Adult social care early invention and prevention

The work of Adult Social Care is primarily focussed meeting its related statutory requirements and on delivering South Tyneside Council's Healthier People priority, which states:

"We want people in South Tyneside to live healthier longer lives. We will encourage people to take positive decisions that will improve their health and wellbeing. We will focus on early intervention and prevention, and improve access to personalised services and support".

The Care Act 2014 requires local authorities to ensure resources are available to Prevent, Reduce and Delay the development of needs for care and support. The following document is focused on understanding where resources are best placed to prevent and reduce the number of people in South Tyneside from needing formal social care services.

Preventing social care need can be thought of as Primary Prevention: For individuals who have no current particular health or care and support needs

Reducing social care need can be thought of as Secondary Prevention: More targeted interventions aimed at individuals who have an increased risk of developing needs.

This assessment will not focus on delaying needs or managing social care demand, as this should form its own needs assessment.

Methodology

To systematically discover the prevention activities and groups of people amenable for prevention related to social care, we first listed the population groups that are more likely to go on to receive social care. The Level of Need section covers this in more detail. From here, we conducted evidence searches for specific references to interventions that would prevent or delay the need for social care within the target population group (Evidence for Interventions section). We then summarised the findings in the Unmet Needs section.

• There have been reductions in funding for social care and increasing demand on resources. This translates to a greater need for a preventative approach to social care demand.
• Nationally and locally there are greater numbers of older people, people with disabilities and increasing complexity. Reducing tobacco use can have short term significant impacts on social care use. While fewer people in South Tyneside than ever before are smokers, quitting smoking remains one of the biggest opportunities for preventing social care use.
• Falls and hip fracture related admission to social care account for 16% of overall admissions, whilst community based prevention services are well evidenced as effective but locally limited.
• Loneliness and isolation, obesity, and limited exercise all have strong links to social care use, but limited evidence for effective interventions.

Adult Social Care is undergoing an improvement programme to meet the increasing demands on its resources, improve services for its residents and their carers and ensure South Tyneside Council is meeting its statutory responsibilities. This programme has highlighted some key areas of focus -

• Improved quality of services and outcomes for service users
• More effective and efficient processes
• Delivery of financial savings
• Better demand management arrangements
• Sustainable market to deliver effective and efficient services
• Better integration across health and social care
• Quality assurance and performance management framework in place
• Cultural change delivered through clear workforce development strategy
• And finally, Improved use of prevention and early intervention measures

There are two components to determining an individual's eligibility for local authority funded social care:

• A care and support need
• Ability to fund their own support.

Care and support need

From NHS guidance, a local authority is required to consider whether a person's needs:

• arise from or are related to a physical or mental impairment or illness
• make them unable to achieve two or more specified outcomes (see link)
• as a result of being unable to meet these outcomes, there is likely to be a significant impact on the adult's wellbeing

People may need care and support because of serious illness, physical disability, learning disability, mental health problems or frailty because of old age. (Source: NHS Social Care and Support Guide)

There is some evidence on how individual conditions, behaviours and events increase the risk of needing social care:

• Tobacco use: twice as likely to enter social care compared to non-tobacco users and, on average need care 9 years earlier. (source: ash.org.uk)
• Falls: 1/3 of over 65s fall each year. 20% of hip fractures result in a permanent social care placement (Kings Fund Publications)
• Ageing: people over 65 account for 51% of local authority spending on social care. (source: NHS Publications )
• Stroke: 5 year risk of care home institutionalisation is 11% after a TIA and 19% after a stroke. (source: AHA Journals - Stroke)
• Long term conditions: 70% of social care spending is on long term conditions. (source: Government Policies)
• Loneliness and Isolation: research suggests links with social care use, but we have not been able to find a quantifiable risk.

Funding ability

• Means testing to determine eligibility for local authority funded social care looks at income and capital limits.
• Those at risk of local authority funded social care have fewer financial assets and lower incomes. They will likely live in more deprived areas.

The local level of need for social care prevention includes the entire population of South Tyneside. There are, however, groups that are more at risk than others of requiring support later in life. The following table identifies those groups where population data exists and compares the group estimates to those in the group known to be receiving formal social care support. The "% not receiving social care support" column identifies the population amenable to prevention interventions.

See Figure 1 Adult Social Care - Primary and Secondary Prevention JSNAA

*The number of contacts to the social care contact centre and the number of calls that go on to receive no further support. Figure will include duplicate client contact.

^social care client size reflects where condition is the primary support need

^a social care client size based on 16% of new admissions resulting from a fall

^b estimated 15% of stroke and TIA population requires permanent social care within 5 years of first event

Determining unmet needs for prevention in social care involves triangulating:

• the population sizes in "Level of Need",
• the evidence on how conditions, behaviours, and events relate to social care use in the short, medium and long term,
• and the evidence on the effectiveness of interventions weighted against the size of the local offer.
• Several categories of unmet needs emerged:

High risk to social care and effective interventions over short term

Falls - high quality evidence on how to prevent falls and a limited local offer. An estimated 8,834 65+ year olds fall each year who are not known to social care. There are 200 hip fractures per year in South Tyneside, 20% of which are predicted to require social care support.

Smoking - High quality evidence on how to help people quit smoking and a short term impact on social care use. The risk of heart attack drops and lung function improves within 3 months of a quit. Within 1 year, the risk of heart attack, heart disease and stroke is 50% less. Smokers are known to enter social care 9 years earlier than non-smokers and are twice as likely to need social care in their lifetimes. There is a full stop smoking service in South Tyneside, but large opportunities exist to integrate more closely with social care.

High risk to social care and effective interventions over long term

Stroke - an estimated 11% of the adult social care population require permanent social care because of a stroke or TIA. There is strong evidence to support reducing the risk of stroke in those with Atrial Fibrillation (AF) through identification and treatment. South Tyneside has a low rate of detection of AF compared to the predicted prevalence, though programmes are underway in primary care to detect more cases. The impact on social care is

High Risk to social care, but limited evidence on effective interventions over short and long term

Loneliness and isolation - over 10,000 people in South Tyneside over 65 are living alone. One-on-one, group and community level interventions have all reported local success, but schemes are not well evaluated and have not yet demonstrated effectiveness. Any locally introduced schemes should be implemented with caution robustly evaluated.

Physical Inactivity and Obesity - there are strong links between physical inactivity, obesity, and long term conditions (LTCs). LTCs are a major risk factor for social care and account for 70% of all spend. There is, however, limited evidence on how to cost effectively improve individuals levels of physical activity and how to reduce obesity levels.

Those eligible for Reablement - By definition, those eligible for reablement services are at immediate risk for social care. The evidence however on the effectiveness of reablement is inconclusive in regards to its ability to cost effectively prevent or reduce the need for social care. Reablement may, however, be a way of delaying the need for higher intensity services.

Adult Social Care supports service users with a variety of conditions and needs that tend to be generally categorised into Sensory/Physical Disabilities, Mental Health, Learning Disabilities, Older People and Carers. By far the biggest group of people supported by Adult Social Care are older people.

The current overall breakdown by client group highlights the predominant client group as Older People Physical Disability (76%).

See Figure 2 Adult Social Care - Primary and Secondary Prevention JSNAA

The chart below highlights forecasted growth in the older population of South Tyneside that indicates approximate growth of the older population of 8.2% within the next 5 years and anticipated growth by 2026 (10 years) of 21% and a 4.2% reduction in working age adults over the same periods.

See Figure 3 Adult Social Care - Primary and Secondary Prevention JSNAA

Given the anticipated growth in the elderly population if no changes were to be made to the current Adult Social Care system using historical full year client information, as highlighted in the chart below, it is anticipated that the amount of clients would increase in the region of 20% by 2018/2019

See Figure 4 Adult Social Care - Primary and Secondary Prevention JSNAA

It is estimated that South Tyneside has around 17500 carers which is slightly over the national average and South Tyneside Council currently supports around 1001 of these carers directly following an assessment and substantially more indirectly through the provision of a variety of services through third sector organisations such as information and advice, peer group and community activities to support them to continue in their caring role.

• South Tyneside has an existing active voluntary sector with more than 2,000 independent voluntary and community organisations established for charitable, social, community or environmental benefit, rather than for profit that provide a range of services to the local community.
• The Voluntary community third sector provides a wide variety of support services including a universal information and advice offer, peer support, social groups, improving independent living skills such as financial management.
• More recently the council and its partners have been working together with South Tyneside Council for Voluntary Services to start considering the future of the third sector market place including how to develop and supplement current community opportunities, identify and reduce overlap, align the sector priorities with the priorities of the statutory services and ensuring consistent and robust monitoring arrangements are in place.

The list below highlights some of the assets commissioned by the local authority. See Figure 5 Adult Social Care - Primary and Secondary Prevention JSNAA

• This list is far from exhaustive and numerous other services and providers support people of the borough. Community resources are not limited to traditional disability related commissioned services but the wider community assets that have a positive impact on people effectiveness to self care, stay healthy and well and improve social isolation.
• The borough has a number of sports and leisure facilities, parks
• Given adult social care focuses heavily on health and wellbeing and empowering individuals to have full control of the resources available to them it is also important to map community assets that are available to all such as leisure, social and community opportunities and ensure, wherever possible through local area coordination, care navigation that all such resources are fully utilised.

We have reviewed the literature for evidence on the effectiveness of interventions based on the conditions and behaviours identified in the Those at Risk section of this report. Types of interventions - See Figure 6. Adult Social Care - Primary and Secondary Prevention JSNAA

[1] NICE: Stop smoking services

[2] Cochrane Library: Community wide interventions for increasing physical activity

[3] Cochrane Library: Interventions for preventing falls in older people living in the community

[4] Medscape: Stroke prevention

[5] Cochrane Library: Time‐limited home‐care reablement services for maintaining and improving the functional independence of older adults

As part of an ongoing co-production process within Adult Social Care a variety of stakeholders were consulted via workshops, staff information sessions, questionnaires, road shows and surveys to get their opinions and ideas in relation to improving support in South Tyneside. Part of the identified principles and areas for development focus on Prevention in particular approaches the service takes in relation to preventing, reducing and delaying needs.

The stakeholders involved included members of the public, service users, carers, council members, social care staff, providers, voluntary/ third sector and the wider community.

Of the people responding to the survey 83.7% of all responses agreed or strongly agreed with the proposed principles which including a stronger focus on prevention. Only 9.1% did not agree with the principles.

Feedback highlighted -

• Delays in the Social Care process in relation to accessing services, advice and support especially quickly during and soon after a crisis as well as gaps in information and advice in relation to community services.
• Importance of supporting people and their families to be in control of their support and only to a level they need including supporting the informal carers
• When asked directly if people agreed with the strategies ideas around preventing needs 80% of people that responded agreed with the ideas for preventing needs whilst only 11% disagreed with the idea.
• Comments also highlighted that purely relying on technology is a general concern for Learning Disability / Mental Health and clients with cognitive impairment and whether older people are receptacle to technology given not everyone can use a computer.
• Improving options in terms on how people communicate with the service - increasing variety and engagement.
• A common theme throughout the questions focussed on the need to have easy to access, timely, accurate information and advice.
• Focus on improving knowledge and skills to self-care and be in control a person's own health and wellbeing including controlling the resources available to them.
• 78.2% agreed with our ideas in relation to reducing needs.
• Respondents highlighted the need to have different conversation and have new innovative services and support. Earlier feedback also highlighted that co-ordination of services and support was also important
• Early identification of needs and strength based assessments with flexible, time limited recovery focused services based upon needs.
• Be clear about what is realistically expected of carers and what can be accessed in the community again highlighting the need for clear and consistent information and advice.
• 76.4% agreed with the councils ideas in relation to delaying needs including 30.9% who strongly agreed.
• The importance of rapid responsive support especially following a crisis(easy access and flexible support was identified in the earlier survey)
• Improving the front door and access into support (92% of people responded to the earlier improvement survey to say the right information and advice would help put them in control of decision making)
• People commented about the resources in voluntary / third sector already being stretched and the need for additional resources
• More promotional work is needed in relation to assistive technology and what it can and can't do, the risks involved and that it should not be at the expense of social interaction - getting the balance with people interaction, the use of technology was identified as a good resource to help people live independently in the earlier survey.
• The need for Adult Social Care to work closer with the wider council and community - housing, planning, transport companies and emergency services to ensure a more holistic community wide approach.
• Comments also related to providers having a focus on recovery
• 60% agreed that providers should work in a way to maximise people's independence and reduce reliance on services indicating that the majority of people are in agreement that, wherever possible people would prefer to be reabled and exit the system.

• Need for data collection systems to systematically capture details of initial contacts to social care, especially those contacts that result in no further action where low level needs might be identified.
• Need for data collection systems to systematically capture outcomes against initial assessments of needs.

Last Updated: September 2017