Tuesday, August 12, 2014
Countdown to the local offer for children with SEND
It might not seem like it as we bask in the midsummer heat, but September is coming up fast and local authorities are preparing to implement their ‘local offer’ for children and young people with special educational needs and disabilities (SEND) from 1st September. The local offer is basically what it says on the tin: what’s on offer for children and young people with SEND and their families, in their local area, and councils are working now to get all the information about this offer into one comprehensive and accessible place.
My fellow OPM researchers and I have been visiting families in a number of areas which took part in the SEND pathfinder evaluation, piloting the education, health and care (EHC) plan which will replace the annual statement of SEN over the next few years. As part of our interviews with families we’ve been asking whether they are aware of their local offer and what they think about it. There’s a mixed picture – some haven’t heard of it at all, while others have, but don’t know what it is yet. But there is one common theme which is plenty of enthusiasm for the concept in principle. Unsurprisingly the parents we’ve talked to love the idea of having information, links and contacts for services that are relevant and accessible to their child or young person, in their area, all listed in one place.
Earlier this summer OPM helped Achieving for Children, a community interest company delivering children’s services in the London boroughs of Richmond and Kingston, to hold a series of engagement events where parents and school staff could find out more about the SEND changes and the local offer in their area. Again the general idea was welcomed: ‘it should have always been there’, and was seen as ‘a step towards greater transparency’. Some key messages from parents and staff who attended were:
- the local offer could help to address patchy knowledge of provision which can leave parents frustrated in their efforts to find out what’s available
- families want the local offer to enable them to meet their family’s individual needs without getting lost in the detail and abundance of information, ‘in order to avoid it becoming like a maze’. Accessibility and usability of the planned website is crucial, i.e. it needs to be clear, user friendly and intuitive
- people also wanted to know who would help them to navigate and make sense of the local offer – ideas included an online forum, someone playing an ‘information navigator’ role, or a telephone helpline?
- as well as the website, alternative formats should be provided for families with different preferences and levels of capacity to access information online.
Richmond and Kingston demonstrated in this engagement process an inclusive and genuinely co-produced approach to developing their local offer, and through it gained valuable input from those who have a real need and appetite for their local offer to meet their needs. Other councils are doing likewise, Darlington for example, who have a survey and wide array of resources on their local offer webpage. Many are drawing on expertise and materials from the Council for Disabled Children and a number of voluntary sector organisations are also offering helpful guides to the SEND reforms more generally.
But while lots of councils have developed smart and clear front-end pages for their local offers, where you can click on categories of services, actually clicking through reveals mixed levels of effectiveness in terms of content and searchability. An article on parent-led website Special Needs Jungle raises interesting questions about how far local offers will end up reflecting local need, if they are developed from a starting point of ‘what technology do we have’, rather than ‘what do users want?’ So concerns remain about how accessible the local offer will be come September and whether families will really notice the difference when they try to get information about what’s available to them. We’ll be continuing to meet with young people and parents in SEND pathfinder areas over the rest of this year and will be keen to find out how it’s panning out from their perspective.
Wednesday, July 16, 2014
End of life care – something needs to change
As the population ages, the question of how we as a society care for people at the end of their lives is becoming ever more pressing. It is widely recognised that current systems for providing care for people at the end of life are not up to scratch. Only 7% of the population want to die in a hospital, with 66% saying they would prefer to die at home; yet in 2010 about 60% of deaths were in hospitals. This is putting a huge strain on individuals and their loved ones, as well as on the healthcare system.
What is preventing people from dying in their own homes if that is their choice? One major factor can be the lack of social care support for everyday needs such as washing, feeding, and emotional support. Social care currently falls within the remit of local authorities and is subject to means testing – which means that many people at the end of their lives are required to pay if they want to have their social care needs met at home. Social care support can, however, also be obtained for free through the NHS Continuing Healthcare route. But this system is widely regarded as too difficult and slow to access. When it comes to providing care for the dying, we only have one chance to get it right – but too often we do not.
The calls to correct this situation have become louder in recent years, with a number of reports and reviews, such as the 2010 Dilnot Commission and the 2011 Palliative Care Funding Review, urging for change. It is in this context that a coalition of six charities has come together to campaign for universal, free social care at the end of life, to enable people to die in the place of their choosing. The coalition brings together Macmillan Cancer Support, Help the Hospices, the National Council for Palliative Care, Motor Neurone Disease Association, Sue Ryder and Marie Curie Cancer Care.
As part of their campaign the coalition commissioned OPM to conduct research on how free social care at the end of life could work in practice. Earlier this month OPM’s Dr Chih Hoong Sin presented our research at the All-Party Parliamentary Group on Hospice and Palliative Care, highlighting key findings from our recently published report, ‘How could free social care at end of life work in practice’.
We looked at a number of existing models of end of life care where social care is free, to learn what was effective about these and how they might be replicated elsewhere. We reviewed existing literature, examined 12 different services including two in-depth case studies, and spoke to a number of practitioners, to try to work out how free social care at end of life can work in practice.
We found that a range of different localities and services are working to make free social care at the end of life a reality. However, this provision is by no means consistent nor universally available. Our key recommendations for how to change this so that everyone has access to free end of life care were:
- Improving what is already available, such as NHS Continuing Healthcare Fast Track funding. National guidance already exists but all too often this is not being followed locally; relevant measures need to be put in place to overcome the ‘implementation gap’;
- Encouraging innovation and new models such as the successful STARS Care programme in Liverpool, which provides a tailored, specialist care service for people at end of life;
- Ensuring commissioning of end of life care is more consistent across the country and prioritises holistic, person-centred care; whilst allowing for adaptation and innovation at the local level;
- Focusing on quality to make sure that everyone has access to the same good standard of care – and robustly monitoring this;
- Supporting strong partnerships between commissioners, services, professionals, providers, patients, carers and families, to embed a collaborative approach centred on the dying person.
There was consensus at the APPG event on 2nd July that the case for free social care at end of life has been definitively made; as Imelda Redmond from Marie Curie put it, “the moral argument has been won.” It is now a case of thinking about how, which our research set out to do. A key remaining question is where funding for free social care at end of life can be found; a significant step has been made in a recent Macmillan report which suggests that the NHS could actually save money by supporting people to die in their own homes rather than in expensive hospital beds.
In the end of life care arena there is much action afoot – with changes in the Care Act, and the Palliative Care Funding Review pilots. But more still needs to happen. And it won’t be a moment too soon, in the face of our ageing society, ongoing patchy provision, and the real challenges of soon ‘unsustainable’ local authority care budgets highlighted in this month’s ADASS report.
These challenges are pressing, and we urgently need a better system for care at the end of life. The campaign for free social care at end of life is thus bound to gather momentum in the months ahead. And, with all three of the main parties expressing support for this policy, can we hope that it will soon be a matter of when, and not how, free social care at end of life will become a reality for everyone?
Leadbeater, C. and Garber, J. (2010). Dying for Change. Demos. p.20.
 Dilnot, A. (2011). ‘Findings of the Commission on Funding of Care and Support’. Slideshow. The King’s Fund website.
 Hughes-Hallett T, Craft A, Davies D (2011). Funding the right care and support for everyone. Report of the Independent Palliative Care Funding Review. London: Department of Health.
Thursday, June 26, 2014
Charities launch new report into free social care at the end of life
A new report, How could free social care at the end of life work in practice?, written by OPM and commissioned by Macmillan Cancer Support, the Motor Neurone Disease (MND) Association and Sue Ryder, looks at the current state of end of life services in England and provides examples of people being able to access non-means tested social care.
It reveals that in some areas commissioners have been able to find innovative ways of integrating the health and social care systems to improve end of life care, including STARS Care Liverpool which is highlighted in the report.
Although the Continuing Healthcare Fast Track system is in place across the country, there is a concerning gap between official guidance on its implementation and how it operates in practice. This, coupled with a lack of awareness of, and clarity about, the established system is limiting choice for people at the end of life about where they can be cared for.
Social care can provide that much-needed practical support to people at the end of life as well as respite for carers to allow people to remain in their own homes if they so wish.
The coalition, which includes Macmillan Cancer Support, Sue Ryder, MND Association, Help the Hospices, The National Council for Palliative Care and Marie Curie Cancer Care, has been working together to campaign for free social care at the end of life to support people to die in the place of their choosing.
Mike Hobday, Director of Policy and Research at Macmillan Cancer Support, says:
“This report shows that access to free social care at the end of life, which gives people a real say in where they are cared for, is only available in small pockets across the country. We know the majority of cancer patients who are dying in hospital, at great expense to the NHS, want to be able to die in the comfort of their own home surrounded by their loved ones. We want to see more examples of the innovative services highlighted in the report and universal access to free social care at the end of life.”
Mike Smeeton, Director of Health and Social Care at Sue Ryder, says:
“It is encouraging to see new initiatives like Stars which focus on improving the quality of life for people at the end of life through the provision of free social care.
“However, we believe that this practice needs to be more common place throughout the country so that everyone, no matter where they live, can achieve the death that they want.
“Alongside local innovation around end of life care there is an urgent need to improve the way in which continuing health care funding is accessed and how the care is delivered. It is disappointing to see such diversion across the country from the Government’s own guidance.
“When it works well, we know that Continuing Health Care can be transformational in ensuring that people access appropriate and adequate care when they are dying, which affects not only them but also their families and carers.”
Chris James, Director of External Affairs at MND Association, says:
“The Motor Neurone Disease (MND) Association welcomes this timely report. The researchers have highlighted the unacceptable inequity that currently exists across England in dying people’s access to social care that is free at point of use. Innovative models like STARS in Liverpool should be commended and replicated across the country, but this requires a catalyst from decision makers at the top as well as those personally committed to the agenda at the local level.
“It is particularly important that we get end of life care right for people dying with conditions other than cancer. This group is still to benefit fully from end of life care initiatives. The social impact of rapidly progressing, terminal conditions such as MND is devastating on families, and the non-medical needs of people with MND are significant. The Government has sent welcoming signals about the introduction of free social care in recent months and years – this report adds more weight to the argument that the time to make this a reality has arrived.”
The charities are urging health and social care commissioners to adopt the recommendations in the How could free social care at the end of life work in practice? report to better support people at the end of life. These include:
- Improving access to high quality free social care services for people at the end of life.
- Collaborating with local partners to deliver integrated health and social care services.
- Monitoring needs and existing services more closely to inform the development of innovative new services.
The coalition is calling on the Government to make non-means tested, social care available to everyone at the end of life.
Wednesday, June 25, 2014
Safeguarding adults from neglect and abuse in care homes
Statistics published recently by the Health and Social Care Information Centre showed a 4% rise in the number of alleged abuse referred for investigation in 2012-2013. 45% of the alleged abuse took place in care homes. High profile media coverage of care home abuse, such as the Panorama programmes on the Winterbourne View and the Old Deanery scandals, drew attention to the neglect and abuse of disabled people and older people, respectively.
Much of the policy and media response have been in relation to addressing care failing through reviews and inspections, while drawing attention to the need for better training and supervision. Many have been quick to argue that, while regrettable, these scandals are one-off incidents and should not be taken as a reflection of the wider care homes sector. While it is clear that there are numerous examples of high quality care in care home settings, to continue thinking about care home failings as random occurrences to be addressed through better regulation and inspection is to settle on a partial solution.
Regulation and inspection serve important purposes. For example, 158 care homes have closed since 2011 following action taken by the Care Quality Commission (CQC). However, there are real limits to what they can achieve on their own. Andrea Sutcliffe, chief inspector of adult social care at the CQC, admitted that: “We cannot always know what goes on behind closed doors”. There are real questions about what goes into any consideration of ‘risk’ that underpins risk-based inspection approaches. In an insightful study published in 2001, Christopher Hood and colleagues argued that professional risk management strategies can often reflect public opinion and market forces, rather than stem from any objective analysis of risk.
Any inspection regime ultimately still relies on information provided to inspectors. The CQC for example accused Castlebeck, the company who ran Winterbourne View, of “misleading” it. It is noteworthy that both the Winterbourne View and Old Deanery scandals came to light as a result of whistleblowing, and even so only after numerous whistleblowers have come forward (11 in the case of Old Deanery).
Over and above doubts about the reliability of information underpinning regulation and inspection, there are additional questions about the effectiveness of the model of inspection. It is notable that a CQC inspection that took place at a time when the Panorama’s undercover investigation was being conducted gave the Old Deanery a clean bill of health. This raises serious questions about whether the model of inspection is fit for purpose.
The clarion call of ‘nothing about us without us’ should be embraced by regulation and inspection. The predecessors of the CQC: the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission, tested a model of reviewing and inspection in 2008 that involved people with learning disabilities as ‘experts by experience’ in looking at learning disability services. The evaluation conducted by OPM found that the involvement of ‘experts by experience’ added real depth and understanding amongst all members of the review/inspection teams about what a ‘good service’ looked like from the perspective of those may be using the service.
While regulation and inspection is important, they are only ever going to work within the context defined by how services have been commissioned, designed and delivered. The same principle of ‘nothing about us without us’ should similarly be applied to service commissioning and design to ensure that structures and processs that reproduce ‘vulnerability’ and ‘risk’ should be designed out of the system. For example, the evidence base points to the fact that inflexible services may actually lead to people being moved into residential care unnecessarily. Truly person-centred care should mean that patient and service user perspectives feed into commissioning and service design. It should not simply be a case of what commissioners or professionals think is ‘good for’ or ‘good enough’.
I will be talking about these issues at the Public Policy Exchange Symposium – Putting Compassionate Care First: Safeguarding Adults from Neglect and Abuse in Hospitals and Care Homes, on Wednesday, 25th June 2014.
Wednesday, June 25, 2014
How could free social care at end of life work in practice?
This report, written by OPM and commissioned by Macmillan Cancer Support, the Motor Neurone Disease (MND) Association and Sue Ryder, looks at the current state of end of life services in England and provides examples of people being able to access non-means tested social care.
It reveals that in some areas commissioners have been able to find innovative ways of integrating the health and social care systems to improve end of life care, including STARS Care Liverpool which is highlighted in the report.
Although the Continuing Healthcare Fast Track system is in place across the country, there is a concerning gap between official guidance on its implementation and how it operates in practice. This coupled with a lack of awareness of, and clarity about, the established system is limiting choice for people at the end of life about where they can be cared for.
Tuesday, June 17, 2014
Social Investment Workshop
Chih Hoong Sin, Director at OPM, recently spoke at a Social Investment Workshop at the Early Intervention Foundation, which brought together representatives from our 20 Early Intervention Places and experts in the field to discuss how social investment can support Early Intervention.
Tuesday, May 13, 2014
Chief Executives must act to secure a sustainable future for hospices
The Help the Hospices Commission report into the future of hospice care states that hospices need to be able to adapt in order to secure a sustainable future and be ready to meet increasing demand for palliative and end of life care. As Chief Executive of Ashgate Hospice in North Derbyshire I agree with this entirely, and to this end, I firmly believe that hospice chief executives cannot underestimate the need to reflect on and review their own approach to working with commissioners in particular, as part of that process of adaptation.
Hospice chief executives are key to driving a culture which is accepting of innovation, risk and transformation. This involves engaging those at every level in hospices, from Board to ward, to ensure a readiness to respond when commissioners begin to look more closely at hospice services or, to ensure that hospices themselves can drive opportunities to increase their offer and reach.
Like many other hospices, Ashgate has struggled in the past to promote itself and to be recognised by local commissioners as a vital service provider of palliative and end of life care provision in the local area. Much of our recent success in securing further income and developing our contractual relationship with commissioners is due to a persistent approach of raising awareness with commissioners about the very broad portfolio of services that the hospice offers, and in describing how a number of our own strategic goals are so closely aligned to those of the local CCG.
This is a challenge that all hospice chief executives face and of key importance is the ability for hospice leaders to have confidence in their own ability to influence, and to show the contribution that hospices can make to all parts of the health and social care system. It is clear that hospices have a fundamental role to play in shaping and transforming palliative and end of life care on a local, regional and national scale. I believe much of this opportunity will come through education and further penetration of hospice expertise into NHS services, care homes and other providers of palliative and end of care.
This thinking may well be met with some internal challenge. Chief executives may find that driving forward this view is unpopular with their local supporters, their workforce or even their Board. However, I would argue that as hospice leaders we have a collective responsibility to respond to the commission report and to be part of transforming the hospice movement. Promoting and developing our influence and reach to raise standards in palliative and end of life care across all settings is essential to improving the environment in which we all operate, and in will lead to longer term improvements in the provision of hospice care, and access to it, by local people.
By reflecting on their own organisation’s readiness to change, challenging those who may resist adaptation where it is needed, chief executives can position individual organisations in local areas to gain maximum support and to provide a much more integrated service. Furthermore, by coming together as a collective group of hospice leaders the opportunity to influence, to educate and to start to transform the provision of a really effective, high quality service for people with palliative and end of life care needs, wherever they are in the country, becomes a really exciting and more realistic strategic goal.
Wednesday, May 7, 2014
A new commissioning deal for hospices
At St Helena Hospice, a well-established charity serving North East Essex, we receive about a third of our net funding from the NHS – which is about the same as the national average. This means that two thirds of our expenditure for things like patient and family services and palliative and end of life care education, comes from the generous support of our local community and our own income generation activities. Yet despite the untypical nature of our funding, the contractual and working relationship between St Helena and the local CCG – like that of many hospices – remains that of the standard purchaser/provider split.
Like most hospices we offer a number of unique benefits to the local health economy. Firstly, we generate considerable social value by being the leading, and largest, local charity in the area, with a great reputation that generates considerable community goodwill and trust. This is something which many other NHS providers are unfortunately struggling to maintain in the context of austere public sector economic conditions and escalating demand (and public expectations).
Professionally hospices are the experts in palliative and end of life care, with an established holistic philosophy and ability to deliver truly integrated health and social care. Financially we invest more than £3 million of our own income each year direct into local services; more than the CCG spends on palliative and end of life services in the community in total. We also mobilise over 1,000 volunteers in support of palliative and end of life care, who contribute the equivalent of another £1.3 million to the local economy through their time and expertise. We follow a social, outcomes-based mission rather than bottom line or profit driven approach to delivery. We also offer benefits to commissioners because of our legal status as charities, such as the flexibility to receive and distribute income and expenditure over a number of financial years; autonomy from arbitrary national targets and bureaucracy; and, where we believe in the best interests of our constituents, a potentially higher risk-appetite than other providers.
Given this, I believe that the relationship between hospices and commissioners would be vastly improved, and the services offered to patients enhanced if, hospices were not treated as just another provider of services, but rather a trusted partner and co-commissioner aligned to long-term strategic goals.
Taking this approach hospices would be empowered to be more proactive and to take on a wider responsibility for the quality of and equitable access to palliative and end of life care in their localities. We need to remind our commissioners of the unique benefits we offer and go to them with solutions that are pitched in a language that they can relate to and that help address their challenges as well as those of the wider community. This means moving away from an over-reliance on qualitative benefits, and a track record of regulatory compliance to make our case, and instead translating our impact into avoided admissions, avoided A&E attendances and reduced acute excess bed days; after all the investment we want to see in the community can only come from unlocking resources being sucked into the acute sector.
This approach will be just as challenging for us as it will be to commissioners. Hospices will have to learn to a change their culture, build trustee engagement and understanding of the wider health and social care agenda, and to develop commissioning, contractual and business intelligence capability needed to co-commission. Commissioners in turn will have to learn to relinquish control and prove themselves open to an alternative procurement process premised on a more mature relationship with hospices. I for one believe that with the right attitude, approach and relationships it will be possible to negotiate a new deal.
Friday, May 2, 2014
Hospices and commissioners must work together to support ageing population
Demand for high-quality end of life care – including that provided by hospices – is set to surge in the next few decades, driven by the UK’s rapidly ageing population. An increasing number of people are living for much longer, many with multiple, complex health conditions. The number of people aged 85 and over alone is expected to double in the next 20 years. In addition, more young people with life-shortening conditions are living for longer. These changes all present huge challenges for all organisations involved in planning and delivering care for people with terminal illness throughout different stages of their condition and as they approach the end of their lives.
Public support for hospice care
The hospice sector cares for 360,000 people each year, of which a third are patients and predominately those with cancer. Those using hospice services as patients, families or carers have confirmed its value to them through positive feedback such as the Voices Survey. The invaluable and significant support provided by the public through fundraising confirms the value that local people place on hospice care. However, concerns have been identified about hospice provision in the future. Firstly, that there are insufficient levels of hospice care to reflect current and future needs. The number of people cared for currently is expected to at least double in the next two decades and the reality is that more hospice care will be needed for many more people with a far wider range of life-limiting conditions such as dementia and heart failure. Last year Help the Hospices commissioned a poll with Populus which showed that seven in ten people think demand for hospice care will “rocket” in coming decades because of the UK’s rapidly ageing population. Almost half of those surveyed (48%) said they were concerned there won’t be enough hospice care available in the future to support them or their loved ones if they need this. This rose to almost two thirds of people (63%) among those aged 65 and over. Secondly, there is concern that hospice care will not be identified as a significant solution by government, local health and wellbeing boards, commissioners and others in plans to meet future needs. While much work is underway currently to revise local systems and structures of end of life care, hospices are often excluded from such plans. It denies local developments of the expertise, innovation and commitment to high quality patient care that has driven hospice care in the past.
How hospices need to change in the future
Led by Dame Clare Tickell, with support from leaders from across the palliative and end of life care sector, the Commission into the Future of Hospice Care calls for adaptation on the part of hospices and particularly:
- investment in the development of new models of care and adaptation of existing services to meet increasing and changing demands for their services
- greater integration with the NHS and local authorities and strong relationships with care homes
- service as advocates and champions of change on behalf of the communities that they serve to influence health and social care service delivery in their locality
- closer engagement with other providers of end of life care as a means of sharing their expertise in providing person-centred care more widely with other organisations, including hospitals.
Increased partnership working will be particularly important for hospices in the future. The OPM event highlighted several examples of hospices working much more closely with a range of providers in their local communities. For example, some hospices are actively leading co-commissioning for end of life care and working in partnership with commissioners to shape and develop services that more closely match the needs of people in their local populations. Commissioners present also described ways in which they are working closely with hospices in their area to redress areas of shared concern. The potential role of hospices in meeting future need must not be ignored within the broader systems of health and social care. They bring a legacy of innovation and adaptation to people’s evolving needs, strong links with their local communities and have a unique position as both funders as well as providers of expert care. Hospices are keener than ever to work in partnership. It is important now that commissioners and others respond – engaging with them to find important solutions fit for the future.
Wednesday, April 16, 2014
Activating the NHS: reablement and patient collaboration
OPM recently played host to a range of NHS stakeholders at our patient engagement seminar. Amongst the lively discussion highlighting the need to include patients throughout the NHS, an emphasis was placed on shifting from passive engagement to active collaboration.
With the advent of social media and the new found ease of providing input and opinion, it is easy for service providers and users alike to feel they are engaged without actually changing processes in a meaningful way. For example, a local GP surgery may now hold regular patient participation groups, produce a practice newsletter, run patient surveys and offer a multitude of feedback mechanisms including online via NHS Choices; but in practical terms how much input are patients having in the provision of their own care?
As the breakfast seminar demonstrated, the NHS is making strides in attempting to including patients, or ‘citizens’ in the macro decision making structures of healthcare. However, it is important we also consider the need to include individuals from the bottom up. Patient engagement is about including the public in shaping the NHS as a whole, but it is also about including individuals in shaping their own healthcare. One way of doing this is through reablement.
Reablement is increasingly being used by local authorities as an adult social service that works with individuals instead of for them. In practice, this means assisting people with illness or disability to regain the capacity to live as independently as possible. As well as providing physical support, reablement is also about a person’s psychological and social health, building a person’s confidence and improving well-being. In this way, reablement is an active means of including patients in their care by setting shared goals and allowing people to own their individual recovery.
As well as feeding into the current trend of NHS patient ownership, reablement has gained government support. In 2011 Andrew Lansley emphasised the need to keep ‘people as independent and in good health for as long as possible’ and recent funding has been provided for adult social care services that have added health benefits; the so-called ‘256 monies’. There are clear reasons behind this policy support for reablement, not least in terms of individual well-being. On top of the benefits to individual quality of life that clearly come from being able to decide whether you wish to remain at home and being given the opportunity to relearn skills following injury; reablement also eases the pressure on acute services and saves the NHS money. For example, a study in Leicestershire found that 62% of people who had reablement did not need any ongoing care package after six weeks, compared to 5% of people who had conventional home care. By supporting people to do things themselves, reablement provides the tools for individuals to improve their health at a pace that meets their own needs and goals, thus decreasing the likelihood of future health problems and ongoing care. Independence is valuable at both the local and institutional levels.
The advantages of patient engagement in making individual, small choices are therefore just as clear as the advantages of including ‘citizens’ in making big, NHS wide decisions. However, as reablement shows, this needs to be done by actively, including individuals through collaboration in their care. The reablement ethos of ‘doing with’ rather than ‘doing for’ should be integrated throughout all levels of health and social care in order to truly engage patients in a meaningful way. Approaches such as reablement are able to reap rewards from the bottom up that can feed into the overarching workings of the NHS.