Prevention in Action 2016

PREVENTION IN ACTION The extent to which English Local Authorities and Health and Wellbeing Boards recognise and prioritise prevention, as defined within the Care Act (2014) British Red Cross Prevention in action [email protected] l l 1

#PreventReduceDelay British Red Cross Prevention in action [email protected] 2 l l

Contents The Care Act: one step closer to putting prevention in action 4 Key recommendations 7 Key findings 7 Context 8 Pressures on health and social care 8 Something needs to change 8 Health and Wellbeing Boards 10 Research objectives 10 Methodology 11 Findings 13 Joint health and wellbeing strategy labels 13 An overview 13 The Care Act, NHS Five Year Forward View and Better Care Fund 13 The triple definition of prevention 14 Minimising the loss of independence for those with existing needs 15 Freedom of Information responses 16 Responses to question 1 16 Information and advice 16 An asset-based/ strengths-based approach 17 New services and the expansion or enhancement of existing ones 18 Investing in prevention 19 Integration 20 Other themes 21 Charging 21 Question 2: Developing a local approach to prevention 21 Question 3: Developing a commissioning strategy for prevention 22 How local authority and Health and Wellbeing Board strategies overlap 23 What this all means for adults in England 24 Conclusion and Recommendations 25 Important Note to Reader: This document is large. It is not intended to be read from cover to cover but as a reference document to support the implementation of the Care Act prevention duties. All readers should consult the Conclusion and Recommendations section. Acknowledgements Authors: Olivia Field, Chloe Carter. Special thanks are due to Briony Martin for her help with data collection and collation. British Red Cross Prevention in action [email protected] l l 3

THE CARE ACT: one step closer to putting prevention in action In 2014 the ambition to shift towards a truly During the passage of the Care Bill, the British preventative system was enshrined in law. Red Cross argued that this wasn’t sufficiently Section 2 of the Care Act places a new duty preventative. We wanted preventative services to on local authorities to ensure the provision of be available to everyone who may benefit from services that prevent, reduce or delay the need them, so that fewer people reach the point of crisis. 1 for care and support. Prevention is also a key Under Section 9(6)(b) of the Care Act, local component of the NHS Five Year Forward View, a authorities now have to consider whether shared vision for the NHS that notably calls for ‘a people could benefit from preventative services 2 radical upgrade in prevention and public health’. when carrying out a needs assessment, before 4 a determination is made as to their eligibility. Earl Howe, the then Parliamentary Under-Secretary And, as noted in the statutory guidance: of State at the Department of Health emphasised the importance of the Care Act’s prevention duty: ‘Where the local authority judges ‘Clause 2 creates a clear legal that the person may benefit from duty on local authorities to ensure such types of support [services the provision of preventative that prevent, reduce or delay the services… we believe that need for support], it should take preventative care can increase steps to support the person to 5 quality of life for individuals, while access those services.’ having the potential to provide The Red Cross also advocated strongly for longer-term financial savings to prevention to be clearly defined. We were concerned that because the term is understood differently the public purse. It is only with this across the country, there was a need to be explicit greater focus on prevention and about what ‘prevention’ entails, in order to support integration that both the NHS and local authorities to fulfil their new duty effectively. care and support can respond We were pleased that three equally important to the financial pressures of an forms of prevention were written into the statutory guidance: 3 ageing population.’ Historically, preventative services were only available to people with needs that met council eligibility thresholds. This meant that in the large majority of areas, people were required to have ‘substantial’ or ‘critical’ needs before they could access preventative services like reablement. 1.Care Act 2014, Section 2: legislation.gov.uk/ukpga/2014/23/section/2/enacted 2. NHS (October 2014), NHS Five Year Forward View: england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf 3. Earl Howe, The Parliamentary Under-Secretary of State at the Department of Health (29 July 2013): publications.parliament.uk/pa/ld201314/ldhansrd/text/130729-0001.htm 4. Care Act 2014, Section 9(6)(b): legislation.gov.uk/ukpga/2014/23/section/9/enacted 5. Department of Health (October 2014), Care and Support Statutory Guidance, Chapter 6 (6.62) British Red Cross Prevention in action [email protected] 4 l l

THE TRIPLE DEFINITION OF PREVENTION PREVENT: REDUCE: primary prevention / secondary prevention / DELAY: promoting wellbeing early intervention tertiary prevention Primary prevention is aimed Secondary prevention is Tertiary prevention is aimed at people who have no more targeted. Interventions at minimising the effect of particular health or care are aimed at people who disability or deterioration and support needs. The have an increased risk of for people with established intention is to help a person developing health or care or complex health avoid developing needs for and support needs, or at conditions. The goal is to care and support, or help carers with an increased support people to regain a carer avoid developing risk of developing support confidence and skills, and support needs. needs. The goal is to help to manage or reduce need slow down or reduce any where possible. For people Primary prevention includes further deterioration, to who have already reached universal policies such as prevent further needs from the point of crisis, the goal health promotion, first aid developing. is also to prevent that learning, dementia-friendly reoccurring. communities, enhancing Secondary prevention factors that are known includes short-term Tertiary prevention includes to help protect all people provision of wheelchairs, reablement, rehabilitation, (e.g. having a sense of handyman services, ‘social bed-based intermediate belonging, enjoying good prescribing’ services, care, outpatient diabetic relationships, housing telecare, earlier diagnosis, and vascular support, and good physical e.g. The NHS Health Check support to self-manage health), raising awareness programme/ screenings conditions, medical initiatives such as National etc., more targeted adherence programmes, HIV Testing Week, vaccinations (e.g.. the flu home adaptations, 6 universal services such as jab given to people assistive technology... community activities that over 65...) prevent social isolation, universal vaccinations (e.g. polio vaccine...) 6. Please note that there is no hard and fast rule as to where each of these examples fit – of course, some examples could apply to more than one type of prevention. Before using these examples it is important to think about the particular condition as well as the stage of the condition you are applying it to. It is, however a useful way of ensuring preventative interventions are being adopted across the pathology of a condition or illness. British Red Cross Prevention in action [email protected] l l 5

Everyone should get the support they need to live independently at home Problem Solution Ask Too many people have to We want to see more people Preventative services should reach the point of health and being able to access be made available to everyone, social care crisis before they preventative services, and fewer regardless of level of need or receive support. people reaching the point of ability to pay. health and social care crisis. British Red Cross Prevention in action [email protected] 6 l l

Key recommendations > Local authorities should implement the full ambition of the Care Act’s prevention duties. > The Government should look again at what resources are required to enable local authorities to implement these new duties in a meaningful way. > Every Health and Wellbeing Board should fully incorporate and prioritise prevention in their joint health and wellbeing strategies. > Decision-makers across health and social care should recognise that prevention is about more than just stopping a condition or illness arising. It is about preventing, reducing and delaying needs and associated costs. > Decision-makers across health and social care should use the Care Act’s triple definition of prevention as the basis of their preventative planning. Key findings > Prevention is an evident consideration in local strategies and plans. All but one of the joint health and wellbeing strategies mention prevention, and more than 80 per cent of local authorities have developed or are in the process of developing a local approach to prevention. > Yet, while prevention is better understood and emphasised than last year, the term ‘prevention’ is still understood differently across the country. This is despite the Care Act’s triple definition of prevention. > Thirty-seven per cent of joint health and wellbeing strategies still do not incorporate a full understanding of prevention. Prevention should be seen as an ongoing consideration and not a single activity or intervention > All too often, joint health and wellbeing strategies fail to recognise tertiary types of prevention. Many of the strategies understand prevention only as minimising the risk of people developing care and support needs (primary prevention), or as targeting people at high risk of developing needs (secondary prevention). > Local authorities have responded to Section 2 of the Care Act in a range of ways. > The majority of local authorities report making changes to the structures and processes that frame their provision of preventative services. These changes include creating new boards and roles, revising procedures, and reviewing guidance and training. > Over a third of local authorities report ‘developing or investing in new services’. However, many have yet to translate structure and process change into enhanced provision. 7 > Local authorities have yet to be ‘truly innovative in the services offered in their area’ . Services cited as ‘new’ tend to be those seed-funded by Government over the last ten to 15 years, such as telecare and handyperson’s services. > And in some cases, local authorities are conflating their duty to provide information and advice with their duty to prevent needs for care and support. These are two distinct duties, which should be distinguished in local strategies and plans. > Local decision makers emphasise the practical difficulties of shifting resources from crisis intervention to prevention, especially in the current economic climate. This Red Cross report is intended to help decision makers make this transition. It provides a national picture of local developments, and highlights areas of good practice. 7. Earl Howe, The Parliamentary Under-Secretary of State at the Department of Health (3 July 2013): publications.parliament.uk/pa/ld201314/ldhansrd/text/130703-0003.htm British Red Cross Prevention in action [email protected] l l 7

CONTEXT Pressures on health and social care While it has long been recognised that care sector have expressed their concern that this is “prevention is better than cure”, the UK’s health not enough to fill the funding gap in an open letter to and social care system has largely focussed on the Chancellor and Secretaries of State: reacting to crises rather than preventing them. Health is under real pressure with figure warnings ‘...the package put forward for of a £30 billion funding gap in the health budget by social care will not enable [them] 8 the end of the decade (28 per cent of the budget) to fill the current gap in funding, and an estimated funding gap for adult social care cover additional costs associated over the same period of £4.3 billion (29 per cent of 9 the budget) . with the introduction of the Britain’s population is ageing fast. More than one National Living Wage, nor fully in 12 of the population is projected to be aged 80 or meet future growth in demand 10 over by mid-2039 . At the same time, local authority 16 budgets have been cut. In the last five years, adult due to our ageing population.’ social care budgets have been reduced by £4.6 billion, representing 31 per cent of real terms net 11 Something needs to change budgets. Further cuts to local authority budgets were announced in the Chancellor’s 2015 Spending One way to ease the pressure is to invest in Review. preventative services… These cuts adversely affect the NHS. 88 per It pays to spend on prevention. Investing in cent of NHS Trust finance directors and 80 per preventing minor situations escalating into crises cent of clinical commissioning group (CCG) finance is more cost-effective than picking up the pieces. leads feel funding pressures on local authorities This principle applies across health and social care are adversely affecting the performance of health 12 and should span our lifetimes. It should also be services in their local health economy. enshrined in universal public health campaigns, right The Chancellor has responded to these up to the management of chronic illnesses and long warnings by committing an additional £10 billion term conditions. a year in real terms to the NHS by 2020. During his Directors of adult social care recognise this. 2015 Spending Review and Autumn Statement, he Seventy-three per cent of the Association of announced that £6 billion of this money will be made Directors of Adult Social Services’ (ADASS) Budget available next year. He also gave local authorities the Survey 2015 respondents see increased prevention power to increase social care funding through a new and early intervention as the top area for savings in two per cent Council Tax precept, claiming this could 17 13 2016/17 and beyond. ‘bring almost £2 billion more into the care system . Yet the two per cent levy has been criticised, with There is good evidence of these cost savings. claims it ‘will not raise enough to close the social An independent economic analysis of Red Cross care funding gap and will disadvantage deprived lower-level preventative services by the London areas with the highest needs for publicly funded School of Economics and Political Science identified 14 cost savings related to a reduced need for care and care’ . And Simon Stevens, the chief executive 18 of the NHS has since called for ‘a new national support equivalent to £880 per person . consensus on properly resourced and functioning 15 social care services’ . Finally, leaders of the social British Red Cross Prevention in action [email protected] 8 l l

The Local Government Association’s prevention Yet, while the triple definition of prevention has been spending model concluded that handyperson adopted by adult social care through the Care Act’s services have a return of £1.13 for every £1 invested statutory guidance, it was notably not mentioned in and telehealth care has a return of £2.68 for every the NHS Five Year Forward View. This is despite the 19 £1 invested. two documents being launched on the same day. Similarly, the Department of Health’s Mental Health The Red Cross is pleased that both recognise the Strategy 2011 estimated that its plans to expand need to shift from reaction to prevention. However, the provision of talking therapies services would ‘be unless we share a common language, we cannot strongly cost saving to the overall public purse, with be confident that we are all talking about the same a net saving of an estimated £302m’, representing a thing. With the Chancellor’s plans to integrate 20 23 public sector saving of £1.75 for every £1 spent. health and social care by 2020 , sharing the same definition will prove ever more important in effectively Yet, while local authorities see prevention as a key working together to make prevention a reality. source of savings for the future, spend on prevention only forms 6.6 per cent of local authorities’ budgets in 2015/2016 (a reduction in cash terms of 6 per 21 cent from the previous year) . As ADASS explains: ‘Many [local authorities] are struggling to balance investment in reducing future demand and costs at a time when budgets to meet existing statutory duties 8. NHS (October 2014), Five Year Forward View: england.nhs.uk/wp-content/ uploads/2014/10/5yfv-web.pdf 9. LGA & ADASS (October 2014), Adult social care funding: 2014 to provide care and support to state of the nation report: local.gov.uk/documents/10180/5854661/ Adult+social+care+funding+2014+state+of+the+nation+report/e32866fa-d512-4e77-9961- those most in need are under 8861d2d93238 10. ONS (October 2015), National population projections, 2014-based Statistical Bulletin: ons. 22 gov.uk/ons/dcp171778_420462.pdf such pressure.’ 11. ADASS (June 2015), ADASS Budget Survey 2015: adass.org.uk/uploadedFiles/adass_ content/policy_networks/resources/Key_documents/ADASS%20Budget%20Survey%20 2015%20Report%20FINAL.pdf A shared language 12. The King’s Fund (October 2015), Quarterly Monitoring Report: qmr.kingsfund.org. uk/2015/17/ 13. Chancellor George Osborne’s Spending Review and Autumn Statement 2015 speech (25 The Care Act clearly recognises that prevention November) is about more than just stopping something 14. The King’s Fund (25 November), The King’s Fund’s response to the Spending Review: kingsfund.org.uk/press/press-releases/kings-funds-response-spending-review arising. It is about preventing, reducing and 15. Simon Stevens (18 January 2015) delaying needs and associated costs. 16. Joint letter for the Chancellor and Secretaries of State, from Care and Support Alliance, Association of Directors of Adult Social Services, Care Provider Alliance, NHS Confederation (December 2015): careandsupportalliance.com/social-care-sector-response-to-the-spending- While public health interventions and reablement review/#sthash.eS0VEpiv.dpuf 17. ADASS (June 2015, ADASS Budget Survey 2015: adass.org.uk/uploadedFiles/adass_ services are generally recognised as preventative, content/policy_networks/resources/Key_documents/ADASS%20Budget%20Survey%20 there is much more to prevention than these 2015%20Report%20FINAL.pdf 18. Personal Social Services Research Unit, LSE & Research, Evaluation and Impact team, alone. And while public health initiatives – such British Red Cross (January 2014), An Analysis of the Economic Impacts of the British Red Cross as diabetes and obesity prevention – are gathering Support at Home Service: pssru.ac.uk/archive/pdf/dp2869.pdf pace, not enough attention is being paid to other 19. LGA (September 2015), Prevention: A Shared Commitment: local.gov.uk/ documents/10180/6869714/Prevention+-+A+Shared+Commitment+(1).pdf/06530655-1a4e- preventative measures. 495b-b512-c3cbef5654a6 20. The Department of Health (February 2011), Talking therapy services – impact assessment: gov.uk/government/publications/talking-therapies-impact-assessment It is not possible to prevent everything 21. ADASS (June 2015), ADASS Budget Survey 2015: adass.org.uk/uploadedFiles/adass_ entirely, so it’s important that preventative content/policy_networks/resources/Key_documents/ADASS%20Budget%20Survey%20 2015%20Report%20FINAL.pdf approaches and interventions are adopted 22. ADASS (15 May 2015), Budget Survey 2015: Key Messages: adass.org.uk/full-report- across the life course and pathology of a adass-budget-survey-2015/ 23. HM Treasury (25 November 2015), Spending review and autumn statement 2015: gov.uk/ condition or illness. The triple definition of government/publications/spending-review-and-autumn-statement-2015-documents/spending- prevention helps us do this. review-and-autumn-statement-2015#a-sustainable-health-and-social-care-system-1 British Red Cross Prevention in action [email protected] l l 9

Health and Wellbeing Boards Research objectives Under the Health and Social Care Act 2012 The aim of this research study was to explore the each top tier and unitary authority in England extent to which local authorities and Health and had to establish a Health and Wellbeing Board Wellbeing Boards across England recognise and in order to improve health and wellbeing and prioritise the Care Act’s understanding of prevention. reduce inequalities. As a minimum, they are made up of one local elected representative, a local Specifically, we wanted to answer the following Healthwatch representative, a representative of questions: each local clinical commissioning group, the local authority director for adult social services, the local > Is pr evention a key consideration in local decision authority director for children’s services and the making, including commissioning? director of public health. One of their core responsibilities is to carry out a > And if so, does the understanding of ‘pr evention’ joint strategic needs assessment and develop a encompass all three tiers (primary, secondary joint health and wellbeing strategy that meets the and tertiary), including support services for needs identified in that assessment. Both should people with lower-level needs? ‘sit at the heart of local commissioning decisions, > Since the Car e Act came into force in April underpinning improved health, social care and 2015, has there been an improvement in the 24 prioritisation and understanding of prevention? public health outcomes for the whole community.’ > How do local authorities and Health and The Care Act’s statutory guidance reiterates the Wellbeing Boards plan to put prevention into importance of these strategies, noting that they action? ‘should be informed and emphasise preventative services that encourage independence and > How well do local authorities’ local appr oaches wellbeing, delaying or preventing the need for acute to prevention and their commissioning strategies 25 reflect the Care Act’s guidance on preventing, interventions.’ reducing and delaying needs? Health and Wellbeing Boards have also played a key role in the development of Better Care Fund We have undertaken a review of joint health and plans. The £5.3 billion Better Care Fund (previously wellbeing strategies two years in a row. Both called the Integration Transformation Fund) created times we concluded that the term ‘prevention’ is a local, single-pooled NHS and local authority understood differently across the country. In both budget to encourage health and social care 2013/14 and 2014/15 many strategies understood integration. The Chancellor committed an extra prevention only as minimising the risk of people £1.5 billion to the Better Care Fund by 2019-20 developing care and support needs in the first place as part of its ‘radical, local-led plan to create an (primary prevention) or as targeting people at high 26 integrated health and social care system by 2020’ risk of developing needs (secondary prevention). during his 2015 Spending Review. With this in mind, we also wanted to explore the Leaders of the social care sector are concerned following question: about the time-frame of this funding, noting that > Has ther e been an improvement in Health and it does not reach ‘levels of any significance until towards the end of this parliament.’ They also warn Wellbeing Boards’ understanding of prevention this puts ‘the delivery of the NHS Five Year Forward in light of the Care Act’s triple definition of 27 prevention? View and the Care Act at risk.’ Others have reiterated the importance of this being ‘new money’ 28 and ‘spent on adult social care.’ 24. Department of Health (2011), Joint strategic needs assessment and joint health and wellbeing strategies explained: gov.uk/government/uploads/system/uploads/attachment_data/file/215261/ dh_131733.pdf 25. Department of Health (October 2014), Care and Support Statutory Guidance, Chapter 4 (4.53) 26. HM Treasury (25 November 2015), Spending review and autumn statement 2015: gov.uk/government/publications/spending-review-and-autumn-statement-2015-documents/spending-review-and- autumn-statement-2015#a-sustainable-health-and-social-care-system-1 27. Joint letter for the Chancellor and Secretaries of State, from Care and Support Alliance, Association of Directors of Adult Social Services, Care Provider Alliance, NHS Confederation (December 2015): careandsupportalliance.com/social-care-sector-response-to-the-spending-review/#sthash.eS0VEpiv.dpuf 28. Lord Porter, Chairman of the Local Government Association (25 November): local.gov.uk/spending-review/-/journal_content/56/10180/7586753/NEWS British Red Cross Prevention in action [email protected] 10 l l

Methodology Very strong: Prevention is a key component of the strategy. It is either part of the vision, appears To achieve the research objectives: as a priority, principle, approach or features in the summary. The prevention that is emphasised clearly > we reviewed joint health and wellbeing strategies encompasses lower-level/ tertiary types of support for the third year in a row, and as well as primary and secondary examples. These > made a Freedom of Information (FOI) request of types of preventative services are available before, all English local authorities. during and after crisis point for a range of people and health problems. When reading the joint health and wellbeing Strong: Prevention is a key component of the strategies, we wanted to know: strategy. It appears as either part of the vision, as 1. Whether prevention was mentioned at all. a priority, principle, approach, or features in the summary. Prevention is in part understood as early 2. Whether prevention was mentioned in the intervention and lower-level support. Although there summary (if there was one). is recognition of the importance of these services, 3. Whether pr evention was mentioned in the they are often focused solely on one stage of the vision/ aim. person’s illness, rather than before, during and after. 4. Whether prevention was mentioned as a priority. A strong recognition of the importance of lower-level 5. Whether pr evention was mentioned as a preventative services but often only to one group of principle, approach or value. people, e.g. people with dementia, rather than all 6. Whether the Car e Act (Care Bill), Better Care people who may benefit. Fund (Transformation Fund) or NHS Five Year Neither strong nor weak: Prevention is probably Forward View were mentioned. mentioned as a principle, approach, priority (or 7. How str ong its focus on prevention was, and component of one) or features in the summary. whether its focus was in line with the Care Act’s However, it is not clear that prevention has been statutory guidance (each strategy was labelled wholly emphasised or understood in Care Act terms. very strong, strong, neither strong nor weak, Although there may be an obvious commitment to weak, or very weak). shifting towards prevention and early intervention, it is unclear whether this encompasses preventative The purpose of 2 to 5 was to determine whether lower-level support. there is any sort of emphasis on prevention. Generally, joint health and wellbeing strategies have Weak: Although prevention is mentioned, or an overriding ‘vision’ or ‘aim’, a set of ‘priorities’ may exist as a component of a priority, principle, (usually between three and five but sometimes approach, or may feature in the summary, it clearly more) and some guiding ‘principles’, ‘approaches’ only focuses on preventing a problem from arising or ‘values’. These tend to frame the strategies and through awareness raising or education (e.g. indicate their main areas of focus. preventing underage pregnancy by investing in sexual education). The purpose of 6 was to help determine whether national policy and practice developments have Very weak: No emphasis of any kind on prevention. translated into local plans. It’s important to note that some strategies were The purpose of 7 was to evaluate whether its due to be reviewed while completing this project interpretation of prevention was in-line with the Care and were subject to change. Moreover, they ranged Act’s statutory guidance. The labels (very strong, in length, detail and had different timeframes. strong, neither strong nor weak, weak, very weak) The combination of these factors makes the were ascribed according to whether prevention labels attributed to the strategies subjective and was a key element of the strategy and whether presumably temporary. Therefore, these results are prevention seemed to encompass lower-level/ intended to provide a guide as to the strength of the tertiary types of support as well as primary and strategies’ focus on prevention, as well as a guide to secondary examples. the year-on-year trend British Red Cross Prevention in action [email protected] l l 11

In addition, FOI requests were sent to all local authorities to see how they are implementing Section 2 of the Care Act. The following questions were asked: 1. What actions your council has taken to comply with Clause [Section] 2 of the Care Act 2014 (“Preventing needs for Care and Support”). 2. a) Whether you have developed a ‘local approach to prevention’ as per Section 2.23 of the Care and Support Statutory Guidance (“Developing a local approach to preventative support”) published in October 2014. b) And whether this approach clearly specifies and includes a range of examples of all three types of prevention set out in Chapter 2 of the Care and Support Statutory Guidance (“Preventing, reducing or delaying needs”) published in October 2014. 3. a) Whether you have developed a ‘commissioning strategy for prevention’ as per 2.24 of the Care and Support Statutory Guidance (within “Developing a local approach to preventative support”) published in October 2014. b) And whether this clearly specifies and includes a range of examples of all three types of prevention set out in Chapter 2 of the Care and Support Statutory Guidance (“Preventing, reducing or delaying needs”) published in October 2014. British Red Cross Prevention in action [email protected] 12 l l

FINDINGS Joint health and wellbeing strategy labels: 29 All 151 Health and Wellbeing Boards’ joint health However, there’s still a way to go. Fifty-six of and wellbeing strategies were read and labelled the strategies have been labelled neither strong accordingly: nor weak, weak or very weak, meaning 37 per cent still do not incorporate a full understanding of > Very strong: 57 (38 per cent) prevention or emphasise the importance of taking > Strong: 38 (25 per cent) a preventative approach. Many of these strategies > Neither strong or weak: 48 (32 per cent) understand prevention only as minimising the risk of > Weak: 7 (5 per cent) people developing care and support needs (primary > Very weak: 1 prevention), or as targeting people at high risk of developing needs (secondary prevention). > Prevention is mentioned in all but one strategy. Recommendation: > In total, 140 strategies include prevention in their > Health and Wellbeing Boards should fully vision, goals, priorities, approaches, principles or incorporate and prioritise prevention in their values. This has increased from 72 per cent joint health and wellbeing strategies. A well- to 93 per cent. rounded understanding of prevention should > It’s the ‘primary approach/ principle/ value’ of 10 be clearly emphasised throughout the strategy strategies and listed as an ‘approach/ principle/ and across the life course and pathology of a value’ in another 66. range of conditions or illnesses mentioned. > Fifty-five strategies mention prevention within their ‘priorities’, five in their ‘goals’ and five in their ‘visions’. The Care Act, NHS Five Year Forward View > Of the 120 that had some sort of summary (an and Better Care Fund executive summary/ foreword/ plan on a page or separate summary strategy), 80 (67 per cent) Only around a third of the strategies have been mention prevention. This has increased from updated since 2014 and only 32 (21 per cent) 57 per cent last year. mention the Care Act (or Care Bill) despite it being > Only about a third of all strategies have ‘the most significant reform of care and support in 30 been updated since 2014 (some have even more than 60 years.’ been out of date since the end of 2013). Only five of the 33 that mention the Care Act (or An overview Care Bill) explicitly refer to the prevention duty (Section 2 of the Care Act). However, others mention Prevention is being better understood and is the Care Act putting greater responsibilities on increasingly prioritised. The number of strategies local authorities, including ‘an increased focus on rated very strong has increased by 10 per cent prevention’. since last year’s review. The number of those that Of the strategies that mention the Care Act (or include prevention in their vision, goals, priorities, Care Bill), 23 (72 per cent) were labelled very strong approaches, principles, values or summary has or strong. This indicates that the Care Act (when increased by 21 per cent. engaged with properly) has likely had a positive This improvement could be due to the Care Act influence on the prioritisation and understanding of coming into force. However, other imperatives for prevention. an increased focus on prevention include the transfer of public health responsibilities to local government and Public Health England, the NHS Five Year 29. While there are 152 local authorities with responsibility for adult social care, Bournemouth Forward View, and the Better Care Fund. and Poole share a Health and Wellbeing Board. 30. Care and Support Minister, The Rt Hon Norman Lamb (15 May 2014). British Red Cross Prevention in action [email protected] l l 13

Just 10 mention the NHS Five Year Forward View. While none of these strategies was rated weak or very weak, there was no obvious correlation between doing so and a high-rating label. Perhaps this is because the Forward View fails to emphasise the importance of tertiary preventative interventions in the same way it emphasises primary and secondary. Thirty-seven strategies mention the Better Care Fund (or Transformation Fund, as it used to be called) in comparison to just six out of 138 last year. This could be because Better Care Fund plans have further developed over the course of the year. Recommendation: > Health and Wellbeing Boards should update their joint health and wellbeing strategies regularly so that they include key policy and practice developments. The triple definition of prevention While many more strategies are emphasising the using the triple definition of prevention is a useful importance of preventative interventions being way to ensure preventative interventions are being adopted across the life course and the pathology adopted across the life course and the pathology of of a condition or illness, only 12 joint health and a condition or illness. wellbeing strategies use the full triple definition of prevention (either primary, secondary, Some Health and Wellbeing Boards have used tertiary / prevent, reduce, delay / both their own terminology. In some cases the terms terminologies). applied cover all three types of prevention, but in many cases do not. For example, sometimes tertiary A further 46 use this terminology in part. For prevention is captured solely as ‘reablement’ or ‘long example, only talking about ‘delaying and reducing term care’. However, tertiary prevention is more than the need for care and support’ (often when referring just reablement and applies to more than those with to the Adult Social Care Outcomes Framework that long term needs. 31 includes this as its second of four key ‘domains’). In other cases, only the terms ‘primary’ or Various strategies also include a definition or ‘secondary prevention’ are mentioned. explanation as to what is meant by ‘wellbeing’. These definitions vary despite ‘wellbeing’ being Confusion as to what constitutes primary, defined under Section 1(2) of the Care Act. secondary or tertiary prevention was evident in some of the strategies. Some strategies appear to conflate ‘secondary’ and ‘tertiary’ prevention into Recommendation: ‘secondary prevention’. > Health and Wellbeing Boards should The British Red Cross does not want the sector to incorporate the Care Act’s triple definition of be diverted by discussions about which interventions prevention into their joint health and wellbeing sit where, so long as preventative interventions are strategies. being adopted before, during and after a crisis. > Health and Wellbeing Boards are Indeed, there is no hard and fast rule as to where encouraged to look to define ‘wellbeing’ using each preventative intervention sits. As the statutory the Care Act’s definition set out in Section 1 of guidance explains, ‘services can cut across any or 33 the Care Act. 32 all of these three general approaches’ . However, British Red Cross Prevention in action [email protected] 14 l l

Minimising the loss of independence often only emphasised at the beginning or end for those with existing needs of that course. They also tend to mention tertiary preventative services towards the latter stages of While there’s a clear increase in the number of life. However, as Warrington’s strategy notes a strategies recognising tertiary types of preventative ‘preventative approach needs to be focussed on interventions, the importance of primary and enabling people to maintain their independence and 34 secondary preventative interventions is still enabling them to regain it at any age’. emphasised much more. And in some cases it’s not clear this third type of Recommendation: prevention is recognised at all. > Health and Wellbeing Boards should In some cases, lower-level tertiary preventative prioritise and emphasise all three types of interventions are mentioned (for example, prevention across the life course. reablement/ care in the home/ support to self- > Health and Wellbeing Boards should pay manage/ home adaptations/ assistive technologies/ special attention to explicitly recognising the respite for carers etc.) but aren’t recognised as value of tertiary preventative interventions. preventative. Recognising their preventative value is an important step to ensuring their provision. Under Section 2 of the Care Act, local authorities must ensure the provision of preventative services. And under Section 9(6)(b), they must assess whether people who do not meet the national eligibility threshold would benefit from such services. Tertiary types of preventative service are sometimes only referred to in the context of 31. The Department of Health (November 2014), The Adult Social Care Outcomes Framework mental health, long term conditions or older 2015/16: gov.uk/government/uploads/system/uploads/attachment_data/file/375431/ ASCOF_15-16.pdf people. While many strategies set out a life course 32. Department of Health (October 2014) Care and Support Statutory Guidance, Chapter 2 (2.5) approach, prevention and early intervention are 33. Care Act 2014, Section 1(2): legislation.gov.uk/ukpga/2014/23/section/1/enacted 34. Warrington Health and Wellbeing Board, Warrington Health and Wellbeing Strategy 2015 – 18: warringtontogether.co.uk/media/1017/health-and-wellbeing-2015-18-low-res.pdf British Red Cross Prevention in action [email protected] l l 15

FREEDOM OF INFORMATION (FOI) RESPONSES We received responses to 149 out of 152 FOI Responses to question 1 requests. The responses varied in detail as well as content. Local authorities have responded to Section 1. What actions your council has taken to comply 2 of the Care Act in a range of ways, including with Clause [Section] 2 of the Care Act 2014 enhancing or expanding existing preventative services (“Preventing needs for Care and Support”). and changing their approaches to commissioning. Various themes were identified within the responses Despite financial pressures, some have allocated to question 1. These included: working with the new funds or set out to gradually shift more voluntary and community sector, working across resources from reactive to preventative services. departments, new services, the expansion or Some are looking for ways to increase the number enhancement of existing services, reviewing of people accessing preventative services by, for services, revised guidance or training, the creation example, not charging for them. of new boards, roles, programmes, strategies, plans, policies or priorities, revised procedures, Bexley Council demonstrated a full understanding implementing new approaches, identifying needs of the new duty to separate access to preventative and services, funds, information and advice. services from decisions about whether a person’s needs meet the national eligibility threshold: Information and advice Over half of the responses to question 1 ‘The eligibility identified for included ‘information and advice’. This was prevention is simply, if we the most commonly recurrent theme within responses to this question. think there is a risk of the The information and advice referred to was focussed individual requiring access on a range of issues, including available services, in the future without an new policies and new rights. immediate intervention, then the Local authorities report providing information and intervention should be actioned.’ advice in a variety of ways (including booklets, face to face, written, fact sheets, videos and via the telephone), but primarily via “universal” websites. However, the overall impression was that local authorities’ responses demonstrate a mixed level Section 2 (“preventing needs for care and of understanding about the new prevention duties, support”) and Section 4 (“information and and developments haven’t been as groundbreaking advice”) of the Care Act have been conflated in or innovative as hoped. This is despite the Care Act some cases. ‘embracing innovation and flexibility, unlike previous legislation that focussed primarily on traditional Information and advice is recognised within the 35 Care and Support Statutory Guidance as a ‘vital models of residential and domiciliary care’. component of preventing or delaying people’s need 36 for care and support.’ However, while good quality information and advice may be necessary for effective prevention, providing information and advice is not sufficient to fulfil the prevention duty. 35. LGA (August 2015) Guide to the Care Act 2014 and the implications for providers: local.gov.uk/documents/10180/6869714/L14-759+Guide+to+the+Care+Act.pdf/d6f0e84c-1a58-4eaf-ac34- a730f743818d 36. Department of Health (October 2014) Care and Support Statutory Guidance, Chapter 3 (3.1) 37. Care Act 2014, Section 4: legislation.gov.uk/ukpga/2014/23/section/2/enacted British Red Cross Prevention in action [email protected] 16 l l

As Chapter Two of the Care and Support Statutory An asset-based/ strengths-based Guidance makes clear, Section 2 of the Care Act is approach about ensuring the provision of a range of services that prevent, reduce or delay the need for care and Several FOI responses and joint health and wellbeing support. strategies mentioned moving towards ‘an asset- based approach’. The information and advice developments referred to within responses centre upon use of the internet. The terms ‘strengths-based approach’ and ‘asset- The focus upon internet-based information based approach’ are often used interchangeably. and advice is concerning. Section 4 of the Care The Care and Support Statutory Guidance uses Act is clear that information and advice must be the terminology ‘strengths-based approach’ and ‘accessible to, and proportionate to the needs of, instructs local authorities to ‘consider what else 37 those to whom it is being provided’. other than the provision of care and support might assist the person in meeting the outcomes they want The ONS Quarterly Internet Access Update in 2014 to achieve’ when carrying out assessments. In doing identified a huge discrepancy between younger and so, ‘authorities should consider the person’s own older generations’ use of the internet. While only strengths and capabilities, and what support might one per cent of 16- to 24-year-olds had never used be available from their wider support network or the internet, 63 per cent of the over 75s had never 38 within the community to help.’ been online. This approach should be centered on the individual, As recognised by Lewisham in their FOI response, co-production and maximizing independence. It internet-based information and advice will not must not be seen as a default alternative to be accessible or proportionate to the needs of a statutory services. Most importantly, family and significant group of users and potential users of friends should not be expected and must not be social care: pressured to take on caring responsibilities. The statutory guidance notes: ‘Despite its ever-growing use of technology and its potential to transform the way we do business to ‘Any suggestion that support could be available from be of benefit to everyone, we need to be mindful family and friends should be considered in light of their that the Digital Inclusion Charity ‘Go On’ estimates appropriateness, willingness and ability to provide any that 23% of UK adults still don’t possess the basic additional support and the impact on them of doing digital skills necessary to take advantage of it. For so. It must also be based on the agreement of the this reason Lewisham is now working with ‘Go On’, 40 adult or carer in question.’ starting by undertaking a series of ‘deep dives’ or work with residents to understand more about the A strengths-based approach should also recognise barriers and enablers to digital inclusion.’ the value of the voluntary sector and community groups. Local authorities recognise this: about a third of the responses to question 1, highlighted Recommendations: the importance of working with the voluntary > Local authorities should clearly distinguish and community sector. between their separate duties to provide As reflected in the FOI responses, local authorities information and advice and to provide are increasingly looking to the voluntary sector and preventative services within their local plans community groups to carry out a variety of functions, and strategies. from promoting wellbeing to providing lower-level > Local authorities must be mindful that many preventative support to those whose needs don’t adults and older people do not have the basic meet the eligibility threshold. skills to use the internet. 38. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 6 (6.63) 39. “Co-production” is when an individual influences the support and services received, or when groups of people get together to influence the way that services are designed, commissioned and delivered. Such interventions can contribute to developing individual resilience and help promote self reliance and independence, as well as ensuring that services reflect what the people who use them want.’ (Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.20)) 40. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 6 (6.4) British Red Cross Prevention in action [email protected] l l 17

New services and the expansion or new cohorts of people and making them available enhancement of existing ones prior to a full social care assessment. Over a third of the FOI responses mentioned ‘developing or investing in new services’. Over Recommendations: 60 different services were mentioned, including sensory reablement, therapeutic services, home > The Care and Support Programme adaptations, domiciliary care, assistive technology, Management Office (Department of Health, debt management, active walking, carers’ support Local Government Association and the and befriending services. Association of Directors of Adult Social Services) should review ‘opportunities for Earl Howe made clear that Section 2 of the Care Act shared learning’ to help local authorities be ‘truly was intended to encourage innovation: 48 innovative in the services offered in their area’. > Despite budget constraints, local ‘We want local authorities authorities should continue to look for ways to be truly innovative in the to invest in ‘a broad range of (preventative) 49 interventions, as one size will not fit all’. services offered in their area’.41 > While reinvesting in services previously seed-funded by Government (such as This ambition was recently reiterated by Una O’Brien, telecare and handypersons services) is then-Permanent Secretary at the Department of welcome, local authorities should seek to Health: ‘What we are seeking to do [through the realise the Care Act ambition of developing Care Act] is orchestrate much greater effort on and ‘truly innovative’ services. 42 attention to prevention and early intervention’. Disappointingly, the ‘new’ services identified The Care and Support Reform Programme were not particularly innovative. For example, 43 telecare and handyperson services were referred Management Office report quarterly findings to in various responses. While they both have clear from a ‘Care Act stocktake’ of local authorities’ preventative value, they should not be new to local progress with implementation. The purpose of authorities. In April 2006, the Government invested these stocktakes is to ‘develop a collective picture £80 million into the Preventative Technology Grant of progress across the country in a way that is useful that focussed on increasing the numbers of people both nationally and locally, providing information to able to remain independent with telecare. Similarly, the facilitate local strategic discussions, map progress Department for Communities and Local Government and identify support needs and opportunities for 44 introduced a handypersons grant in 2009/10 allocating shared learning’ . Findings from the fourth stocktake approximately £13 million in 2009/10 and £17 million (the one most recently available at the time of going in 2010/11 to English local authorities. to print) show 37 per cent of local authorities were identified as having potential support needs in Nevertheless, we were pleased to see a variety relation to arrangements for preventing needs for of lower-level preventative interventions listed care and support, an increase from 29 per cent in 45 (including those mentioned above). Despite the previous stocktake. the cuts local authorities have faced over the last Technology could play a huge role in five years they clearly recognise the importance of prevention. For example, the UK’s National Weather continuing to invest in services that prevent, reduce Service, ‘Healthy Outlook’, is helping people with or delay the need for care and support. COPD (chronic obstructive pulmonary disease) Around 15 per cent spoke about ‘expanding or to self-manage their illness by sending warning enhancing existing services’ in light of the texts about local weather conditions and providing prevention duty. This ranged from redesigning simple health advice. While the evidence base is still services so that they are more preventative to emerging, the alerts should prove useful, ‘given that improving their accessibility. Reablement was extreme temperatures, humidity and/or viruses in the consistently included under this theme. Several local air can aggravate the ill health of people who have authorities described opening up these services to COPD and increase hospital admissions’.46 British Red Cross Prevention in action [email protected] 18 l l

Investing in prevention being spent on preventing or coping with problems ‘makes it possible to plan and scrutinise the Both the FOI responses and joint health and transition to early action and to understand the wellbeing strategies indicate recognition that trade-offs between prevention and downstream 53 resources need to be shifted from reactive services.’ The triple definition of prevention can be to preventative spend. However, there is a useful tool in doing this. demonstrated uncertainty about how to go Local Government Information Unit (LGiU) recognised about doing this. that one of the biggest barriers to prevention is indeed ‘a lack of clarity around what constitutes Pleasingly, Staffordshire’s joint health and wellbeing preventative activity, how this links to outcomes and 54 strategy devotes a whole section to ‘shifting how much money councils spend on it overall.’ In resources’. While acknowledging that spending partnership with the British Red Cross and Mears, ‘more on prevention and early help means spending they therefore piloted an approach to mapping less on reactive intensive support’, it also recognises preventative spend against one of Camden Council’s the cost benefits of doing this: ‘This should quickly key outcomes. At the end of the pilot, LGiU published a 55 become a virtuous circle, where increased focus on toolkit for other local authorities to do the same. prevention and early help reduces the need for later intensive intervention, releasing further resources for Recommendations: 50 prevention and early help.’ > Local authorities should commit to shifting Staffordshire’s strategy also recognises that such a percentage of their resources towards a shift in spend would have to be accompanied by prevention. In doing so, they may find the significant changes to how this intensive support recommendations set out in the Southwark is delivered. The cited options include: reducing and Lambeth Early Action Commission’s the number of hospital beds used by emergency report, ‘Local early action: how to make it patients, reconsidering the number of hospitals happen’, useful. within the county or ‘reducing expenditure on > Local authorities (and Health and Wellbeing residential care, through helping many people to Boards) can use LGiU’s toolkit to track and 51 better understand their preventative spend. remain independent and living in their own homes.’ Several FOI responses mentioned the creation 41. Earl Howe, The Parliamentary Under-Secretary of State at the Department of Health (3 July of whole new prevention-focussed funds 2013): publications.parliament.uk/pa/ld201314/ldhansrd/text/130703-0003.htm or budgets. Others intend to gradually shift 42. Care Act first-phase reforms and local government new burdens: oral evidence, October 2015: data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/public-accounts- resources from reactive to preventative committee/care-act-firstphase-reforms-and-local-government-new-burdens/oral/22864.html 43. The Local Government Association, Association of Directors of Adult Social Services and the spend. A tangible commitment has been made Department of Health are working in partnership to support local areas in implementation of the by Nottingham: ‘Nottingham City’s Procurement care and support reforms. 44. Local Government Association, Care Act Stocktake: local.gov.uk/care-support-reform/-/ Strategy states as an aim that the Council should journal_content/56/10180/6341378/ARTICLE “Increase % spend on early intervention and 45. Local Government Association, Association of Directors of Adult Social Services and the Department of Health ,Care Act Implementation : Results of Local Authority Stocktake local.gov. preventative approaches by 1% each year across uk/documents/10180/6869714/2015-08-11+Stocktake+4+report+%28Final%29.pdf/c1db7184- 5ea6-4a11-8d8d-07691a36e902 support services for adults and children.”’ 46. Phil Hope with Sally-Marie Bamford, Stephen Beales, Kieran Brett, Dr Dylan Kneale, Michael Macdonnell and Andy McKeon (Report of the Ageing Societies Working Group 2012), Creating Sustainable Health and Care Systems in Ageing Societies, Case Study 10 47. Malaria Journal (October 2012), Toward malaria elimination in Botswana: a pilot study The Southwark and Lambeth Early Action to improve malaria diagnosis and surveillance using mobile technology: malariajournal.com/ Commission (set up to find local ways of taking early content/11/S1/P96 48.Earl Howe, The Parliamentary Under-Secretary of State at the Department of Health (3 July action and preventing problems) noted in its final 2013): publications.parliament.uk/pa/ld201314/ldhansrd/text/130703-0003.htm Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.42) report: ‘The only way to ensure a significant move 49. Staffordshire Health and Wellbeing Board (2013), Living well in Staffordshire: Keeping you well towards early action is to commit to an incremental Making life better: staffordshirepartnership.org.uk/Health-and-Wellbeing-Board/Health-Wellbeing- Strategy-Staffordshire-2013.pdf 52 50. Staffordshire Health and Wellbeing Board (2013), Living well in Staffordshire: Keeping you well funding shift.’ Making life better: staffordshirepartnership.org.uk/Health-and-Wellbeing-Board/Health-Wellbeing- Strategy-Staffordshire-2013.pdf 51. Staffordshire Health and Wellbeing Board (2013), Living well in Staffordshire: Keeping you well As a precursor to doing this, it recommends Making life better: staffordshirepartnership.org.uk/Health-and-Wellbeing-Board/Health-Wellbeing- ‘classifying spending’ to distinguish reactive from Strategy-Staffordshire-2013.pdf preventative spend. Knowing whether money is 52. NEF, Southwark & Lambeth Early Action Commission (November 2015) Local early action: how to make it happen: b.3cdn.net/nefoundation/a5845188d1801a18bc_3nm6bkn3b.pdf British Red Cross Prevention in action [email protected] l l 19

Integration accrue to other agencies such as the NHS or the 62 benefits system…’ ‘It is only with this greater focus on At the same time, integration should eradicate prevention and integration that both the NHS the sometimes false distinction between people’s and care and support can respond to the ‘health’ and ‘social care’ needs. Distinguishing between such needs all too often results in no financial pressures of an ageing population.’ statutory agency taking responsibility for the person 58 or service in question. As a result, we see too many (Earl Howe, 29th July 2013) people falling through the gaps and too many The importance of ‘integration’ was highlighted people’s needs escalating when they needn’t be. in a number of the joint health and wellbeing The provision of short-term wheelchair loans is just strategies and FOI responses. Under Section 3 one example of this. There is currently no clearly of the Care Act, ‘local authorities must ensure the defined duty for their statutory provision in England integration of care and support provision, including despite being included as an example of secondary prevention with health and health-related services, 63 59 prevention in the Care Act’s statutory guidance. which include housing’. It is particularly important Research demonstrates that they can prevent and to integrate ‘with partners to prevent, reduce or delay people’s need for health, social care and 60 delay needs for care and support.’ As the statutory support and reduce the level of need that already guidance notes: ‘Preventing needs will often be 64 most effective when action is undertaken at a local exists. This gap in provision is largely because of the level, with different organisations working together to false distinction between clinical and social needs for understand how the actions of each may impact on short-term wheelchairs resulting in a disagreement as 61 to where the responsibility should sit. the other.’ With almost a third of the FOI respondents Recommendation: highlighting their plans to work better with a range of other bodies (such as the NHS, faith > Devolved areas should seize the opportunity sector, police and businesses) or departments to eradicate the false distinction between (from housing to education), it seems local people’s clinical and social needs, and to authorities recognise the importance of joint return prevention savings to a single working in the context of preventing, reducing integrated budget. or delaying needs. > Local leaders should ensure prevention (in all The benefits of integration have been widely its forms) is a key aspect of all health and acknowledged for some time. However, there social care devolution deals going forward. have been some recent developments aimed at > Leaders within Greater Manchester and escalating the integration of health and social care. other devolved areas should ensure strategic These include the Better Care Fund and health and plans for the integration of health and social social care devolution developments in England. For care fully incorporate and prioritise prevention. example, Greater Manchester has been given control of a £6 billion integrated health and social care 56. NEF, Southwark & Lambeth Early Action Commission (November 2015) Local early action: how budget as part of its devolution deal and Cornwall is to make it happen: b.3cdn.net/nefoundation/a5845188d1801a18bc_3nm6bkn3b.pdf also developing a strategic plan for the integration of 57. LGiU (October 2013), Tracking your preventative spend: a step-by-step guide: lgiu.org. health and social care as part of its deal. uk/2013/10/16/tracking-your-preventative-spend-a-step-by-step-guide/ 58. Earl Howe (29 July 2013), publications.parliament.uk/pa/ld201314/ldhansrd/text/130729-0001. htm#1307296000176 The devolution of integrated health and social care 59. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.34) 60. Ibid. budgets provides a real opportunity to properly 61. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.32) invest in prevention. This is partly because both local 62. LGA (September 2015), Prevention: A shared commitment: local.gov.uk/ documents/10180/6869714/Prevention+-+A+Shared+Commitment+(1).pdf/06530655-1a4e- authorities and the NHS would benefit financially 495b-b512-c3cbef5654a6 from doing so. As noted by the Local Government 63. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.8) 64. McNulty, Carter and Beswick (July 2015), Putting the wheels in motion: Assessing the value Association: ‘It is (also) difficult for local authorities of British Red Cross short-term wheelchair loan: British Red Cross redcross.org.uk/~/media/ to build a business case to invest their scarce BritishRedCross/Documents/About%20us/BRC%20Wheels%20in%20Motion%20-%20July%20 resources in initiatives where the financial benefits 2015.pdf British Red Cross Prevention in action [email protected] 20 l l

Other themes ‘As part of its preparation for Care Act implementation, the Council consulted on how to Various other themes mentioned in responses to increase the take-up of preventative services and question 1 may enable local authorities to carry whether applying a charge for these could deter out their new prevention responsibilities but are not take-up, in which case it could easily transpire to be results in themselves: a false economy. Consultation feedback supported the Council’s preference not to exercise its charging > about 20 per cent mentioned reviewing their powers in relation to preventative services…’ guidance and training > 25 per cent have created new boards and roles The council’s ‘Provision of Free Preventative and > 25 per cent mentioned revising their Carer Support Policy’ explains its reasoning further: procedures (for example how they carry out ‘Making a charge for these services could act as a assessments or evaluate their services) barrier to access, and the Council’s administrative costs of collecting fees would reduce the funding > around half mentioned developing new 67 available for preventative support.’ strategies or plans > around 15 per cent noted they were reviewing Question 2: Developing a local approach their existing services to prevention > about 20 per cent mentioned they were identifying local preventative services and needs. 2. a) Whether you have developed a ‘local approach to prevention’ as per Section 2.23 of the Care and Support Statutory Guidance (“Developing Exploring new ways of working: Coventry a local approach to preventative support”) Council has developed an ‘Early Action Resilience published in October 2014. Centre’ that sets out to ‘understand how public b) And whether this approach clearly specifies sector organisations can support citizens to develop and includes a range of examples of all three resilience and thus reduce their need for statutory types of prevention set out in Chapter 2 of health and social care services.’ Exploring new ways the Care and Support Statutory Guidance of working and sharing good practice will be key to (“Preventing, reducing or delaying needs”) moving towards a truly preventative system and will published in October 2014. hopefully lead to increased innovation. Charging The responses to question 2 were in some cases not clear enough to allocate a simple ‘yes’ or ‘no’ to. As The Care Act Regulations prohibit local authorities a result, some responses were marked ‘not clear’/ from charging for intermediate care (including ‘not answered’. Eight responses to question 2a) out reablement) provided for up to six weeks, and minor of the 149 received were either marked ‘not clear’ or aids and adaptations up to the value of £1,000. ‘not answered’. While the Care and Support (Preventing Needs Of the remaining 141, we were reassured 65 that over 80 per cent of local authorities for Care and Support) Regulations 2014 allow have already developed a ‘local approach to local authorities to charge for certain preventative prevention’ as per Section 2.23 of the Care services, facilities or resources, the statutory and Support Statutory Guidance or are in guidance warns of the risks this may have on the process of doing so. Eighty-eight (62 per uptake: cent) confirmed that they have developed a local ‘Where a local authority chooses to charge for a approach to prevention. Another 27 (19 per cent) are particular service, it should consider how to balance in the process of developing one. the affordability and viability of the activity with the 66 likely impact that charging may have on uptake’. 65. The Care and Support (Preventing Needs for Care and Support) Regulations 2014, Regulation 4(a): legislation.gov.uk/uksi/2014/2673/pdfs/uksi_20142673_en.pdf Reading has decided not to exercise these charging 66. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.56) powers: 67. Reading (March 2015) Provision of Free Preventative and Carer Support Policy (2015): reading. gov.uk/media/2758/Item8/pdf/Item8.pdf British Red Cross Prevention in action [email protected] l l 21

According to this Section, ‘local authorities should Question 3: Developing a commissioning develop a clear, local approach to prevention which strategy for prevention sets out how they plan to fulfil this responsibility, taking into account the different types and focus of 3. a) Whether you have developed a 68 preventative support…’ ‘commissioning strategy for prevention’ as per 2.24 of the Care and Support Statutory While four respondents confirmed that they have Guidance (within “Developing a local not developed such an approach, the remaining 22 approach to preventative support”) published referred to pre-Care Act strategies or new plans that in October 2014. are not specific to prevention. b) And whether this clearly specifies and includes a range of examples of all three types of prevention set out in Chapter 2 of the Care and Support Statutory Guidance (“Preventing, reducing or delaying needs”) published in October 2014. Fifteen responses to question 3a) were either unclear or unanswered. Of the remaining 134, just over a quarter (36) have developed a commissioning strategy for prevention as per Section 2.24 of the statutory guidance and a further 25 are in the process Just over half (45) of the local approaches to of doing so. prevention that have already been developed clearly specify and include a range of examples According to this Section, ‘a local authority’s of all three types of prevention. A further 26 (30 commissioning strategy for prevention should per cent) clearly include a range of examples for consider the different commissioning routes available, all three types of prevention without specifying the 70 and the benefits presented by each.’ different types of prevention. Twenty local authorities confirmed they have not Eighteen (67 per cent) of the 27 local approaches to developed a commissioning strategy for prevention. prevention being developed will specify and include The others have refreshed existing commissioning a range of examples of the three types of prevention. strategies or developed new ones that are not It was not clear whether the remaining ones being specific to prevention. developed specified and included a range of examples of all three types of prevention. Of all the commissioning strategies (new and old), 40 (30 per cent) clearly specify and As noted in the statutory guidance, ‘prevention include a range of examples of all three types should be seen as an ongoing consideration and not of prevention, 15 will do and 31 include a 69 a single activity or intervention’. With this in mind, range of examples for all three types of it is likely local authorities’ approaches to prevention prevention without specifying the different will continue to develop over time. types of prevention. Recommendation: Recommendation: > Those local authorities yet to do so should > Those local authorities yet to do so develop a local approach to prevention. should develop a commissioning strategy for This approach should clearly specify and prevention or at least update their existing include a range of examples of all three types commissioning strategies to reflect the changes of prevention set out in Chapter 2 of the made through the Care Act. These should current Care and Support Statutory Guidance clearly specify and include a range of examples (“Preventing, reducing or delaying needs”). of all three types of prevention. British Red Cross Prevention in action [email protected] 22 l l

How local authority and Health and Wellbeing Board strategies overlap Local authorities are engaging with the triple regard to the importance of prevention through definition of prevention terminology more than Clause 1(3). Accordingly, there is a clear duty on local Health and Wellbeing Boards. Over half of the authorities and their relevant partners to co-operate local approaches to prevention that have already with one another in preventing, delaying and reducing been developed and over a quarter of local authority needs for care and support and carer’s support. commissioning strategies specify all three types These duties, coupled with the return of public health of prevention compared to just 12 (eight per cent) responsibilities to local authorities as a result of the of the joint health and wellbeing strategies. This is 2012 Act and the new prevention duty, present a perhaps to be expected, as the legislation’s duties unique opportunity for aligning prevention services 73 pertain to local authorities. However, the Care Act across health and care and support.’ statutory guidance is clear that a local authority’s commissioning strategy should be ‘integrated with As the place where key partners come together, the Joint Strategic Needs Assessment and Joint Health and Wellbeing Boards are well-placed to 71 Health and Wellbeing Strategy’. The statutory enable this sort of co-operation. The Care Act’s guidance recognises: statutory guidance also identifies joint health and wellbeing strategies as the ‘key means by which local ‘Preventative services, facilities or resources are authorities work with Clinical Commissioning Groups often most effective when brought about through to identify and plan to meet the care and support 74 partnerships between different parts of the local needs of the local population, including carers.’ It authority and between other agencies and the is therefore vital they continue to update their community such as those people who are likely to use strategies and prioritise prevention accordingly. 72 and benefit from these services’. However, as also seen in the joint health Recommendation: and wellbeing strategies, local authority FOI responses sometimes demonstrated confusion > All health and social care decision makers as to what constitutes primary, secondary or should adopt the triple definition of tertiary prevention. They also cited more prevention terminology – unless we share primary and secondary preventative the same language, we can’t be sure we interventions than tertiary. share the same ambition. As we move to increased integration and joint-working Finally, a number of local authorities referred to joint this will become ever more important health and wellbeing strategies in their responses to one or more of the questions asked in the FOI request. While – as noted above – this connection is welcome, it is particularly concerning that only around a third of the joint health and wellbeing strategies have been updated since 2014 and fewer than a quarter mention the Care Act (or Care Bill). Under Sections 6 and 7 of the Care Act, local authorities and their relevant partners must ‘co- operate’ in order to carry out their various functions. 68. Department of Health (October 2014), Care and Support Statutory Guidance, Chapter 2 Earl Howe noted how this relates to prevention: (“Developing a local approach to preventative support”), Section 2.23 69. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.5) 70. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.24) ‘Such co-operation is to be performed for the 71. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 4 (4.51) 72. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 2 (2.30) purposes of, among other things, promoting an 73. Earl Howe, The Parliamentary Under-Secretary of State at the Department of Health (3 July individual’s well-being, which in turn includes having 2013): publications.parliament.uk/pa/ld201314/ldhansrd/text/130703-0003.htm 74. Department of Health (October 2015), Care and Support Statutory Guidance, Chapter 15 (15.9) British Red Cross Prevention in action [email protected] l l 23

WHAT THIS ALL MEANS FOR ADULTS IN ENGLAND The new duties and responsibilities reiterated This research study does not tell us whether more throughout this research report are important steps people are accessing preventative services, as in ensuring fewer people fall into crisis. However, the Care Act intended. However, the number of they will only truly mean something when more FOI responses focused upon the provision of people are able to access services that prevent, “information and advice” rather than of “prevention” reduce and delay their needs for care and support. services suggests this ambition is yet to be realised. The same applies to the strategies, policies and approaches labelled ‘strong’ or ‘very strong’. This research therefore only tells part of the story. Recommendation: While there is no individual entitlement to > The Department of Health should preventative services under the Care Act, there is focus its Care Act implementation work a duty on local authorities to ensure the provision on understanding the legislation’s impact of preventative services and assess whether on people. We hope this research serves people could benefit from these services before a as a useful foundation with regard to determination has been made as to their eligibility. implementation of the prevention duties. When adults would benefit from a preventative intervention, they should expect support from their local authority to access those services. British Red Cross Prevention in action [email protected] 24 l l

Conclusion We will not sufficiently improve outcomes for people and their carers, nor will we release the associated It is widely accepted that prevention should sit cost efficiencies and savings. at the heart of the sector’s plans to innovate, FOI responses and joint health and wellbeing integrate and adapt to new challenges, strategies also emphasise the practical difficulties including financial. As previous British of shifting resources away from crisis intervention Red Cross studies have shown, there is no to prevention, especially in the current economic consistent understanding of exactly what climate. We hope this report supports this transition. ‘prevention’ is and how to put it into action. We also encourage local decision makers to The Freedom of Information (FOI) responses continue to explore ways of overcoming these indicate that local authorities are engaging with the challenges and to share useful learning. Care Act’s triple definition of prevention, but this terminology has yet to be embraced by Health and Recommendations Wellbeing Boards. We believe the triple definition of prevention is just as useful for the NHS, public health Decision makers across health and voluntary and community sector as it is for adult and social care: social care. > All health and social care decision makers It’s vital to ensuring preventative services are made should recognise that prevention is about more available across the life course and pathology of a than just stopping a condition or illness arising. condition or illness. Sharing the same language will It is about preventing, reducing and delaying become increasingly important as we move towards needs and associated costs. increased integration and joint working. > All health and social care decision makers should adopt the triple definition of prevention Both the FOI responses and joint health and terminology – unless we share the same wellbeing strategy review indicate that prevention is a language, we can’t be sure we share the key consideration in local decision making, including same ambition. As we move to increased commissioning. integration and joint-working this will become ever more important. However, while the review of joint health and Government and Whitehall: wellbeing strategies indicates an improved > The Government should look again at how understanding of prevention, tertiary types of to best enable local authorities to implement prevention are still not being emphasised as much the Care Act’s new duties in a meaningful way. as primary and secondary prevention. In some > The Department of Health should do more cases, they are forgotten altogether. Many Health and Wellbeing Boards are yet to place importance to distinguish between the older and on preventative measures that could stop the current versions of the Care and Support deterioration or reoccurrence of a health or social Statutory Guidance. care-related crisis by providing lower-level support. > The Department of Health should focus its Care Act implementation work on Local authorities are generally working to meet their understanding the legislation’s impact on new responsibilities under the Care Act. However, people. We hope this research serves as a there is so far little evidence of the innovative useful foundation with regard to solutions to preventing, reducing and delaying the implementation of the prevention duties. need for care and support that were the ambition of > The Care and Support Programme the legislation. Given the huge financial pressures on Management Office (Department of Health, local authorities, this is perhaps not so surprising. Local Government Association and the We are concerned that some local authorities are Association of Directors of Adult Social conflating their duty to provide information and Services) should review ‘opportunities for advice with their duty to prevent needs for care and shared learning’ to help local authorities be support. We will not achieve a truly preventative ‘truly innovative in the services offered in system by providing information and advice alone. their area’. British Red Cross Prevention in action [email protected] l l 25

Health and Wellbeing Boards > Local authorities must ensure they are > Health and Wellbeing Boards should fully operating in accordance with the most recent incorporate and prioritise prevention in their version of the Care and Support Statutory joint health and wellbeing strategies. A well- Guidance. rounded understanding of prevention should > Local authorities should commit to shifting be clearly emphasised throughout the strategy a percentage of their resources towards and across the life course and pathology of a prevention. In doing so, they may find the range of conditions or illnesses mentioned. recommendations set out in the Southwark > Health and Wellbeing Boards should pay and Lambeth Early Action Commission’s special attention to explicitly recognising the report, ‘Local early action: how to make it value of tertiary preventative interventions. happen’, useful. > Health and Wellbeing Boards should update > Local authorities (and Health and Wellbeing their joint health and wellbeing strategies Boards) can use Local Government Information regularly so that they include key policy and Unit’s toolkit to track and better understand practice developments. their preventative spend. > Health and Wellbeing Boards should incorporate the Care Act’s triple definition of Areas devolving or integrating health prevention into their joint health and wellbeing and social care: strategies. > Devolved areas should seize the opportunity > Health and Wellbeing Boards are encouraged to eradicate the false distinction between to look to define ‘wellbeing’ using the Care Act’s people’s clinical and social needs, and to definition set out in Section 1 of the Care Act. return prevention savings to a single integrated budget. Local authorities: > Local leaders should ensure prevention > Local authorities should clearly distinguish (in all its forms) is a key aspect of all health and between their separate duties to provide social care devolution deals going forward. information and advice and to provide > Leaders within Greater Manchester and preventative services within their local plans other devolved areas should ensure strategic and strategies. plans for the integration of health and social > Local authorities must be mindful that many care fully incorporate and prioritise prevention. adults and older people do not have the basic skills to use the internet. Voluntary and community sectors, > Those local authorities yet to do so should including the British Red Cross: develop a local approach to prevention. > The voluntary and community sectors > Those local authorities yet to do so should should continue to raise awareness of both develop a commissioning strategy for prevention people’s social care entitlements and local or at least update their existing commissioning authorities’ adult social care duties. strategies to reflect the changes made through the Care Act. These should clearly specify and include a range of examples of all three types of prevention. > Despite budget constraints, local authorities should continue to look for ways to invest in ‘a broad range of (preventative) interventions, as one size will not fit all’. While reinvesting in services previously seed-funded by Government (such as telecare and handypersons services) is welcome, local authorities should seek to realise the Care Act ambition of developing ‘truly innovative’ services. British Red Cross Prevention in action [email protected] 26 l l

British Red Cross Prevention in action [email protected] l l 27

Where we are: British Red Cross 44 Moorfields London EC2Y 9AL redcross.org.uk [email protected] Published February 2016 All photographs © Simon Rawles ISBN 978-0-900228-27-8 Copyright © 2016 Any part of this publication may be cited, translated into other languages or adapted to meet local needs without prior permission of the British Red Cross, provided that the source is clearly stated. The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949), Scotland (SC037738) and Isle of Man (0752). British Red Cross Prevention in action [email protected] 28 l l