The success of treatment models is quantifiable but funding prevention strategies and services could prove to be a wiser use of CCGs’ resources, say Rachael Rothero and colleagues
It is a truism that prevention is better than cure, but the reality in health and social care is that for both commissioners and politicians, investment in treatment has always been safer than investment in prevention.
‘The increasing demands being placed on health and social care budgets and services cannot be met by the treatment model’
This is because the impact of treatment is more visible and its measurement more straightforward. But this approach needs to change as our society ages.
The increasing demands being placed on health and social care budgets and services simply can’t be met by the treatment model. We need preventative strategies that mitigate or defer the need for costly interventions.
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These preventative strategies usually focus on one of two approaches.
The first “formal” approach seeks to change the work of health and care professionals so greater investment is placed “upstream”, through community based interventions aimed at early detection and reduction of unnecessary admissions and referrals to secondary or specialist care. Examples of these interventions include:
- public health campaigns;
- self (or carer led) management and monitoring;
- enhanced community and primary care networks; and
- incentives and disincentives aimed at providers.
The second “informal” approach focuses on boosting the capacity and role of individuals and communities to ensure people can act on their natural preference when faced with care needs. That preference is usually to be supported by the people they know – friends, family, local networks.
This “asset based” approach prioritises investment in liberating the untapped resources of individuals and communities over investment in reorganising formal, professional services.
‘Really effective integration finds ways to connect people’s natural social and trusted circles with professional health and care services’
When neither of these approaches are adopted, and especially where communities are fragmented and passive, hospitals and care homes struggle to cope with rising demand and shrinking budgets. When both are promoted, the integration between the “formal” and “informal” becomes a critical success factor.
Really effective integration goes beyond the professional integration of health and social care, finding ways to connect people’s natural social and trusted circles on the one hand, with professional health, care and other civic services on the other.
Prevention Matters, a programme led by health and social care commissioners in Buckinghamshire, is doing just that. Funded by health transfer of funds under section 256 arrangements, it is one of the largest programmes in the UK focused explicitly on prevention.
The Buckinghamshire example
Prevention Matters is aimed at around 7,000 adults across the county who are vulnerable or at risk of losing their independence. In a semi-rural county like Buckinghamshire, social capital – the human relationships that contribute to our wellbeing and prospects in life – is seen as a crucial lever for extending residents’ independence and quality of life.
With support from the Innovation Unit, Buckinghamshire County Council and Aylesbury Vale and Chiltern clinical commissioning groups are working with more than 100 partners across health, housing and the local voluntary and community sector to address the needs of this group through a whole system approach.
This meant shared objectives and definitions of success had to be agreed at the outset and an analysis of the whole system had to be included in the co-design process.
Our analysis revealed what many commissioners across the UK might recognise as challenges of their own social care systems:
- complex or weak relationships between sectors and services, which make setting shared outcomes or targets difficult;
- insufficient incentives to overcome the barriers inherent in joint working across sectors and services;
- a reactive rather than proactive system when it comes to understanding and growing support networks and services delivered by small and medium sized organisations, many of which lack the confidence and capacity to innovate;
- a lack of consistent, shared information about the needs and assets of users, their families and other support networks, and what gaps exist in informal provision;
- significant untapped resources, including physical assets, time and knowledge, at both formal and informal levels; and
- an active faith sector that plays a significant community role in supporting vulnerable adults, although it is is insufficiently connected to formal service providers and commissioners.
The programme sought to address these system challenges through the design and delivery of services, changes to roles, funding and governance across the partnership. This was undertaken through a co-design process, which established agreed principles to underpin the delivery of all services under Prevention Matters, including:
- nurturing and growing confidence and capacity for independence;
- developing strong and cohesive social capital;
- blurring formal and informal support networks; and
- better listening and deeper relationships to spot key risks and respond accordingly.
By taking an asset based approach, Prevention Matters is building the capacity of community and voluntary groups to grow and become more effective at supporting hard to reach individuals. For example, newly recruited community practice workers spend longer periods of time listening, motivating and connecting people to community groups by identifying their skills and interests, rather than their needs or conditions.
However, the creation of new ways of bridging community and voluntary organisations with formal health and care services is the greatest innovation, such as through the introduction of community links officers and the Intelligence Hub, which comprises a dedicated council team that monitors and details information about the existing provision of community and other prevention related services and activities.
How does it work?
Prevention Matters has three key functions:
- Supporting individuals through a range of intermediate activities such as “hand holding”, confidence building, signposting, coaching and assessments. CPWs, who are employed by local voluntary and community sector organisations, work closely with GPs and other health professionals who refer individuals to the service.
- Building community capacity to meet the needs of vulnerable and isolated adults. Seventy per cent of the project is commissioned through the third sector. This is led by seven specialist CLOs, employed by Buckinghamshire County Council, based in districts, and operating in close collaboration with leaders of communities, faith and volunteer groups. CLOs are the bridge between formal and informal sectors, working to establish new community based services and enhance existing services, as well as identifying gaps. Additional resources have also been made available to voluntary and community sector organisations: the Volunteer Hub helps with the recruitment, screening and training of volunteers; a new time banking scheme has provided a boost to local volunteering; and new funding is provided through a community grants scheme run by an independent charity.
- Building the sustainable capability of commissioners across health and social care to invest in preventative activities through the Intelligence Hub managed by, and based in, the council. This team monitors and gathers information about existing provision, users and the services they are accessing.
Now in its second year, the programme aims to counter the growth curve of the number of adults with high or very high long term care needs. It is doing this by combining informal and formal approaches; it is building community capacity and assets, and boosting volunteering and peer support while also providing targeted, innovative referral routes from primary care and social care.
The programme’s delivery is distributed among a partnership comprising the county council, district councils, GP hubs and a number of voluntary and community sector organisations.
GPs have found that Prevention Matters provides a solution to patients they simply cannot provide – it connects them to their communities to ensure they get the support and care they need to lead better lives.
CLOs said the programme gives them a unique opportunity to listen and respond to the needs of the community in new and innovative ways, especially by using the skills and resources with that community.
Since Prevention Matters started in July 2013, more than 1,400 individuals have been referred to the CPWs. We know the service is having a positive impact as individual users have reported improved health and wellbeing.
We have also committed to assessing the economic impact, for example: how well the service prevents emergency and acute admissions, expedites discharge and defers the transition from independent to supported living.
It is hoped that external evaluation, due to report at the end of 2015, should also be able to demonstrate that Prevention Matters has significantly reduced the pressure on primary, secondary and social care in Buckinghamshire, as well as providing better outcomes for residents.
Rachael Rothero is service director for commissioning and service improvement at Buckinghamshire County Council; Aviv Katz is a partner at the Innovation Unit; Dr Steven Murphy is clinical commissioning director at Chiltern CCG; and Dr Kevin Suddes is clinical commissioning director at Aylesbury Vale CCG