Preventing, Reducing or Delaying Needs

1. Introduction

It is very important 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 and its partners can achieve the aims of promoting wellbeing and independence and reducing dependency. The Care and Support Statutory Guidance sets out how they 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 and their partners 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 peiople 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, adaptations 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 and their partners 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.

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 bedbased 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.

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 and their partners 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 and its partners 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 and partners 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.

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 and their partners 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. They 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.

Social workers, occupational therapists, other professionals, service providers and commissioners and partner agencies 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.

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.

5.5 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.

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.

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 and their partners 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.

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 its partners 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 and its partners 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 or its partners may become aware that a child is carrying out a caring role through an assessment or informed through family members or a school. They 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.