THE ESSENCE PROJECT

Care and support planning

Case studies

Read the full case study for 'Advance care planning: economic evidence' here (PDF)
Annette Bauer, Danielle Guy 2019

KEY POINTS

  • Advance care planning is an important end of life care intervention that helps people at risk of losing their mental capacity or their ability to communicate plan for their future care and support needs, including medical treatment.
  • It helps people get the treatment they want during the final stage of their life and increases their chance to die in their preferred place of death. It benefits the mental health of the person caring for them.
  • Advance care planning is likely to be cost-effective. This is due to improvements in carer’s quality of life, reductions in the use of aggressive life-sustaining treatment and more people dying at their place of residence rather than in hospitals.
  • Future research needs to address gaps in implementation knowledge of advance care planning.
  • Implementing advance care planning effectively is challenging and requires substantial organisation and system-wide changes.

Read the full case study for 'Help-at-home: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

  • Help-at-home schemes provide older people with access to a range of highly-valued support and can lead to health and wellbeing benefits.
  • Help-at-home schemes appear to save local government and the NHS around £1500 per person per year, owing to:
    • people remaining longer in their homes, rather than moving to care homes;
    • fewer GP appointments;
    • fewer hospital admissions.
  • Benefits of help-at-home schemes might also accrue to volunteers providing support (who are more likely to find jobs after gaining skills through volunteering with the schemes).
  • Findings from the economic evaluation summarised here are the first to demonstrate that help-at-home schemes also have the potential to offer value for money
  • Despite the support provided by help-at-home schemes some older people continue to experience loneliness, financial worries and personal care.
  • Despite economic evidence that help-at-home schemes can be good value for money, many benefits are likely to depend on local infrastructures and how such schemes are run, making it hard to generalise their value.

Read the full case study for 'Transition into and from hospital for people with social care needs: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

  • Interventions that seek to improve the transition between hospital and other settings include: comprehensive geriatric assessments; specialist dementia / delirium unit; short-term early discharge home care and rehabilitation packages; early supported discharge with multidisciplinary community care; multi-professional palliative care.
  • Each has been linked to some positive outcomes – although for specialist delirium/ dementia unit and for multi-professional palliative care outcomes referred to small changes in mood, satisfaction or symptom control rather than to changes in health-related quality of life.
  • Early supported discharge programmes that include a rehabilitation-focused community care package are likely to be cost-effective from a combined health and social care perspective. The evidence refers to older people and people with stroke.
  • Comprehensive geriatric assessment and short-term rehabilitation provided to older people in hospital units may be cost-effective from a hospital perspective, but the wider impacts are unclear.
  • Multi-professional palliative care might be cost-effective; evidence refers to people with multiple sclerosis and people with breathlessness; there might cost savings for people with multiple sclerosis due to reductions in hospital and primary care.
  • A specialist delirium/ dementia unit was not cost-effective based on health-related quality of life but might importantly improve experiences of people using it and their carers.
  • Various national initiatives have been recently implemented to support development of innovative services to integrate care between hospitals and other settings.

Evidence

A Cost Comparison of Supported Living in Wales: A Swansea Case Study
Nash P, Farr A, Phillips C Centre for Innovative Ageing, Swansea. 2013

The key findings from the data are: •The least expensive environment for delivery of care is in service users’ own homes with the most expensive being residential care. Caveats to this are that residential care supports older adults with higher levels of care needs, so type of care needs to be considered. Further, residential care includes housing costs where neither Extracare nor community based care include rent or mortgage payments, as these are not costs incurred by Social Services (Section 4.2). •The lowest equipment/modification costs were incurred by residents in Extracare with the highest by those receiving care and support in the community. This is reflective of the age of housing stock and support infrastructure, with Extracare having communal aides and ready modified flats, whereas this is not the case for community properties (Section 4.3) In-patient costs were significantly higher in residential care than in Extracare, again reflective of the underlying care need of older adults in each environment. The highest costs were associated with those in receipt of care in the community, which is likely because of delays in enacting assessments, re-ablement and new community support care packages (Section 4.4). •Outpatient admissions and A&E costs were relatively stable across each of the care environments (Section 4.5) •The most common GP services utilised by residents in each of the care environments were telephone consultations, home visits and GP surgery consultations (Section 4.7). •Overall, Residential care appears to be the most expensive for all costs relating to GP activity (Section 4.8).

A Return on Investment Tool for the Assessment of Falls Prevention Programmes for Older People Living in the Community
Public Health England Public Health England, London. 2018

This report presents results of a tool developed by York Health Economics Consortium to assess the potential return on investment (ROI) of falls prevention programmes targeted at older people living in the community. The tool pulls together evidence on the effectiveness and associated costs for four programmes where there was evidence of cost-effectiveness: Otago home exercise, Falls Management Exercise group programme, Tai Chi group exercise, and home assessment and modification. Based on an example analysis, all four interventions were found to be cost-effective, thus producing a positive societal ROI. One out of four interventions was also found to have a positive financial ROI (ie cost savings outweigh the cost of implementation). An accompanying Excel sheet allows for results to be tailored to the local situation based on the knowledge of the user. (Edited publisher abstract)

A Review of the Evidence Assessing Impact of Social Prescribing on Healthcare Demand and Cost Implications
Polley M, et al University of Westminster, London. 2017

This paper critically appraises the current evidence as to whether social prescribing reduces the demand for health services and is cost effective. It draws on the results of a systematic review of online databases which identified 94 reports, 14 of which met the selection criteria. They included studies on the effect of social prescribing on demand for general practice, the effect on attendance at accident and emergency (A&E) and value for money and social return on investment assessments. The evidence broadly supports the potential for social prescribing to reduce demand on primary and secondary care, however, the quality of the evidence is weak. It also identifies encouraging evidence that social prescribing delivers cost savings to the health service, but this is not proven or fully quantified. In conclusion, the paper looks at the possible reasons for the growth in scale and scope of social prescribing across the UK and makes recommendations for more evaluations of on-going projects to assess the effectiveness of social prescribing.

A Structured Literature Review to Identify Cost-effective Interventions to Prevent Falls in Older People Living in the Community
Public Health England Public Health England, London. 2018

Summarises the findings from a literature review to identify cost-effective interventions in preventing falls in older people living in the community in England. The review was conducted to inform an economic model to estimate the return on investment of the cost effective interventions across communities in England. The review identified 26 studies, of which 12 were judged to be directly applicable. These included 6 types of interventions: exercise, home assessment and modifications, multifactorial programmes; medicines review and modification to drugs; cardiac pacing and expedited cataract surgery. Based on the evidence, the review recommends interventions to be included in the economic model.

An Analysis of the Economic Impacts of the British Red Cross Support at Home Service
Dixon J, Winterbourne S, Lombard D, et al Personal Social Services Research Unit, London. 2015

This British Red Cross volunteer-based scheme offers short-term (4-12 week) practical and emotional support at home for older people recently discharged from hospital. Using data from the British Red Cross internal evaluation (n=52 individuals; Joy et al., 2013), savings from needing less help with daily activities and improvements in subjective well-being averaged £884 per person. This covered savings up until 6 months following the intervention and included reduced use of paid homecare workers (£167), unpaid care valued at minimum wage (£411) and general help (£75), as well as reduced healthcare costs for treatment associated with falls (£153), malnutrition (£74) and depressive symptoms (£4). The internal British Red Cross evaluation could not identify a control group and no adequate external comparison group could be identified for our economic evaluation. However, we estimated that the intervention costs an average £169 per person, including volunteer time valued at minimum wage. The scheme would need to be responsible for 19 per cent of the estimated savings to be considered cost-saving. Qualitative research, conducted as part of the British Red Cross evaluation, indicated that there were also wider benefits, including enabling safe discharge, supporting carers, enabling patient advocacy and quality of life benefits that could not be included in the economic analysis. More detailed results are available.

An Independent Review of Shared Lives for Older People and People Living with Dementia
PPL, Cordis Bright, Social Finance PPL, London. 2018

Shared Lives is based around a Shared Lives carer sharing their home with an adult in need of care, to encourage meaningful relationships, independent living skills and community integration. This review explores how Shared Lives’ respite service for older people and people with dementia compare to ‘traditional’ forms of care for across three areas: outcomes for service users, carer and care commissioners; direct care costs to commissioners; and impact on the broader health system, such as a reduced usage. The review found that Shared Lives model provides positive outcomes for both service users and carers. It found that Shared Lives arrangements were able to reduce social isolation experience by carers and help increase their general wellbeing. Shared Lives also resulted in increased independence, wellbeing and choice for service users. In addition, the study found that the costs Shared Lives approach are similar to ‘traditional’ respite provision and provide an important option for commissioners. Appendices include details of calculations of the cost of providing Shared Lives respite care and day services; the results of a rapid evidence assessment on outcomes of ‘traditional’ respite care; and details of Healthcare service usage modelling.

Building Wellbeing and Resilience - Living Well
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2016

The Living Well scheme aims to improve prevention and resilience amongst older people with multiple long-term conditions by providing low-level support to day-to-day living and utilising asset-based resources to promote empowerment and wellbeing.

The process begins with a conversation between the person and the voluntary sector coordinator, who helps them to identify their goals and coordinate a management plan. Trained volunteers provide support to build social networks around the individual to help them become better connected to their community, be more physically and socially active and subsequently have better health outcomes. Practical support, navigation and coordination are provided in order to boost self-confidence and self-reliance, leading to reduced adult social care spend and primary/community health benefits.

Care and Health Improvement Programme: Efficiency Project
Local Government Association Local Government Association, London. 2018

This report provides practice examples from ten councils who took part in the Care and Health Improvement Programme during 2016/17. It describes the innovative approaches they took to achieve greater efficiencies from their adult social care budgets and draws conclusions as to what other councils might learn from them. The examples cover three main areas: managing demand for social care by offering residents a different type of service; more effectively using the capacity in communities to help find new care solutions; and working closer with partners in the NHS to reduce pressures in the care and health system. They highlight the importance of councils dealing with people effectively at their first point of contact; the benefits of using strength-based approaches; that developing social enterprises can be a cost effective way of meeting demand and reducing shortage of supply; and the potential of collaboration between councils to reduce costs and demand for services. The 10 councils are: Bristol City Council, Poole Borough Council, Swindon and Wiltshire Councils; Norfolk County Council; Waltham Forest Council; Somerset Council; Newcastle City Council; Nottingham City Council; and Nottinghamshire County Council.

Care and Support of People Growing Older with Learning Disabilities [NG96]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers care and support for adults with learning disabilities as they grow older. It covers identifying changing needs, planning for the future, and delivering services including health, social care and housing. It aims to support people to access the services they need as they get older.

We have produced an EasyRead version and video to explain this guideline, which are available from information for the public.

Recommendations
This guideline includes recommendations on:

overarching principles
organising and delivering services
identifying and assessing care and support needs
planning and reviewing care and support
identifying and managing health needs
end of life care
staff skills and expertise
Who is it for?
Providers of social care, health and housing support for people growing older with learning disabilities
Practitioners in social care, health and housing who work with people growing older with learning disabilities and their families and carers
Commissioners and people with a strategic role in assessing and planning local services
Practitioners in other related services, including older people’s services, adult learning disability services, employment, education and criminal justice services
People with learning disabilities, their families, carers and advocates

Related NICE guideline:
Appendix C2: Economic report Bauer A and Knapp M

Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill-Health
McDaid D, Park A, Knapp M Public Health England, London. 2017

A return on investment resource to support local commissioners in designing and implementing mental health and wellbeing support services.

Community Development in Health: A Literature Review
Fisher B Health Empowerment Leverage Project, London. 2016

This literature review offers a brief background to the current state of play in the NHS and statutory services, and ideas that services more flexible, place-based services are likely to offer more effective and efficient outcomes. It then provides an overview of the nature of community development, its relationship to community health and to enhancing the responsiveness of commissioning of services. It brings together evidence which shows how communities can be supported to develop their own strengths and their own trajectories of development. It also examines the health benefits of community engagement, and identifies the limitations of some studies and where evidence that suggests poor outcomes or risks. It looks developing a business case, and what is already known of costs and benefits of community development. It finds that although it is difficult to express costs and benefits of community development in monetary terms, some effective techniques do exist. The evidence shows that community development helps to strengthen and increase social networks and therefore build up social capital. Evidence shows that they to contribute significantly to individual and to community health and resilience. Existing data also suggests that community development in health is cost-effective and provides good value for money. The review includes definitions of community development and key related concepts, including as asset-based approaches, co-production, social networks, social capital, and community capital.

Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people
Sahota O, Pulikottil-Jacob R, Marshall F, et al Health Services and Delivery Research, 4, 7. 2016

Background:
Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater.

Objective:
To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years.

Methods:
A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients.

Results:
In total, 250 participants were randomised (n = 125 CIRACT service, n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services.

Conclusions:
The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team.

Costs and economic consequences of a help-at-home scheme for older people in England
Bauer A, Knapp M, Wistow G Health and Social Care in the Community, 25, 780-789. 2017

Abstract
Solutions to support older people to live independently and reduce the cost of an ageing population are high on the political agenda of most developed countries. Help-at-home schemes offer a mix of community support with the aim to address a range of well-being needs. However, not much is currently known about the costs, outcomes and economic consequences of such schemes. Understanding their impact on individuals’ well-being and the economic consequences for local and central government can contribute to decisions about sustainable long-term care financing. This article presents results from a mixed-methods study of a voluntary sector-provided help-at-home scheme in England for people of 55 years and older. The study followed a participatory approach, which involved staff and volunteers. Data were collected during 2012 and 2013. Social care-related quality of life was measured with the Adult Social Care Outcomes Toolkit for 24 service users (59% response rate) when they started using the scheme and 4-6 months later. A customised questionnaire that captured resource use and well-being information was sent to 1064 service users (63% response rate). The same tool was used in assessment with service users who started using the scheme between November 2012 and April 2013 (100% response rate). Costs of the scheme were established from local budget and activity data. The scheme was likely to achieve a mean net benefit of £1568 per person from a local government and National Health Service (NHS) perspective and £3766 from the perspective of the individual. An expenditure of £2851 per person accrued to central government for the additional redistribution of benefit payments to older people. This article highlights the potential contribution of voluntary sector-run help-at-home schemes to an affordable welfare system for ageing societies.

Decision-making and Mental Capacity [NG018]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers decision-making in people 16 years and over who may lack capacity now or in the future. It aims to help health and social care practitioners support people to make their own decisions where they have the capacity to do so. It also helps practitioners to keep people who lack capacity at the centre of the decision-making process.

This guideline should be read in conjunction with the Mental Capacity Act 2005. It is not a substitute for the law or relevant Codes of Practice.

It does not cover Deprivation of Liberty Safeguards processes.

Recommendations
This guideline includes recommendations on:

supporting decision-making
advance care planning
assessing mental capacity to make specific decisions at a particular time
best interests decision-making
Who is it for?
Health and social care practitioners working with people who may (now or in the future) lack mental capacity to make specific decisions.
Independent advocates, with statutory and non-statutory roles.
Practitioners working in services (including housing, education, employment, police and criminal justice) who may come into contact with people who lack mental capacity.
People using health and social care services who may (now or in the future) lack mental capacity to make specific decisions, as well as their families, friends, carers and other interested parties.

Related NICE guideline:
Appendix C3: Economic report. DECISION-MAKING AND MENTALCAPACITY Bauer A and Knapp M

Dementia care costs and outcomes: a systematic review
Knapp M, Iemmi V, Romeo R International Journal of Geriatric Psychiatry, 28:, 551-556. 2013

Abstract
OBJECTIVE:
We reviewed evidence on the cost-effectiveness of prevention, care and treatment strategies in relation to dementia.

METHODS:
We performed a systematic review of available literature on economic evaluations of dementia care, searching key databases and websites in medicine, social care and economics. Literature reviews were privileged, and other study designs were included only to fill gaps in the evidence base. Narrative analysis was used to synthesise the results.

RESULTS:
We identified 56 literature reviews and 29 single studies offering economic evidence on dementia care. There is more cost-effectiveness evidence on pharmacological therapies than other interventions. Acetylcholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease were found to be cost-effective. Regarding non-pharmacological treatments, cognitive stimulation therapy, tailored activity programme and occupational therapy were found to be more cost-effective than usual care. There was some evidence to suggest that respite care in day settings and psychosocial interventions for carers could be cost-effective. Coordinated care management and personal budgets held by carers have also demonstrated cost-effectiveness in some studies.

CONCLUSION:
Five barriers to achieving better value for money in dementia care were identified: the scarcity and low methodological quality of available studies, the difficulty of generalising from available evidence, the narrowness of cost measures, a reluctance to implement evidence and the poor coordination of health and social care provision and financing.

Dementia: Assessment, Management and Support for People Living with Dementia and their Carers [NG97]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers diagnosing and managing dementia (including Alzheimer’s disease). It aims to improve care by making recommendations on training staff and helping carers to support people living with dementia.

Recommendations
This guideline includes recommendations on:
• involving people living with dementia in decisions about their care
• assessment and diagnosis
• interventions to promote cognition, independence and wellbeing
• pharmacological interventions
• managing non-cognitive symptoms
• supporting carers
• staff training and education

Who is it for?
• Healthcare and social care professionals caring for and supporting people living with dementia
• Commissioners and providers of dementia health and social care services
• Housing associations, private and voluntary organisations contracted by the NHS or social services to provide care for people living with dementia
• People living with dementia, their families and carers

Related NICE guideline:
Appendix J:Health Economics Authors not listed

Economic Evaluation of an "Experts by Experience" Model in Basildon District
Bauer A, et al Personal Social Services Research Unit, London. 2011

The aim of the project was the development of a business case based on economic evaluation
methods which supports local commissioners in Basildon in the reconfiguration of services, following
the implementation of Turning Point’s Connected Care community led audit and recommendations
for commissioning and provision of services in the communities of SE Pitsea and Vange. One of the
recommendations made by the Connected Care Community researchers was for a community led
and delivered service, Experts by Experience (EbE). The business case examined likely costs and
outcomes of a community navigator programme, (EbE), which targets high-risk individuals and those
with complex or multiple needs in the deprived neighbourhoods of SE Pitsea and Vange in Basildon
district. The service design was developed by members of the community, commissioners and other
stakeholders, based on the audit of local needs carried out by local people. The economic evaluation
explored, from a societal and total public budget perspective, the short-term (1 year) likely costs and
benefits of a hypothetical implementation of the EbE programme. An interactive toolkit was
developed to illustrate the contributions of different service pathways to the costs and benefits of
the EbE programme

Effectiveness and Cost-effectiveness of 'Usual Care' versus 'Specialist Integrated Care': A Comparative Study of Hospital Discharge Arrangements for Homeless People in England
Cornes M Forthcoming.

Purpose
To explore specialist services set up to improve homeless people’s experiences of leaving hospital. It is investigating different types of services; for example, some put patients in touch with a specially trained GP, others might employ a housing support worker to ensure people do not return to living on the streets after hospital discharge. We want to know what homeless people think of specialist services, how they help them tackle the range of problems they may have, and if this support prevents them returning to hospital. To compare effectiveness and costs we will also study hospital discharge arrangements where no specialist support for homeless people is in place.

End of Life Care for Adults in the Last Year of Life: Service Delivery [GID-CGWAVE0799]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London.

In development

Related NICE guideline:
In development In development

Evaluation of the Doncaster Social Prescribing Service
Dayson C and Bennett E Centre for Regional Economic and Social Research, Sheffield. 2016

An evaluation of the Doncaster Social Prescribing Service, providing an analysis of outcomes for service users and the costs and benefits of the service between August 2015 and July 2016. It uses interviews with staff and key stakeholders from across health and social care, and users of the service; self-evaluation questionnaires from 292 people using the Service; and quality of life surveys completed by 215 users of the Service. The Social Prescribing Service reached more than 1,000 people referred by their GP, Community Nurse or Pharmacist and enabled almost 600 local people to access support within the community during the evaluation period. The main reasons for referral were a long term health or mental health condition. Positive outcomes for clients included improvements in health related quality of life (HRQL), social connectedness, and financial well-being. However, there was little evidence to suggest a reduction in the use of secondary care and inpatient stays. In health terms, the evaluation estimates that for every £1 of the £180,000 funding spent, the Service produced more than £10 of benefits in terms of better health.

Evaluation of the Rotherham Mental Health Social Prescribing Service 2015/16/-2016/17
Dayson C and Bennett E Centre for Regional Economic and Social Research, Sheffield. 2017

Updated findings of an independent evaluation of the Rotherham Social Prescribing Mental Health Service, a service to help users of secondary mental health services build their own packages of support by accessing voluntary activity in the community. Voluntary activities covered four broad themes: befriending and peer support, education and training, community activity groups and therapeutic services. The service was delivered in partnership by Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH) and a group of local voluntary sector organisations led by Voluntary Action Rotherham. The evaluation looks at the impact of the service on the well-being of service users, the wider outcomes and social benefits, the impact of the service on discharge from secondary mental health services and explores the potential economic benefits of the service. It reports that over the two years of the evaluation, the service had engaged with more than 240 users of secondary mental health services in Rotherham. The service made a significant and positive impact on the well-being of mental health service users, with more than 90 per cent of service users making progress against at least one wellbeing outcome measure. Service users also experienced a range of wider benefits, including taking part in training, volunteering, taking up physical activity and sustained involvement in voluntary sector activity. Initial evidence about discharge from mental health services was also positive. The evaluation estimates that the well-being benefits experienced by service users equate to social value of up to £724,000: a social return on investment of £1.84 for every £1 invested in the service.

Going Home Alone: Counting the Cost to Older People and the NHS
Royal Voluntary Service Royal Voluntary Service, Cardiff. 2014

Assesses the impact of home from hospital services, which focus on supporting older people in their homes following a stay in hospital and seek to reduce the likelihood that they will need to be readmitted to hospital. The report brings together the findings of a literature review (as well as discussions with relevant experts), the results of the survey of 401 people aged 75 or over who had spent at least one night in hospital on one or more occasions within the past five years, and the outputs from a cost-impact analysis using national data and results from the survey. It sets out the policy context in England, Scotland and Wales, with its focus on preventive care, better integration of health and care services, and on shifting care away from the hospital into homes and communities. It then discusses the demand drivers for these schemes, including the ageing population, the growth in hospital readmissions, and decreasing length of stay. The report examines the experiences of older people after leaving hospital, looking at admissions, discharge, need for support following discharge, and type and duration of support. It suggests that home from hospital schemes can help to improve the well-being of their users and to reduce social isolation and loneliness and the number of hospital readmissions, as well as demand for other health and care services. The results of the cost-impact analysis suggest that, were home from hospital schemes appropriately targeted and effective in addressing ‘excess admissions’, they may produce a saving for the NHS of £40.4m per year

Growing Innovative Models of Health, Care and Support for Adults
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2018

Key Messages: Innovation is needed more than ever as our challenges grow. Innovation does not only mean technological breakthroughs or large restructures. New and better ways of delivering relationship-based care are needed, and already exist, but are inconsistently implemented or poorly scaled.
For innovation to flourish, we need to find better ways to help people bring good ideas from the margins into core business. The keys to success are:
a shared ambition to ‘embed person- and community-centred ways of working across the system, using the best available tools and evidence’
co-production: planning with the people who have the greatest stake in our services from the beginning
a new model of leadership which is collaborative and convening
investment and commissioning approaches which transfer resources from low quality, low outcomes into approaches which work effectively
effective outcomes monitoring and use of data to drive change
a willingness to learn from experience.

Health at Home: A New Health and Wellbeing Model for Social Housing Tenants
Peabody Peabody Group, London. 2018

The report from Peabody is based on research with some of their general needs residents aged 50 and focuses on helping them to improve their understanding and confidence around managing their own health. It looked at how:

services can be delivered effectively at lower cost?
self-care can be encouraged for the most vulnerable customers and reduce dependency on direct support?
partnerships with other agencies can ensure a coordinated response to support residents’ complex and multiple health needs?

The report shows how housing associations can play an important role in empowering residents to stay healthy and also demonstrated the value of a person-centred approach to build more system resilient.

Health Begins at Home
Family Mosaic Family Mosaic, London. 2013

This new pamphlet provides interim results at 6 months from a fascinating Family Mosaic research project being undertaken by the London School of Economics. It seeks to measure and test out the impact of their services, both as a social landlord and as a provider of housing-related care and support services, and ways in which they can improve the health and wellbeing of older residents whilst at the same time help reduce NHS costs in the areas they operate in. Initial findings suggest an annual saving of £860,000 to local health economies for the 597 participants alone. With a range of useful information and examples of prevention and reablement at work, read below.

Home Care: Delivering Personal Care and Practical Support to Older People Living in their Own Homes [NG21]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers the planning and delivery of person-centred care for older people living in their own homes (known as home care or domiciliary care). It aims to promote older people’s independence and to ensure safe and consistently high quality home care services.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
The guideline includes recommendations on:

ensuring care is person centred
providing information about care and support options
planning and reviewing home care and support
delivering home care, including recommendations on the length home care visits
joint working between health and social care
ensuring safety and safeguarding people using home care services
recruiting, training and supporting home care workers
Who is it for?
Health and social care practitioners
Home care provider organisations
Home care managers and workers
Older people using or planning to use home care services, and their carers
Commissioners of home care services should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
APPENDIX C3 – Economics Report Bauer A, King D, Knapp M

Home from Hospital: How Housing Services are Relieving Pressures on the NHS
Copeman I, Edwards M, Porteus J National Housing Federation, London. 2017

This report shows how housing services are helping to relieve pressure on the NHS by reducing delays in discharging people from hospital and preventing unnecessary hospital admissions. It features 12 case studies to show the positive impact these services have on people’s lives and the cost benefit to the NHS. The case studies highlight services that will benefit people most at risk of delayed discharge, such as older people, people with mental health problems and people experiencing homelessness. The case studies also demonstrate a diversity of housing and health services including: ‘step down’ bed services for people coming out of hospital who cannot return to their own home immediately; hospital discharge support and housing adaptation services to enable timely and appropriate transfers out of hospital and back to patients’ existing homes; providing a new home for people whose existing home or lack of housing mean that they have nowhere suitable to be discharged to; and Home from Hospital services to keeping people well at home who would otherwise be at risk of being admitted or readmitted to hospital. The report also considers the impact and additional savings that could be made by housing providers if this work were to be scaled up.

How can Local Authorities with Less Money Support Better Outcomes for Older People?
Centre for Policy on Ageing Joseph Rowntree Foundation, York. 2011

Research shows that older people want and value low-level support – ‘that bit of help’ – but the benefits of investing in this are realised over many years, making it harder to prove impact and protect funding in the face of severe pressure on spending.

This ‘Solutions’ published by Joseph Rowntree Foundation provides examples of imaginative, affordable and effective ways of supporting older people’s health, well-being, social engagement and independence. It highlights projects with some local authority involvement whether as lead commissioner, subsidiary partner, or through small grants or seed-funding.

The projects demonstrate the importance of:

involving people who use support and services in shaping them;
investing in collective solutions, small grants or seed-funding for self-help groups, and developing local markets to provide the support people want and value;
greater emphasis on the assistance that older people need and choose, and their experiences rather than on conventional social care and/or services;
developing place-based approaches that reflect the whole of people’s lives, and delivering value for money, for example by including transport

Investing in Recovery: Making the Business Case for Effective Interventions for People with Schizophrenia and Psychosis
Knapp M, Andrew A, McDaid D, et al Rethink Mental Illness, London. 2014

This study provides economic evidence to support the case for investing in effective, recovery-focused services for people with schizophrenia and psychosis. Drawing on a wide range of data, it sets out the evidence for the cost-effectiveness for a range of interventions and service. Those discussed are: Early Detection (ED) services; Early Intervention (EI) teams; Individual Placement and Support (IPS); Family therapy; Criminal justice liaison and diversion; Physical health promotion, including health behaviours; Supported housing; Crisis Resolution and Home Treatment (CRHT) teams; Crisis houses; Peer support; Self-management; Cognitive Behavioural Therapy (CBT); Anti-stigma and discrimination campaigns; Personal Budgets (PBs); and Welfare advice. For each intervention the report provides information on the context, the nature of the intervention, the evidence on effectiveness and cost-effectiveness, and the policy and practice implications. The report finds evidence to suggest that all of the interventions contribute to recovery outcomes, reduced costs and/or better value for money. Examples of the savings incurred through particular interventions are also included. The study was undertaken by a team from the Personal Social Services Research Unit (PSSRU), at the London School of Economics and Political Science (LSE), the Centre for Mental Health, and the Centre for the Economics of Mental and Physical Health (CEMPH) at King’s College London.

Investing in Recovery: Making the Business Case for Effective Interventions for People with Schizophrenia and Psychosis
Knapp M, Andrew A, McDaid D, et al Personal Social Services Research Unit and Centre for Mental Health, London. 2014

The health service spent £2.0 billion on services for people with psychosis in
2012/13. Over half (54%) of this total was devoted to inpatient care. This means
that spending is currently skewed towards the more expensive parts of the
system, at £350 average cost per day for inpatient care compared with £13
average cost per day in community settings.

Learning Disabilities and Behaviour That Challenges: Service Design and Delivery [NG93]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers services for children, young people and adults with a learning disability (or autism and a learning disability) and behaviour that challenges. It aims to promote a lifelong approach to supporting people and their families and carers, focusing on prevention and early intervention and minimising inpatient admissions.

This guideline should be read alongside the NICE guideline on challenging behaviour and learning disabilities: prevention and interventions.

We have produced an EasyRead version and video to explain this guidance, which are available from information for the public.

Recommendations
This guideline includes recommendations on:

strategic planning and infrastructure
enabling person-centred care and support
early intervention and support for families and carers
services in the community
housing and related support
services for children and young people
carers’ breaks services
making the right use of inpatient services
staff skills and values
Who is it for?
Commissioners and providers of health and social care services for children, young people and adults with a learning disability and behaviour that challenges
Health and social care practitioners working with children, young people and adults with a learning disability and behaviour that challenges
Providers of related services, including housing, education, employment and criminal justice services
Practitioners working with children, young people and adults with a learning disability and behaviour that challenges in other services or settings, including education, housing, voluntary and community services, employment and criminal justice services
Children, young people and adults with a learning disability and behaviour that challenges and their families and carers, including people who pay for their own care

Related NICE guideline:
Service models guidance: individuals with intellectual disabilities and behaviour that challenges Trachtenberg M and Knapp M

Learning from International Models of Advance Care Planning to Inform Evolving Practice
Dixon J Personal Social Services Research Unit, London. 2017

Reform of end of life care in England has been a priority for some time, with a desire, amongst other things, to ensure that more people can have a ‘good death’ in line with their wishes for what this would be and where this might happen. Advance care planning (ACP) is a key element in this end-of-life care in England. An economic perspective policy, with an important role for social care envisaged. The complex interventions that research suggests are most effective and the social care role within them are, however, under-developed. While research evidence suggests that ACP interventions are associated with improved quality outcomes and potential acute-care cost savings, interventions are poorly described in the literature, and information on costs and cost drivers is almost entirely lacking. This project addresses these gaps, identifying and interrogating the activities and resources needed to deliver complex ACP interventions, drawing on the experiences of ACP programmes in the US and Australia, including Respecting Choices and four programmes adapting this approach. These programmes use (or, in Australia, are considering use of) social workers, allied professionals and volunteers as facilitators. We will use quantitative and in-depth qualitative methods to produce detailed descriptions of the programmes and their practices, develop a method for costing them, collect and compare cost data, and explore the main cost drivers and sources of cost variation. We shall also review the literature to identify, and ideally model, the likely economic and quality outcomes of such interventions in England. We will work with an expert advisory panel and facilitate a stakeholder workshop to comprehensively consider transferability into an English context.

LinkAge Bristol
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2012

An independent evaluation of LinkAge by the University of the West of England concluded that: LinkAge meets the agendas established by the Marmot Review–Fair Society Healthy Lives. Its outreach work draws people in that may feel isolated in their community. Through activities LinkAge helps people feel more socially connected, improves wellbeing and happiness (on the ONS Happiness Index) and increases physical activity.

In 2012 a Social Return on Investment Calculation was completed on the Whitehall and St. George LinkAge hub and found that for every £1 invested there was a SROI of at least £1.20. LinkAge believes this represents a substantial underestimate as, since 2012, the organisation has increased its public profile, expanded its referral network and is now drawing in more lonely
and isolated individuals – supporting them with befriending and through the ACE project.

Living Well for Longer: The Economic Argument for Investing in the Health and Wellbeing of Older People in Wales
Edwards RT, Spencer LH, Bryning L, et al Centre for Health Economics and Medicines Evaluation, Bangor. 2018

This report by the University of Bangor makes the economic argument for investing in prevention at different stages of the life course, in particular, older people.

Commissioned by Public Health Wales, it brings together robust international and UK evidence on the relative cost-effectiveness and return on investment of devoting public sector resources to programmes and practices supporting older people.

In relation to housing, it notes that the Welsh Government spends around £50 million per year on adapting the homes of older and disabled people, helping them to live safely and independently.

For every £1 invested in Care & Repair there is £7.50 savings to the taxpayer. It comes to the conclusion that it is cost-effective to improve housing by providing heating and insulation for high risk groups of over 65s.

Local Community Initiatives in Western Bay: Formative Evaluation Summary Report
Swansea University Swansea University, Swansea. 2016

An evaluation of the early implementation of Local Area Coordination (LAC) and Local Community Coordination (LCC) in Neath Port Talbot and Swansea, covering recruitment and initial delivery activities between July 2015 and April 2016. The initiative used both LAC and LCC coordinators to help communities to develop local relationships and support, reduce dependence on services and create conditions for long-term resilience. The evaluation identifies positive outcomes for people, communities and local finances; highlights factors which help create the conditions for good outcomes; and provides recommendations for the development and improvement of LAC. The report also contains case study examples to show how the initiative was able to help individuals. The results of the evaluation found good progress in both LAC and LCC areas, including community engagement, identifying community assets and individuals for support. It also found LAC helped development of strong and sustained personal networks for individuals and communities, reducing isolation and helping to build local resilience. The LAC implementation in Swansea demonstrated cost benefits of £800k – £1.2m, with expected benefits to rise when LAC is embedded more fully within communities. Findings and recommendations are listed across a number of key themes, including: strategy, funding, shared learning, leadership, information recording, recruitment and roles, cost benefits.

Making the Case for Investing in Actions to Prevent and/or Tackle Loneliness: A Systematic Review. A Briefing Paper
McDaid D, Bauer A, Park A Personal Social Services Research Unit, London. 2017

Summarises findings from a systematic review on the available economic evidence on the cost effectiveness of loneliness interventions for older people. The review found mixed evidence for the cost effectiveness of befriending interventions and the benefits of participation in social activities, ranging from cost saving to cost ineffective interventions. Recent evidence identified suggests that signposting and navigation services have the potential to be cost effective, with a saving of up to £3 of health costs for every £1 invested. The paper also makes suggestions for strengthening the evidence based on the cost effectiveness of interventions to address loneliness.

Making the Case for Public Health Interventions: Public Health Spending and Return on Investment
King's Fund, Local Government Association King's Fund and Local Government Association, London. 2014

These infographics from the King’s Fund and the Local Government Association set out key facts about the public health system and the return on investment for some public health interventions. They show the changing demographics with a growing ageing population and the impact of social and behavioural determinants on people’s health. The document also highlights the costs of key health and social services and estimates the potential returns on investment on preventative interventions. For instance, Birmingham’s Be Active programme of free use of leisure centres and other initiatives returned an estimated £23 in quality of life, reduced NHS use and other gains for every £1 spent. Every £1 spent on improving homes saves the NHS £70 over 10 years. Befriending services have been estimated to pay back around £3.75 in reduced mental health service spending and improvements in health for every £1 spent. Every £1 spent on drugs treatment saves society £2.50 in reduced NHS and social care costs and reduced crime.

Mental Health of Adults in Contact with the Criminal Justice System [NG66]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2017

This guideline covers assessing, diagnosing and managing mental health problems in adults (aged 18 and over) who are in contact with the criminal justice system. It aims to improve mental health and wellbeing in this population by establishing principles for assessment and management, and promoting more coordinated care planning and service organisation across the criminal justice system.

Also see NICE’s guideline on physical health of people in prison, which covers mental health assessment for the prison population as part of the first-stage health assessment for people going into prison, and continuity of mental health care for people leaving prison.

Recommendations
This guideline includes recommendations on:

assessing and managing a person’s mental health problems, including assessing risk to themselves and others
planning their care
psychological and pharmacological interventions
how services should be organised
staff training
Who is it for?
Commissioners and providers of health and justice services
All health and social care professionals working with adults in contact with the criminal justice system in community, primary care, secondary care and secure settings
Adults in contact with the criminal justice system who have or may have mental health problems

Related NICE guideline:
Appendix T: Health economic evidence – economic profiles Authors not listed

Money Matters: Reviews of Cost-effective Initiatives
Institute of Public Care The Institute for Research and Innovation in Social Services, Glasgow. 2011

This set of eight case studies, produced by the Institute of Public Care on behalf of IRISS (the Institute for Research and Innovation in Social Services), provides detailed analysis of the cost-effectiveness of a series of recent social care initiatives, ranging from nationwide and relatively high-profile schemes such as individual budgets to those thus far unique to one country, city or local authority area in the UK.

In each case, the report provides an overview of the initiative – its origins, including previous variants of the scheme, who it is intended to help, and how it works in practice – before justifying claims of cost-effectiveness by reference to detailed comparative costings, using one illustrative implementation of the scheme where the initiative is nationwide. Based on the analysis, the report sets out the initiative’s applicability to other settings as well as potential impediments to broader implementation.

The eight initiatives scrutinised are:

A study of Shared Lives schemes in south east England for providing care in the carer’s own home for individuals placed there by the local authority.
An extra-care housing scheme completed in Bradford.
Health in mind – social inclusion support for people with mental health needs in Bradford based round a series of mental health “well-being cafes”.
LinkAge Plus – analysis of nationwide DWP-funded pilot schemes for an holistic approach to provision of services for older people.
The Rapid Response Adaptations Programme – a Welsh initiative for providing adaptations such as ramps to let people return to their own homes.
A project in north west England to guide older people with low-level needs through a self-assessment process.
Analysis of various pilot sites taking different approaches to individual budgets, based on a broader evaluation conducted in 2008.
A project in two acute trusts in London to reconfigure hospital discharge procedures to emphasise rehabilitation.

National Evaluation of Partnerships for Older People Projects: Final Report
Windle K, Wagland R, Forder J, et al Personal Social Services Research Unit, Kent. 2009

The Partnership for Older People Projects (POPP) were funded by the Department of Health to
develop services for older people, aimed at promoting their health, well‐being and independence
and preventing or delaying their need for higher intensity or institutional care. The evaluation found
that a wide range of projects resulted in improved quality of life for participants and considerable
savings, as well as better local working relationships.
 Twenty‐nine local authorities were involved as pilot sites, working with health and voluntary
sector partners to develop services, with funding of £60m
 Those projects developed ranged from low level services, such as lunch‐clubs, to more formal
preventive initiatives, such as hospital discharge and rapid response services
 Over a quarter of a million people (264,637) used one or more of these services
 The reduction in hospital emergency bed days resulted in considerable savings, to the extent
that for every extra £1 spent on the POPP services, there has been approximately a £1.20
additional benefit in savings on emergency bed days. This is the headline estimate drawn from a
statistically valid range of £0.80 to £1.60 saving on emergency bed days for every extra £1 spent
on the projects.
 Overnight hospital stays were seemingly reduced by 47% and use of Accident & Emergency
departments by 29%. Reductions were also seen in physiotherapy/occupational therapy and
clinic or outpatient appointments with a total cost reduction of £2,166 per person
 A practical example of what works is pro‐active case coordination services, where visits to A&E
departments fell by 60%, hospital overnight stays were reduced by 48%, phone calls to GPs fell
by 28%, visits to practice nurses reduced by 25% and GP appointments reduced by 10%
 Efficiency gains in health service use appear to have been achieved without any adverse impact
on the use of social care resources
 The overwhelming majority of the POPP projects have been sustained, with only 3% being closed
– either because they did not deliver the intended outcomes or because local strategic priorities
had changed
 PCTs have contributed to the sustainability of the POPP projects within all 29 pilot sites.
Moreover, within almost half of the sites, one or more of the projects are being entirely
sustained through PCT funding – a total of 20% of POPP projects. There are a further 14% of
projects for which PCTs are providing at least half of the necessary ongoing funding
 POPP services appear to have improved users’ quality of life, varying with the nature of
individual projects; those providing services to individuals with complex needs were particularly
successful, but low‐level preventive projects also had an impact
 All local projects involved older people in their design and management, although to varying
degrees, including as members of steering or programme boards, in staff recruitment panels, as
volunteers or in the evaluation
 Improved relationships with health agencies and the voluntary sector in the locality were
generally reported as a result of partnership working, although there were some difficulties
securing the involvement of GPs

Older People with Social Care Needs and Multiple Long-term Conditions [NG22]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers planning and delivering social care and support for older people who have multiple long-term conditions. It promotes an integrated and person-centred approach to delivering effective health and social care services.

Recommendations
The guideline includes recommendations on:

identifying and assessing social care needs
care planning, including the role of the named care coordinator
supporting carers
integrating health and social care planning
delivering care
preventing social isolation
training health and social care practitioners

Who is it for?
Health and social care practitioners
Providers of care and support in health and social care services
Older people with social care needs and multiple long-term conditions (including both physical and mental health conditions), and their carers.
Commissioners should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
Appendix C3: Cost-consequence and cost-utility analysis of an outpatient geriatric multidisciplinary assessment and case management intervention: the ‘GRACE’ model of care Trachtenberg M and Fernandez JL

People Powered Recovery: Social Action and Complex Needs. Findings from a Call for Evidence
Turning Point All-Party Parliamentary Group on Complex Needs and Dual Diagnosis, London. 2018

The UK All-Party Parliamentary Group (APPG) on complex needs and dual diagnosis was established in 2007 in recognition of the fact that people seeking help often have a number of over-lapping needs including problems around access to housing, social care, unemployment services, mental health provision or substance misuse support. This report sets out the findings from a call for evidence on how social action can improve outcomes and develop more responsive services for people with complex needs or a dual diagnosis. Social action is about people coming together to tackle an issue, support others or improve their local area, by sharing their time and expertise through volunteering, peer-led groups and community projects. The report provides examples of how social action can support recovery, self-worth and confidence, boost employment prospects and skills, reduce stigma, better shape services to meet people’s needs, contribute to better health and wellbeing and save money. It also looks at how to overcome some of the challenges and barriers to developing social action focused around complex needs. These include resources, stigma, procedural issues, leadership, commissioning structures and demonstrating benefits.

Preventing Loneliness and Social Isolation: Interventions and Outcomes. SCIE Research Briefing 39
Windle K, Francis J, Coomber C Social Care Institute for Excellence, London. 2011

This is one in a series of research briefings about preventive care and support for adults.

Prevention is broadly defined to include a wide range of services that:

promote independence
prevent or delay the deterioration of wellbeing resulting from ageing, illness or disability
delay the need for more costly and intensive services.

Preventive services represent a continuum of support ranging from the most intensive, ‘tertiary services’ such as intermediate care or reablement, down to ‘secondary’ or early intervention, and finally, ‘primary prevention’ aimed at promoting wellbeing. Primary prevention is generally designed for people with few social care needs or symptoms of illness. The focus therefore is on maintaining independence and good health and promoting wellbeing. The range of these ‘wellbeing’ interventions includes activities to reduce social isolation, practical help with tasks like shopping or gardening, universal healthy living advice, intergenerational activities and transport, and other ways of helping people get out and about.

Just as the range of wellbeing services is extensive, so too is the available literature examining how well they work. For this research briefing, the focus has been narrowed to the effectiveness and cost-effectiveness of services aimed at preventing social isolation and loneliness. Our review question was: ‘To what extent does investment in services that prevent social isolation improve people’s wellbeing and reduce the need for ongoing care and support?’

While ‘social isolation’ and ‘loneliness’ are often used interchangeably, one paper examined the distinct meanings that people attach to each concept. ‘Loneliness’ was reported as being a subjective, negative feeling associated with loss (e.g. loss of a partner or children relocating), while ‘social isolation’ was described as imposed isolation from normal social networks caused by loss of mobility or deteriorating health. This briefing focuses on services aimed at reducing the effects of both loneliness and social isolation. Although the terms might have slightly different meanings, the experience of both is generally negative and the resulting impacts are undesirable at the individual, community and societal levels.
Key messages

Older people are particularly vulnerable to social isolation or loneliness owing to loss of friends and family, mobility or income.
Social isolation and loneliness impact upon individuals’ quality of life and wellbeing, adversely affecting health and increasing their use of health and social care services.
The interventions to tackle social isolation or loneliness include: befriending, mentoring, Community Navigators, social group schemes.
People who use befriending or Community Navigator services reported that they were less lonely and socially isolated following the intervention.
The outcomes from mentoring services are less clear; one study reported improvements in mental and physical health, another that no difference was found.
Where longitudinal studies recorded survival rates, older people who were part of a social group intervention had a greater chance of survival than those who had not received such a service.
Users report high satisfaction with services, benefiting from such interventions by increasing their social interaction and community involvement, taking up or going back to hobbies and participating in wider community activities.
Users argued for flexibility and adaptation of services. One-to-one services could be more flexible, while enjoyment of group activities would be greater if these could be tailored to users’ preferences.
When planning services to reduce social isolation or loneliness, strong partnership arrangements need to be in place between organisations to ensure developed services can be sustained.
We need to invest in proven projects. Community Navigator interventions have been shown to be effective in identifying those individuals who are socially isolated. Befriending services can be effective in reducing depression and cost-effective.
Research needs to be carried out on interventions that include different genders, populations and localities.
There is an urgent need for more longitudinal, randomised controlled trials that incorporate standardised quality-of-life and cost measures.

Prevention. A Shared Commitment: Making the Case for a Prevention Transformation Fund
Local Government Association Local Government Association, London. 2015

This document identifies and collates key pieces of evidence about the cost effectiveness of prevention in order to make the case for greater investment in prevention interventions. The report recommends that the Government should introduce a Prevention Transformation Fund, worth at least £2 billion annually. This would enable some double running of new investment in preventative services alongside ‘business as usual’ in the current system, until savings can be realised and reinvested into the system – as part of wider local prevention strategies. Based on the analysis of an extensive range of intervention case studies that have provided a net cost benefit, the report suggests that investment in prevention could yield a net return of 90 per cent.

Quantifying the benefits of peer support for people with dementia: a social return on investment (SROI) study
Willis E, Semple A, de Waal H International Journal of Social Research and Practice, 17, 266–278. 2018

Objective: Peer support for people with dementia and carers is routinely advocated in national strategies and policy as a post-diagnostic intervention. However there is limited evidence to demonstrate the value these groups offer. This study looked at three dementia peer support groups in South London to evaluate what outcomes they produce and how much social value they create in relation to the cost of investment. Methods: A Social Return on Investment (SROI) analysis was undertaken, which involves collecting data on the inputs, outputs and outcomes of an intervention, which are put into a formula, the end result being a SROI ratio showing how much social value is created per £1 of investment. Results: Findings showed the three groups created social value ranging from £1.17 to £5.18 for every pound (£) of investment, dependent on the design and structure of the group. Key outcomes for people with dementia were mental stimulation and a reduction in loneliness and isolation. Carers reported a reduction in stress and burden of care. Volunteers cited an increased knowledge of dementia. Conclusions: This study has shown that peer groups for people with dementia produce a social value greater than the cost of investment which provides encouraging evidence for those looking to commission, invest, set up or evaluate peer support groups for people with dementia and carers. Beyond the SROI ratio, this study has shown these groups create beneficial outcomes not only for the group members but also more widely for their carers and the group volunteers.

Releasing Somerset's Capacity to Care: Community Micro-providers in Somerset
Community Catalysts Community Catalysts, Harrogate. 2017

An evaluation of the Community Catalysts project in Somerset. Community Catalysts is a social enterprise working across the UK to make sure that people who need care and support to live their lives can get help in ways, times and places that suit them, with real choice of attractive local options. In Somerset, the project aimed to increase the number of flexible, responsive, high quality local services and supports that can give people real choice and control over their care. As part of the project Community Catalysts has worked with partners to develop the Community Somerset Community Micro-enterprise Directory. The directory features 275 community-enterprises all of whom offer services linked to health, care or wellbeing. 223 offer help to older people to enable them to stay at home. 58% of these providers offer personal care services, including for people with more complex care needs. This care is often provided alongside home help, domestic and social support. 42% offer home help type services including support, companionship, domestic help, gardening, cleaning, trips out, transport. 3,500 hours of care a week are delivered by Community micro-enterprises in Somerset. Community Catalysts also undertook a survey of 45 families who have used both a micro-provider and a traditional domiciliary agency. The results showed that community micro-providers are able to deliver strong and valued outcomes for the people they support, and significantly outperform traditional domiciliary care delivery. The evaluation indicates that 32 community micro-enterprises in rural West Somerset are delivering £134,712 in annual savings. Projected across the 223 micro-enterprises supported by Community Catalysts in Somerset, the project delivers: £938,607 in annual savings; 56% of people supported use direct payments, showing £525,619 of direct and ongoing annual savings to the council.

Report of the Annual Social Prescribing Network Conference
Social Prescribing Network Social Prescribing Network, University of Westminster, London. 2016

Report of the annual social prescribing network conference, which sets out a definition of social prescribing, outlines principles for effective service provision and the steps needed to evaluate and measure the impact of social prescribing. It also includes an analysis of a pre-conference survey, completed by 78 participants to explore their experience of social prescribing. Key ingredients identified that underpin social prescribing included: funding, healthcare professional buy-in, simple referral process, link workers with appropriate training, patient centred care, provision of services, patient buy-in and benefits of social prescribing. The benefits of social prescribing fell into six broad headings: physical and emotional health and wellbeing; behaviour change; cost effectiveness and sustainability; capacity to build up the voluntary community; local resilience and cohesion; and tackling the social determinants of ill health. Afternoon sessions covered the following topics: obtaining economic data on social prescribing; engaging different stakeholders in social prescribing; standards and regulations that could be applied to social prescribing services; qualities and skills necessary to commission high quality social prescribing services; designing research studies on social prescribing. Short case studies are included. There was consensus from participants that social prescribing provides potential to reduce pressures on health and care services through referral to non-medical, and often community-based, sources of support.

Room to Improve: The Role of Home Adaptations in Improving Later Life
Centre for Ageing Better Centre for Ageing Better, London. 2017

This report summarises the findings from an evidence review on how home adaptations can improve later lives and provides recommendations to improve access to, and delivery of, home adaptation and repair services. It shows that both minor and major home adaptations are an effective intervention to improve outcomes for people in later life, including improved performance of everyday activities, improved mental health and preventing falls and injuries. It also identifies good evidence that greatest outcomes are achieved when individuals and families are involved in the decision-making process, and when adaptations focus on individual goals. Based on the findings, the report makes recommendations for commissioners and service provides. These include for Local Sustainability and Transformation partnerships to put in place preventative strategies to support people at risk in their home environment; for local authorities to make use of the Disabled Facilities Grant to fund both major and minor adaptations; and for local authorities to ensure people have access to information and advice on how home adaptations could benefit them, in line with the Care Act 2014.

Rotherham Social Prescribing Scheme
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2017

An evaluation conducted by the Centre for Regional Economic and Social Research (CRESR) at Sheffield Hallam University of the pilot phase of the service found that the service had positive social and economic impacts. The service uses a specially developed health and wellbeing tool to measure social outcomes for people referred to the service. Its 8 measures cover different aspects of self-management and wellbeing, such as lifestyle and managing symptoms, to work and volunteering, to friends and family, and people are asked to use a 5 point scale to rate their progress. 17 qualitative interviews were also held with participants and their carers, who were referred to 5 of the 31 service providers.

During the pilot phase of the project, of the 280 participants who had their wellbeing measures followed up after 3-4 months, 83 per cent of people experienced positive change in at least one social outcome area. The biggest changes were seen for patients who scored the least at baseline (work, volunteering etc., and feeling positive); and a majority of low scoring participants (two points or less at baseline) made progress- among them 54% improved their score in work & volunteering area, while 61% improved their score in the feeling positive area. Among the case studies (those interviewed), the positive outcomes described using four broad themes of increased well-being, reduced social isolation and loneliness, increased independence, and access to wider welfare benefits.

There were also significant benefits to the NHS, with inpatient admissions reduced by 21 per cent; Accident and Emergency attendances reduced by as much as 20 per cent; and outpatient appointments reduced by as much as 21 per cent, These increases were calculated looking at patient-level Hospital Episode Statistics provided by the Commissioning Support Unit (CSU), of a cohort of 108 participants who had 12-months of post-referral data available, after being referred between September and December 2012.

Shared Lives Costs and Effectiveness (SLiCE)
Brookes N Personal Social Services Research Unit, Kent. 2018

In the Shared Lives model, an adult who needs support and/or accommodation moves in with or regularly visits an approved Shared Lives carer after they have been matched for compatibility. At present there is a limited evidence base for Shared Lives. The proposed research will mean that a thorough exploration of how successful the model is and whether it represents a good investment can be explored. An outcome evaluation will include: collection of data including service user characteristics, risks and needs, case management information, service use, quality of life and well-being measures; data collection from a comparison group of Shared Lives-suitable, non-participating service users; interviews with service users and Shared Lives carers focusing on outcomes; and use of other administrative and survey data.

Six Innovations in Social Care
Think Local Act Personal Think Local Act Personal, London. 2018

A group of innovators in social care have produced a summary of six innovations.
The innovations covered are:

Community Catalysts
Community Circles
Local Area Coordination
Shared Lives
Homeshare UK
Wellbeing Teams

Each innovation is presented as a one- page summary which cover:

the problem they are aiming to solve
the solution they have created
their evidence base and expected impact
the stage they are at currently
what else is needed to support it
and what would stop the innovation from happening successfully

This document is useful for anyone who is interested in new models of care and support, and would like to find out about different innovations that are being developed across the UK

Small But Significant: The Impact and Cost Benefits of Handyperson Services
Adams S Care and Repair England, London. 2018

An evaluation of the impacts and cost benefits of handyperson services carrying out small repairs and minor adaptations in the home for older people. It looks at how handyperson service fit into the current policy landscape summarises current evidence on their impact and cost effectiveness. It then provides an in depth evaluation of the of Preston Care and Repair handyperson service, with analysis of outputs, outcomes and examines the cost benefits in relation to falls prevention. The evaluation involved data analysis of jobs completed, a survey of users of the service and interviews with staff and service users. It reports that during the 9 month evaluation period 1,399 jobs were carried out in the homes of 697 older people, which exceeded outcome targets. Of people using the service, 46 percent were over 80 years and 72 percent were older people living alone. Older people also valued the service. Ninety-six percent of those surveyed said that the Preston Care and Repair handyperson service made them less worried about their home and 100 percent said that they would recommend the service to others. Analysis of the falls prevention impact on a small number of higher risk cases, found that for every £1 spent on the handyperson service the saving to health and care was £4.28. Other health and social care related outcomes included a risk reduction for hospital admission risk reduction and faster discharge to home, improved wellbeing, safer independent living, and reduced isolation. The report illustrates the impacts of handyperson services cover health, housing and social care aims and objectives. They also offer a cost effective solution with significant cost benefits and a high rate of return on investment, both financial and social

Social prescribing: less rhetoric and more reality. A systematic review of the evidence
Bickerdike L, et al BMJ Open, 7, e013384. 2017

Objectives: Social prescribing is a way of linking patients in primary care with sources of support within the community to help improve their health and well-being. Social prescribing programmes are being widely promoted and adopted in the UK National Health Service and this systematic review aims to assess the evidence for their effectiveness. Setting/data sources: Nine databases were searched from 2000 to January 2016 for studies conducted in the UK. Relevant reports and guidelines, websites and reference lists of retrieved articles were scanned to identify additional studies. All the searches were restricted to English language only. Participants: Systematic reviews and any published evaluation of programmes where patient referral was made from a primary care setting to a link worker or facilitator of social prescribing were eligible for inclusion. Risk of bias for included studies was undertaken independently by two reviewers and a narrative synthesis was performed. Primary and secondary outcome measures: Primary outcomes of interest were any measures of health and well-being and/or usage of health services. Results: A total of 15 evaluations of social prescribing programmes were included. Most were small scale and limited by poor design and reporting. All were rated as a having a high risk of bias. Common design issues included a lack of comparative controls, short follow-up durations, a lack of standardised and validated measuring tools, missing data and a failure to consider potential confounding factors. Despite clear methodological shortcomings, most evaluations presented positive conclusions. Conclusions: Social prescribing is being widely advocated and implemented but current evidence fails to provide sufficient detail to judge either success or value for money. If social prescribing is to realise its potential, future evaluations must be comparative by design and consider when, by whom, for whom, how well and at what cost.

Tackling Loneliness and Social Isolation: The Role of Commissioners
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2018

With one million people aged 65 and over in the UK reporting they are often or always lonely, few would refute the need to tackle this issue. (1)
However, loneliness and social isolation are conditions that are difficult to identify, complex to address and hard to resolve. The evidence base for interventions to address the problems of loneliness and social isolation is emerging but inconclusive at this stage.

Taking Stock: Assessing the Value of Preventative Support
New Economics Foundation and British Red Cross British Red Cross, London. 2012

The aim of this report is to illustrate how British Red Cross preventative services providing time-limited practical and emotional support deliver savings for public sector partners including the NHS and local authorities. It presents brief case studies of 5 people who received personalised support from British Red Cross staff and volunteers to help them live independently in their communities. In each case it describes the action taken and the impact of the services and support provided. It includes an independent economic analysis of each case study assessing the costs which could have been incurred by statutory services in delivering care in the absence of the British Red Cross services. It reports that savings of between £700 and over £10,000 were delivered per person, and that this reflects a minimum return on investment of over 3.5 times the cost of the British Red Cross service provided.

Targeting, care management and preventative services for older people: The cost-effectiveness of a pilot self-assessment approach in one local authority
Clarkson P British Journal of Social Work, 40, 2255-2273. 2010

As social services councils face a more constrained economic environment and as eligibility criteria tighten, the issue of targeting becomes increasingly relevant. This paper presents findings from a pilot project in one local authority that aimed to target access to assessment for older people with low-level needs who would normally have fallen under eligibility thresholds. Self-assessment was used as a tool whereby these older people could identify, with assistance, their preferences for a range of preventative services. Via a randomised design, the study evaluated the costs and benefits, in terms of reported satisfaction, of the approach compared with the usual care management assessment. Although self-assessed cases were offered more advice as to a wider range of preventative services, which generated greater costs, total costs were lower for this group. This cost saving arose from the use of staff with a lower unit cost who also spent less time on administrative duties and gathering information. Satisfaction with self-assessment was comparable to a professional assessment, therefore representing a cost-effective approach. The project offers evidence of how councils can target resources through assessment and how self-assessment approaches may be appropriately configured to offer value for these users whilst also generating resource savings.

Technical Guide: Building a Business Case for Prevention
Social Finance Social Finance, London. 2014

This guide sets out the issues that need to be considered when developing a business case to invest in preventive services and to ensure that any decision are based on robust and reliable data. The guide focuses on the following arguments: the importance of ‘investing to save’, arguing that prevention is cheaper in the long term; promotion of service innovation; placing the focus of commissioning on outcomes rather than outputs; and managing a shift in spending from acute to prevention to reduce demand over time. The guide outlines key four activities required to build a business case: understanding needs; understanding current costs; assessing possible interventions; and deciding how to measure the value and outcome of the interventions. It also provides a summary business case for prevention and using a Social Impact Bond (SBI) to finance a business case for prevention. An example case study of making a business case for prevention services in early years services in Greater Manchester is included.

The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency
Sahota O, Pulikottil-Jacob R, Marshall F, et al Age and Ageing, 46, 26-32. 2017

Objective: to compare the clinical and cost-effectiveness of a Community In-reach Rehabilitation and Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service. Design: pragmatic randomised controlled trial with an integral health economic study. Settings: large UK teaching hospital, with community follow-up. Subjects: frail older people aged 70 years and older admitted to hospital as an acute medical emergency. Measurements: Primary outcome: hospital length of stay; secondary outcomes: readmission, day 91-super spell bed days, functional ability, co-morbidity and health-related quality of life; cost-effectiveness analysis. Results: a total of 250 participants were randomised. There was no significant difference in length of stay between the CIRACT and THB-Rehab service (median 8 versus 9 days; geometric mean 7.8 versus 8.7 days, mean ratio 0.90, 95% confidence interval (CI) 0.74–1.10). Of the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days from the CIRACT and THB-Rehab services, respectively (risk difference 3.8%, 95% CI −5.8% to 13.4%). There were no other significant differences in any of the other secondary outcomes between the two groups. The mean costs (including NHS and personal social service) of the CIRACT and THB-Rehab service were £3,744 and £3,603, respectively (mean cost difference £144; 95% CI −1,645 to 1,934). Conclusion: the CIRACT service does not reduce major hospital length of stay nor reduce short-term readmission rates, compared to the standard THB-Rehab service; however, a modest (<2.3 days) effect cannot be excluded. Further studies are necessary powered with larger sample sizes and cluster randomisation.

The Long Term Care Revolution
Housing Learning and Improvement Network Housing Learning and Improvement Network, London. 2013

This Housing LIN Report comprehensively outlines the case for a revolution in long term care and captures some of the supporting material that has aided the development of the TSB’s Assisted Living Innovation Platform’s, ‘Long Term Care Revolution’ programme.

It sets out a vision for an alternative to institutional care, drawing on substantial evidence about the views of older people and their carers in the UK, lessons from abroad, the implications for industry/providers and makes recommendations to government and industry leaders on key factors for revolutionizing long term care for older people, including mainstream and specialist living environments.

The Role of Home Adaptations in Improving Later Life
Powell J, et al Centre for Ageing Better, London. 2017

A systematic review of evidence on the effectiveness and cost effectiveness on how home adaptations can contribute in helping older people to maintain their independence for as long as possible and what works best to improve the health and wellbeing. Conducted by a team from the University of the West of England, the review covered peer-reviewed literature and professional and practitioner-led grey literature published between 2000 and 2016. It found evidence that both minor and major home adaptations can improve outcomes for people in later life, including improved performance of everyday activities, improved mental health and preventing falls and injuries. It also identified good evidence that greatest outcomes are achieved when individuals and families are involved in the decision-making process, and when adaptations focus on individual goals. It also found strong evidence that minor home adaptations are an effective and cost-effective intervention. The report also includes analysis from the Building Research Establishment which shows that home interventions to prevent falls on stairs, can lead to savings of £1.62p for every £1 spent. Based on the findings, the report makes recommendations for commissioners and service provides. These include for Local Sustainability and Transformation partnerships to put in place preventative strategies to support people at risk in their home environment; for local authorities to make use of the Disabled Facilities Grant to fund both major and minor adaptations; and for local authorities to ensure people have access to information and advice on how home adaptations could benefit them, in line with the Care Act 2014

The Rotherham Social Prescribing Service for People with Long-term Conditions: Evaluation Update
Dayson C and Damm C Centre for Regional Economic and Social Research, Sheffield. 2017

An updated assessment of the social and economic impact of the Rotherham Social Prescribing Service between September 2012 and March 2016. Originally commissioned as a two-year pilot in 2012 the service is now funded until 2018 through the Better Care Fund. Its two core features are: advisors providing a single gateway to voluntary and community sector (VCS) support for GPs and service users (advisors assess the support needs of patients and carers before referring on to appropriate VCS services) and a grant funding programme for VCS activities to meet the needs of service users. The evaluation reports that between September 2012 and March 2016 the Rotherham Social Prescribing Service supported more than 3,000 local people with long-term health conditions and their carers. It identifies reductions in service users’ use of secondary care, reduced admissions to Accident and Emergency, and improvements in the well-being of service users. Wider benefits seen in the VCS across Rotherham, include additional investment; developing and promoting social action and volunteering; and the development of a ‘micro-commissioning’ model. The evaluation also consistently demonstrated costs avoided by the NHS, with figures across the first four years of service equating to an estimated £647,000 of NHS costs avoided: an initial return on investment of 35 pence for each pound (£1) invested.

Total Transformation of Care and Support: Creating the Five Year Forward View for Social Care
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2017

Adult social care has repeatedly demonstrated its capacity for transformation: pioneering de-institutionalisation, personal budgets and more recently, asset-based approaches.Health and care systems will not provide good services that meet rising demand without realigning around people and communities.There are five areas where transformation needs to take place: 1Helping all people and families to stay well, connected to others and resilient when facing health or care needs.2Supporting people and families who need help to carry on living well at home.3Enabling people with support needs to do enjoyable and meaningful things during the day, or look for work.4Developing new models of care for adults and older people who need support and a home in their community.5Equipping people to regain independence following hospital or other forms of health care. If the sector scales up promising practice, economic modelling shows that outcomes can be improved and costs reduced.The sector needs to have difficult, challenging and creative local conversations involving people who use services and others, which create space to move forward together. Further research and economic modelling is needed on the promising practices to build a business case for proper and effective investment in truly integrated care and health.

Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Needs [NG27]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people’s experience of admission to, and discharge from, hospital by better coordination of health and social care services.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
The guideline includes recommendations on:

person-centred care and communication and information sharing
before admission to hospital including developing a care plan and explaining what type of care the person might receive
admission to hospital including the establishment of a hospital-based multi-disciplinary team
during hospital stay including recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge
discharge from hospital including the role of the discharge coordinator
supporting infrastructure
training and development for people involved in the hospital discharge process.
Who is it for?
The guideline is for health and social care practitioners; health and social care providers; commissioners; service users and their carers (including people who purchase their own care).

Related NICE guideline:
Appendix C3 Bauer A and Fernandez JL

What Role Can Local and National Supportive Services Play in Supporting Independent and Healthy Living in Individuals 65 and Over?
WIindle K Government Office for Science, London. 2015

This report explores the evidence base around effective and cost-effective preventative services and the role that they can play in supporting older people’s independence, health and wellbeing. It looks at the available evidence to support the benefits of preventative services in mitigating social inclusion and loneliness and improving physical health. It also highlights evidence on the effectiveness of information, advice and signposting in helping people access preventative services and the benefits of providing practical interventions such as minor housing repairs. It considers a wide range of primary and secondary preventative services, including: health screening, vaccinations, day services, reablement, and care coordination and management. It then outlines two teritary prevention services which aim to prevent imminent admission to acute health settings. These are community based rapid response services and ambulatory emergency care units, which operation within the secondary care environment. The report then highlights gaps in the evidence base and and looks at what is needed to develop preventative services to achieve health and independent ageing by 2013. It looks at the changes needed in service funding and commissioning, the balance between individual responsibility and organisational support, and how preventative services should be implemented.

What Works in Community Led Support?
Bown H, Carrier J, Hayden C National Development Team for Inclusion, Bath. 2017

This report has been written to share the findings, learning and examples of impact identified from working with 9 authorities across England, Wales and Scotland who are working differently to improve the lives and support of local people.

It is essentially an evaluation report on the authorities’ progress towards the outcomes and longer-term aims of community led support over the last 18 months, but we believe it is more than that.

We hope the learning shared here will help demonstrate what’s possible when applying core principles associated with asset based approaches at the same time as tackling hard systemic and cultural issues around speed of response, ease of access, changing the nature of ‘assessment’, reducing waiting times and lists, turning eligibility criteria on their heads and making the best use of local resources for people with a wide range of support needs.

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