context that seeks to shift the balance of care towards allowing people to live at home, healthy and independent, for as long as possible. This has been a key policy objective of the Scottish Government for a number of years. Reports such as the Better Outcomes for Older People (May 2005) call for a significant shift forward in health and social care services in the community to support this overall policy by developing innovative health and social care services. The Scottish Government has sharpened the focus on improving outcomes for individuals through the provision of public services by introducing a National Performance Framework, and Single Outcome Agreements between each Community Planning Partnership and the Scottish Government. These are underpinned by the Community Care Outcomes Framework (Community Care Outcomes) and the Talking Points: Personal Outcomes Approach to assessment, care and support planning, and review. These frameworks are intended to offer means to demonstrate how individuals' quality of life has improved as a consequence of receiving services or support. The ethos and design of Edinburgh's Re-ablement Service fit closely with this approach, through the strong focus on goal setting and the robust review of success in meeting these goals.
1.2 To support this agenda, the Scottish Government Health Analytical Services Division has commissioned work on homecare re-ablement services on behalf of the Joint Improvement Team ( JIT). The work involved an evaluation of the new re-ablement focussed home care service that was introduced into one area, the South East, in Edinburgh in October 2008 by the City of Edinburgh Council ( CEC). The re-ablement service has subsequently been rolled out across the other areas within the City of Edinburgh. The evaluation took place between October 2008 and June 2009 and covered the first eight months after the service was introduced. It is intended to inform other authorities in Scotland who are currently reviewing their home care provision.
The English experience of Re-ablement
1.3 In recent years many councils in England have developed re-ablement services. These services have targeted interventions in Home Care mainly for older people specifically designed to either prevent earlier than necessary entry in care home settings or to help support them after a period of hospitalisation. The most recent figures state that some 88 (out of 150) councils are providing re-ablement services across England. 2
1.4 In 2000, Leicestershire County Council commissioned De Montfort University to undertake an evaluation of a pilot of the Home Care Re-ablement Team. The findings demonstrated a 28% reduction in Home Care hours for those clients who had gone through a Re-ablement service, compared to a control group who had not. However, this study did not provide evidence of how long this benefit lasted. Nevertheless, despite the lack of any longitudinal element to the evaluation, the report concluded that the new service 'had been very positive.' In fact, one of the final recommendations of the report was that 'Home Care Re-ablement Team(s) (should act) as an 'intake' teams for all home care referrals.'
1.5 To address the lack of longitudinal evidence, the Care Services Efficiency Delivery Programme ( CSED) 3 commissioned a very focused and rapid study of the longer term impact of re-ablement. This was designed to assist and support councils in England considering developing a re-ablement service, and to help inform and scope a more robust evaluation of the long term impact and effectiveness of re-ablement services generally. The Social Policy Research Unit ( SPRU) in the University of York was commissioned to undertake a retrospective study in conjunction with 4 councils to analyse data over a longitudinal period to determine whether such benefits were long lasting 4.
1.6 The SPRU team examined data from 4 councils across a two year period for Re-ablement services that had been established for at least four years. In 3 of the 4 schemes some 53% to 68% of clients left re-ablement requiring no immediate homecare package. Also, some 36% to 48% of clients continued to require no care package two years after re-ablement and in one scheme 55 users who had previously required homecare before re-ablement continued to require no care package two years after re-ablement. Even after two years, in 2 of the council areas, hours of care required by clients were continuing to decrease.
1.7 However, the lack of any control group in the SPRU methodological approach meant that the findings could not be conclusively linked to the Re-ablement services. Nevertheless, it should be noted that the findings from staff interviewed from all 4 sites were of the view that their Re-ablement service had the effect of reducing demand for on-going social care support. It was noted this was not just related to improving people's physical functioning and ability to manage practical tasks in the home, but staff also stressed the importance of building people's confidence and a sense of well-being.
The City of Edinburgh Council Re-ablement service
1.8 The positive experience of the re-ablement services implemented in England has clearly been an important driver for City of Edinburgh Council ( CEC) Health and Social Care Department to introduce this new service as part of the modernisation of their domiciliary care services. Over the last few years, as part of the Review of Home Care and Support and Care at Home Services, a number of staff from CEC have made visits to English councils to study progress and practice of re-ablement services in situ. These visits helped shape the conclusions of the Home Care Modernisation Board to recommend to the Council's Health, Social Care and Housing Committee in March 2008, that
'a Re-ablement Team be created on a phased basis building on the success of the Hospital Discharge Team....The Re-ablement Team is anticipated to reduce the overall size of home care by changing the practice from doing tasks for people to assisting people to re-learn life skills. The evidence for this is based on reductions achieved from both our own Hospital Discharge Team and best practice by local authority home care services in England.'
1.9 The development of Home Care Re-ablement was one element of a wider vision to redesign the service around the needs of people who use the service and their carers by introducing improved management arrangements and valuing staff; arranging the service around the service users' needs; making best use of technology; working in partnership with service users, their carers and other agencies.
1.10 The first phase of modernisation to implement Home Care Re-ablement in Edinburgh started in October 2008 in the South East locality and was completed across the city by March 2009. The lead in time for Phase 2 - redesigning services for people with complex needs - starts in August 2009 with implementation commencing in the Spring of 2010.
1.11CEC chose a phased roll-out of Re-ablement in order to apply lessons learnt to subsequent phases so, as the first sector to start re-ablement, South East was in the vanguard for any problems as well as for successes.
1.12CEC Health and Social Care Department prepared a list of guidance, forms and other documents used during the implementation of Re-ablement that other council may find useful in planning and implementing Home Care Re-ablement. This list is attached at Appendix 1.
1.13 Learning from the English experience, the evaluation in Scotland has included both a control group and a longitudinal element into the research. It is worth noting that the SPRU retrospective study acknowledged in the conclusion that a control group element would have been of benefit, and they have included a control group element as part of their current evaluation in England.