Low intensity support services: a systematic literature review

Deborah Quilgars

Although a number of initiatives and policy developments over the last two years have reasserted the importance of low intensity support services, current discussion on these services is largely taking place without a comprehensive assessment of the evidence.

Through the findings of a systematic literature review examining their effectiveness, Low intensity support services aims to inform the debate and provide information that will be useful in the development of the most appropriate low level services.

The report provides detailed methodology, which will be vital reading for anyone undertaking similar evidence-based reviews, and presents the review’s findings in three broad areas of study:

  • tenancy and housing support services;
  • practical support for people with support needs;
  • services which aim to increase social well-being and/or provide companionship or befriending.

It concludes with an assessment of the research evidence as a whole and looks at what is known about the effectiveness of low intensity support services, highlighting key issues for effective service provision and making recommendations for future research.

Summary

Summary

Despite some recent policy acknowledgement of the potential role of low intensity support services in assisting people to live independently, community care resources continue to be targeted mainly on high level, often crisis, interventions. Partly because of this continuing focus, there has been little consideration of the evidence of the value of low intensity services. The Centre for Housing Policy, University of York, has now undertaken a systematic research literature review of the effectiveness of such services in enabling people to live independently in ordinary housing. The review found that:

  • Users, across all types of services, consistently reported that services had a positive effect on their lives. In particular, they mentioned improved feelings of well-being and self-esteem.
  • There was a lack of good quality data on services' effects on housing-related issues (such as the rate of successful tenancies or movements to residential care). However, qualitative research indicated that how a service is delivered (e.g. timing, amount and length of support, attitudes of staff) heightens the likelihood of the tenancy being successful.
  • Research stressed the importance of social support; however, whilst there were evident benefits from one-to-one relationships between workers and users, evidence that services have increased users' social networks and activities was limited.
  • Few studies looked at how services affected health or the use of more acute services. However, a number of studies demonstrated that low intensity services, such as befriending, could maintain health and/or lead to an improvement in users' own views of their state of health.
  • The review revealed limitations in existing research, including: poorly developed ways of measuring effectiveness; the small scale of many studies, making general conclusions difficult; a shortage of long-term evaluations; and a lack of control or comparison groups. More use could also be made of qualitative methods. 
  • The researcher concludes that developing more robust methods of assessing effectiveness needs to take a higher priority. Service providers could contribute to this by collecting better routine information; incorporating users' views into the designing of research studies would also give a fuller perspective.

Background

It is now widely accepted that, over the past decade, limited statutory community care resources have been increasingly targeted on high level need, often crisis, interventions at the expense of lower level, preventative services. As a result, it is thought that an increasing proportion of people with support needs now live alone and unsupported in ordinary tenancies in the community. A number of initiatives and policy developments over the last two years have begun to reassert the value of low level support services, most particularly Supporting People and the new Social Services Prevention Grant, but overall such services are still a lower priority than higher level interventions.

The review

A systematic review involves a staged process of identifying, locating and assessing the research evidence in a particular area. Given the changing policy context, the aim of this review was to examine the effectiveness of low intensity support services in enabling people to live independently in their own ordinary housing. It thus excluded shared provision, special 'schemes' and sheltered housing. It covered services for all groups of people with support needs. The review was confined to British evidence and to the last ten years.

Three main types of low level support were covered:

  • Housing/tenancy support: including 'floating support', resettlement and other types of housing support. Such services are primarily designed to support people with tasks related to moving into and sustaining their own tenancies, which they are subsequently able to undertake themselves. Such services are usually time-limited.
  • Direct practical support: including housework and domestic services, shopping services, handyperson schemes, and good neighbour schemes. Such services are primarily designed to provide direct practical assistance for people in their own homes who are unable (and likely to remain unable) to undertake basic tasks in and outside the home.
  • Emotional/social support: including mutual support networks, befriending services, home-visiting services, telephone support services and 'virtual' (i.e. computer-mediated) social support. Such services are primarily designed to provide companionship and emotional support or to extend social networks for people living alone. They can be either temporary or long-term, usually depending on the user group.

The review found 41 studies to be relevant. Twenty studies focused on housing/tenancy support services, eight on direct practical support and 13 on schemes primarily delivering social/emotional support.

Effective services?
What can be concluded from a review of research in this area? What services are effective in helping people to live independently?

Effects for users 
A consistent finding across all types of service was that many users felt the service had added something to their lives, particularly in helping them to approach life in a more positive way.

  • Qualitative interviews revealed that many users felt their overall sense of well-being - including self-esteem, confidence and attitude to life - had improved through being involved with the service;
  • Other positive outcomes included users feeling more comfortable and safer at home (particularly evident from direct practical services);
  • A striking finding was the way that users consistently valued the support of a worker or volunteer, often in preference to other more formal service interventions such as social work.

Housing-related issues 
There was a lack of good quality data in this area from which to draw firm conclusions. However, the review did find that:

  • Most studies showed a high demand for tenancy support services;
  • It was not possible to state the precise extent to which services prevented tenancies from breaking down, but qualitative data highlighted that a complex range of factors influenced whether tenancies were successful (including sufficient support, location, social networks, individual motivation, timing etc);
  • Some studies indicated that users were concerned that support ended after a specified period of time;
  • A minority of services had helped improve the fabric of the home;
  • The extent to which services were enabling some people to remain in their own homes as opposed to moving to more institutional provision (such as residential care) was rarely measured.

Effects on users' social lives
Users and service providers all stressed the importance of social support. However, whilst some one-to-one relationships were successful, there was little evidence that services increased social activity more broadly.

  • The relationship between worker/volunteer and user was key to the success of a service;
  • Some housing/tenancy services had limited success in addressing emotional and social needs;
  • Most types of services did not widen social networks, particularly networks involving people without similar support needs;
  • Befriending and other services designed specifically to promote social networks sometimes had a low take-up;
  • There was some limited evidence of the potential value of virtual (i.e. computer-mediated) support;
  • Few studies looked at the importance of support by users for other users, or of the social value of employment or training.

Effects on health
Whilst few studies looked at the effectiveness of services in improving health, available evidence indicated that services might expect to achieve significant results in this area:

  • Services aimed at people with specific health problems did have some success, including an increased rate of remission for women experiencing depression, and reduced drug use;
  • Studies rarely measured reduced hospital admissions. While examples of successes were given, it was not possible to measure the significance of the effect without information on prior health;
  • Some users felt their state of health had improved.

Wider consequences
Very few studies looked at the potential for low intensity support services to have a broader impact, such as reducing poverty or increasing social cohesion.

  • One study reported that service users were committing less serious (although not fewer) crimes than before the intervention.

Effective evaluations?
Overall, the body of research evidence on the effectiveness of low intensity support services was poorly developed. A number of limitations were evident.

Measuring results
Much research was largely descriptive rather than evaluative. Most studies concentrated on processes, such as referrals, staffing and organisational structure. The effects services had were rarely explicitly specified.

Problems drawing general conclusions
Most studies were small in scale, localised to particular areas of the country, and examined services for a small number of users or only one user group. Large data sets were rare. This makes the drawing of general findings relating to other groups of people, in different settings and locations, problematic. 

Measurement over time
Most studies were snapshots of the success of schemes. The shortage of long-term evaluations, true longitudinal studies and sophisticated baseline data made it difficult to measure the effects of services over time.

Lack of control for other factors
Very few studies have tried to answer the question: what would have happened if people had not received support from a service? The review found only two randomised controlled trials. 

Assessing subjective accounts
A small number of good quality pieces of qualitative work were found, providing insights into people's feelings, experiences and views on service interventions. However, these studies were the exception to the rule and there is scope for developing and exploiting the value of qualitative interviewing in future evaluations.

Value base of research
Researchers rarely make their ideological or value beliefs explicit; the main starting point for many researchers appears to be an assumption that these services are a 'good thing'. A more explicit discussion of the value base of research studies may lead to more challenging and robust pieces of research.

Conclusions for future research
The researcher concludes that a higher priority needs to be placed on developing more robust ways of assessing the effectiveness of low intensity support services. All parties involved in this area can play an important part in this process:

Research community: Ways of measuring outcomes in social care and policy research are still being developed. More open and honest discussions between researchers on the limitations of present research methods might help this process. A thorough discussion of research methods in research publications would also allow readers to assess the quality of the research. 

Users: It is likely that users' views will differ from those of professionals and policy makers but at present, users are not involved in developing ways of measuring outcomes and this perspective is lost. 

Research funders: Research projects with short timescales may produce findings earlier, but more robust studies are likely to produce findings which are more useful in deciding which services to commission. Funders of research could place more emphasis on evaluating outcomes in research specifications, but would need to be aware of the likely cost and time implications. 

Service providers: Commissioners and service providers need to be as explicit as possible about the aims of their services. The routine collection of information by projects could also be improved. Service providers and practitioners could be more aware of using sensitive measures to evaluate services.

Policy-makers: Policy-makers are already concerned with performance monitoring. However, policy-makers need to take a broader interest in the assessment of the effectiveness of services. Opportunities exist for government to support local authorities and other bodies in the design of better evaluation, for example through the emerging Supporting People arrangements.

About the study

The study involved a systematic review of the research evidence on the effectiveness of low intensity support services. The method of evidence-based systematic reviewing, which offers a standard approach to summarising and assessing research material, is most commonly used in the health field. The method is, however, increasingly being adapted for use by social policy researchers. A search strategy was designed and used on fifteen electronic databases, retrieving over 5000 references which were checked for relevance against specified study criteria. In addition, key players in the area were contacted and a website search and hand searches of library resources were undertaken.

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