Background

Increased life expectancy, brought about mainly by improvements in health care, presents a number of health and care policy challenges. Increased rates of hospital admissions due to long-term health problems or frailty, subsequent delays in discharge from hospital, and growing demands for social care caused by heightened rates and levels of dependency have placed significant demands on services.

The 1990s saw the development of models of care to address these challenges, which, collectively, came to be designated as ‘intermediate care’.^1,2 This concept became formally recognised and defined in the National Service Framework for Older People,³ published in 2001:

. . . a new layer of care, between primary and specialist services . . . to help prevent unnecessary hospital admission, support early discharge and reduce or delay the need for long-term residential care.

p. 13.³

© Crown copyright. Contains public sector information licensed under the Open Government Licence v3.0.

Crown copyright

In response to the National Service Framework, and supported by £900M investment from the UK government, new models of care, or practices, emerged.

The health-care sector saw the development of admission avoidance and supported early discharge schemes, typically described, or defined, as intermediate care. Importantly, some – but not all – supported early discharge schemes specifically sought to restore an individual’s ability to look after themselves, perhaps independently, in their own homes.

Similarly, local authorities (LAs) began to develop interventions for individuals who presented concerns in terms of their ability to continue to stay well and live independently, or at least remain in their homes with low levels of support.⁴ Importantly, these latter developments were informed by a challenge, issued by the Department of Health and Social Care and directed at LAs, to develop approaches to care that reduced dependency on services and supported individuals to ‘make most use of their own capacity and potential’.⁵ These twin levers saw the emergence of services across the country that shared similar features: short-term and intensive support delivered in the home with a focus on regaining, or preventing the decline of, daily living skills and social participation. By the early 2000s this approach had gained considerable traction and government support.^5,6 The term ‘reablement’ was used to describe the approach and significant levels of investment made in the development of such provision. In some countries, a similar shift in, approach to providing social care support was also taking place; some also referred to this new approach as ‘reablement’. Others, for example the USA, Australia and New Zealand, used the term ‘restorative care’.⁷

The challenge of defining reablement

The past 15 or so years have seen changing and inconsistent use of the terms ‘intermediate care’ and ‘reablement’, both within policy⁸ and as applied to specific health and social care provision. In terms of the latter, the criteria, or ‘labels’, applied to different government funding initiatives (typically directed via health to encourage integrated planning) go some way to accounting for this.

In the context of this study, it is not useful or necessary to recount these changes in great detail. However, this lack of a shared definition was something that had to be explicitly addressed when developing the bid for funding and the study protocol. Indeed, the lack of an agreed description of reablement using a standard intervention framework⁹ continues to present significant challenges to those seeking to review existing evidence and those conducting primary research.¹⁰

Defining reablement for the purposes of the study

This study was commissioned in mid-2014, and arose from a commissioning call issued by the National Institute for Health Research (NIHR) in early 2013. From the outset, it was essential that a clear definition of reablement was established that was relevant and meaningful in terms of current policy and practice, and made reference to the concepts of intermediate care and rehabilitation. Therefore, an analysis of recent evaluative literature^11,12 and current policy and practice guidance documents^7,13 was carried out. It was clear from this exercise that two key characteristics distinguish intermediate care and reablement from other health and care services:

1. The objectives of intermediate care/reablement. These are – acute admission avoidance at the point of clinical need for acute care; early supported discharge after acute admission; longer-term avoidance of unplanned hospital admission; reduction in the use of home-care services; and avoidance of admission to long-term care.
2. The time-limited nature of the service offered (usually up to a maximum of 6 weeks). This is the key defining characteristic that distinguishes intermediate care or reablement from, for example, generic rehabilitation services.

A further characteristic emerged as distinguishing reablement from intermediate care, namely its restorative, self-care approach. In other words, a reablement service is about enabling people to regain or retain self-care function for themselves, rather than providing input that replaces that function (e.g. reablement teaches people how to cook for themselves again, rather than providing meals on wheels). Table 1 sets out these distinctions, and overlaps, between reablement and intermediate care.

TABLE 1

Distinguishing between intermediate care and reablement

The study’s definition of reablement

Drawing on the work referred to above, the following definition of reablement was used.

• Intervention objective:
  • to support people to regain or maintain independence in their daily lives.
• Intervention approach:
  • to restore previous self-care skills and abilities (or relearn them in new ways) that enable people to be as independent as possible in the everyday activities that make up their daily lives (e.g. cleaning the house, shopping, or bathing and dressing themselves) rather than having someone (e.g. an informal or formal carer) do things ‘to’ them or ‘for’ them.^7,8 The provision of equipment may be used to support this
  • individualised and goals-focused.
• Population:
  • individuals returning home from hospital or other inpatient care setting following an acute episode
  • individuals in whom there is evidence of declining independence or ability to cope with everyday living.
• Nature of intervention delivery:
  • intensive
  • time-limited (up to 6 weeks)
  • goals-focused
  • delivered in the usual place of residence.

This definition aligns with current policy and practice guidance.^14,15

Subsequent developments in policy and definitions of reablement

While the study was under way, the Care Act 2014¹⁵ – heralded as the most significant reform to social care in over 60 years – became law. Full implementation of the Act is ongoing, but phase 1 implementation had significant implications in terms of the perceived role of reablement within the wider portfolio of social care provision.

First, reablement was presented as one of the core interventions that can delay, or reduce, demands for care services and keep individuals living independently in their own homes. To this end, LAs are now required to consider providing reablement before, or alongside, carrying out a needs assessment. Furthermore, this approach should now be considered both for individuals not previously known to adult social care and for existing users. Second, reablement was presented as an intervention falling under the umbrella term of ‘intermediate care’, and was specifically identified as having the function of helping individuals leave hospital in a timely way and regain their independence. The need for integrated working with health services to deliver this was made explicit.

Together, these elements of the Care Act 2014 – and the continued growing and significant concerns within the NHS about the delayed discharge of older patients¹⁶ – have seen the emergence and adoption of ‘discharge to assess’ pathways, with these pathways including discharge to social care for assessment and reablement.¹⁷

The 2017 National Institute for Health and Care Excellence (NICE) guidance, Intermediate Care Including Reablement¹⁴ makes clear that, as an intervention, reablement is regarded as one of the four core elements of ‘intermediate care’, the other three being (health) crisis response and bed- and home-based intermediate (health) care. It is important to note that the guidance continues to represent reablement as being distinctive in its restorative approach and focus on supporting independence in self-care and everyday life skills, with social care leading on its delivery. The guidance also stresses the need for integrated working within the context of providing intermediate care.

These significant changes in health and social care policy and guidance had two important implications for this study. First, it meant that changes to services and service developments were happening during the study period (2014–17), and are ongoing. Second, it signals that, as an intervention, reablement is highly topical and likely to remain a core aspect of meeting the health and social care needs of older people. As a result, the findings from this study are highly relevant and timely.

Existing evidence on reablement

The 2017 NICE guideline¹⁴ offers a useful review of existing evidence. It concludes that the quality of existing evidence on the effectiveness of reablement is not as high as for other forms of intermediate care (e.g. home- or bed-based intermediate care). To date, there have been just three comparative evaluations, of variable quality, that have used randomisation,¹⁸ none of which is UK-based. Among another four non-randomised comparative evaluations,^19–22 two were carried out in England, both of which reported in 2010.^19,20 On the basis of this set of evidence, the following conclusion was drawn:

There is a moderate amount of moderate quality evidence that reablement is more effective when compared with conventional home care.

NICE Guideline 74, p. 137.¹⁴ © NICE 2017 Intermediate care including reablement. Available from www.nice.org.uk/guidance/ng74 All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

NICE

It was noted that the evidence was most consistent and positive with respect to care needs or impact on service use. Similarly, overall, findings related to quality of life and ability to carry out activities of daily living (ADL) suggest that reablement is an effective intervention, although this was not found in a low-quality trial.^11,12 NICE also reports that it did not find any evidence on cost-effectiveness that was relevant to the UK.

A separate set of evidence concerns issues of the design of reablement services. Here, low- to moderate-quality evidence indicates that access to particular specialisms (e.g. physiotherapy, occupational therapy) may influence the effectiveness of reablement.^19,23,24 In addition, there is reasonable evidence to suggest that the skills of reablement workers may have an impact on outcomes,^24,25 for example being able to judge the timing and degree of support to offer a service user when carrying out a task and increasing service users’ confidence and motivation. Two studies conclude that reablement services should include the ability to respond to users’ goals that concern their social or leisure lives, which, for some users, will be a high priority or have the greatest impact on their lives.^25,26 Finally, there is some indication that service models should incorporate the ability to be flexible and responsive to user needs and progress.²⁴ However, this may have implications for service users’ views and experiences of the service.^23,24

Some existing studies have investigated issues related to the characteristics of the service user. There is reasonable evidence that individual motivation may have an impact on the effectiveness of reablement.^24,25 More specifically, there is weak- to moderate-quality evidence, primarily based on practitioner views, that individuals with end-of-life care needs or complex needs should not be referred to reablement services.^19,20,27 No studies have investigated the effectiveness of reablement in people living with dementia.

Finally, in terms of service users’ and family members’ views and experiences, the key issue identified by existing research is the potential lack of understanding of the objectives of reablement, and the fundamental difference of approach compared with home care.^23,24,26,27

A number of other systematic reviews of reablement were published in 2016/17.^10,28–30 Their inclusion criteria (in terms of study design and quality) vary and, as a result, the conclusions drawn differ somewhat. However, all note the pressing need for further research as a result of the core place given to reablement within health and social care policy, particularly with respect to older people and the investment in services delivering this intervention.

Evidence gaps

Studies into the effectiveness of reablement per se are beginning to be reported, although, as noted above, more are required. A further gap in evidence concerns the way in which to deliver reablement. Since the early days of ‘reablement’ in the late 1990s, different localities and sectors have developed different service models by which to deliver this intervention.^7,14,31 Thus, in addition to evaluating the impact of reablement with a no-intervention comparator group, a complementary stream of research is required that looks at different approaches, or service models, to providing reablement. In addition, although there is some evidence on factors that may have an impact on intervention outcomes (e.g. service user characteristics such as motivation/engagement, reason for referral to reablement, comorbidities and living circumstances), clearly, further work in this area is required and particularly with respect to factors that are amenable to intervention. Finally, and also highlighted in the 2016 NICE guidance,³² increasing the evidence base on the costs and cost-effectiveness of reablement and providing reablement to people with dementia are both important priorities.

Study aims and objectives

This study was funded by NIHR in response to a commissioned call³³ that sought research proposals addressing the following overarching questions: how effective are reablement services in enhancing self-care and independence in the population they are designed to cover; and how are they best delivered?

When responding to this call, we chose to focus on some of the specific evidence gaps discussed in the previous section. Table 2 presents the study aims and associated objectives as set out in the study protocol.³⁴

TABLE 2

Study aims and objectives

Thus, the focus of the study was not the effectiveness per se of reablement. Rather, its aim was to evaluate and compare existing reablement service models and to also conduct a smaller, parallel piece of work focused on reablement for groups for whom adjustments to a generic model of provision may be required (e.g. young adults, people with dementia).

Structure of the report

The report comprises 10 chapters. Chapter 2 provides a high-level overview of the study and reports deviations from the original protocol. Chapter 3 reports on work package (WP) 1, the national survey of reablement services and the reablement service models derived from that work. Chapter 4 describes the selection and recruitment of research sites for WP2 and provides a description of the characteristics of each site. In Chapter 5 we report the outcomes evaluation (WP2a). Chapter 6 describes one element of the process evaluation (WP2b), namely the interviews with reablement staff. In Chapter 7 we report the second element of WP2b: the user perspective. The economic evaluation (WP2c) is reported in Chapter 8. Chapter 9 turns to WP3, the qualitative study of practitioner views and experiences regarding reabling people with dementia. Chapter 10 discusses the implications of the study findings for health and social care, and recommendations for future research.