Home care

Bundle contents: Home care, professional support services

Professional support services with carrying out everyday activities that allow a person to live safely in their home. It includes delivery of person-centred care for older people living in their own homes to promote older people’s independence and to ensure safe and consistently high quality home care services.

Case studies

Read the full case study for 'A coping programme for family carers of people with dementia: economic evidence' here (HTML)
Martin Knapp, Klara Lorenz, Adelina Comas-Herrera, Gill Livingston, Michela Tinelli, Danielle Guy 2019

  • what dementia is and how it affects people
  • carer stress, how to recognise it and techniques for managing it
  • how to manage difficult behaviour
  • how to access support that is available for people with dementia and family carers
  • maintaining skills learned and planning for the future.

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


  • 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 'Home care reablement for older people: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019


  • Home care reablement helps older people do things themselves, enabling them to re-learn skills and recover their confidence to live at home.
  • Studies have consistently shown that home care reablement leads to improved functioning and a decrease in dependence as well as reductions in ongoing home care.
  • Across different age groups, home care reablement for older people also has a high probability of reducing costs when compared with standard home care.
  • The National Institute for Health and Care Excellence (NICE) recommends that every older person referred to home care should be offered reablement if it is indicated that person would benefit from it.
  • It is plausible that some people (e.g. those living alone) are less likely to benefit from reablement without additional support. Future research needs to focus on what populations should receive home care reablement and for how long.


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 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 introduction to economic evaluation in occupational therapy: cost-effectiveness of pre-discharge home visits after stroke (HOVIS)
Sampson C, James M, Whitehead P, et al British Journal of Occupational Therapy, 77, 330-335. 2014

Introduction: Occupational therapy interventions, such as home visits, have been identified as being resource-intensive, but cost-effectiveness analyses are rarely, if ever, carried out. The authors sought to estimate the cost-effectiveness of occupational therapy home visits after stroke, as part of a feasibility study, and to demonstrate the value and methods of economic evaluation. Method: The authors completed a cost-effectiveness analysis of pre-discharge occupational therapy home visits after stroke compared with a hospital-based interview, carried out alongside a feasibility randomised controlled trial. Their primary outcome was quality-adjusted life years. Full cost and outcome data were available for 65 trial participants. Findings: The mean total cost of a home visit was found to be £183, compared with £75 for a hospital interview. Home visits are shown to be slightly more effective, resulting in a cost per quality-adjusted life year of just over £20,000. Conclusion: The author’s analysis is the only economic evaluation of this intervention to date. Home visits are shown to be more expensive and more effective than a hospital-based interview, but the results are subject to a high level of uncertainty and should be treated as such. Further economic evaluations in this field are encouraged.

Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT
Gathercole R, Bradley R, Harper E, Davies L, Pank L, Lam N, Davies A, Talbot E, Hooper E, Winson R, Scutt B, Montano VO, Nunn S, Lavelle G, Lariviere M, Hirani S, Brini S, Bateman A, Bentham P, Burns A, Dunk B, Forsyth K, Fox C, Henderson C, Knapp M, Leroi I, Newman S, O'Brien J, Poland F, Woolham J, Gray R, Howard R. Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT 2021

Bathing Adaptations in the Homes of Older Adults – The BATH-OUT Trial
Whitehead P University of Nottingham, Nottingham. 2017

The BATH-OUT study is a feasibility randomised controlled trial with nested qualitative interview study. It involves adults aged 65 or over, and their carers, who have been assessed by a social care occupational therapist and referred for an accessible showering facility. We want to investigate the impact of the accessible showering facility on disabled older adults and their carers.

Our long term aim is to evaluate the effect of these adaptations on quality of life, health and wellbeing and functional ability. We also want to investigate the impact on health and social care costs and whether waiting times lead to increased costs and poor outcomes. The first stage is this feasibility study which is being carried out within Nottingham City. If we show that it is feasible to use this method in our research we aim to plan a further study involving different areas of the UK.

The study is being led by Dr Phillip Whitehead from The University of Nottingham and is collaboration between the University and Nottingham City Council. It is funded by NIHR School for Social Care Research. Favourable ethical opinion has been given by the Social Care Research Ethics Committee (ref. 16/IEC08/0017).

Befriending of Older Adults
Bauer A, Knapp M, Perkins M Personal Social Services Research Unit, London. 2011

Befriending initiatives, often delivered by volunteers, provide an‘upstream’ intervention that is potentially of
value both to the person being befriended and the ‘befriender’. For those receiving the intervention,
particularly older people, it promotes social inclusion and reduces loneliness;
for the befriender, there is the personal satisfaction of contributing to the local community by offering support and skills. Specific potential
benefits include the improved mental well­being of the person receiving the intervention, a reduced risk of
depression, and associated savings in health care costs.

Building Community Capacity: Making an Economic Case
Knapp M, Bauer A, Perkins M Personal Social Services Research Unit, London. 2010

Our aim in this small study was to develop simple ‘models’ of interventions that can contribute
to local community development programmes by examining some of the possible impacts. We
could not look at all impacts because of data limitations. These are necessarily simplified
representations of reality, because of the availability of evidence. But this is a pragmatic
approach, using published, unpublished and experiential evidence, and working closely with local experts, and was the most helpful way to go forward given time constraints. We
calculated the costs of three particular community initiatives – time banks, befriending and
community navigators for people with debt or benefits problems – and found that each
generated net economic benefits in quite a short time period. Each of those calculations was
conservative in that we only attached a monetary value to a subset of the potential benefits.

Building community capital in social care: is there an economic case?
Knapp M, Bauer A, Perkins M, et al Community Development Journal, 48, 313-331. 2013

Current debates in many countries about the sustainability of public commitments include
discussion of the adequacy and affordability of collective health and social care responses to the
rapidly growing needs of ageing communities. A recurrent theme in England is whether
communities can play greater roles in preventing the emergence of social care needs and/or in
helping to meet them. A number of approaches have been suggested, employing a range of
concepts and terms, including community development, community capacity-building and
creating social capital. We investigated whether initiatives of this kind generate cost-savings to the
public purse and more broadly to society. We used a cost-benefit approach and decisionmodelling techniques to demonstrate potential costs and economic consequences in a context
where evidence is limited and there is little opportunity to collect primary data. We found that
there could be sizable savings to the public purse when investing in community capital-building
initiatives at relatively low cost. We discuss the limitations of our analysis and recommend
collection of better outcome data.

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.

Can aging in place be cost effective? A systematic review.
Graybill EM, McMeekin P, Wildman J Public Library of Science One, 9, e102705. 2014

Purpose of the Study
To systematically review cost, cost-minimization and cost-effectiveness studies for assisted living technologies (ALTs) that specifically enable older people to ‘age in place’ and highlight what further research is needed to inform decisions regarding aging in place.

People aged 65+ and their live-in carers (where applicable), using an ALT to age in place at home opposed to a community-dwelling arrangement.

Studies were identified using a predefined search strategy on two key economic and cost evaluation databases NHS EED, HEED. Studies were assessed using methods recommended by the Campbell and Cochrane Economic Methods Group and presented in a narrative synthesis style.

Eight eligible studies were identified from North America spread over a diverse geographical range. The majority of studies reported the ALT intervention group as having lower resource use costs than the control group; though the low methodological quality and heterogeneity of the individual costs and outcomes reported across studies must be considered.

The studies suggest that in some cases ALTs may reduce costs, though little data were identified and what there were was of poor quality. Methods to capture quality of life gains were not used, therefore potential effects on health and wellbeing may be missed. Further research is required using newer developments such as the capabilities approach. High quality studies assessing the cost-effectiveness of ALTs for ageing in place are required before robust conclusion on their use can be drawn.

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.

Carer preferences for home support services in later stage dementia
Eleni Kampanellou, Helen Chester, Linda Davies, Sue Davies, Clarissa Giebel, Jane Hughes, David Challis, Paul Clarkson Carer preferences for home support services in later stage dementia 2019

Case management approaches to home support for people with dementia.
Reilly S, Miranda-Castillo C, Malouf R, et al Cochrane Database Systematic Review, 5, 1, CD008345. 2015

Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital.

To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including ‘treatment as usual’, standard community treatment and other non-case management interventions.

We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated.

We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care.

We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made ‘Risk of bias’ assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic.

We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 – 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services. AUTHORS' CONCLUSIONS: There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.

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

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.

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.

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.

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.

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.

Connecting with Health and Care
Foundations and Housing Learning and Improvement Network, London. 2009

In Autumn 2007 Foundations, the National Body for home improvement agencies, was commissioned by Communities and Local Government to carry out research and produce a report examining the options for the future delivery of home improvement agency (HIA) services. The report draws on examples from within and outside the HIA sector to highlight possible areas for development. It does not present a ‘one-size-fits-all’ model, but a series of options that may be appropriate depending on the identified needs of the local population, taking account of other services already in place.


Cost‐minimisation analysis of home care reablement for older people in England: a modelling study.
Bauer A, Fernandez JL, Henderson C, Wittenberg R, Knapp M. Cost‐minimisation analysis of home care reablement for older people in England: a modelling study. 2019

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

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.

Dying Well at Home: The Case for Integrated Working
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2013

The NHS should have a better evidence-based understanding of the relative costs of specialist and generalist care at the end of life, analysed according to place of care delivery.
Time spent in hospital in the last year of life is the most expensive factor in end of life care. Policy makers and commissioners should concentrate on interventions to keep people out of hospital if they do not need to be there, and to discharge them as early as possible.
Economic analyses should reflect the ‘cost’ to family members of caring, and should consider how savings to the state can be harnessed to support carers to continue to care at home.

Economic Analysis of the Health Champions Scheme in Hammersmith and Fulham
Bauer A and Fernandez JL Personal Social Service Research Unit, London. 2012

This study assesses costs and economic benefits of the Health Champions scheme under the Well London programme. As part of their volunteering role, health champions and other volunteers signposted
individuals to services and – after receiving additional training – provided health promotion advice and supported the delivery of activities on a broad range of topics including physical activity, healthy eating, smoking cessation and mental wellbeing. At the same time as the health champion scheme was set up, the Well London programme ran locally providing a wide range of (mental) health promotion
activities which health champions and volunteers referred to. The analysis showed that it was not possible to derive a single economic value that could be attributed to the Scheme.

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

Economic impact of social care services. Assessment of the outcomes for disabled adults with moderate care needs
Deloitte Deloitte, London. 2013

This report provides evidence on the costs and benefits of providing care to working aged disabled adults with with moderate care needs

Effects of preventive home visits on older people's use and costs of health care services: a systematic review
Liimatta H, Lampela P, Laitinen-Parkkonen P, et al European Geriatric Medicine, 7, 571-580. 2016

The aim of this study was to systematically review the evidence from randomized controlled trials (RCT) concerning effectiveness of preventive home visit (PHV) programs on older people’s use and costs of health and social services. We also evaluated resultant costs-changes achieved with intervention in older people’s functioning, quality-of-life (QOL) or mortality.

Materials and methods
A systematic review of published RCTs reporting use and/or costs on PHVs on multimorbid older people was performed. The characteristics and methodological quality of studies were assessed.

Of the 3219 articles screened, 19 met the inclusion criteria. The methodological quality of the trials was principally moderate (n = 5) or good (n = 10). Of the studies, 12 evaluated the overall costs of health and social services. None of these studies was able to show significant differences in total costs between intervention and control groups. Six studies suggested that PHVs may decrease nursing home admissions and/or hospital days. Seven studies showed some favorable effect on physical functioning, QOL, or mortality, without increasing the total health care costs.

Of the high number of studies investigating efficacy of PHVs on older people, only a few studies explore economic effects. PHVs do not provide overall savings to health care costs, but some interventions might offer some cost-neutral positive effects on functioning, QOL and/or mortality. More studies are needed to clarify the effective aspects of the programs and cost-effectiveness of the PHVs.

Effects of remote feedback in home-based physical activity interventions for older adults: a systematic review
Geraedts H, Zijlstra A, Bulstra SK, et al Patient Education and Counselling, 91, 14-24. 2013

To evaluate the literature on effectiveness of remote feedback on physical activity and capacity in home-based physical activity interventions for older adults with or without medical conditions. In addition, the effect of remote feedback on adherence was inventoried.

A systematic review. Data sources included PubMed, PsycInfo, Cochrane and EMBASE. A best-evidence synthesis was used for qualitative summarizing of results.

Twenty-four studies met the inclusion criteria for systematic effectiveness evaluation and 22 for adherence inventory. Three categories of contact were identified: frequent, non-frequent, and direct remote contact during exercising. Evidence for positive enhancement of physical activity or capacity varied from conflicting in frequent contact strategies (16 studies) to strong in non-frequent (5 studies) and direct contact strategies (3 studies). Adherence rates in intervention groups were similar or higher than treatment-as-usual or exercise control groups.

Results imply with varying strength that interventions using frequent, non-frequent or direct remote feedback seem more effective than treatment as usual and equally effective as supervised exercise interventions. Direct remote contact seems a particularly good alternative to supervised onsite exercising.

Remote feedback is promising in an older population getting increasingly used to new technology.

Evaluation of Direct Payments in Residential Care Trailblazers
Stefanie Ettelt, Raphael Wittenberg, Lorraine Williams, Jackie Damant, Daniel Lombard, Margaret Perkins and Nicholas Mays Evaluation of Direct Payments in Residential Care Trailblazers 2017

Evaluation of Redcar and Cleveland Community Agents Project: Outputs and Outcomes Summary Report
Watson P and Shucksmith J Social Care Institute for Excellence, London. 2015

The Community Agents Project, a programme jointly funded through health and adult social care services, is an innovative approach to meeting the social needs of the elderly and vulnerable population. Community agents act as a one-stop shop, signposting people to the appropriate service that meets their needs. This could be an organisation or voluntary group that can help with shopping, arrange transport to the GP surgery or hospital appointments, help to complete forms, offer encouragement to maintain a care plan, organise a befriender, accompany to a local social activity or signposting to other agencies. The project has received a total of 486 referrals across the borough of Redcar & Cleveland for the period September 2014-September 2015, generating positive outcomes in the following areas: maintaining independence; faster discharge from hospital; reducing admissions to hospital; reducing isolation; improved financial status; appropriate use of health and social services; cost saving; and increases in community capacity. The report estimates a social return on investment of £3.29 for every £1 invested in the Community Agents Project

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.

Home Care in Dementia: Critical Components for Effectiveness
Challis D, Clarkson P, Sutcliffe C, et al Personal Social Services Research Unit, Manchester. 2019

Most people with dementia live in private households and promoting their wellbeing is a key policy objective. However, little is known about the most appropriate or effective forms of home care, taking into account the views of service users and their carers. Home care has become an area of increasing concern in recent years in terms of availability, quality, cost and effectiveness. This mixed methods study will investigate the effectiveness of home care for people with dementia. First, using data from an evidence synthesis of relevant literature, metrics relating to process and effectiveness will be calculated for specialist home care support for people with dementia, generic forms of home care and service receipt which is a mix of the two. Second, a naturalistic study will follow up people receiving different forms of home care over a 6-month period. Post-hoc analysis will estimate the relative effectiveness and cost by comparing each approach. Third, the views of carers about home care support to people with dementia will be canvassed using themes identified in the literature review. Data will be analysed both qualitatively and quantitatively. An established Public, Patient and Carer Involvement Group will contribute to the study.

Home Care Re-ablement Services: Investigating the Longer-term Impacts (Prospective Longitudinal Study)
Glendinning C, Baxter K, Rabiee P Social Policy Research Unit, York. 2010

Re-ablement is a new, short-term intervention in English home care. It helps users to regain confidence and relearn self-care skills and aims to reduce needs for longer-term support.

Research by the Social Policy Research Unit, University of York and the Personal Social Services Research Unit, University of Kent examined the immediate and longer-term impacts of home care re-ablement, the cost-effectiveness of the service, and the content and organisation of re-ablement services. People who received home care re-ablement were compared with a group receiving conventional home care services, both groups were followed for up to one year.

The study found that:
* Re-ablement was associated with a significant decrease in subsequent costs of social care service use
* Re-ablement had positive impacts on users’ health-related quality of life and social care-related quality of life, in comparison with users of conventional home care services
* Using the National Institute for Health and Clinical Excellence cost-effectiveness threshold, re-ablement was cost effective in terms of health and social care costs
* The reduction in social care costs was almost entirely offset by the initial cost of the re-ablement intervention. The average cost of a re-ablement episode was 2,088 pounds with a mean cost of 40 pounds per hour of service user contact time.

Recommendations for the future organisation of these services are made in the report. In autumn 2010, 70 million pounds was allocated to NHS Primary Care Trusts to develop re-ablement services, this will be followed by an additional 150 million pounds in 2011/12, rising to 300 pounds million per annum from 2012 to 2015.

Research areas
ill/disabled adults, social care services issues, older people

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.

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

Homecare Re-ablement Prospective Longitudinal Study: Final Report
Social Policy Research Unit, University of York Department of Health, London. 2010

A study conducted with ten participating councils to investigate and provide
further information and evidence of the benefits of homecare re-ablement and
the duration of these benefits.

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

Impact and economic assessment of assistive technology in care homes in Norfolk, UK
Al-Oraibi S, Fordham Ric, Lambert R Journal of Assistive Technologies, 6, 192-201. 2012

This study looked at whether new assistive technology (AT) systems in care homes for elderly residents, reduced the number of falls and demands for formal health services. The project collected retrospective data about the incidence of falls before and after AT systems were installed in two care homes in Norfolk, UK. These homes were selected purposefully because a recent assessment identified the need for upgrading their call system. They had different resident profiles regarding the prevalence of dementia. Standard incident report forms were examined for a period starting ten months before the upgrades to ten months after in Care Home 1 and from six months before to six months afterwards in Care Home 2. Overall there were 314 falls reported during the course of the study; the number reduced from 202 to 112 after the introduction of AT. The mean health care costs associated with falls in Care Home 1 were significantly reduced (more than 50%). In Care Home 2 there was no significant difference in the mean cost. The results suggest that installing an AT system in residential care homes can reduce the number of falls and health care cost in homes with a lower proportion of residents with advanced dementia compared to those with more residents with advanced dementia

Interventions for preventing falls in older people in care facilities and hospitals
Cameron ID, Gillespie LD, Robertson MC, et al Cochrane Database Systematic Reviews, 12, CD005465. 2012

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010.

To assess the effectiveness of interventions designed to reduce falls by older people in care facilities and hospitals.

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2012); The Cochrane Library 2012, Issue 3; MEDLINE, EMBASE, and CINAHL (all to March 2012); ongoing trial registers (to August 2012), and reference lists of articles.

Randomised controlled trials of interventions to reduce falls in older people in residential or nursing care facilities or hospitals.

Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate.

We included 60 trials (60,345 participants), 43 trials (30,373 participants) in care facilities, and 17 (29,972 participants) in hospitals.Results from 13 trials testing exercise interventions in care facilities were inconsistent. Overall, there was no difference between intervention and control groups in rate of falls (RaR 1.03, 95% CI 0.81 to 1.31; 8 trials, 1844 participants) or risk of falling (RR 1.07, 95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care.In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants).For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possible benefits, but this evidence was not conclusive.In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, 54 participants) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, 83 participants).In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37).One trial (1822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74).Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, 4824 participants), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings.

In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in interventions and levels of dependency. There is evidence that multifactorial interventions reduce falls in hospitals but the evidence for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive.

Interventions for preventing falls in older people living in the community
Gillespie LD, Robertson MC, Gillespie WJ, et al Cochrane Database Systematic Reviews, 9, 1-4. 2012

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.

This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.

Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.

Multifactorial interventions assess an individual’s risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.

Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.

Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.

Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.

Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.

In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.

The evidence relating to the provision of educational materials alone for preventing falls is inconclusive

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 to Save: Assessing the Cost-effectiveness of Telecare. Summary Report
Clifford P, et al Face Recording and Measurement Systems, Nottingham. 2012

This summary report describes the findings of a project evaluating the potential cost savings arising from the use of telecare. Another aim was to develop a methodology that will support routine evaluation and comparison of the cost-effectiveness of local telecare implementations. Evaluation was made of the suitability of telecare for 50 clients for whom Overview Assessments had been completed by FACE Recording & Measuring Systems Ltd. Where telecare appeared suitable, the social care costs of meeting the client’s needs before and after provision of telecare were estimated. Estimates were also made of the total savings achievable by the deployment of telecare. Out of the 50 cases, 33 were identified as potentially benefitting from telecare. The average weekly cost of telecare was £6.25, compared to £167 for the average weekly care package for the sample pre-telecare. The results confirmed previous studies showing that very substantial savings are achievable through the widespread targeted use of telecare. Potential savings lie in the range of £3m to £7.8m for a typical council, or 7.4-19.4% of total older people’s social care budget.

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.

Loneliness and Social Isolation Among Older People in North Yorkshire
Bernard SM Research Report. SPRU Working Paper, WP 256 . Social Policy Research Unit, York. 2013

This report was commissioned by the Loneliness Task Group of the North Yorkshire
Older People‟s Partnership Board (NYOPPB). Its purpose was to build on the
findings from the „Voice of Ripon‟ loneliness survey carried out in 2009 on behalf of
NYOPPB(1) . The report aims to provide a review of current literature that brings
together knowledge about the extent and nature of loneliness among older people.
This will help to clarify current thinking about what a „good practice‟ or service looks
like and start to identify likely models of good practice in North Yorkshire.
The report looks at how loneliness and social isolation are understood in the
literature, why they should be important concerns of local strategic organisations,
such as health and wellbeing boards, and what might be done. This evidence is set
in the context of the geography and demography of North Yorkshire and suggestions
for future work are made.

Long-term clinical and cost-effectiveness of psychological intervention for family carers of people with dementia: a single-blind, randomized, controlled trial
Livingston G, Barber J, Rapaport P Lancet Psychiatry, 1, 539-548. 2014

Background Two-thirds of people with dementia live at home supported mainly by family carers. These carers
frequently develop clinical depression or anxiety, which predicts care breakdown. We aimed to assess the clinical
eff ectiveness (long-term reduction of depression and anxiety symptoms in family carers) and cost-eff ectiveness of a
psychological intervention called START (STrAtegies for RelaTives).
Methods We did a randomised, parallel-group trial with masked outcome assessments in three UK mental-health
services and one neurological-outpatient dementia service. We included self-identifi ed family carers of people with
dementia who had been referred in the previous year and gave support at least once per week to the person with
dementia. We randomly assigned these carers, via an online computer-generated randomisation system from an
independent clinical trials unit, to either START, an 8-session, manual-based coping intervention delivered by
supervised psychology graduates, or treatment as usual (TAU). The primary long-term outcomes were aff ective
symptoms (Hospital Anxiety and Depression Scale total score [HADS-T]) 2 years after randomisation and costeff ectiveness (health and social care perspectives) over 24 months. Analysis was by intention to treat, excluding
carers with data missing at both 12 and 24 months. This trial is registered ISCTRN70017938.
Findings From November 4, 2009, to June 8, 2011, we recruited 260 carers. 173 carers were randomly assigned to
START and 87 to TAU. Of these 260 participants, 209 (80%) were included in the clinical effi cacy analysis
(140 START, 69 TAU). At 24 months, compared with TAU the START group was signifi cantly better for HADS-T
(mean diff erence –2·58 points, 95% CI –4·26 to –0·90; p=0·003). The intervention is cost eff ective for both carers
and patients (67% probability of cost-eff ectiveness at the £20 000 per QALY willingness-to-pay threshold, and 70%
at the £30 000 threshold).
Interpretation START is clinically eff ective, improving carer mood and anxiety levels for 2 years. Carers in the
control TAU group were seven times more likely to have clinically signifi cant depression than those receiving
START. START is cost eff ective with respect to carer and patient outcomes, and National Institute for Health and
Care Excellence (NICE) thresholds. The number of people with dementia is rapidly growing, and policy
frameworks assume that their families will remain the frontline providers of (unpaid) support. This cost-neutral
intervention, which substantially improves family-carers’ mental health and quality of life, should therefore be
widely available.

Micro-enterprises: Small Enough to Care?
Needham C, et al University of Birmingham, Birmingham. 2015

Outlines the findings of an evaluation of micro-enterprises in social care in England, which ran from 2013 to 2015. The report focuses on very small organisations, here defined as having five members of staff or fewer, which provide care and support to adults with an assessed social care need. The research design encompassed a local asset-based approach, working with co-researchers with experience of care in the three localities. Twenty seven organisations took part in the study overall, including 17 micro-providers, whose performance was compared to that of 4 small, 4 medium and 2 large providers. A total of 143 people were interviewed for the project. The study found that: micro-providers offer more personalised support than larger providers, particularly for home-based care; they deliver more valued outcomes than larger providers, in relation to helping people do more of the things they value and enjoy; they are better than larger providers at some kinds of innovation, being more flexible and able to provide support to marginalised communities; and they offer better value for money than larger providers. Factors that help micro-providers to emerge and become sustainable include: dedicated support for start-up and development, strong personal networks within a localities, and balancing good partnerships (including with local authorities) with maintaining an independent status. Inhibiting factors, on the other hand, include a reliance on self-funders and the financial fragility of the organisation. The report makes the following recommendations: commissioners should develop different approaches to enable micro-enterprises to join preferred provider lists; social care teams should promote flexible payment options for people wanting to use micro-enterprises, including direct payments; social workers and other care professionals need to be informed about micro-enterprises operating close-by so that they can refer people to them; regulators need to ensure that their processes are proportional and accessible for very small organisations; and micro-enterprises need access to dedicated start-up support, with care sector expertise, as well as ongoing support and peer networks.

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 and Social Isolation: A Review of the Evidence
Kinsella S Wirral Council Business & Public Health Intelligence Team, Wirral. 2015

Reducing social isolation is likely to have positive effects on health and mortality:
Greater benefits were observed (in reducing mortality) from improving levels of social
isolation, compared to reducing loneliness.
Targeting has the greatest impact: Focussing public health intervention efforts on
those most at risk, e.g those who live alone, are on low incomes, have poorer health,
been recently bereaved or are carers – rather than all older people – is more effective.
There is still considerable stigma attached to being lonely: and initiatives should
bear this in mind. For example, their marketing materials, should not use the ‘L’ word (as
Age UK call loneliness), particularly if they wish to attract more men
Initiatives based on evidence were more effective than those that were not: 87% of
interventions based on evidence reported beneficial effects compared to 59% of
interventions which were not. Studies aiming to achieve and maintain characteristics
essential for positive mental health (e.g people realising their own abilities, having a
purpose in life, a sense of belonging and support) appeared to be most effective.
Group activities achieve good outcomes: 79% of group based interventions reported
at least one improved outcome, compared to 55% of one-to-one interventions.
Group activities which have an arts, educational learning or social focus are
particularly beneficial: A systematic review supported this finding that group
interventions involving some form of educational, training, arts or social activity that
target specific groups of people are the most effective.
Participatory initiatives are most beneficial: Positive effects are reported in 80% of
initiatives which were participatory, compared to 44% of non-participatory initiatives.
One-to-one initiatives (e.g befriending) only appears to be effective in certain
circumstances: Namely, when the befriender and recipient have enough in common to
build a genuine relationship. They do not appear to reduce use of health services, but
can result in reductions in depression and improvements in quality of life. One-to-one
interventions targeted at specific groups of older people (e.g the recently bereaved, or
recently discharged from hospital), may offer more benefit than trying to reach to all
older people. Currently, there is little evidence of benefit for mentoring support.
The impact of new technologies is inconclusive: The evidence is often contradictory
on the subject of new technologies, but there is some evidence of benefit for training on
the use of computers, the internet, Skype (particularly for specific groups such as carers)
Real and practical barriers to reducing isolation should be the focus of joint
efforts by all agencies concerned with the wellbeing of older people: particularly
those relating to transport, toilets, continence issues and long term health conditions

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.

Reablement, reactivation, rehabilitation and restorative interventions with older adults in receipt of home care: a systematic review
Sims-Gould J, Tong CE, Wallis-Meyer L, et al Journal of the American Medical Directors Association, 18, 653-663. 2017

To systematically review the impact of reablement, reactivation, rehabilitation, and restorative (4R) programs for older adults in receipt of home care services.

Systematic review.

We searched the following electronic bibliographic databases: MEDLINE, EMBASE, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health), SPORTDiscus and The Cochrane Library and reference lists.

Randomized controlled trials that describe original data on the impact of home-based rehabilitative care and were written in English.

Fifteen studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed by 2 independent reviewers. If there were discrepancies, a third author resolved these.

Given the tailored and personalized approach of the 4R interventions, a range of primary outcomes were assessed, including functional abilities, strength, gait speed, social support, loneliness, and the execution of activities of daily living (ADL) and instrumental ADL (IADL). 4R interventions are intended to reduce the long-term use of home care services. As such, health care resource utilization will be assessed as a secondary outcome.

There are 2 distinct clusters of interventions located in this systematic review (defined by hospitalizations): (1) “hospital to home” programs, in which participants are discharged from hospital wards with a 4R home care, and (2) those that focus on clients receiving home care without a hospital stay immediately preceding. Reflecting the highly tailored and personalized nature of 4R interventions, the studies included in this review assessed a wide range of outcomes, including survival, place of residence, health care service usage, functional abilities, strength, walking impairments, balance, falls efficacy and rates of falls, pain, quality of life, loneliness, mental state, and depression. The most commonly reported and statistically significant outcomes were those pertaining to the service usage and functional abilities of participants.

From cost savings to improvements in clinical outcomes, 4R interventions show some promise in the home care context. However, there are several key issues across studies, including questions surrounding the generalizability of the results, in particular with respect to the ineligibility criteria for most interventions; the lack of information provided on the interventions; and lack of information on staff training.

Reablement: Key Issues for Commissioners of Adult Social Care
Social Care Institute for Excellence, Association of Directors of Adult Social Services Social Care Institute for Excellence, London. 2012

A short briefing paper which outlines research and practice evidence about reablement and describes what is required for successful implementation. Sections cover: setting up a reablement service, tips for commissioners, key considerations in providing an efficient and cost effective service. It also presents two case examples of the impact reablement can have on the population and on local authority budgets. Links are provided to freely available evidence and information.

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.

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.

Safe at Home: A Preventive Handyperson Service in Devon
Evans S Housing Learning and Improvement Network, London. 2011

This case study showcases a successful handyperson scheme in Devon. It describes how the scheme was established and its subsequent evolution in the face of changes in the organisational and financial landscape. A range of Evaluation data are included to demonstrate the value of the scheme in promoting independence and reducing risks at home for older people and children and families across the community. Publication of this case study follows the launch of the national evaluation of the government funded handyperson programme by York Health Economics Consortium and the Centre for Housing Policy at the University of York.

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

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.

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 Cost Effectiveness of Homecare Re-ablement: A Discussion Paper to Explore the Conclusions that can be Drawn from the Body of Evidence
Gerald Pilkington Associates Gerald Pilkington Associates, Hampshire. 2011

The report ‘Homecare Re-ablement Prospective Longitudinal Study Final Report’ (Dec 2010) commissioned by the Department of Health’s Care Services Efficiency Delivery programme (CSED) has provided further insight and understanding about the nature and beneficial impacts of homecare re-ablement. However, some of the report content has resulted in a lack of clarity. The aim of this paper is to set out some of the background to the report and provide clarity on the learnings that can be gained with regard to the cost effectiveness of homecare re-ablement services. Contrary to impressions set out in various articles, the report does not indicate that homecare re-ablement as an approach has little financial benefits for a council. What it does illustrate is that councils should undertake a baseline exercise to establish an understanding of the local position and then to operationally performance manage their service to ensure that it is and remains cost effective whilst maximising the benefits of independence for as large a number of people as possible.

The Costs and Benefits of Preventative Support Services for Older People
Pleace N Centre of Housing Policy, York. 2011

This paper is a brief overviewc ommissioned by Scottish Government Communities Analytical Services. This paper reviews the evidence on the cost effectiveness of preventative support services that assist older people with care and support needs to remain in their own homes. The costs of these preventative support services are contrasted with the costs of specialisthousing options, such as sheltered and extra care housing and also with the costs of health services, as part of reviewing the value for money of preventative support services

The Economic Case for a Befriending and Practical At-Home Support Scheme for Older People in Shropshire, England
Bauer A, Knapp M, Perkins M, et al LSE PSSRU and NIHR SSCR Research Findings, Personal Social Services Research Unit, London. 2014

Our aim for this particular case study was to examine the economic case for a help-at-home scheme focused on supporting older people to live more independently in their homes. For this purpose we sought to evaluate the costs of the scheme and the outcomes it achieved, including those linked to cost savings. While the focus was on assessing whether the scheme was able to achieve potential cost savings from a public sector perspective, and in particular an adult social care perspective, we also evaluated additional social benefits, including those to the individual older people (including in their role as carers for their spouse in some cases) and volunteers. We also wanted to explore the capacity of the project to engage with a process of economic analysis and to present our economic evidence in the wider context of qualitative data about, for example, service user satisfaction.

The Economic Value of the Adult Social Care sector -England
Kearney J and White A Skills for Care, Leeds. 2018

Key findings

Sector characteristics

An estimated 45,000 sites were involved in providing adult social care in the UK in 2016. Most of these sites provided residential care. A further 72,000 individuals receive direct payments and employ Personal Assistants (PAs);
There were an estimated 1.6 million jobs in the adult social care sector in the UK in 2016. Most of these jobs were involved in providing domiciliary care. There were a further 151,300 jobs due to individuals employing PAs, meaning there were a total of 1.8 million jobs in the adult social care sector in 2016;
There were an estimated 1.2 million Full-Time Equivalents (FTEs) in the adult social care sector in the UK, and a further 69,500 FTEs employed as PAs;
Most of the adult social care workforce providing regulated services were employed at sites run by private sector providers (845,200);
The level of employment in the adult social care sector represents 6% of total employment in the UK; and
The average earnings in the adult social care sector in the UK was estimated to be £17,300.

Economic value of the sector

It was estimated that in 2016, adult social care sector GVA was £23.6 billion (using the income approach). Most of this was estimated to be in domiciliary care (£7.0 billion, 30%);
This represents 1.4% of total GVA in the UK; and
It was estimated that the average level of productivity (GVA generated per FTE) in the adult social care sector was £19,200.

Indirect and induced value of the sector

The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) was estimated to contribute a further 603,500 jobs (424,800 FTEs) and £10.8 billion of GVA to the UK economy;
The induced effect of the adult social care sector (resulting from purchases made by those directly and indirectly employed in the adult social care sector) was estimated to contribute a further 251,300 jobs (176,100 FTEs) and £11.1 billion of GVA to the UK economy
The total direct, indirect and induced value of the adult social care sector in the UK was estimated to be 2.6 million jobs (1.8 million FTEs) and £46.2 billion.

The Economic Value of the Adult Social Care sector -UK
Kearney J and White A Skills for Care, Leeds. 2018

Key FindingsSector characteristics■An estimated 45,000sites were involved in providing adult social care in the UKin 2016. Most of these sitesprovided residentialcare. A further 72,000 individuals receive direct payments and employ Personal Assistants (PAs);■There were an estimated 1.6 millionjobs in the adult social care sector in the UKin 2016. Most of these jobs were involved in providing domiciliarycare. There were a further 151,300jobs due to individuals employing PAs, meaning there were a total of 1.8 millionjobs in the adult social care sector in 2016;■There were an estimated 1.2 millionFull-Time Equivalents (FTEs) in the adult social care sector in the UK, and a further 69,500FTEs employed as PAs;■Most of the adult social care workforce providing regulated services were employed at sites run by private sector providers (846,600);■The level of employment in the adult social care sector represents 6% of total employment in the UK; and■The average earnings in the adult social care sector in the UK was estimated to be £17,300.Economic value of the sector(using the income approach)■It was estimated that in 2016, adult social care sector GVA was £24.3billion. Most of this was estimated to be in domiciliarycare (£7.6billion, 31%);■This represents 1.4% of total GVA in the UK;and■It was estimated that the average level of productivity (GVA generated per FTE) in the adult social care sector was £19,700.Indirect and induced value of the sector(using the income approach)■The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) was estimated to contribute a further 603,500 jobs (424,800FTEs) and £10.8billion of GVA to the UKeconomy;■The induced effect of the adult social care sector (resulting from purchases made by those directly and indirectly employed in the adult social care sector) was estimated to contribute a further 251,300jobs (176,100FTEs) and £11.1billion of GVA to the UKeconomy; and■The total direct, indirect and induced value of the adult social care sector in the UKwas estimated to be 2.6million jobs (1.8 millionFTEs) and £46.2billion in 2016.

The Economic Value of the Adult Social Care sector -Wales
Kearney J and White A Skills for Care, Leeds. 2018

Key FindingsSector characteristics■An estimated 2,070sites were involved in providing adult social care in Walesin 2016.Most of these sites were provided nursing care.A further 1,700 individuals receive direct payments and employ Personal Assistants (PAs);■There were an estimated 79,800jobs in the adult social care sector in Walesin 2016.Most of these jobs were involved in providing residential care.There were afurther 3,600 jobs due to individuals employing PAs,meaning there were a total of 83,400 jobs in the adult social care sector in 2016;■There were an estimated 60,000 Full-Time Equivalents (FTEs) in the adult social care sector in Wales,and a further 1,600 FTEs employed as PAs;■Most of the adult social care workforce providing regulated services wereemployed at sites run by private sector providers (44,500);■The level of employment in the adult social care sector represents 6% of total employment in Wales; and■The average earnings in the adult social care sector in Wales was estimated to be £16,900.Economic value of the sector(using the income approach)■It was estimated that in 2016, adult social care sector GVA was £1.2billion. Most of this was estimated to be in residential care (£328 million, 28%);■This represents 1.9% of total GVA in Wales;■It was estimated that the average level of productivity (GVA generated per FTE) in the adult social care sector was £18,700; and■The estimated GVA in the adult social care sector in Wales is estimated to be higher than the Agriculture, forestry andfishing, Arts, entertainment andrecreationand Water supply; sewerage andwaste managementsectors.Indirect and induced value of the sector(using the income approach)■The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) wasestimated to contribute a further 31,200 jobs (23,000 FTEs) and £554million of GVA to the Welsh economy;■The induced effect of the adult social care sector (resulting from purchases made by those directly and indirectly employed in the adult social care sector) wasestimated to contribute a further 12,200 jobs (9,000 FTEs) and £543 million of GVA to the Welsh economy;and■The total direct, indirect and induced value of the adult social care sector inWales was estimated to be 126,800 jobs (93,600 FTEs) and £2.2 billion in 2016.

The Economic Value of the Adult Social Care Sector in England
ICF GHK Skills for Care, Leeds. 2013

Skills for Care is part of the Sector SkillsCouncil, Skills for Care and Development. It is responsible for improving qualifications, training and development for alladult social care workers in England. Skills for Care had identified a need to establish the economic contribution of the activitiesprovided by the sector, measured as the economic value of the sector. However, the adult social care sector in England has historically been difficult to assess in terms of its economic value, as distinct from the children’s workforce and the wider UK workforce.Skills for Care has recently generated estimates of the number of employers, enterprises and employees in the sector, through its work on the National Minimum Dataset for Adult Social Care (NMDS-SC). ICF GHK was commissioned by Skills for Care to build on this work and to assess the economic significance of the adult social care sector in England to the wider economy.This study was commissioned in support of further policy development towards the sector including consideration of a broader case for investment in skills in the sector. The purpose of the study was to establish the economic contribution of adult social care servicesin England(defined in terms consistentwith the UK national accounts)and provide estimates of:■the annual GDP andGVAgenerated directly by the adult social care sector in England (including the public sector activities within the sector as well as the independent sector) (direct impact);■productivity -GVA per worker for the adult social care sector in England;■the supply chain multiplier for the adult social care sector in England (indirect impact);■the wage multiplier for the adult social care sector in England (induced impact)

The effectiveness and cost-effectiveness of strength and balance Exergames to reduce falls risk for people aged 55 years and older in UK assisted living facilities: a multi-centre, cluster randomised controlled trial
Emma K Stanmore, Alexandra Mavroeidi, Lex D de Jong, Dawn A Skelton, Chris J Sutton, Valerio Benedetto, Luke A Munford, Wytske Meekes, Vicky Bell, Chris Todd The effectiveness and cost-effectiveness of strength and balance Exergames to reduce falls risk for people aged 55 years and older in UK assisted living facilities: a multi-centre, cluster randomised controlled trial 2019

The Home Cure
Wood C and Salter J Demos, London. 2012

A report by Demos that describes the policy background and current evidence about cost effectiveness of reablement services. Based on research with Midland Heart Housing Association it makes recommendations for improving outcomes by engaging housing providers in reablement. In particular it suggests ways to ensure that the reablement process can continue for those who need more than 6 weeks support and that more attention is given to regaining independence outside the home.

The PEDRO Study: Partnerships Between Deaf People and Hearing Dogs
Beresford B Socia Policy Research Unit, York. Due to complete 2019

The PEDRO study is evaluating and exploring hearing dog partnerships. The aim of the study is to understand the impacts and experiences of these partnerships, and their place within wider support and provision for deaf people and people with hearing loss.

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

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.

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.

When practical help is valued so much by older people, why do professionals fail to recognise its value?
Brannelly T and Matthews B Journal of Integrated Care, 18, 33-40. 2010

This article draws on the evaluation of a handyperson service which augments health and social services to enable older frail people to remain living at home. It considers current trends and policy, and asks why practical help is under‐valued by professionals caring for older people.

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