Dedicated funding to enable councils to establish reablement services was first made available in the 2010 Spending Review.
The policy was launched with the Minister for Health saying reablement had “shown dramatic benefits in helping people to regain their independence after a crisis” and that development of reablement services “will save money across the health and social care system”.
Six full years into the strategy, what can be concluded about its success?
The annual council returns of spending and activity have been changed in ways that reflect the policy. Councils now report their spending divided between short and long-term support and the numbers of service users who get short and long-term support. Reablement services will be accounted for as short-term services.
The following concerns older people as this is the group for whom reablement is most usually associated. The returns for 2016-17 show that nationally, some £400k was spent on short-term support (the original government allocation in 2010 was £300k).
This was 5.5% of total gross spending on older people. However, councils varied considerably in how much they spent on short term services. The 10% of councils who spent the least committed an average of just 0.4% of their budgets to short-term services while the 10% who spent the most committed an average of 13%. This range enables a comparison of the impact on demand for long- term support. Would the highest spenders reap the benefits by reducing dependency and therefore demand?
Service users in receipt of support
One measure is the spend per service user in receipt of long-term support. If reablement works, it would be expected that fewer people will need the costly forms of support, whether residential and nursing care or intensive support at home. Spend per service user would therefore be lower. But this has proved not to be the case. The 10% of councils spending the most on short-term services spent more per long-term service user than the 10% lowest spending councils – £13k against £11.7k.
However, it may be that the councils spending the most on short-term services were also spending the most on long-term service users because reablement had ensured only the most highly dependent people required long-term support. A test is the number of people supported by each council per head of their population served.
It was indeed the case that the councils spending the most on short-term services were serving fewer people. The highest spenders supported 66 people per 1,000 population over 65 against 73 by the lowest spenders.
However, the range of numbers of people supported per 1,000 population between the councils is very large – from 37 in West Sussex to 139 in Tower Hamlets; 66 against 73 therefore begins to not look significant.
Level of deprivation
More importantly, the biggest factor determining how many people a council supports is the level of deprivation. This is because the means test results in far fewer older people qualifying for support in wealthier than in more deprived areas.
A key measure of deprivation is the Index of Multiple Deprivation (IMD). The national average in 2015 was 23.1, with the most affluent area – Wokingham – 5.6 and the most deprived – Blackpool – 42. The average IMD score for the councils who spent the most on short-term support is 21.4 and for the lowest spending councils it is 22.9. This means the councils who spent the least on short-term services serve populations a little more deprived. This alone would account for them serving more people per head of population than the highest spending councils.
There is strong anecdotal evidence that reablement services are very helpful to individuals for whom such support is relevant. It is an important resource, but the evidence undermines expectations of dramatic reductions in dependency and demand.
The usual suspects when national social care strategy fails are local authorities, deemed to have failed in implementation. However, there is a case for the real culprit to be the research into reablement which generated the expectation in the first place.
The research reported huge reductions – up to 60% – in support for people who went through a reablement service against those who didn’t. But did the research adequately account for the fact that reablement services select their clients on the basis of their potential to improve? Given the focus of reablement services on people recovering from a hospital episode, how many of their clients’ needs for support would reduce or be removed altogether anyway, as they recovered from whatever took them into hospital in the first place?
Enabling people to do as much as their physical and mental powers allow must continue to be an essential objective. It’s a win-win. However, national policy makers and local leaders would do well to reflect on a key finding, hitherto overlooked, by the Care Services Efficiency Delivery Team which first ploughed the reablement furrow.
Having worked with pioneer reablement teams, they reported the dismay of the pioneers at how their good work was so often undone by the dependency inducing nature of the continuing support system to which their clients moved on. What they believed was required was a reablement culture, as much if not more than a reablement service. But creating such a culture would represent a major challenge for councils and providers. They would have to learn how to replace the regressive task and volume basis of contract to meet their respective financial imperatives with one rooted in progressive personal outcomes.
Although much discussed, it is a concept yet to become established.
Colin Slasberg is a social care consultant