Reablement – Contract Monitoring QIPP

The Journey –

The Somerset Clinical Commissioning Group (SCCG) led the review and redesign of reablement services over the last two years to help improve outcomes for patients.  We worked with local authority colleagues to lead a joint programme to review existing services and implement a redesigned service model based on systems thinking methodology.  We also worked with a range of stakeholders from the NHS, adult social care providers, and independent and voluntary sector organisations.  The programme has been discussed and supported by the Somerset Health and Wellbeing Board.

Compass Disability was commissioned to bring together focus groups and develop a questionnaire giving people the opportunity to feedback their experiences of reablement services.  We held extensive stakeholder events with representatives from NHS, adult social care providers, independent and voluntary sector organisations and undertook a ‘deep dive’ exercise to understand what was happening in existing systems.

A pilot integrating health and social care teams at one GP surgery has been in place for 18 months.  It has been rolled out to 15 practices in the Taunton and Area GP Federation with plans to phase in the service across the whole of Somerset.

A clear message from the service users was: “I want to maintain my independence:  help me to find the solutions to do the things that matter to me”.  The key difference with this model is that we are asking patients what they feel is important to them and what goals they want to achieve.  The teams have flexibility to find solutions centred on these goals.  This is a fundamental shift from the ‘one size fits all’ approach often seen in existing services.



Improved patient experience and quality of life as care delivered in a more appropriate setting; 1{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} reduction in emergency admissions 7{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} reduction in readmissions


Annual value of savings made

2012/13           £311,000 (Gross) Recurrent

2013/14           £1,659,000 (Gross) Recurrent


Patient setting

In-patient          X Out-patient Community base     X
Mental health Chronic illness Cross-systems        X


Clinical area

Staying healthy Maternity/Newborn Children and young people Acute care    X
Planned care Mental health Long-term conditions   X End of life


Information, tools and techniques used 

Project Management Board jointly with Local Authority with Project Manager



County wide Somerset

Project being rolled out Somerset wide.  Population 550,000



2008 and ongoing

April 2012 to March 2013


Contact details and further information

Ann Anderson

Director for Clinical Commissioning Development

01935 384190

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