Enhancing Independence Through Reablement and Enablement

CASE STUDIES

At a Glance…

Between October and December 2024, Peopletoo partnered with Stockton-on-Tees Borough Council (SBC) to assess and strengthen its reablement, enablement, and hospital discharge services. The objective was to help more people live independently for longer, reduce reliance on long-term care, and deliver cost-effective services. Our work focused on understanding current performance, modelling future capacity, and identifying opportunities to improve the system offer for people with learning disabilities, autism, and mental health needs. This partnership forms a core part of Stockton’s “Powering Our Futures” programme to transform Adult Social Care.

The Challenge

Stockton faced multiple challenges stemming from an ageing population, health inequalities, and rising demand across Adult Social Care. Key issues included:

A 60% increase in demand for learning disability support since 2022, with rising per-person costs.
An 85% increase in reablement referrals between October 2023 and October 2024, overwhelming capacity.
High rates of declined reablement referrals (73%), mostly due to staffing shortages and limitations on evening or double-handed care.
Inconsistent awareness and referral practice across community teams, leading to missed opportunities for reablement.
Fragmented data systems and Excel-based tracking, limiting outcome monitoring.
Lack of capacity and formal performance management in preventative services such as STEPs and Community Support Workers.

Stockton needed a system-wide review to evaluate impact, align resources, and scale what works, ensuring more people regain independence and reduce their reliance on formal care.

Our Approach & Delivery

Peopletoo delivered a comprehensive diagnostic and modelling exercise across three workstreams: reablement, enablement, and hospital discharge. Our delivery included:

Quantitative analysis and benchmarking: We assessed demand trends, unit costs, capacity, outcomes, and performance against regional and CIPFA comparators.
Qualitative case reviews: A multidisciplinary case file exercise showed to identify adults with the potential for reablement or enablement, highlighting the scale of missed opportunities.
Process mapping and workforce engagement: Site visits, interviews, and workshops with teams such as enablement services, Community Support Workers, and the in-house reablement team uncovered strengths and bottlenecks.
Financial modelling and the development of Invest to Save business case design to support an expansion or efficiencies in services, with identified financial opportunities. This included Digital solutions.
Best practice and national policy alignment: We tested local services against NICE, Care Act, NHS LTP and D2A guidance to identify improvement areas in integration, digital tools, and outcome tracking.
Supported Stockton to co-develop a “Reablement Profile” to support more targeted referrals and improve system decision-making.

The Impact

Outcomes Achieved

The work delivered measurable improvements and a clear roadmap for change:

£1.094m annual financial benefit identified within the expansion of Reablement.
Over £1m annual benefits as a result of improvements to hospital discharge.
Cost Avoidance Potential: The case review exercise and modelling identified potential savings of £675,000 annually through earlier and more accurate referrals.
Cultural and Process Change: The exercise improved understanding of reablement across teams and revealed opportunities to integrate reablement into care act reviews, reducing inappropriate long-term placements.
Foundations for System Change: The Council is now positioned to scale enablement through targeted investment, better data collection, and clearer roles for Community Support Workers.

Through a focus on person-centred outcomes, integrated delivery, and smarter targeting of resources, Stockton is now better equipped to meet current and future demand, helping residents live independently and well in their communities.