1.2 Preventing, Reducing or Delaying Needs

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1. Introduction

It is critical to the vision in the Care Act 2014 that the care and support system works to actively promote wellbeing and independence, and does not just wait to respond when people reach a crisis point. To meet the challenges of the future, it will be vital that the care and support system intervenes early to support individuals, helps people retain or regain their skills and confidence, and prevents need or delays deterioration wherever possible.

There are many ways in which a local authority can achieve the aims of promoting wellbeing and independence and reducing dependency. The Care and Support Statutory Guidance sets out how local authorities should go about fulfilling their responsibilities, both individually and in partnership with other local organisations, communities, and people themselves.

The local authority’s responsibilities for preventing, reducing and delaying needs apply to all adults, including:

• adults who do not have any current needs for care and support;
• adults with needs for care and support, whether their needs are eligible and / or met by the local authority or not;
• carers, including those who may be about to take on a caring role or who do not currently have any needs for support, and those with needs for support which may not be being met by the local authority or other organisation.

The term ‘prevention’ or ‘preventative’ measures can cover many different types of support, services, facilities or other resources. There is no single definition for what constitutes preventative activity and this can range from wide-scale, whole population measures aimed at promoting health, to more targeted, individual interventions aimed at improving skills or functioning for one person or a particular group or lessening the impact of caring on a carer’s health and wellbeing.

‘Prevention’ is often broken down into three general approaches – primary, secondary and tertiary prevention. The use of these terms aim to illustrate what type of services, facilities and resources could be considered, arranged and provided as part of a prevention service, as well as to whom and when such services could be provided or arranged. Prevention should be seen as an ongoing consideration and not a single activity or intervention.

2. Prevent, Reduce, Delay

2.1 Prevent: primary prevention/ promoting wellbeing

These are aimed at adult who have no current health or care and support needs. They are services, facilities or resources provided or arranged that may help an adult avoid developing needs for care and support, or help a carer avoid developing support needs by maintaining independence and good health and promoting wellbeing. They are generally universal services (which means they are, available to all) and may include:

• universal access to good quality information;
• supporting safer neighbourhoods;
• promoting healthy and active lifestyles;
• reducing loneliness or isolation or;
• encouraging families to have early discussions about potential changes in the future, for example conversations about potential care arrangements or suitable accommodation should a family member become ill or disabled.

2.2 Reduce: secondary prevention/ early intervention

These are more targeted interventions aimed at adults who have an increased risk of developing needs, and the provision of services, resources or facilities may help slow down or reduce any further deterioration or prevent other needs from developing. Early support can help stop a person’s life tipping into crisis, for example helping an adult with a learning disability manage their money, or a providing a few hours support to help a family carer.

Early intervention could also include a fall prevention clinic, adaptations to housing to improve accessibility or provide greater assistance, handyperson services, short term provision of wheelchairs or telecare / technology enabled card services. To identify adults most likely to benefit from such targeted services, local authorities may undertake screening or case finding, for instance to identify individuals at risk of developing specific health conditions or experiencing certain events (such as strokes, or falls), or those that have needs for care and support which are not currently met by the local authority. Targeted interventions should also include identifying carers, including those who are taking on new caring responsibilities.

2.3 Delay: tertiary prevention

These are interventions aimed at minimising the effect of disability or deterioration for people with established or complex health conditions, (including progressive conditions, such as dementia), supporting people to regain skills and manage or reduce need where possible. Tertiary prevention could include, for example the rehabilitation of people who are severely sight impaired (see also Register of Sight Loss / Certificate of Vision Impairment). Local authorities must provide or arrange services, resources or facilities that maximise independence for those already with such needs, for example, the provision of formal care such to meet a person’s needs in their own home; rehabilitation / reablement services, community equipment services and adaptations; and the use of joint case management for people with complex needs.

Tertiary prevention services can also include helping improve the lives of carers by enabling them to continue to have a life of their own alongside caring, for example through respite care / short breaks, peer support groups like dementia cafés, or emotional support or stress management classes which can provide essential opportunities to share learning and coping tips with others.

Prevention is not a one off activity. For example, a change in the circumstances of an adult and/or carer may result in a change to the type of prevention activity that would be of benefit to them. Prevention can sometimes be seen as something that happens primarily at the time of (or very soon after) a diagnosis or assessment or when there has been a subsequent change in the person’s condition. Prevention services are, however, something that should always be considered. For example, at the end of life in relation to carers, prevention services could include the provision of pre-bereavement support.

3. Intermediate Care and Reablement

‘Intermediate care’ is a time limited, structured programme of care to assist a person to maintain or regain their ability to live independently at home. ‘Reablement’ is a type of intermediate care, which aims to help the person regain their capabilities and live independently in their own home.

The terms ‘reablement’, ‘rehabilitation’ and ‘intermediate care’ can be used interchangeably.

There are four models of intermediate care (see Intermediate Care (SCIE):

1. Bed-based services are provided in an acute hospital, community hospital, residential care home, nursing home, standalone intermediate care facility, independent sector facility, local authority facility or other bed-based settings.
2. Community-based services provide assessment and interventions to people in their own home or a care home.
3. Crisis response services are based in the community and are provided to people in their own home or a care home with the aim of avoiding hospital admissions.
4. Reablement services are based in the community and provide assessment and interventions to people in their own home or a care home. These services aim to help people recover skills and confidence to live at home and maximise their independence.

The term ‘rehabilitation’ is sometimes used to describe a particular type of service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness or disease. Rehabilitation services can include provisions that help people attain independence and remain or return to their home and participate in their community, for example independent living skills and mobility training for people with visual impairment.

‘Intermediate care’ services are provided to people, usually older people, after they have left hospital or when they are at risk of being sent to hospital. Intermediate care is a programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live independently – as such they provide a link between places such as hospitals and people’s homes, and between different areas of the health and care and support system – community services, hospitals, GPs and care and support.

4. Carers and Prevention

Carers play a significant role in preventing the needs for care and support for the people they care for, which is why it is important that local authorities consider preventing carers from developing needs for care and support themselves. Services, facilities or resources that can contribute to preventing, delaying or reducing the needs of carers may include but is not limited to those which help carers to:

• care effectively and safely – both for themselves and the person they are supporting, for example timely interventions or advice on moving and handling safely or avoiding falls in the home, or training for carers to feel confident performing basic health care tasks;
• look after their own physical and mental health and wellbeing, including developing coping mechanisms;
• make use of IT and assistive technology;
• make choices about their own lives, for example managing their caring role and paid employment;
• find support and services available in their area;
• access the advice, information and support they need including information and advice on welfare benefits, other financial information and entitlement to carers’ assessments (see Assessment).

As with the people they care for, the duty to prevent carers from developing needs for support is distinct from the duty to meet their eligible needs. While a person’s eligible needs may be met through universal preventative services, this will be an individual response following a needs or carers assessment.

5. The Focus of Prevention

5.1 Promoting wellbeing

The local authority must have regard to promote wellbeing and its principles (see Promoting Wellbeing), and view the adult’s life holistically. This will mean considering care and support needs in the context of the adult’s skills, ambitions, and the outcomes they want to achieve. The role their family or friends can play in helping them to meet their goals should also be considered. Local authorities should also consider how carers can be supported to look after their own health and wellbeing and to have a life of their own alongside their caring responsibilities.

5.2 Involving adults

In developing and delivering preventative approaches to care and support, local authorities should ensure that adults are not seen as passive recipients of support services, but are able to design care and support based around achievement of their goals. Interventions should be co-produced with adults, families, friends, carers and the community.

Through the assessment process, adults should be asked: ‘what does a good life look like for you and your family and how can we work together to achieve it?’ Giving people choice and control over the support they may need and access to the right information enables them to stay as well as possible, maintain independence and any caring role for longer.

5.3 Working with other partners to focus on prevention

Whilst local authorities may choose to provide some types of preventative support themselves, others may be more effectively provided in partnership with other local partners (for example rehabilitation or falls clinics provided jointly with the local NHS), and further types may be best provided by other organisations (for example specialist housing providers or some carers’ services).

In developing a local approach to prevention, the local authority must take steps to identify and understand both the current and future demand for preventative support, and the supply in terms of services, facilities and other resources available.

Local authorities must consider the importance of identifying the services, facilities and resources that are already available in their area, which could support people to prevent, reduce or delay needs, and which could form part of the overall local approach to preventative activity?

Local authorities must promote diversity and quality in provision of care and support services, and ensure that a person has a variety of providers to choose from (see Market Shaping and Commissioning of Adult Care and Support).

Identifying ‘unmet need’ – that is those people with needs which are not currently being met, whether by the local authority or anyone else – is particularly important when developing a longer-term approach to prevention that reflects the true needs of the local population.

Local authorities should consider how they can work with different partners to identify unmet needs for different groups and coordinate shared approaches to preventing or reducing such needs, for example working with the NHS to identify carers, and working with independent providers including housing providers and the voluntary sector, who can provide local insight into changing or emerging needs beyond eligibility for publicly funded care.

5.4 Identifying those who may benefit from preventative support

The local authority should have arrangements to identify and target those individuals who may benefit from particular types of preventative support. Helping people to access such types of support when they need can have to have a significant impact on their longer term health and wellbeing, as well as potentially reducing or delaying the need for ongoing care and support from the local authority.

In developing such approaches, the local authority should consider the different opportunities for coming into contact with people who may benefit, including where the first contact maybe with a professional outside the local authority for example, GPs, pharmacists or welfare and benefit advisers. There are a number of interactions and access points that could bring a person into contact with the local authority or a partner organisation and act as a trigger point for the local authority to consider whether the provision of a preventative service or some other step is appropriate. These may include:

• initial contact through a customer services centre, whether by the person concerned or someone acting on their behalf;
• contact with a GP, community nurses, housing officers or other professionals which leads to a referral to the local authority;
• an assessment of needs or a carer’s assessment (see Assessment), which identifies the person may benefit from a preventative service or other type of local support.

Many people with low level care and support needs will approach the voluntary sector for advice in the first instance. Local authorities and the voluntary sector should work together on how it can share this information to gain a fuller picture of local need as possible.

Prevention should be a consistent focus for the local authority in undertaking their care and support functions. However, there may be key points in a person’s life or in the care and support process however, where a preventative intervention may be particularly appropriate or of benefit to the person. The local authority should consider circumstances which may help to identify people who may benefit from preventative support, for example:

• bereavement;
• hospital admission and or discharge;
• people who have been recently admitted to or released from prison;
• application for benefits such as Attendance Allowance, or Carer’s Allowance;
• contact with/use of local support groups;
• contact with/use of private care and support;
• changes in housing.

5.5 Helping people access preventative support

A variety of different kinds of service, facilities or resources can be preventative and can help adults live well and maintain their independence or caring roles for longer.

Where a local authority has mechanisms for identifying people who may benefit from a type of preventative support, it should take steps to ensure that the person concerned understands the need for the particular measure, and is provided with further information and advice as necessary.

Contact with a person who is identified as likely to benefit from preventative services may lead to the local authority becoming aware that they have needs for care and support, including support as a carer. The appearance of need is likely to trigger a needs assessment or a carer’s assessment.

Where an adult is provided with any type of service or supported to access a facility or resource as a preventative measure, the local authority should also provide information in relation to the measure undertaken. A care and support plan or a carer’s support plan is not required for the provisions of prevention services only. However, people should be provided with information to help them understand:

• what needs the adult has or may develop, and why the intervention or other action is proposed in their regard;
• the expected outcomes for the action proposed, and any relevant timescale in which those outcomes are expected; and
• what is proposed to take place at the end of the measure (for instance, whether an assessment of need or a carer’s assessment will be carried out at that point).

The adult concerned must agree to the provision of any service or other step proposed by the local authority. Where the adult refuses but continues to appear to have needs for care and support (or for support, in the case of a carer), the local authority must offer an assessment.

6. Assessment of the Needs of Adults and Carers

See also Assessment.

In assessing whether an adult has any care and support needs or a carer has any needs for support, the local authority must consider whether they would benefit from the preventative services, facilities or resources provided by the local authority or which might otherwise be available in the community. This is regardless of whether, in fact, the adult or carer is assessed as having any care and support needs or support needs.

As part of this process, the local authority should also take into account the adult’s own capabilities, and the potential for improving their skills, as well as the role of any support from family, friends or others that could help them to achieve what they wish for from day-to-day life. This should not assume that others are willing or able to take up caring roles. Where it appears to the local authority that a carer may have needs for support (whether currently or in the future), a carer’s assessment must always be offered.

Children should not undertake inappropriate or excessive caring roles that may have an impact on their development. A young carer becomes vulnerable when their caring role risks impacting upon their emotional or physical wellbeing and their prospects in education and life. The local authority should consider how supporting an adult can prevent a young carer from under taking excessive or inappropriate care and support responsibilities. Where a young carer is identified, the Children’s Social Care should be notified so they can undertake a young carer’s assessment.

Regardless of whether or not a person is ultimately assessed as having any needs or any needs which are to be met by the local authority, they must be provided with information and advice about what can be done to prevent, delay, or reduce development of their needs.  This should be in an accessible form and is to ensure that all people are provided with information and advice that can support them to take steps to prevent or reduce their needs, and delay the onset of future needs. Where an adult has some needs that are eligible, and some other needs that are not deemed to be eligible, the local authority must provide information and advice on services facilities or resources that would contribute to preventing, reducing or delaying the needs which are not eligible.

It is important that people receive information in a timely manner. Access to the right information at the right time is a key element of preventing, delaying and reducing needs for care and support.

7. Charging for Preventative Support

Preventative services, like other forms of care and support, are not always provided free, and charging for some services is vital to ensure affordability. The Care and Support (Preventing Needs for Care and Support) Regulations 2014  allow local authorities to make a charge for the provision of certain preventative services, facilities or resources. The regulations also provide that some other specified services must be provided free of charge.

Where a local authority chooses to charge for a particular service, it should balance the affordability and viability of the activity with the likely impact that charging may have on uptake. In some cases, charging may be necessary in order to make a preventative service viable or keep a service running.

When charging for any type of preventative support, local authorities should take reasonable steps to ensure that any charge is affordable for the person concerned. This does not need to follow the method of the financial assessment used for mainstream charging purposes; and the use of such a process is likely to be disproportionate.

However, local authorities should consider adopting a more proportionate or ‘light-touch’ approach which ensures that charges are only paid by those who can afford to do so. In any event, a local authority must not charge more than it costs to provide or arrange for the service, facility or resource.

The regulations require that intermediate care and reablement must be provided free of charge for up to six weeks, as must aids and minor adaptations (that is, adaptations up to the value of £1,000).

Where local authorities provide intermediate care or reablement to those who require it, this must be provided free of charge for a period of up to 6 weeks. This is for all adults, irrespective of whether they have eligible needs for ongoing care and support. Although such types of support will usually be provided as a preventative measure, they may also be provided as part of a package of care and support to meet eligible needs. In these cases, regulations also provide that intermediate care or reablement cannot be charged for in the first six weeks, to ensure consistency.

Whilst they are both time-limited interventions, neither intermediate care nor reablement should have a strict time limit, since the period of time for which the support is provided should depend on the adult’s needs and outcomes. In some cases, a period of rehabilitation for a visually impaired person (a specific form of reablement), may be expected to last longer than six weeks. Whilst the local authority does have the power to charge for this where it is provided beyond six weeks, local authorities should consider continuing to provide it free of charge beyond six weeks in view of the clear preventative benefits for the adult.

8. Further Reading

8.1 Relevant chapters

Promoting Wellbeing

Information and Advice

8.2 Relevant information

Chapter 2, Preventing, Reducing or Delaying Needs, Care and Support Statutory Guidance (Department of Health and Social Care)

Prevention and wellbeing (SCIE)

See also Preventing, Reducing or Delaying Needs Case Studies, Resources

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