P1246990943OWRGo

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Research into policy and practice the
evidence-base for preventive services
Simon NorthmoreAge Concern England Research
Development Unit
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Age Concern Englands approach to research

• Achieving corporate priorities
• Raising awareness of older peoples contribution
• Policy work on ageing
• Developing innovative service models

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An evidence-based industry

• But ..
• there is little evidence to date on the
  efficacy of EBP in terms of improving the overall
  lot of the (user) in the beleaguered health and
  social care systems translations of evidence
  into practice guidelines have so far made little
  impact on the theory-practice divide
• Swinkels et al 2002

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The evidence base where are we?

• Recent developments
• Wanless Social Care Review
• ODPM Making life better for older people
• Growing body of qualitative researchbut
• Lack of quantitative evidence on impact
• Almost no evidence on cost effectiveness

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Why is there a lack of evidence?

• Difficulties of attributing cause and effect in
  social care
• Wide-ranging focus few studies are directly
  comparable
• Studies are mainly small-scale and specific
  difficult to generalise
• Dominance of the bio-medical model in what
  counts as evidence for health and social care
  outcomes

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Difficult to define prevention

• Same word, different meanings-
• Health promotion exercise, diet, smoking
  cessation, falls prevention
• That bit of help low intensity practical
  support services
• Earlier intervention support to sustain and
  restore wellbeing
• Admissions avoidance last minute, intensive
  support

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A continuum of services
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Key assumptions of traditional medical research

• The need for objectivity especially randomised
  controlled trials
• Hierarchies of evidence
• Qualitative research including the views of
  service users and carers seen as subjective
  or anecdotal

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Knowledge-based practice

• Organisational knowledge
• Practitioner knowledge
• Policy community knowledge
• Research knowledge
• Users and carers knowledge
• Pawson, R. et al (2003) Types and quality of
  knowledge in social care, London Social Care
  Institute for Excellence

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• Knowledge evidence practice wisdom service
  user and carer experiences and wishes
• Marsh, P. Fisher, M. (2005) Developing the
  evidence base for social work and social care
  practice, London Social Care Institute for
  Excellence

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Looking at the evidence

• Longitudinal studies
• Quality of life studies
• Cost effectiveness studies
• Low-level interventions
• Formal health and social care services
• Event/condition specific interventions
• Curry, N. (2006) Preventive Social Care is it
  cost-effective? London Kings Fund

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Longitudinal studies

• Population based study of social and productive
  activities as predictors of survival among
  elderly Americans
• Thomas A Glass, Carlos Mendes de Leon, Richard A
  Marottoli, Lisa F Berkham (1999)
  BMJ Volume 319478-83

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• Social and productive activities that involve
  little or no enhancement of fitness lower the
  risk of all cause mortality as much as fitness
  activities do. and
• the effect of social and productive activity
  on mortality was the strongest amongst the least
  physically active

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Quality of life studies

• Older people say they want to be
• Competent and in control
• Involved and participating
• Purposeful and productive
• Contributing (as well as receiving)
• Low-level interventions that support independence
  are highly valued
• that bit of help practical, emotional, social

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Cost effectiveness studies

• Longitudinal studies point to cost savings
  downstream
• Difficult to determine cost effectiveness of
  interventions on a locality basis
• No standard measurements to speak of or
  consensus about the time period over which it is
  reasonable and appropriate to measure outcomes
  (Wanless)
• Few published cost effectiveness studies

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Formal health and social care services
Intermediate Care

• Difficulties of definition
• Spans health and social care services measuring
  outcomes and cost-effectiveness is extremely
  complex
• Evidence not clear-cut benefits to patients (64
  return home) but longer lengths of stay overall
  financial gains may be felt over the longer term
• Godfrey, M. et al (2005) An Evaluation of
  Intermediate Care for Older People, Leeds
  Institute of Health Sciences and Public Research,
  University of Leeds

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A social rehabilitation pilot

• ACE funded 5 social rehabilitation projects in
  local Age Concerns
• Each project employed a co-ordinator to
• Manage the project recruit and train volunteers
  work with service users
• Three year pilot externally evaluated by
  Birmingham University
• Le Mesurier (2003) So much more than just
  walking an evaluation of a pilot programme of
  social rehabilitation projects provided by Age
  Concerns in five locations in England, London
  Age Concern England

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Task-centred practice

• Achievable goals framed in the language of
  service users get down the pub again join
  Weight Watchers make tea for my wife
• Addresses problems prioritised by users
• Time-limited 13 weeks
• Strong social/emotional component
• Planned tasks focus on mobility, exercise and
  functional skills

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Evaluation objectives

• To measure the impact of the projects on quality
  of life
• To assess how well they complemented other
  community services and the factors that
  influenced integration
• To assess organisational implications of
  developing the model

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Findings

• 500 referrals 75 aged over 75
• 50 completed the programme
• Successful in helping older peoples confidence,
  motivation and self-esteem
• Many exceeded their own expectations
• Rewarding for volunteers but recruitment
  difficulties

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Securing resources

• Positive working relationships with professionals
• No service contracts established
• Only one project was integrated into an existing
  care pathway
• Essentially a high quality, low-volume service
• Future for social rehabilitation may lie in its
  contribution to a general service ethos

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Key messages

• Long-term population based studies provide a
  quantitative measure of the link between
  well-being and welfare
• Recognition should be given to the wealth of
  qualitative evidence about the value placed on
  lower-level services by older people in helping
  them maintain their independence (Wanless)
• Effective prevention depends on good partnership
  working and appropriate targeting of services

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Tips and hints

• VCOs should take a pro-active approach
• develop promising interventions
• build in evaluation at the start
• include clear outcome measures and relevant unit
  costs
• challenge the dominant medical perspective on
  measuring outcomes

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The last word So much more than just walking!

• All we did, we walked up the street and back
  again, and then we walked as far as the park at
  the end of the road. I cant do that on my own
  yet, but I hope to God I do. I like to take my
  dog, and we always meet someone we knowIt means
  so much more than just walking!