A case-study analysis of Knowsley Reablement Service is used to understand home care re-ablement more deeply. In this sense, speaking to members of the Social Services Department provides a rich description of the field that would not have been possible by conducting a survey (Zainal, 2007). The senior manager mentions several complex issues such as capacity, referral process and integration. Once these issues were mentioned it became very important to further explore how they affect their re-ablement service. Since case-study research is not limited to a single source of data, multiple sources of evidence such as discussion, observations, and documents are used to deepen the understanding of the operational challenges. Combining data from multiple sources is instrumental to research because it helps to understand Knowsley’s re-ablement service and the issues they face.
Knowsley Reablement Service became operational as an in-house re-ablement service in 2009. The service is available for adults aged 18 and older and living in the boroughs of Halton, Knowsley, St Helens, Warrington and Wigan. Knowsley Metropolitan Borough Council runs the Knowlsey Reablement service. The council decided it was in the best of their residents’ health and wellbeing to form partnerships with 5 boroughs. In addition, having a partnership with 5 boroughs allows the council to commission health and social care services from a larger network of care providers. Commissioning a variety of providers increases competition and improves value for money. This kind of market
should support the kind of self-directed social-care services people need to access in order to meet their individalised needs.
In 2011 the population of the Metropolitan of Knowlsey was 145,900 (Office for National Statistics, 2011); as of 2011 the total population of the Metropolitan Borough of St Helens was 175,308 (Office for National Statistics, 2011), Borough of Halton was 125,746 (Office for National Statistics, 2011), Warrington was 202,200 (Office for National Statistics, 2011), and Metropolitan Borough of Wigan was 317,800 (Office for National Statistics, 2011). In the Metropolitan of Knowsley, adults 85 and older are set to outnumber any other age group by 2019 (Cammell, 2010). These demographic changes are an indication of what lies ahead for the local authority.
In November 2011 a meeting was organised with a manager from Knowsley Reablement Service to discuss the service. The service provides up to six weeks of re-ablement for those needing help to return to independent living; the service is used the most by adults’ aged 80 and older. According to data provided by a manager from Knowsley “a total of 48 adults aged 80 and older were receiving re-ablement care from Knowsley Reablement Service compared to a total of 40 adults aged 65-79 in March 2011; in February 2011 a total of 45 adults aged 80 and older and 41 adults aged 65-79” were receiving re- ablement care from Knowsley Reablement Service (Knowsley, 2011). The source of most of the referrals was from the Hospital Care Management Team; they had increased
the capacity of bed-based intermediate care to meet rising demand. Since most of the referrals were from hospital a major focus was on preventative care services - such as falls prevention and community therapy - in order to reduce future demand for health and social care services.
In 2010 Knowsley budgeted £1.7 million for re-ablement and in 2011 this was reduced to £1.4 million; in 2013-14 funding was £1.015 million (Knowsley Clinical Commissioning Group, 2013). Part of central government’s care and support reforms is drawing out efficiencies across the health and social care system (Local Government Association, 2013). Note, additional funding for social care was allocated in 2010 Spending Review but, since councils spend more than one third of their budget on adult social care, they had to make service reductions by 2.68 billion, or 20% of the budget. This is a way for councils to produce savings albeit it placing a lot of pressure on them to run an efficient and effective re-ablement service (Local Government Association, 2013). Clearly, major funding cuts are affecting them and the community and are an ongoing problem. Because of this, more efficient and effective strategies have to be considered without reducing access to needed care services or creating burdens for providers.
An integral part of the organisation and delivery of re-ablement by Knowsley is the referral process. Referrals are made by hospital and community teams; the hospital discharge team accounts for approximately 60% of referrals and the community teams account for 40%. It is fraught with flaws - inconsistent quality of referrals and
assessments, need for streamlined paperwork and supportive information and communication technology arrangement - that often lead to service delays because hospital and community teams work independently and use different referral forms and methods albeit there is a referrals office that houses health and social professionals. For major change to occur to Knowsley Reablement Service, health and social care need to collaborate in the referral process in order to reduce errors, delays in service delivery, hospital admissions, and long-term care use. Unlike Knowsley Reablement Service, some health and social care services are working to remove paper-based processes in order to create an efficient and effective care system.
Aintree University Hospital NHS Foundation Trust has actually implemented a new electronic medical records system to improve the quality of patient care, enhance operational productivity and reduce cost (Pearson, 2014). The Trust’s new electronic medical records system provides clinicians instant access to patient information, guarantee notes availability and reduce the costs, risks and space associated with paper handling and storage (Pearson, 2014). Like Aintree University Hospital, Knowsley should implement a similar electronic records system as a solution for all the problems associated with their referral process. Also, it enhances collaboration among care providers irrespective of location. Clearly, re-ablement harnesses the joint input of health and social services (Social Care Institute for Excellence, 2011). Knowsley’s Clinical Commissioning Group should be working and commissioning collaboratively with their local council so that a person’s re-ablement needs are being met.
The referral process is not a static process, but dynamic (Department of Health, 2010). Instead of a single, one-off assessment, a service user’s care or support package needs to be continually reviewed and reassessed in order to provide the right kind of care package. For it to be successful, it needs to be accurate and timely. To achieve this, local authority and hospital should work together so that people receive care packages based on their care needs and preferences.
In 2011 a major focus of Knowsley was to develop a thorough and generally applicable definition of home care re-ablement. Progress can be stymied and process improvement may be severely limited if there is no clearly defined definition and process (VanVactor, 2013). Knowsley Metropolitan Borough Councils and NHS Knowsley have adopted their own working definition of re-ablement: “The restoration of optimal levels of physical, psychological and social ability within the needs and desires of the individual and his/her carer” (Joint Improvement Partnership South East, 2010; Wood and Salter, 2012). It was important to Knowsley to clearly define re-ablement in order to improve their relationship with health.