Author
JACOBS Sally; et al.;
Modernising social care services for older people: scoping the United Kingdom evidence base.
Journal citation/publication details
Ageing & Society, 29(4), May 2009, pp.497-538.
Summary
The findings of this systematic review of 124 publications are presented within a framework based on six themes associated with the 19 areas of reform which apply to older people's services. The most significant evidence is tabulated for each of the six themes and discussed more fully for three of the themes: integration of health and social care, independence of older people, and fitting services to individual's needs. Weaknesses in the evidence base are identified, particularly with respect to the quality of studies and in terms of gaps in the evidence available.
Context
In line with its commitment to evidence-based policy making the UK Department of Health commissioned a review of the delivery, commissioning and impact of social care services for four adult user groups (mental health, physical/sensory impairments, learning disability, and older people) before the influence of modernisation. This study (one of four systematic literature reviews) was undertaken to provide an overview of the research literature relating to 'the social care of older people in the UK from the introduction of the community care reforms of the early 1990s to the New Labour reforms at the turn of the 21st century'.
Methods
What sources were searched?
The following electronic databases were searched: ASSIA (Applied Social Sciences Index and Abstracts), Sociological Abstracts, Social Services Abstracts, CareData, CINAHL (Cumulated Index to Nursing and Allied Health Literature), the Cochrane Library, HMIC (Health Management Information Consortium), Medline, PsycINFO, and Social Sciences Citation Index. A number of key papers and nine journals (specified in additional notes) were hand searched and the reference lists of retrieved articles were scanned.
What search terms/strategies were used?
Keywords and search terms used in the searches to describe older people, social care and study type are detailed in Table 1; both 'inclusion terms' and 'exclusion terms' are presented.
What criteria were used to decide on which studies to include?
In order to be eligible for inclusion articles had to be peer-reviewed studies of people aged at least 65 years, or their carers, receiving community-based social care services in the United Kingdom in which the focus of the investigation was on service delivery, organisation, effectiveness, or commissioning. Studies had to be empirical with data collected between 1990 and 2001, inclusive. Studies without a social care component, or which were generic without specifying service recipients were excluded.
Who decided on their relevance and quality?
Titles and abstracts were initially screened; full text versions of potentially relevant articles were then obtained and examined in full against the inclusion criteria. Methodological quality was assessed using a rating system based on seven questions (see Table 3); a score of seven denoted high methodological quality. The process was carried out by the lead author and any queries were resolved by the review team.
How many studies were included and where were they from?
Over 7,000 references were initially identified, 234 were eligible for inclusion, and 124 high quality articles were included in the review (details outlined in Table 8). By definition all of the studies were based on the UK.
How were the study findings combined?
Data was extracted and coded using pre-determined categories; studies were also categorised according to their ability to address six themes of modernisation: integrated health and social care; promotion of independence; consistency of service provision; support to carers; fitting services to individuals' needs, and; the social care workforce. The results are presented as a narrative synthesis with numbers expressed as publications rather than studies as some studies generated multiple papers and addressed several questions.
Findings of the review
Overview of the literature
The proportion of relevant articles relating to each of the six themes was: fitting services to individuals' needs 67%, integrated health and social care 25%, promotion of independence 23%, consistency of service provision 16%, social care workforce 11%, and support to carers 10%. Data was broken down further within each theme and is reported in Table 4. Only 33% of the publications measured the impact of services for older people, the majority were descriptive. A small minority of papers (10) were randomised controlled trials and no systematic reviews were identified. Almost a quarter of the studies were of poor methodological quality and less than a third was rated as being transferable to a wider population. Quality scores for each of the six themes and the number of studies attaining the various dimensions of methodological quality are presented in Tables 5 and 6 respectively. In depth discussion of study methodology and quality is available in a related paper by Reilly et al., 2008.
Evidence supporting the modernisation of social care for older people is summarised for each of the six themes and categorised as 'strong' or 'weak/no evidence' in Table 7.
Integration
There was strong evidence that :Primary Care Trusts were slow to bring about integrated working practices, and; more progress had been made towards integrated service delivery in the field of mental health care for older people than in mainstream older people's services. Little or no evidence was found on the beneficial effects of integrated organisations in terms of quality of service delivery or on the development of a generic health and social care worker for older people.
Independence
Although few studies addressed hospital discharge of older people there was strong evidence that organisational issues, such as co-ordinating with social services, were the main cause of delayed discharges. One study provided strong evidence that intensive-care management was an effective alternative to care-home admission but few local authorities offered such a service. Evidence was lacking on social services contribution to intermediate care, the impact of day care, and the use of direct payments.
Individuals' needs
There was no strong evidence on the cost-effectiveness of different ways of managing care, or on preventative or low-level service provision. Barriers to a needs led or user-focused approach to assessment were identified as were predictors of service use and care home admissions.
Consistency
There was evidence that: eligibility criteria varied within and between local authorities; barriers to service use existed for people from ethnic minorities, and; self-funded admissions to care homes were not treated equally. There was no evidence of an extension in the range of services to meet assessed needs.
Carers
Carers' emotional needs were found to be neglected, the assessment of their needs was uncommon and there were high levels of unmet needs. There was no strong evidence on the cost effectiveness of different approaches to supporting carers.
Workforce
Studies found that social workers experience high levels of stress, and recruitment and retention are a problem in the care sector.
Authors' conclusions
The systematic review has 'provided baseline information from which to judge the impact of modernisation of social care for older people'. In order for evidence-based practice and policy to become a reality in the field there is a need for high quality research.
Implications for policy or practice
None are discussed.
Related references
Challis, D., et al. 2004. Social care services at the beginning of the 21st century: findings. Discussion paper M098, Personal Social Services Research Unit, University of Manchester.
Reilly, S., et al., 2008. Examining the state of adult social care research 1990-2001: a systematic synthesis of research methods and quality. Evidence and Policy, 4, 3, 155-182.