Overview
Colleagues in West Sussex were experiencing high demand for long-term adult social care services, needs becoming more complex, and continued financial pressures. Action was taken to strengthen reablement as a core intervention, promoting independence and managing long term care demand. The Community Reablement Service was recommissioned, with approximately £0.72m additional investment.
The Occupational Therapists and Occupational Therapy Assistants of the Regaining Independence Service at the County Council work in partnership with a commissioned reablement provider, accepting referrals from both acute hospitals and the community. The service also directly employs a physiotherapist.
Action
As part of the recommissioning process, the service transitioned from a starts-based model to an hours based model, to improve value for money and access for customers with complex needs. The contract was tendered for up to six years, and the service operates seven days a week, between 7am and 11pm. Access was expanded to wider customer groups, including people with mental health and neurodiverse diagnoses.
Eligibility criteria are:
- aged 18 years old or over and resident in West Sussex
- have a primary social care reabling need, medically fit and not require nursing support
- have a cognitive capacity to consent and engage with a reablement programme as assessed
OT leadership has been embedded throughout the service. Council OTs work closely with the reablement provider to support people with the most complex needs, and those likely to need longer term care, as well as reviewing data from the service.
An internal culture change programme, ‘Why Not Reablement?’, has featured a sustained focus on growing community referrals, earlier intervention from the front door, and widening the customer profile of the service beyond the traditional cohort of older people. OTs form part of the adult social care access team to identify appropriate referrals among people not previously known to social care.
Colleagues see partnership working across health and care as essential. The Principal OT works to increase understanding among partners of the specialist skills of OTs, and how they can contribute to collective system aims. A pan-Sussex Rehabilitation and Reablement Programme has been an important space for joint working, including on reducing duplication of assessment between health and social care partners, and increased understanding of OT practice delivered in the community – strengths based, least restrictive, risk enablement and the promotion of resilience plans for people after rehab (health provision) and reablement (social care provision).
Key efficiency measures have included the participation of social workers in the Home First pathway. Their strong understanding of social care services ensures that appropriate referrals are made to reablement services. Provision was also made in the recommissioned contract to simplify transitions to other kinds of care for people who had been inappropriately referred to reablement.
The additional investment in the service was secured by robust data collection by adult social care teams and the reablement provider. The core metric was a comparison of the prescribed care hours of service users before and after reablement. Colleagues were able to benchmark their spend on reablement per capita, evidencing that their current spend was low against comparators, and the service also aligned with the Council’s strategic priorities of independence and wellbeing.
Outcomes
The programme led to improvements in:
- Triage accuracy, supporting people, their family and carers to receive the right care at the right time
- Accuracy of allocation of assessing resource to appropriately qualified staff
Governance and oversight of practice, with realistic and achievable goal setting, least restrictive care and support planning, and strengths-based practice - Measuring and evidencing informed innovation and expansion with commissioning and operational teams
- Reduced hand off – where there are residual care needs, OTs can ‘un pause’ Care Act Assessment and progress to determine eligibility, ensuring least restrictive care and support is achieved.
Measurements of change included:
- Total referrals increased by 38% from 2023/24 to 2024/25.
- Total starts increased by 49% from 2023/24 to 2024/25.
- 18,149 weekly care hours saved in 2025/26.
- “Aim achieved” with no ongoing care and support needs - rate improved from 68% (2022) to 76% (2025)
- Increase in average reduction in care hours for all reablement users from 6.7 hours in 2022 to 8.6 hours in 2025.
Peers to contact
Meg Brownings, Principal OT: [email protected]