This chapter outlines for multi-agency practitioners how local authorities must actively promote wellbeing and independence, and intervene early to support adults and carers in order to prevent, delay or reduce needs wherever possible. Whilst it is the responsibility of the local authority, the principle is relevant to all agencies.
- 1. Introduction
- 2. Prevent, Reduce, Delay
- 3. Intermediate Care and Reablement
- 4. Carers and Prevention
- 5. The Focus of Prevention
- 5.1 Promoting wellbeing
- 5.2 Developing resilience and promoting individual strength
- 5.3 Developing a local approach to preventative support
- 5.4 Working with other partners to focus on prevention
- 5.5 Working with other partners to focus on prevention
- 5.6 Identifying those who may benefit from preventative support
- 5.7 Helping people access preventative support
- 6. Assessment of the Needs of Adults and Carers
It is critical to the vision in the Care Act 2014 that the care and support system works to actively promote wellbeing and independence, and does not just wait to respond when people reach a crisis point. To meet the challenges of the future, it will be vital that the care and support system intervenes early to support individuals, helps people retain or regain their skills and confidence, and prevents need or delays deterioration wherever possible.
There are many ways in which a local authority can achieve the aims of promoting wellbeing and independence and reducing dependency. The Care and Support Statutory Guidance (revised 2016) sets out how local authorities should go about fulfilling their responsibilities, both individually and in partnership with other local organisations, communities, and people themselves.
The local authority’s responsibilities for prevention, reducing and delaying needs apply to all adults, including:
- people who do not have any current needs for care and support;
- adults with needs for care and support, whether their needs are eligible and / or met by the local authority or not;
- carers, including those who may be about to take on a caring role or who do not currently have any needs for support, and those with needs for support which may not be being met by the local authority or other organisation.
The term ‘prevention’ or ‘preventative’ measures can cover many different types of support, services, facilities or other resources. There is no single definition for what constitutes preventative activity and this can range from wide scale, whole population measures aimed at promoting health, to more targeted, individual interventions aimed at improving skills or functioning for one person or a particular group or lessening the impact of caring on a carer’s health and wellbeing. In considering how to give effect to their responsibilities, local authorities should consider the range of options available, and how those different approaches could support the needs of their local communities.
‘Prevention’ is often broken down into three general approaches – primary, secondary and tertiary prevention – which are described in more detail below. The use of such terms is aimed to illustrate what type of services, facilities and resources could be considered, arranged and provided as part of a prevention service, as well as to whom and when such services could be provided or arranged. However, services can cut across any or all of these three general approaches and as such the examples provided under each approach are not to be seen as limited to that particular approach. Prevention should be seen as an ongoing consideration and not a single activity or intervention.
2. Prevent, Reduce, Delay
2.1 Prevent: primary prevention/ promoting wellbeing
These are aimed at individuals who have no current particular health or care and support needs. These are services, facilities or resources provided or arranged that may help an individual avoid developing needs for care and support, or help a carer avoid developing support needs by maintaining independence and good health and promoting wellbeing. They are generally universal (that is, available to all) services, which may include interventions and advice that:
- provide universal access to good quality information;
- support safer neighbourhoods;
- promote healthy and active lifestyles;
- reduce loneliness or isolation or;
- encourage early discussions in families or groups about potential changes in the future, for example conversations about potential care arrangements or suitable accommodation should a family member become ill or disabled.
2.2 Reduce: secondary prevention/ early intervention
These are more targeted interventions aimed at individuals who have an increased risk of developing needs, where the provision of services, resources or facilities may help slow down or reduce any further deterioration or prevent other needs from developing. Some early support can help stop a person’s life tipping into crisis, for example helping someone with a learning disability with moderate needs manage their money, or a few hours support to help a family carer who is caring for their son or daughter with a learning disability and behaviour that challenges at home.
Early intervention could also include a fall prevention clinic, adaptions to housing to improve accessibility or provide greater assistance, handyman services, short term provision of wheelchairs or telecare services. In order to identify those individuals most likely to benefit from such targeted services, local authorities may undertake screening or case finding, for instance to identify individuals at risk of developing specific health conditions or experiencing certain events (such as strokes, or falls), or those that have needs for care and support which are not currently met by the local authority. Targeted interventions should also include approaches to identifying carers, including those who are taking on new caring responsibilities. Carers can also benefit from support to help them develop the knowledge and skills to care effectively and look after their own health and wellbeing.
2.3 Delay: tertiary prevention
These are interventions aimed at minimising the effect of disability or deterioration for people with established or complex health conditions, (including progressive conditions, such as dementia), supporting people to regain skills and manage or reduce need where possible. Tertiary prevention could include, for example the rehabilitation of people who are severely sight impaired. Local authorities must provide or arrange services, resources or facilities that maximise independence for those already with such needs, for example, interventions such as the provision of formal care such as meeting a person’s needs in their own home; rehabilitation / reablement services, for example community equipment services and adaptations; and the use of joint case management for people with complex needs.
Tertiary prevention services could also include helping improve the lives of carers by enabling them to continue to have a life of their own alongside caring, for example through respite care, peer support groups like dementia cafés, or emotional support or stress management classes which can provide essential opportunities to share learning and coping tips with others. This can help develop mechanisms to cope with stress associated with caring and help carers develop an awareness of their own physical and mental health needs.
Prevention is not a one off activity. For example, a change in the circumstances of an adult and/or carer may result in a change to the type of prevention activity that would be of benefit to them. Prevention can sometimes be seen as something that happens primarily at the time of (or very soon after) a diagnosis or assessment or when there has been a subsequent change in the person’s condition. Prevention services are, however, something that should always be considered. For example, at the end of life in relation to carers, prevention services could include the provision of pre-bereavement support.
3. Intermediate Care and Reablement
‘Intermediate care’ is a time limited, structured programme of care to assist a person to maintain or regain their ability to live independently at home. ‘Reablement’ is a type of intermediate care, which aims to help the person regain their capabilities and live independently in their own home.
There is a tendency for the terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ to be used interchangeably. The National Audit of Intermediate Care categorises four types of intermediate care:
- crisis response – services providing short-term care (up to 48 hours);
- home based intermediate care – services provided to people in their own homes by a team with different specialties but mainly health professionals such as nurses and therapists;
- bed based intermediate care – services delivered away from home, for example, in a community hospital; and
- reablement – services to help people live independently which are provided in the person’s own home by a team of mainly care and support professionals.
The term ‘rehabilitation’ is sometimes used to describe a particular type of service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness or disease. Rehabilitation services can include provisions that help people attain independence and remain or return to their home and participate in their community, for example independent living skills and mobility training for people with visual impairment.
‘Intermediate care’ services are provided to people, usually older people, after they have left hospital or when they are at risk of being sent to hospital. Intermediate care is a programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live independently – as such they provide a link between places such as hospitals and people’s homes, and between different areas of the health and care and support system – community services, hospitals, GPs and care and support.
To prevent needs emerging across health and care, integrated services should draw on a mixture of qualified health, care and support staff, working collaboratively to deliver prevention. This could involve, for instance, reaching beyond traditional health or care interventions to help people develop or regain the skills of independent living and active involvement in their local community.
4. Carers and Prevention
Carers play a significant role in preventing the needs for care and support for the people they care for, which is why it is important that local authorities consider preventing carers from developing needs for care and support themselves. There may be specific interventions for carers that prevent, reduce or delay the need for carers’ support. These interventions may differ from those for people without caring responsibilities. Examples of services, facilities or resources that could contribute to preventing, delaying or reducing the needs of carers may include but is not limited to those which help carers to:
- care effectively and safely – both for themselves and the person they are supporting, for example timely interventions or advice on moving and handling safely or avoiding falls in the home, or training for carers to feel confident performing basic health care tasks;
- look after their own physical and mental health and wellbeing, including developing coping mechanisms;
- make use of IT and assistive technology;
- make choices about their own lives, for example managing their caring role and paid employment;
- find support and services available in their area;
- access the advice, information and support they need including information and advice on welfare benefits, other financial information and entitlement to carers’ assessments.
As with the people they care for, the duty to prevent carers from developing needs for support is distinct from the duty to meet their eligible needs. While a person’s eligible needs may be met through universal preventative services, this will be an individual response following a needs or carers assessment. Local authorities cannot fulfil their universal prevention duty in relation to carers simply by meeting eligible needs, and nor would universal preventative services always be an appropriate way of meeting carers’ eligible needs.
5. The Focus of Prevention
5.1 Promoting wellbeing
The local authority must have regard to promote wellbeing and its principles (see Promoting Wellbeing), and view an individual’s life holistically. This will mean considering care and support needs in the context of the person’s skills, ambitions, and priorities. This should include consideration of the role a person’s family or friends can play in helping the person to meet their goals. This is not creating or adding to their caring role but including them in an approach supporting the person to live as independently as possible for as long as possible. In regard to carers, the local authority should consider how they can be supported to look after their own health and wellbeing and to have a life of their own alongside their caring responsibilities.
As highlighted in the case study, where people live alone a person may not always have the support from family or friends because they may not live close by. For this group of people prevention needs to be considered through other means, such as the provision of community services and activities that would help support people to maintain an independent life.
5.2 Developing resilience and promoting individual strength
In developing and delivering preventative approaches to care and support, local authorities should ensure that individuals are not seen as passive recipients of support services, but are able to design care and support based around achievement of their goals. Local authorities should actively promote participation in providing interventions that are co-produced with individuals, families, friends, carers and the community. ‘Co-production’ is when an individual influences the support and services received, or when groups of people get together to influence the way that services are designed, commissioned and delivered. Such interventions can contribute to developing individual resilience and help promote self-reliance and independence, as well as ensuring that services reflect what the people who use them want.
Through the assessment process, an individual will have direct contact with a local authority. A good starting point for a discussion that helps develop resilience and promotes independence would be to ask: ‘what does a good life look like for you and your family and how can we work together to achieve it?’ Giving people choice and control over the support they may need and access to the right information enables people to stay as well as possible, maintain independence and caring roles for longer.
Social workers, occupational therapists, other professionals, service providers and commissioners who are effective at preventing, reducing, or delaying needs for care and support are likely to have a holistic picture of the individuals and families receiving support. This will include consideration of a person’s strengths and their informal support networks as well as their needs and the risks they face. This approach recognises the value in the resources of voluntary and community groups and the other resources of the local area.
5.3 Developing a local approach to preventative support
The local authority must provide or arrange for services, facilities or resources which would prevent, delay or reduce an individual’s needs for care and support, or the needs for support of carers. It should develop a clear, local approach to prevention which sets out how they plan to fulfil this responsibility, taking into account the different types and focus of preventative support as outlined above. Developing a local approach to preventative support is a responsibility wider than adult care and support alone, and should include the involvement, by way of example, of those responsible for public health, leisure, transport, and housing services which are relevant to the provision of care and support.
5.4 Working with other partners to focus on prevention
A local authority must provide or arrange for services, facilities or resources which would prevent, delay or reduce individuals’ needs for care and support, or the needs for support of carers. Local authorities should develop a clear, local approach to prevention which sets out how they plan to fulfil this responsibility, taking into account the different types and focus of preventative support as described above. Developing a local approach to preventative support is a responsibility wider than adult care and support alone, and should include the involvement, by way of example, of those responsible for public health, leisure, transport, and housing services which are relevant to the provision of care and support.
Whilst local authorities may choose to provide some types of preventative support themselves, others may be more effectively provided in partnership with other local partners (for example rehabilitation or falls clinics provided jointly with the local NHS), and further types may be best provided by other organisations (for example specialist housing providers or some carers’ services). A local authority’s commissioning strategy for prevention should consider the different commissioning routes available, and the benefits presented by each. This could include connecting to other key areas of local preventative activity outside care, including housing, planning and public health.
In developing a local approach to prevention, the local authority must take steps to identify and understand both the current and future demand for preventative support, and the supply in terms of services, facilities and other resources available.
Local authorities must consider the importance of identifying the services, facilities and resources that are already available in their area, which could support people to prevent, reduce or delay needs, and which could form part of the overall local approach to preventative activity. Understanding the breadth of available local resources will help the local authority to consider what gaps may remain, and what further steps it should itself take to promote the market or to put in place its own services.
Where the local authority does not provide such types of preventative support itself, it should have mechanisms in place for identifying existing and new services, maintaining contact with providers over time, and helping people to access them. Local approaches to prevention should be built on the resources of the local community, including local support networks and facilities provided by other partners and voluntary organisations.
Local authorities must promote diversity and quality in provision of care and support services, and ensure that a person has a variety of providers from which to choose. Considering the services, facilities and resources which contribute towards preventing or delaying the development of needs for care and support is a core element of fulfilling this responsibility. A local authority should engage local providers of care and support in all aspects of delivery and encourage providers to innovate and respond flexibly to develop interventions that contribute to preventing needs for care and support.
Local authorities should consider the number of people in its area with existing needs for care and support, as well as those at risk of developing needs in the future, and what can be done to prevent, delay or reduce those needs now and in the future. In doing so, a local authority should draw on existing analyses such as the Joint Strategic Needs Assessment, and work with other local partners such as the NHS and voluntary sector to develop a broader, shared understanding of current and future needs, and support integrated approaches to prevention.
In particular, local authorities must consider how to identify ‘unmet need’ – that is those people with needs which are not currently being met, whether by the local authority or anyone else. Understanding unmet need will be crucial to developing a longer-term approach to prevention that reflects the true needs of the local population. This assessment should also be shared with local partners, such as through the health and wellbeing board, to contribute to wider intelligence for local strategies. Preventative services, facilities or resources are often most effective when brought about through partnerships between different parts of the local authority and between other agencies and the community such as those people who are likely to use and benefit from these services.
Local authorities should consider how they can work with different partners to identify unmet needs for different groups and coordinate shared approaches to preventing or reducing such needs, for example working with the NHS to identify carers, and working with independent providers including housing providers and the voluntary sector, who can provide local insight into changing or emerging needs beyond eligibility for publically funded care.
5.5 Working with other partners to focus on prevention
Developing and delivering local approaches to prevention, the local authority should consider how to align or integrate its approach with that of other local partners. Preventing needs will often be most effective when action is undertaken at a local level, with different organisations working together to understand how the actions of each may impact on the other.
Within the local authority, prevention of care and support needs is closely aligned to other local authority responsibilities in relation to public health, children’s services, and housing, for example. Across the local landscape, the role of other bodies including the local NHS (for example GPs, dentists, pharmacists, ophthalmologists etc.), welfare and benefits advisers (for example at Jobcentre Plus), the police, fire service, prisons in respect of those persons detained or released with care and support needs, service providers and others will also be important in developing a comprehensive approach.
Local authorities must ensure the integration of care and support provision, including prevention with health and health-related services, which include housing (see Integration, Cooperation and Partnerships). This responsibility includes in particular a focus on integrating with partners to prevent, reduce or delay needs for care and support.
A local authority must cooperate with each of its relevant partners and the partners must cooperate with the local authority, for example, in relation to the provision of preventative services and the identification of carers, a local authority must cooperate with NHS bodies.
A local authority must also set up arrangements between its relevant partners and individual departments in relation to its care and support functions, which includes prevention. Relevant partners and individual departments include, but are not limited to, housing departments where, for example, housing services or officers may be well placed to identify people with dementia and their carers, and provide housing related support and/or in partnership with others, home from hospital services or ‘step up step down’ provision.
5.6 Identifying those who may benefit from preventative support
The local authority should put in place arrangements to identify and target those individuals who may benefit from particular types of preventative support. Helping people to access such types of support when they need it is likely to have a significant impact on their longer term health and wellbeing, as well as potentially reducing or delaying the need for ongoing care and support from the local authority.
In developing such approaches, the local authority should consider the different opportunities for coming into contact with people who may benefit, including where the first contact maybe with a professional outside the local authority for example, GPs, pharmacists or welfare and benefit advisers. There are a number of interactions and access points that could bring a person into contact with the local authority or a partner organisation and act as a trigger point for the local authority to consider whether the provision of a preventative service or some other step is appropriate. These may include:
- initial contact through a customer services centre, whether by the person concerned or someone acting on their behalf;
- contact with a GP, community nurses, housing officers or other professionals which leads to a referral to the local authority;
- an assessment of needs or a carer’s assessment, which identifies the person may benefit from a preventative service or other type of local support.
Many people with low level care and support needs will approach the voluntary sector for advice in the first instance. Local authorities and the voluntary sector should work together on how it can share this information to gain a fuller picture of local need as possible. Authorities should bring data from these different sources together to stratify who in the community may need care and support in the future and what types of needs they are likely to have, and use this information to target their preventative services effectively.
Prevention should be a consistent focus for the local authority in undertaking their care and support functions. However, there may be key points in a person’s life or in the care and support process however, where a preventative intervention may be particularly appropriate or of benefit to the person. The local authority should consider circumstances which may help to identify people who may benefit from preventative support, for example:
- hospital admission and or discharge;
- people who have been recently admitted to or released from prison;
- application for benefits such as Attendance Allowance, or Carer’s Allowance;
- contact with/use of local support groups;
- contact with/use of private care and support;
- changes in housing.
A local authority must establish and maintain a service for providing people with information and advice relating to care and support (see Information and Advice). In addition to any more targeted approaches to communicating with individuals who may benefit from preventative support, this service should include information and advice about preventative services, facilities or resources, so that anyone can find out about the types of support available locally that may meet their individual needs and circumstances, and how to access them.
5.7 Helping people access preventative support
A variety of different kinds of service, facilities or resources can be preventative and can help individuals live well and maintain their independence or caring roles for longer.
Local authorities should be innovative and develop an approach to prevention that meets the needs of their local population. A preventative approach requires a broad range of interventions, as one size will not fit all.
Where a local authority has put in place mechanisms for identifying people who may benefit from a type of preventative support, it should take steps to ensure that the person concerned understands the need for the particular measure, and is provided with further information and advice as necessary.
Contact with a person who is identified as being able to benefit from preventative support may lead to the local authority becoming aware that the person appears to have needs for care and support, including support as a carer. This appearance of need is likely to trigger a needs assessment or a carer’s assessment. However, where a local authority is not required to carry out such an assessment, it should nonetheless take steps to establish whether the person identified will benefit from the type of preventative support proposed.
Where a person is provided with any type of service or supported to access a facility or resource as a preventative measure, the local authority should also provide the person with information in relation to the measure undertaken. The local authority is not required to provide a care and support plan or a carer’s support plan where it provides prevention services only. It should, however, consider which aspects of a plan should be provided in these circumstances, and should provide such information as is necessary to enable the person to understand:
- what needs the person has or may develop, and why the intervention or other action is proposed in their regard;
- the expected outcomes for the action proposed, and any relevant timescale in which those outcomes are expected; and
- what is proposed to take place at the end of the measure (for instance, whether an assessment of need or a carer’s assessment will be carried out at that point).
The person concerned must agree to the provision of any service or other step proposed by the local authority. Where the person refuses but continues to appear to have needs for care and support (or for support, in the case of a carer), the local authority must offer the individual an assessment.
6. Assessment of the Needs of Adults and Carers
In assessing whether an adult has any care and support needs or a carer has any needs for support, the local authority must consider whether the person concerned would benefit from the preventative services, facilities or resources provided by the local authority or which might otherwise be available in the community. This is regardless of whether, in fact, the adult or carer is assessed as having any care and support needs or support needs. As part of the assessment process, the local authority considers the capacity of the person to manage their needs or achieve the outcomes which matter to them, and allows for access to preventative support before a decision is made on whether the person has eligible needs.
As part of this process, the local authority should also take into account the person’s own capabilities, and the potential for improving their skills, as well as the role of any support from family, friends or others that could help them to achieve what they wish for from day-to-day life. This should not assume that others are willing or able to take up caring roles. Where it appears to the local authority that a carer may have needs for support (whether currently or in the future), a carer’s assessment must always be offered.
Children should not undertake inappropriate or excessive caring roles that may have an impact on their development. A young carer becomes vulnerable when their caring role risks impacting upon their emotional or physical wellbeing and their prospects in education and life. A local authority may become aware that a child is carrying out a caring role through an assessment or informed through family members or a school. A local authority should consider how supporting the adult with needs for care and support can prevent the young carer from under taking excessive or inappropriate care and support responsibilities. Where a young carer is identified, the local authority must undertake a young carer’s assessment under the Children Act 1989.
Considering the support from family, friends or others is important in taking a holistic approach to see the person in the context of their support networks and understanding how their needs may be prevented, reduced or delayed by others within the community, rather than by more formal services.
If a person is provided with care and support or support as a carer by the local authority, the authority must provide them with information and advice about what can be done to prevent, delay, or reduce their needs as part of their care and support plan or support plan. This should also include consideration of the person’s strengths and the support from other members of the family, friends or the community.
Regardless of whether or not a person is ultimately assessed as having either any needs at all or any needs which are to be met by the local authority, the authority must in any case provide information and advice in an accessible form, about what can be done to prevent, delay, or reduce development of their needs. This is to ensure that all people are provided with targeted, personalised information and advice that can support them to take steps to prevent or reduce their needs, connect more effectively with their local community, and delay the onset of greater needs to maximise their independence and quality of life. Where a person has some needs that are eligible, and also has some other needs that are not deemed to be eligible, the local authority must provide information and advice on services facilities or resources that would contribute to preventing, reducing or delaying the needs which are not eligible, and this should be aligned and be consistent with the care and support plan for the person with care needs, or support plan for the carer.
It is important that people receive information in a timely manner about the services or interventions that can help or contribute to preventing an escalation in needs for care and support. Supporting people’s access to the right information at the right time is a key element of a local authority’s responsibilities for prevention.