1.2 Preventing, Reducing or Delaying Needs

Audio & Quick Read Summary

1. Introduction

A central aim of the Care Act 2014 is that the care and support system works to actively promote wellbeing and independence, and does not wait to respond when people reach a crisis point. Services must intervene early to support adults and carers, help them retain or regain their skills and confidence, and prevent the development of additional needs or delay the deterioration of existing needs.

There are many ways in which local authorities can achieve the aims of promoting wellbeing and independence. The Care and Support Statutory Guidance describes how local authorities should fulfil their responsibilities, both individually and in partnership with other local organisations, communities, adults and carers.

The local authority’s responsibilities for prevention and reducing and delaying needs apply to all adults, including:

• those who do not have any current needs for care and support;
• those with needs for care and support, whether their needs are eligible and / or being 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 and other resources. There is no single definition of 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 reducing the impact of caring on a carer’s health and wellbeing.

‘Prevention’ is often broken down into three general approaches – primary, secondary and tertiary. These terms are used to illustrate what type of services 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. 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 adults who have no current particular health or care and support needs. They are services, facilities or resources provided or arranged that may help people avoid developing needs for care and support, or help carers avoid developing support needs by maintaining independence and good health and promoting wellbeing. They are generally universal services (which means they are available to all) and may include:

• providing universal access to good quality information;
• supporting safer neighbourhoods;
• promoting healthy and active lifestyles;
• reducing loneliness or isolation or;
• encouraging families to have early discussions 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 adults who have an increased risk of developing needs, and the provision of services, resources or facilities may help slow down or reduce any further deterioration or prevent other needs from developing. Early support can help prevent a person’s life tipping into crisis.

Early intervention services can include falls prevention clinics, adaptations to housing to improve accessibility or provide greater assistance, handyperson services, the short term provision of wheelchairs or telecare services. Screening can help to identify adults most likely to benefit from such services, for instance by identifying adults at risk of developing specific health conditions or experiencing certain events (such as strokes, or falls). Targeted interventions should also include approaches to identifying carers, including those who are taking on new caring responsibilities.

2.3 Delay: tertiary prevention

These are interventions aimed at minimising the effect of disability or deterioration for adults 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 adults who already have such needs; for example, the provision of formal care in a person’s home or rehabilitation / reablement services, including community equipment services and adaptations

Tertiary prevention services can also include helping improve the lives of carers by enabling them to continue to have a life of their own alongside caring responsibilities, for example through the provision of short breaks, peer support groups like dementia cafés, or emotional support or stress management groups which can provide essential opportunities to share learning and coping tips with others.

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.

Sometimes the terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ can be used interchangeably.

There are four models of intermediate care (see Intermediate Care (SCIE)):

1. Bed-based services are provided in an acute hospital, community hospital, residential care home, nursing home, standalone intermediate care facility, independent sector facility, local authority facility or other bed-based settings.
2. Community-based services provide assessment and interventions to people in their own home or a care home.
3. Crisis response services are based in the community and are provided to people in their own home or a care home with the aim of avoiding hospital admissions.
4. Reablement services are based in the community and provide assessment and interventions to people in their own home or a care home. These services aim to help people recover skills and confidence to live at home and maximise their independence.

The term ‘rehabilitation’ is often 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 admitted to hospital. Such services are provided for a limited period of time to assist a person to maintain or regain the ability to live independently.

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 provide support to prevent carers from developing needs for care and support themselves. Services or resources that can help to prevent, delay or reduce the needs of carers include those which help carers to:

• provide safe and effective care – both for themselves and the person they are supporting, for example 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 (see Assessment of Needs).

5. The Focus of Prevention

5.1 Promoting wellbeing

Local authorities must promote wellbeing (see Wellbeing Principle), and view the adult’s life holistically. This involves considering the adult’s care and support needs in the context of their skills, ambitions, and priorities, and also consider their family or friends can play in helping them to meet their goals. Local authorities should also consider how carers can be supported to look after their own health and wellbeing and to have a life of their own alongside their caring responsibilities.

5.2 Involving adults

In developing and delivering preventative approaches to care and support, local authorities should ensure that adults are active participants and involved in designing care and support which meets their own goals and preferred outcomes. Local authorities should actively promote participation in providing interventions that are co-produced with individuals, families, friends, carers and the community. ‘

Through the assessment process, adults should be asked: ‘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 them to stay as well as possible, maintain independence and any caring roles for longer.

5.3 Working with other partners to focus on prevention

Whilst local authorities may 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).

In developing a local approach to prevention, local authorities 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.

It is important to identify the services, facilities and resources that are already available in the local area, which could support people to prevent, reduce or delay needs, and which could form part of the overall local approach to preventative activity.

Local authorities must promote diversity and quality in provision of care and support services, and ensure that a person has a variety of providers to choose from (see Market Shaping and Commissioning of Adult Care and Support chapter).

Identifying ‘unmet need’ – that is those people with needs which are not currently being met, whether by the local authority or anyone else, is particularly important when developing a longer-term approach to prevention.

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 publicly funded care.

5.4 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.

Identifying different opportunities for coming into contact with people who may benefit from preventative services is important, including where the first contact maybe with a professional outside the local authority (such as GPs, pharmacists or welfare and benefit advisers).

Often people with low level care and support needs will approach the voluntary sector for advice in the first instance.

Although prevention should be a consistent focus for the local authority when undertaking their care and support functions, there are key points in a person’s life where a preventative intervention may be of particular benefit. These include:

• bereavement;
• 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.

5.5 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.

Where a local authority has 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.

A care and support plan or a carer’s support plan is not required for the provisions of prevention services only. However, people should be provided with information to help them 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 adult 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. Assessing the Needs of Adults and Carers

See also Assessment of Needs policy and Carer’s Assessments policy.

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 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 this process, the local authority should also take into account the adult’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 undertaking 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.

Regardless of whether or not a person is assessed as having either any needs at all or any needs which are to be met by the local authority, they must be provided with information and advice about what can be done to prevent, delay, or reduce development of their needs. This should be provided in an accessible format 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 future needs. Where an adult 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.

It is important that people receive information in a timely manner. Access to the right information at the right time is a key to preventing, reducing or delaying needs for care and support.

7. Charging for Preventative Support

Preventative services, like other forms of care and support, are not always provided free of charge. The Care and Support (Preventing Needs for Care and Support) Regulations 2014 allow local authorities to make a charge for the provision of certain preventative services, facilities or resources. The regulations also provide that some other specified services must be provided free of charge.

Where a local authority chooses to charge for a particular service, it should balance the affordability and viability of the activity with the likely impact that charging may have on uptake. In some cases, charging may be necessary in order to make a preventative service viable or keep a service running.

When charging for any type of preventative support, local authorities should take reasonable steps to ensure that any charge is affordable for the person concerned. This does not need to follow the method of the financial assessment used for mainstream charging purposes; and the use of such a process is likely to be disproportionate.

Adopting a more proportionate or ‘light-touch’ approach which ensures that charges are only paid by those who can afford to do so should be considered. Local authorities must not charge more than it costs to provide or arrange for the service, facility or resource.

The regulations require that intermediate care and reablement must be provided free of charge for up to six weeks, as must aids and minor adaptations (that is, adaptations up to the value of £1,000).

Where local authorities provide intermediate care or reablement to those who require it, this must be provided free of charge for a period of up to 6 weeks. This is for all adults, irrespective of whether they have eligible needs for ongoing care and support. Although such types of support will usually be provided as a preventative measure, they may also be provided as part of a package of care and support to meet eligible needs. In these cases, regulations also provide that intermediate care or reablement cannot be charged for in the first six weeks, to ensure consistency.

Whilst they are both time-limited interventions, neither intermediate care nor reablement should have a strict time limit, since the period of time for which the support is provided should depend on the needs and outcomes of the individual. In some cases, for instance a period of rehabilitation for a visually impaired person (a specific form of reablement), may be expected to last longer than six weeks. Whilst the local authority does have the power to charge for this where it is provided beyond six weeks, local authorities should consider continuing to provide it free of charge beyond six weeks in view of the clear preventative benefits to the individual and, in many cases, the reduced risk of hospital admissions.

8. Further Reading

8.1 Relevant chapters

Wellbeing Principle

Information and Advice

8.2 Relevant information

Chapter 2, Preventing, Reducing or Delaying Needs, Care and Support Statutory Guidance (Department of Health and Social Care)

Prevention and wellbeing (SCIE)

See also Preventing, Reducing or Delaying Needs Case Studies, Resources