From 2012/13 acute trusts will be responsible for arranging and funding reablement for people who are ready for discharge from hospital. So where does this leave the role of councils?
The work that councils up and down the country have done to test, pilot and roll out enablement homecare has drawn the excellent potential of this type of service to the attention of the Department of Health.
In some places the clear link and overlap between this type of service and what we have previously termed intermediate care is leading to integrated services that focus on reablement, recovery and rehabilitation. Reablement is now very much in vogue.
Enablement/reablement/intermediate care – the terms are used interchangeably and to cover slightly different ranges of services. The DH has begun to use the term 'reablement' to cover both health and social care inputs after hospital discharge in particular – but these types of services are just as important in preventing admissions or in just supporting people in the community to re-gain independence.
In order to try and engage acute trusts in the beneficial impact of reablement post discharge, and specifically in its potential to prevent re-admission, the DH has issued new regulations which mean that from 2012/13 acute trusts will be responsible for arranging and funding reablement for people when they are ready for discharge. Indeed it seems they will be responsible for all health and social care for 30 days post discharge, with the exception of long term care placements.
The aim is to adjust the tariff to provide them with the funds to do this, and the funding available to PCTs or clinical commissioning groups for this purpose will include the money saved by not paying for hospital re-admissions within 30 days( which has kicked in this year) and the reablement funds provided to PCTs as part of the £1bn identified to support adult social care. It has been assumed by the DH that savings will accrue to councils as a result of the reablement which will be funded by trusts.
So – if at the moment councils are funding enablement homecare, including on hospital discharge then surely this is a good news/money saving proposition for councils? Well – maybe….
This plan has the potential to deliver some really good outcomes and efficiencies if implemented and managed effectively and in partnership across local health and social care economies. But it equally has the potential to cause disruption and chaos if organisations do not work together effectively.
As acute trusts become responsible for reablement, how will they discharge this new responsibility? Will they attempt to provide reablement services themselves? This seemed to be implicit in the original proposals – but what of Joe Bloggs or Joanna Brown who made the choice to go to XYZ trust but who live far afield - how will XYZ trust discharge its duty to offer them reablement in their own homes? Maybe then acute trusts will commission these services - but from whom? And what expertise do they have in commissioning homecare services or even, in many cases, community health services?
They are, after all, providers – and the NHS has a 'strict' purchaser/provider split rule… doesn’t it? And who will decide who needs reablement – will the focus be on those people at greatest risk of re-admission? Or will everyone who could benefit be able to access services – thereby achieving the intended impact of reducing demand for ongoing social care services and potentially avoiding unnecessary admissions to care homes?
What of councils who currently have staff providing enablement homecare services or who have contracts with the private and voluntary sector to deliver these? If acute trusts choose not to use existing services there will be staff to redeploy or make redundant and contracts to re-negotiate. Similar issues apply to community intermediate care teams if run by anyone other than acute trusts, and for health and social care bed-based reablement services.
Under current arrangements most reablement type services serve people who need support in their own homes and assist in preventing hospital admission, with `step-up’ services as important as those required after discharge. In most places these services are available for up to six weeks. If acute trusts arrange or deliver separate provision will people have to transfer to a new provider if they need the full six weeks reablement? If trusts decide to procure or provide services other than from existing providers then there may be questions of the viability of residual services and in some cases there may be contractual issues around commitments to purchasing particular volumes of service.
So there are lots of issues! The good news is that there is a way to make all this work and to share responsibility for, and funding of, reablement across local systems by pooling resources and agreeing to use the organisations best placed to commission to fulfil that role - and the organisations best placed to provide services to do just that. What that sort of arrangement needs is early and detailed local discussions informed by clear information about tariffs and resources more generally.
In this situation you’d expect to see these discussions being actively pursued across the country – yet that is not the case. Indeed there seems to be a relatively low level of awareness about the detail of this policy and of the actions that we should all be taking now to make it fly.
Discussions have been underway with a number of organisations who volunteered to be early adopters, but early adoption of a policy that is not yet fully formed and where the tariff at the heart of the change is not yet set is tricky to say the least. So in reality the group is acting mainly as a forum for discussion of some of the issues outlined above and as a source of information and as a sounding board.
With guidance expected to be issued in September, implementation planning will have to really step up a gear if all this is to run smoothly from April 2012. Local authorities, PCTs/clinical commissioning groups and community and mental health providers all need to engage with these changes and work closely with acute trusts to shape workable local solutions.
Sarah Pickup is vice-president of the Association of Directors of Adult Social Services
