'The Billion Dollar Question': embedding prevention in older people's services—Ten 'High-Impact' changes
Allen K and Glasby J British Journal of Social Work, 43, 904-924. 2013

With ageing populations, social changes and rising public expectations, many countries are exploring ways of developing a more preventative approach within their health and social care services. In England, this has become a growing priority over time—made even more significant by recent economic change and by the urgent need to reduce public sector spending. However, a key dilemma for policy makers and managers is the patchy nature of the evidence base—with a lack of certainty over how to reform services or prioritise spending in order to develop a more genuinely preventative approach. Against this background, this commentary reviews national and international evidence around ten policy measures and interventions, highlighting some of the most promising approaches as well as the fragmented and contested nature of the evidence base.

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

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

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

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

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

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

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

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

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.

At a Glance 53. Reablement: Implications for GPs and Primary Care
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2012

Key messages

Reablement focuses on restoring independence rather than resolving health care issues.
Research findings are positive and show that reablement is cost-effective compared with conventional home care.
It is the intention of the Secretary of State for Health that clinical commissioning groups should embrace reablement.
While reablement usually begins in hospital, this is not inevitable as people can be referred from the community, for instance by general practitioners (GPs) and social workers.
A multidisciplinary team activates a reablement plan with clear objectives and an analysis of likely outcomes. The team could be organised around clusters of practices, with combined health and social care input.
Flexibility and reassessment throughout the intervention period is necessary to ensure improvements in outcomes. Strategies and services should be deployed that lead to improvements in independence and self-care after an illness.
People using reablement must be consulted to assess satisfaction and measure quality of life indices through and after the reablement period.

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

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

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

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

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

Commissioning Befriending: A Guide for Adult Social Care Commissioners
Association of Directors of Adult Social Services Association of Directors of Adult Social Services, London. 2014

A guide developed to inform commissioners of adult social care about how befriending services are being delivered across the South West and how to effectively commissioning high quality befriending services. It describes what befriending is; the different ways it can be delivered; and the positive benefits it can have through improving health, well being and increasing independence. It also explains how people and communities can be involved in delivering and developing services through volunteering. Case study examples of current befriending practice are used throughout. The guide also draws upon materials and guidance produced by the Mentoring and Befriending Foundation (MBF) and feedback from commissioners and befriending providers through a series of consultations undertaken by the MBF.

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.

Dance to Health: Evaluation of the Pilot Programme
Aesop Arts Enterprise with a Social Purpose, Oxford. 2017

Outlines the results of Aesop’s falls prevention dance programme for older people, Dance to Health. This arts based intervention address older people’s falls and problems with some current falls prevention exercise programmes, by incorporating evidence-based exercise programmes into creative, social and engaging dance activity. The programme was developed using the Aesop 7-item checklist, which lists the features an arts programme should have for it to be taken up by the health system and made available to every patient who could benefit. The report outlines the rationale for creating the programme, the outcomes achieved – in addition to reduced falls, cost effectiveness, and the wider impact of the programme. It reports that the pilot successfully brought people from the worlds of dance and older people’s exercise together, was able to train dance artists in the evidence-based falls programme, and also developed six evidence-based falls prevention programmes with 196 participants. A total of 73 per cent of participants achieved the target of 50 hours’ attendance over the six months, compared with a national average for completing standard falls prevention exercise programmes of 31 per cent for primary prevention and 46 per cent for secondary prevention. Additional outcomes identified included increases in group identification, relationships and reduced loneliness, functional health and wellbeing, and mental health and wellbeing

Demonstrating the Health and Social Cost-benefits of Lifestyle Housing for Older People
Housing Learning and Improvement Network Housing Learning and Improvement Network, London. 2017

This report, commissioned by Keepmoat Regeneration/ENGIE, sets out the evidence for the benefits of developing specialist retirement housing for people aged over 55, including cost savings. It focuses on the benefits of age restricted retirement housing or sheltered accommodation, care villages and specialist extra care housing with services and care on-site. Part one lists key facts and figures on the health and social care cost-benefits of lifestyle housing for older people. Part two provides more detailed findings of the potential benefits including the areas of: social connectedness and reducing loneliness; life expectancy, keeping couples together and supporting informal carers, financial savings in adult social care and the NHS, and preventing the need for institutional care. References and links are listed at the end of the document.

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 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

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

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

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

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

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

Evidence and Initiatives for Integrating Personal Budgets for People with Mental Health Problems
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2014

Because integrating personal budgets is a relatively new initiative, evidence is still emerging about the impact they might have on people’s health and wellbeing.

However, evidence suggests that people with mental health problems can benefit significantly from having increased choice and control over their care, because their needs tend to cross boundaries between health and social care.

This section discusses some of the evidence from a recent evaluation of personal health budgets. It also describes some recent initiatives by government to promote the integration of services around an individual’s needs.

Evidence to Inform the Commissioning of Social Prescribing
Centre for Reviews and Dissemination, University of York Centre for Reviews and Dissemination, York. 2015

Summarises the findings of a rapid appraisal of available evidence on the effectiveness of social prescribing. Social prescribing is a way of linking patients in primary care with sources of support within the community, and can be used to improve health and wellbeing. For the review searches were conducted on the databases: DARE, Cochrane Database of Systematic Reviews and NHS EED for relevant systematic reviews and economic evaluations. Additional searches were also carried out on MEDLINE, ASSIA, Social Policy and Practice, NICE, SCIE and NHS. Very little good quality evidence was identified. Most available evidence described evaluations of pilot projects but failed to provide sufficient detail to judge either success or value for money. The briefing calls for better evaluation of new schemes. It recommends that evaluation should be of a comparative design; examine for whom and how well a scheme works; the effect it has and its costs.

Extending the Housing Options for Older People: Focus on Extra Care
Petch A Institute for Research and Innovation in Social Services, Glasgow. 2014

This Insight summarises the evidence on policy and practice issues for housing with care and support for older people, focusing on extra care provision, and the extent to which different models provide an effective alternative to residential and nursing care. The review begins by providing a short overview to the policy context in Scotland. It then looks at the evidence in the following areas: location, support arrangements, quality of life, provision for dementia, building design, end of life and cost. The Insight covers ‘extra care’ that offers self-contained accommodation units, support accessible 24 hours, some collective meal provision and a range of leisure and other facilities on site.

Factors that promote and hinder joint and integrated working between health and social care services
Cameron A, Lart R, Bostock L, et al Health and Social Care in the Community, 22, 225-233. 2012

Key messages

This is an update of a previous systematic review on the factors that promote and hinder joint working between health and social care services. It demonstrates some positive outcomes of such an approach for people who use services, carers and organisations delivering services.
Three broad themes are used to organise the factors that support or hinder joint or integrated working: organisational issues; cultural and professional issues; and contextual issues.
There is significant overlap between positive and negative factors, with many of the organisational factors identified in research as promoting joint working also being identified as hindering collaboration when insufficient attention is paid to their importance.
Securing the understanding and commitment of staff to the aims and desired outcomes of new partnerships is crucial to the success of joint working, particularly among health professionals.
Defining outcomes that matter to service users and carers is important. Outcomes defined by service users may differ from policy and practice imperatives but are a crucial aspect of understanding the effectiveness of joint or integrated services.
Although most service users and carers report high levels of satisfaction, more can be done to involve them in care planning and influencing future care options. Joint and integrated services work best when they promote increased user involvement, choice and control.
The evidence base underpinning joint and integrated working remains less than compelling. It largely consists of small-scale evaluations of local initiatives which are often of poor quality and poorly reported. No evaluation studied for the purpose of this briefing included an analysis of cost-effectiveness.
There is an urgent need to develop high-quality, large-scale research studies that can test the underpinning assumptions of joint and integrated working in a more robust manner and assess the process from the perspective of service users and carers as well as from an economic perspective.

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.

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

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

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.

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

Intermediate Care: SCIE Highlights
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2017

Intermediate care can deliver better outcomes for people and reduce the pressures on hospitals and the care system. Yet its potential has not been fully realised. Evidence offers some clear learning points that can guide the growth of intermediate care.

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.

LGA Adult Social Care Efficiency Programme: The Final Report
Local Government Association Local Government Association, London. 2014

This is the concluding report from the LGA Adult Social Care Efficiency (ASCE) programme. The programme was launched in 2011 in response to the significant cuts to council budgets and their impact on adult social care. The aim of the programme is to support councils to develop transformational approaches to making the efficiency savings required to meet the challenge of reduced funding. The report shares innovative and transformational examples of how councils are bringing together businesses, public sector partners and communities to develop lower-cost solutions to support the most vulnerable in our society. In particular, it outlines some key lessons around developing a new contract with citizens and communities, managing demand, transformation, commissioning, procurement and contract management, and integration. It looks at efficiency approaches in practice, with specific reference to assessment, advice and information, delivering preventative services, avoiding admissions and reducing costs of residential care, reducing costs in domiciliary care and transforming learning disability services. In addition, it considers local approaches to developing effective internal management, reshaping the service and working with partners, customers and suppliers.

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

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

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

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

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

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

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

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

Living, Not Existing: Putting Prevention at the Heart of Care for Older People in Wales
Royal College of Occupational Therapists Royal College of Occupational Therapists, London. 2017

This report focuses on the important contribution that occupational therapists can make to support further integration of health and social care in Wales. It looks at the role of occupational therapy in helping older people to remain independent and live in their own communities for as long as possible, preventing or delaying the need for expensive care long-term. The report focuses on three key areas: prevention or delaying the need for care and support; helping older people to remain in their communities; and ensuring equality of access to occupational therapy. It provides recommendations to improve the design and delivery of services and examples of best practice and individual case studies to how occupational therapists can contribution to integrated, person-centred services. These include for occupational therapists to work more closely with general practitioners, take on leadership roles to provide expertise to community providers on the development of person and community centred services; and the development of formal partnership agreements across local housing, health and social care sectors to ensure all older people have access to occupational therapy services.

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

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

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

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

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

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

Maximising the Potential of Reablement
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2013

This guide is based on research and practice evidence about the effectiveness and cost-effectiveness of reablement.

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.

Peer Support for People with Dementia: A Social Return on Investment (SROI) Study
Semple A, Willis E, de Waal H Health Innovation Network, London. 2015

Reports on a study using Social Return on Investment (SROI) analysis to examine the impact and social value of peer support groups as an intervention for people with dementia. Three peer support groups in South London participated in the study. A separate SROI analysis was carried out for each individual group to find out what people valued about the groups and how they helped them. The report presents the outcomes for each group, the indicators for evidencing these outcomes and the quality and duration of outcomes experienced. It then provides detail on the methodology used to calculate the impact and the social return on investment. Overall, the study found that peer support groups provide positive outcomes for people with dementia, their carers and the volunteers who support the groups. The benefits of participating in peer support groups included: reduced isolation and loneliness; increased stimulation, including mental stimulation; and increased wellbeing. Carers experienced a reduction in carer stress, carer burden and reduction in the feeling of loneliness. Volunteers had an increased sense of wellbeing through their engagement with the group, improved knowledge of dementia and gained transferrable skills. Overall the study found that for every pound (£) of investment the social value created by the three groups evaluated ranged from £1.17 to £5.18.

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

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

Personalisation, Productivity and Efficiency
Carr S Social Care Institute for Excellence, London. 2010

This report focuses on the potential for personalisation, particularly self-directed support and personal budgets, to result in cost-efficiencies and improved productivity as well as improved care and support. The overall result of this is greater independence and better outcomes for people’s lives. The report provides an overview of some emerging evidence for efficiency from the implementation of personalisation so far, to inform the next stage of delivery.

Reform of social care and personalisation is part of the coalition agreement, which states that:

we understand the urgency of reforming the system of social care to provide much more control to individuals and their carers
we will break down barriers between health and social care funding to incentivise preventative action
we will extend the greater roll-out of personal budgets to give people and their carers more control and purchasing powers.

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

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

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

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

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

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

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

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

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

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

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

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

Research briefing 36: Reablement: a cost-effective route to better outcomes
Francis J, Fisher M, Rutter D Research Briefing, Social Care Institute for Excellence Research, 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 ‘primary prevention’ aimed at promoting wellbeing, through to ‘secondary’ or early intervention, and on to ‘tertiary services’ such as intermediate care provided by health and social care professionals. Tertiary services are aimed at minimising disability or deterioration from established health conditions or complex social care needs.1 The emphasis is on maximising people’s functioning and independence through approaches such as rehabilitation, intermediate care and reablement. This research briefing focuses on reablement.

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.

Reducing Delayed Transfer of Care through Housing Interventions: Evidence of Impact. Case Study
Adams S Care and Repair England, London. 2016

A case study and independent evaluation of a housing intervention designed to help older patients to return home from hospital more rapidly and safety. The initiative is delivered by West of England Care & Repair (WE C&R), who organise clutter clearance/deep cleaning; urgent home repairs, emergency heating repairs and essential housing adaptations for older people in hospital. The evaluation examined all case records, interviewed 15 hospital staff and undertook an in depth analysis of a sample of 4 cases. Analysis of the case records estimated a saving in hospital bed days of £13,526. The cost of housing interventions was £948, resulting in a cost benefit ratio of 14:1. Additional savings in hospital staff time amounted to a further £897. A short case study illustrates how the service was able to help one woman return home from hospital. It concludes that the small scale evaluation is indicative of the potential savings that a practical and effective home from hospital housing intervention service can generate for the health service

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

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

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

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

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

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

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

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

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

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

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

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

Social Prescribing and Health and Well-being
Welsh NHS Confederation Welsh NHS Confederation, Cardiff. 2017

This briefing paper sets out the important role that social prescribing has on the health and well-being of the population in Wales and highlights some of the social prescribing initiatives already in place which show how patients are benefiting from integrated, person-centred and non-medical services. The initiatives include the Valleys Steps programme which considers alternatives for seeking medical treatment for ongoing mental health issues; Gofal Community Food Co-ops, which provide opportunities for mental health patients to interact with members of the local community; and Care and Repair Cymru’s Warm Homes Prescription Scheme. It also highlights existing evidence which shows the effectiveness and cost effectiveness of social prescribing.

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

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

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

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

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

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

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 preventive, integrated care for community‐dwelling frail older people: a systematic review
Looman WM, Huijsman R, Fabbricotti IN Health and Social Care in the Community, 27, 1-30 2018

Integrated care is increasingly promoted as an effective and cost‐effective way to organise care for community‐dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost‐effectiveness of preventive, integrated care for community‐dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost‐effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk‐of‐bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom‐reported outcomes such as well‐being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost‐effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost‐effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected. (Edited publisher abstract)

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 effectiveness of local authority social services' occupational therapy for older people in Great Britain: a critical literature review
Boniface GE, Mason M, Macintyre J, et al British Journal of Occupational Therapy, 76, 538-547. 2013

This literature review systematically selected, critically appraised, and thematically synthesized the post 2000 published and unpublished evidence on the effectiveness and cost effectiveness of occupational therapy interventions for older people in social care services. Identified themes established: the localized nature of social care services for older people; organizational and policy impacts on services, and factors influencing effectiveness and cost effectiveness. Although occupational therapists are increasingly involved in rehabilitation and reablement, there is a continuing focus on equipment and adaptations provision. A high level of service user satisfaction was identified, once timely occupational therapy services were received. Overall, occupational therapy in social care is perceived as effective in improving quality of life for older people and their carers, and cost effective in making savings for other social and healthcare services. However, the complex nature of social care services makes it difficult to disaggregate the effectiveness of occupational therapy from other services.

The Implementation of Individual Budget Schemes in Adult Social Care. SCIE Research Briefing 20
Carr S, Robbins D Social Care Institute for Excellence, London. 2009

Introduction

This briefing examines some of the recent UK and international literature relating to the development of personal budget schemes for adults eligible for support from social care services. These include older people, people with physical or sensory disabilities, people with learning disabilities and people with mental health problems

The briefing is an update of Research briefing 20: Choice, control and individual budgets: emerging themes (2007) and incorporates some new findings from research published between 2006 and 2008. It includes highlights from the In Control evaluation, the UK Direct Payments survey and the Department of Health Individual Budgets pilot.

The briefing is intended to provide an outline of – and signpost to – some of the most recent research for all those interested in the role of individual budget schemes for the development of personalised adult social care in England. The findings presented here are not comprehensive or conclusive, but give a brief indication of how personal or individual budgets have been working to date.
Key messages

The international evidence to date is based on many relatively small examples, but given the right level of support, user views are very positive and they report improvements.
All schemes are still working to balance safeguarding and registration of the workforce with individual choice and control. There are emerging risks to be overcome at the level of the organisation and the individual.
There are both advantages and disadvantages for carers and families. Support arrangements are needed to ensure successful implementation.
Older people and people with complex needs may need greater time and support to help them get the most from individual budget schemes, particularly the cash direct payment option.
Brokerage and support is needed but the support infrastructure is not yet sufficiently well developed in the UK. Emerging evidence indicates that support is more successful when it is independent of the service system. Support brokers should provide a task-focused service and be trained and regulated.
Early studies of personal assistants (PAs) paint a mixed picture of poorer pay and conditions but higher job satisfaction.
Most schemes share the same goals of improving freedom of choice, independence and autonomy and using public funds more efficiently.
Schemes still vary to take account of national context, but central government leadership is always a vital component.
All schemes have taken time to embed and have needed strong local leadership and investment in targeted training and support for frontline staff.
In the UK, IBSEN claims that individual budgets have ‘the potential’ to be more cost effective and there is improved satisfaction for people who use services.
Reliable evidence on the long-term social care cost implications is not yet available. This is an area which needs urgent attention to sustain confidence. There is emerging international evidence that self-directed care can lead to health gains and consequent efficiency gains

The Lightbulb project: switched on to integration in Leicestershire
Moran A Housing Learning and Improvement Network, London. 2017

A case study of the Lightbulb project, which brings together County and District Councils and other partners in Leicestershire to help people stay in their homes for as long as possible. The approach includes GPs and other health and care professionals and relies on early at home assessment process at key points of entry. This is delivered through a ‘hub and spoke’ model with an integrated Locality Lightbulb Team in each District Council area and covers: minor adaptations and equipment; DFGs; wider housing support needs (warmth, energy, home security); housing related health and wellbeing (AT, falls prevention); planning for the future (housing options); and housing related advice, information, and signposting. The Lightbulb service also includes a cost effective specialist Hospital Housing Enabler Team based in acute and mental health hospital settings across Leicestershire. The team work directly with patients and hospital staff to identify and resolve housing issues that are a potential barrier to hospital discharge and also provide low level support to assist with the move home from hospital to help prevent readmissions.

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

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

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

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

The UTOPIA Project: Using Telecare for Older People in Adult Social Care. The Findings of a 2016-17 National Survey of Local Authority Telecare Provision for Older People in England
Woolham J, Steils N, Fisk M, et al Social Care Workforce Research Unit, King's College London, London. 2018

This report describes how electronic assistive technology and telecare are used by local authorities in England to support older people. It is based on an online survey of local authority telecare managers to identify local authority’s aims when offering telecare to older people, the methods they use to assess whether their objectives are achieved, and how telecare is operationalised and delivered. It also aimed to explore why the findings of the earlier the Whole System Demonstrator project – which found no evidence that telecare improved outcomes – have been overlooked by local authorities and policy makers, and whether there is other evidence that could account for WSD findings. The survey results found a third of local authorities used research evidence to inform telecare services and half were also aware of the Whole System Demonstrator. It also found that telecare is used in most local authorities to save money. Although there was some evidence of monitoring, there was no evidence of local authorities adopting agreed standards. The final section of the report provides suggestions for improving telecare service practice. They include the areas of using telecare as a substitute for social care; expanding the focus on telecare beyond risk management, safety and cost reduction; the impact of telecare on family members, carrying out effective assessments, and training

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? Findings and Lessons from Local Approaches and Solutions for Transforming Adult Social Care (and Health) Services
Brown H, et al National Development Team for Inclusion, Bath. 2017

The first evaluation report of the Community Led Support (CLS) programme, which supported nine authorities across England, Wales and Scotland to develop and implement a new model of delivering community based care and support. The findings show what can be achieved when applying core principles associated with asset based approaches. CLS involves local authorities working collaboratively with their communities, partner organisations and staff to design a health and social care service that works for everyone. Its core principles include co-production; a focus on communities; preventing crises by enabling people to get support and advice when they need it; a culture based on trust and empowerment; and treating people as equals, and building on their strengths. The evaluation found evidence that CLS resulted in better experiences and outcomes for local people, improved access to services; greater efficiencies in services; reduced waiting times and lists; increased signposting and resolution through community services; improvement in staff morale; and a potential for cost savings. Sites achieved these changes by adopting a variety of approaches to implementing CLS – from implementing CLS across an entire authority area at the same time, to implementing in one innovation site and encouraging others to adopt aspects of the service. The report identifies six priority areas for action to further develop and embed community led support over the next 12-18 months.