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2 Review of Respite Services and Short-Term Breaks for Carers for People with Dementia Report for the National Co- ordinating Centre for NHS Service Delivery and Organisation R & D ( NCCSDO) July prepared by Hilary Arksey* Karen Jackson* Karen Croucher Helen Weatherly Su Golder Philippa Hare Elizabeth Newbronner Sally Baldwin* * * Social Policy Research Unit, Centre for Housing Policy, Centre for Health Econom ics, Centre for Reviews and Dissem ination, Acton.Shapiro, * * Departm ent of Social Policy and Social Work Address for correspondence Hilary Arksey Social Policy Research Unit, University of York, Heslington, York, YO1O 5DD E- m ail: ha4@york.ac.uk Telephone: NCCSDO

3 Contents Acknow ledgem ents 6 Executive Sum m ary Background 7 Objectives of the study 7 Research m ethods: literature review 7 Research m ethods: consultation 8 Key findings: literature review 8 Key findings: consultation 12 Policy im plications 13 Recom m endations for further research on respite services 14 Recom m endations for im proving research m ethods 14 Dissem ination and im plem entation of research findings 15 The Report Section 1 I ntroduction I ntroduction Background Aim s and objectives of the study Challenges Structure of report Term inology and definitions 23 Section 2 Research m ethods I ntroduction The review question Generic literature review Search strategy Study selection Strength of evidence References retrieved in generic literature review Econom ic -evaluation literature review Study selection Econom ic -evaluation references retrieved Consultation I nterviews with national organisations Local consultation with carers Expert reference group and workshop Reporting the findings 39 Section 3 Scoping the field: initial m apping I ntroduction Geographical distribution of evaluation studies Types of respite service and short-term break Geographical distribution of evalution studies according to type Distribution of studies according to characteristics of care recipients and carers Type of research design used 45 NCCSDO

4 3.7 Measures of effectiveness and cost -effectiveness Sum m ary of characteristics of available research 48 Section 4 Evidence from the literature review about the effectiveness and cost- effectiveness of respite services and short - term breaks I ntroduction Day-care services I ntroduction Overview of studies Evidence on the effectiveness and cost -effectiveness of day-care services I n- hom e respite services I ntroduction Overview of studies Evidence on the effect iveness and cost -effectiveness of in-hom e respite Host -fam ily respite I ntroduction Overview of studies Evidence on the effectiveness of host -fam ily respite I nstitutional/ overnight respite services I nt roduction Overview of studies Evidence on the effectiveness of institutional/ overnight services Respite program m es I ntroduction Overview of studies Evidence on the effectiveness and cost -effectiveness of respite program m es Multi-dim ensional carer-support packages I ntroduction Overview of studies Evidence on the effectiveness and cost -effectiveness of m ulti-dim ensional carer-support packages Video respite I ntroduction Overview of studies Evidence on the effectiveness of video respite 87 Section 5 Findings from the consultation about respite services and short - term breaks I ntroduction The overall state of respit e services and short-term breaks for carers The im pact of recent policy developm ents The barriers faced by providers Measuring effectiveness and cost -effectiveness What underpins an effective respite service and short-term break? What are the characteristics of an effective respite service and short-term break? Recognising the im portance of assessm ent and on-going review Meeting the needs and circum stances of the carer 101 NCCSDO

5 5.7.3 Ensuring services are tailored to the age, culture, condition and stage of illness of the care recipient Maintaining or im proving the well-being of the care recipient Recognising the im portance of appropriately trained and caring staff Understanding the significance of affordable services 106 Section 6 Review sum m ary, im plications for policy and recom m endations for further research and im proving research designs I ntroduction Overview of results Benefits to carers Benefits to care recipients I m pact on use of other services Cost -effectiveness of respite services Gaps and weaknesses in the evidence base Gaps Methodological and quality issues Policy im plications Recom m endations for further research on respite services New respite services and short-term breaks Alternative form s of respite service and short-term break Respite care and other com m unit y care services Am ount of respite care Respite services for specific groups of carers of people with dem entia Organisational context Recom m endations for im proving research m ethods Outcom e m easures Pluralistic evaluations Views of carers and people with dem entia Com parative studies Longitudinal studies Reporting of studies Prim ary research Modelling Dissem ination and im plem entation of research findings 128 References NCCSDO

6 Appendices Appendix 1 Search strategy for generic and econom ic literature review s Appendix 2 Databases searched Appendix 3 Data- extraction form Appendix 4 a Sum m ary of studies/ articles included in the generic review Appendix 4 b Econom ic evaluations of support services for carers for people w ith dem entia Appendix 5 Representatives of national organisations consulted Appendix 6 Telephone interview schedule: consultation w ith na tional bodies Appendix 7 Topic guide for carers groups Appendix 8 Telephone interview schedule: consultation w ith carers NCCSDO

7 Acknowledgem ents The research was funded by the NHS Service Delivery and Organisation (SDO) Research and Developm ent Program m e (project reference SDO/ 48/ 2003). We are grateful to all those individuals who contributed their tim e and expertise to the consultation. The on- going contributions and advice from the Expert Reference Group, com prising Caroline Cantley, I sabel Hem mings, Manuel Montoro - Blanch, Jo Moriarty, Derek Podesta and Joyce Sleightholm e, were particularly valuable. Colleagues from outside organisations and within the Social Policy Research Unit have provided helpful advice and support during the course of the work, in particular Em ily Holzhausen, Hazel Qureshi, Casandra Wade and Alison Wallace. We are grateful to librarians in the J.B. Morrell Library at the University of York for all their assistance. Sally Pulleyn provided m uch- needed secretarial support throughout the study. Sally Baldwin died in a tragic accident in Rom e in October NCCSDO

8 Executive Sum m ary Background I t is estim ated that dem entia currently affects approxim ately people in the UK, a figure that is increasing. The m ajority of older people with dem entia are cared for at hom e by a relative or friend. The em otional and psychological im pact that dem entia has on patients suffering from the condition leads in turn to stress on carers, whose practical needs for support and alleviation of em otional stress are especially high. Respite care and short - term breaks are widely regarded as a key intervention to reduce the stress of caring. The Carers Special Grant, first introduced in 1999 as part of the national strategy for carers, m akes ring- fenced m o nies available to local authorities for the enhancem ent of services to allow carers to take a break from caring. Given the rising num bers of dem entia sufferers, the key role of respite services and the policy em phasis on im proving services, the identificat ion of service m odels that benefit carers of people with dem entia, and care recipients them selves, is essential. Objectives of the study The study aim ed to establish the current state of knowledge about the effectiveness and cost- effectiveness of respite services and short breaks for carers for people with dem entia. The overall aim encom passed six objectives: to identify the range of services available for carers, to exam ine evidence from national and international published and grey (unpublished) literature about effectiveness and cost -effectiveness of respite services for carers of people with dem entia, to develop existing conceptualisations of effectiveness and costeffectiveness, to ensure the views of key stakeholders were central to the lit erature review, to identify exam ples of good practice, to advise on areas of priority for further research. The report presents the findings from the literature review and consultation with representatives from national statutory and voluntary organisations, and carers. Research m ethods: literature review The aim of the literature review was to identify all studies published since 1985 that could help answer the central review question: what is known from NCCSDO

9 the existing literature about the effectiveness and cost - effectiveness of respite services and short - term breaks for carers for people with dem entia? Searches were m ade of key electronic databases and the I nternet. Other search strategies included hand searching, searching websites of key organisations and contacting key researchers in the field. Bibliographies of studies were checked to ensure relevant referenced studies were included. The initial num ber of references generated in the searches was 2287; of these, 52 articles reporting on a total of 45 studies m et the inclusion criteria. Fortyseven of the 52 articles reported on general issues related to the effectiveness of services; the rem aining five articles com prised econom ic evaluations. Relevant data were extracted from each article using a Microsoft Access database. The review findings were reported according to type of respite service: day care, in- hom e respite, host- fam ily respite, institutional/ overnight respite, respite program m es, m ulti- dim ensional carer- support packages and video respite. Research m ethods: consultation Key individuals from 20 statutory and voluntary organisations contributed to the consultation. The inform ation they provided helped to identify four areas of the country with respite services providing exam ples of good practice. Focus groups and telephone interviews were then conducted with carers who were current or recent users of respite services in these four locations. The consultation aim ed: to set the context for exam ining gaps in the literature, to help indicate the relevance of the literature- review findings to current policy and practice in the NHS, to exam ine whether the outcom es that carers and carers representatives value are the sam e as, or sim ilar to, those used in the research literature, to help identify respite services and projects that are regarded as innovative. At key points in the review process, the research team benefited from the advice of m em bers of an Expert Reference Group, com prising professionals and key inform ant carers. Key findings: literature review The evidence from the studies included in the review was m ixed and at tim es contradictory. Overall, however, the review found that on the basis of the outcom e m easures used and on the service that was offered, evidence of the effectiveness and cost- effectiveness of respite care and short -term breaks is lim ited. I n contrast, there was considerable qualitative evidence from carers (and som e from care recipients) of the perceived benefits of the use of respite services. I t would be wrong to assu m e that lack of evidence of effectiveness should be interpreted as evidence that respite is ineffective. This is a very com plex area; m ethodologically, undertaking studies of respite services is NCCSDO

10 particularly challenging. The review identified the following key points in respect of the different types of respite care available. Day care Day care encom passes planned services provided outside of the hom e, not involving overnight stays. Many carers placed a high value on day-care services, perceiving benefits for both them selves and the person with dem entia. However, problem s relating to day-care attendance acted as barriers to usage for som e carers. Few studies attem pted to collect the views of people with dem entia them selves, but there was som e evidence to suggest patients enjoy the com pany, the sense of belonging and the activities provided. The evidence about the im pact on carers of using day care was unclear. Som e studies showed dem onstrable im provem ents in physical health, stress and psychological well- being, yet others showed no change. The evidence about the im pact on people with dem entia of day-care attendance was unclear. Som e studies showed im provem ents or stabilisation, whereas others showed no positive effects. The m ixed results are likely to reflect issues such as: weaknesses/ differences in study design, the wide range of outcom e m easured used, study tim escales, differences and/ or deterioration in disease severity and differences in the frequency and am ount of day care used. Tim e freed up by day care did not necessarily reduce the total am ount spent on caregiving. There was som e evidence to suggest that day-care attendance m ight have a preventative effect on entry to long- term care. Two of the econom ic evaluations suggested that day care m ight be cost - saving whereas two suggested that day care m ight provide greater benefits but at a higher cost as com pared to standard care. All four studies suggested that the benefits of day care m ight be sim ilar to, or greater than, those achieved through standard care. I n - hom e respite I n- hom e respite involves a (paid) care worker com ing into the fam ily hom e to sit with the care recipient. Carers reported high levels of satisfaction with in- hom e respite services; satisfaction appeared to be closely linked to their perceptions of the benefits that the service bought to their relative, and the quality of care provided. Carers reported that they would have liked the service m ore often, and liked visits to last longer as the relatively short periods of respite constrained the type of activities they could undertake. NCCSDO

11 None of the studies were able to dem onstrate statistically significant positive effects of in- hom e respite on a range of m easures. The evidence suggested that in- hom e respite could assist in m aintaining fam ily routines, and roles, and the dem entia sufferer s sense of self. I t is difficult to separate the im pact of in- hom e respite on the dem and for other types of respite care, or in reducing or delaying entry into longterm care as m ost c arers in these studies were accessing a range of different services. No evidence was retrieved in relation to cost- effectiveness of in- hom e respite. Host - fam ily respite Host - fam ily respite gives an opportunity for the carer and person with dem entia to take a break together, staying with a host fam ily. The little evidence available suggests that host - fam ily respite was effective in addressing the needs of carers and care recipients. Carers reported positive outcom es, feeling com fortable, relaxed an d happy during the respite period. Care recipients preferred a break in a hom ely environm ent to a stay in a residential hom e. Very little is known about the longer- term im pacts of host- fam ily respite. Host - fam ily respite is a m eans of m eeting the needs of those carers and care recipients who want to spend tim e together. I nstitutional/ overnight respite I nstitutional/ overnight respite allows breaks away from the fam ily hom e for the care recipient for one or m ore nights. Physical and em otional benefits were seen as worthwhile when set against the difficulties of organising institutional/ overnight services. I nstitutional and overnight services were seen to help in som e way, but other short - term breaks were seen as m ore beneficial to the care recipient. Standards of care and quality of service influence use of services. There was som e evidence that care recipients returned hom e in a worse state, but also that m edical conditions could be diagnosed during breaks. Although som e carers experienced guilt in using services, others reported that services helped them to continue in their caring role. There appeared to be a m ajor benefit to sleep, with increased and better- quality sleep. There was m ixed evidence on the im pact of services in relation to act ivities of daily living, behaviour and dependency, but it is difficult to unravel the potentially negative effects of respite from the natural progression of the disease. NCCSDO

12 There was little evidence that services reduced the dem and for long- term placem ents. Respite program m es Respite program m es offer carers, and care recipients, the choice of com bining together different form s of respite care and short breaks. Respite program m es m ight reduce carer burden, depression and carers reported health problem s. There m ight be differential im pact of respite care reflecting the characteristics of the person with dem entia. Tim e freed up was likely to be spent catching up on chores rather than leisure activities. Patients were as likely to m aintain or im prove in physical and cognitive functioning as to decline. Multi- dim ensional carer- support packages Multi- dim ensional carer- support packages provide a range of services to carers and care recipients, including a respite or short - break option. A com m on thread was that there were no dem onstrable lasting im provem ents carers health and well- being. Whereas som e carers believed they them selves had benefited, they were less positive about gains for people with dem entia. The results suggested no gains in term s of care recipients psychological health, but positive effects regarding behavioural problem s. There was a strong trend towards delayed entry to long- term institutional care. Only a single econom ic evaluation had been conducted in this field. The cost per quality- adjusted life year (QALY) 1 of the support package was reported to com pare favourably with other health- care interventions and m ight therefore present value for m oney. Video respite Video respite uses a tailored video to occupy the care recipient s attention, thus freeing up the carer s tim e for a m ini- break. The tape was well received by carers and care recipients, and was used regularly to create respite tim e. There was greater participation in video respite when it was watched alone by individuals, rather than in a group setting. 1 The QALY is a measure of health outcome that simultaneously captures changes in mortality (a quantity issue) and changes in morbidity (a quality issue), aggregating them into a single, numeric measure. NCCSDO

13 Key findings: consultation There was little divergence between the views of representatives from national bodies and carers; m any of the issues raised in the national interviews were illustrated by the carers experiences. I n term s of the overall state of respite care and short -term breaks, m any carers still have only lim ited access to a break from caring, although the picture varies significantly across the country. There was felt to be a need for a broader range of services, including greater access to in- hom e respite. There was a strong view that the quality and appropriateness of respite services were very variable, with services for carers of younger people with dem entia or those with m ultiple problem s or challenging behaviour being the least well served. Many contributors felt that m ore innovative services were being developed in som e areas of the country, in part due to recent governm ent policy in relation to carers. The Health Act flexibilities, and the em ergence of Care Trusts and Partnership Trusts, were perceived to be leading to som e interesting innovations, as was the requirem ent in the National Service Fram ework (NSF) for Mental Health to recognise and address the needs of younger people with dem entia by I n general, contributors felt that the Carers Special Grant had allowed providers and com m issioners to think m ore broadly, and the com bination of ring- fenced m onies to pum p - prim e projects and the goodpractice guidelines in the Carers and Disabled Children s Act 2000 encouraged providers to offer a wider range of services. There were, however, concerns about how the Carers Special Grant had been used in som e areas. Finally, the introduction of direct paym ents and voucher schem es was welcom ed as a way of increasing the flexibility of respite provision. The consultation highlighted m any of the barriers faced by providers delivering respite care. These included m ajor difficulties in recruiting and retaining staff with the right skills, knowledge and attitude. The significant cost constraints which m any services work within were also felt to affect their ability to respond to carers needs in a flexible and individualised m anner. There was concern that the Best Value tendering process could stifle innovation by insisting that services fit into social services categories and, in general, contributors called for better co- ordination between com m issioners and providers. The consultation also explored contributors views about the ways in which the effectiveness and cost - effectiveness of respite service could be m easured. There was agreem ent that respite is com plex and that a range of m easures are needed which would encom pass the following. Qualitative m easures based on carers (and, where possible, care recipients ) own perceptions of the im pact of respite care on quality of life. Qualitative and quantitative m easures based on the im pact of respite care on the health and well- being of the carer and care recipient. NCCSDO

14 Quantitative m easures based on long- term cost -effectiveness analysis of the im pact of respite care on service usage by both carer and care recipient. Respite services do not exist in isolation from other services to support carers, and these services and system s play a crucial role in facilitating access to, and take- up of, respite, and generally enabling carers to get the m ost out of the respite services that exist in their area. The focus groups and interviews with carers revealed m uch about the factors or characteristics which are im portant in delivering effective respite services. These can be grouped together into the following seven underpinning factors: knowledgeable and supportive doctors, appropriate m anagem ent of the condition, responsive social services, fair and understandable benefits/ charging system s, supportive carers networks, helpful fam ily, friends and neighbours, well- coordinated services. The consultation also suggested that for short -term breaks to be effective, they not only need to be underpinned by these seven factors but also need to display a num ber of key characteristics, which are in effect drivers (rather than m easures) of effectiveness. These characteristics indicate that the m ost effective respite service is likely to be: based on thorough assessm ent and on- going review, appropriate to the needs and circum stances of the carer, appropriate for the age, culture, condition and stage of illness of the care recipient, able to m aintain or im prove the well- being of the care recipient, delivered by appropr iately trained and caring staff, affordable to the carer. Policy im plications The planning, delivery and evaluation of respite services and short -term breaks m ust be set in the context of other support services. Services need to be sufficiently diverse to m eet the needs of carers and care recipients in different situations and from varied backgrounds, for instance younger people with dem entia and from black and ethnic - m inority populations. Delivering flexible and person- centred services im plies the need for spare capacity to be built into service provision. Quality standards m ay need strengthening in order to reduce variability in the quality of, and access to, services. NCCSDO

15 Anom alies in charging and benefits system s, which m ay deter carers from taking breaks, should be addressed. The recruitm ent and retention of high- quality staff, together with on- going training and developm ent, is im portant. Local authority social services departm ents need to be responsive and accessible. I n particular, regular assessm ents and reviews should be conducted to help identify carers (and care recipients) who would benefit from a short - term break. I f the new Carers (Equal Opportunities) Bill becom es law, this will have im plications for the developm ent and prom otion of respite services for carers of people with dem entia. Ways to enhance the opportunities for carers (and people with dem entia) to have a voice in the developm ent of respite services and short -term breaks should be prom oted. Recom m endations for further research on respite services New respite services and short-term breaks. Research into new services set up in the wake of the Carers Special Grant, which should have been developed following consultation with local carers. Alternative form s of respite services and short-term breaks. Research into different form s of respite care, including carers preferences and decision- m aking about use of services at different points in the disease progression. Respite care and other com m unity care services. Research to investigate the effectiveness of different com m unity care packages, and/ or the interface between short-term breaks and entry into long- term care. Am ount of respite care. Research to exam ine the m agnitude or am ounts of respite care used, in particular to exam ine the idea that there m ay be a threshold below which breaks m ay not have significant effects. Respite services for specific groups of carers. Research to investigate the regional availability, quality and appropriateness of short - term breaks for carers for younger people with dem entia, black and ethnic - m inority carers and carers of people with Down s syndrom e and dem entia. Organisational context. Research into the organisational context and service configurations of respite-care provision. Recom m endations for im proving research m ethods Outcom e m easures. Research to establish the appropriateness of different outcom e m easures to help gauge whether or not a service is effective. NCCSDO

16 Pluralistic evaluations. Evaluation studies that adopt m ultiple methods, take account of a broad range of potential outcom es and reflect the views of all key stakeholders. Views of carers and people with dem entia. Studies that not only use outcom e m easures to collect quantitative data, but also collect qualitative dat a that provides in- depth inform ation about the experiences and views of carers and people with dem entia who use, and do not use, respite care and short -term breaks. Com parative studies. Com parative data exploring: cost- effectiveness; variations in different types of respite care provision for different groups of carers and care recipients between different geographical areas; which different types of short- term break best m eet the needs of black and ethnic - m inority carers, carers supporting younger people with dem entia and carers of people with Down s syndrom e and dem entia; spouse carers and adult children caring for elderly parents; the im pact of rural and urban settings on access to, and provision of, respite. Longitudinal studies. Longitudinal studies to help determ ine the m ediumto long- term effects of respite on carers and care recipients. Reporting of studies. Studies that report m uch greater detail about the context of the service, including inform ation about the am ount of respite received (frequency and duration), staffing issues, accom m odation, facilities provided and available activities. Prim ary research. Studies that are powered to detect a true difference in costs and effects across com parator interventions would provide m orerobust inform ation to policy- m akers. Also, in order to include appropriate outcom e m easures within studies m ore clarity is needed as to what constitutes effective respite care. I f policy- m akers are interested in obtaining inform ation on the cost - effectiveness of interventions then it would be useful to conduct m ore econom ic evaluations along side effectiveness studies in this field. Modelling. The reporting of sum m ary statistics of patient- level data in prim ary studies would enhance the potential to undertake secondary analysis of the data. Dissem ination and im plem entation of research findings I t is im portant that continued efforts are m ade to im prove the dissem ination and im plem entation of existing and future research evidence, particularly the publication and wide distribution of reader- friendly sum m aries of research. NCCSDO

17 The Report Section 1 I ntroduction 1.1 I ntroduction This review of respite services and short - term breaks for carers for people with dem entia builds on an earlier scoping study undertaken for the NHS Service Delivery and Organisation (SDO) Research and Developm ent Program m e (Arksey et al., 2002a, b; Newbronner and Hare, 2002). The scoping study m apped the literature relating to the effectiveness and cost - effectiveness of services to support carers of people with m ental health problem s. Eighteen per cent (36 out of 204) of the studies included in the scoping review focused on breaks from caring of one sort or another. Of these, nearly three- quarters involved breaks for carers for people with dem entia. Given that a m ajor com ponent of a scoping study is to m ap or identify the literature that currently exists in the field of interest (Mays et al., 2001) rather than address the issue of quality of individual studies, the review did not seek the best evidence (Slavin, 1995). The analysis did suggest, however, that the evidence on the effectiveness and cost -effectiveness of services was inconclusive, and som etim es contradictory (Arksey et al., 2002a, b). The scoping study also indicated that outcom e m easures com m only adopted in evaluations, such as changes in carers psychological health (for exam ple levels of distress, burden or strain), did not capture the levels of satisfaction with services reported by carers. Current thinking recognises the need for a wider m ethodological approach to evaluating the effectiveness of services (Moriarty, 1999; Arksey et al., 2002a, b; Ryan et al., 2002). The present study was com m issioned to take forward this earlier work; our specific rem it was to exam ine the evidence for the effectiveness and cost - effectiveness of respite care and short -term breaks for carers for people with dem entia. This report presents the findings. 1.2 Background Dem entia is estim ated to affect about people in the UK (Departm ent of Health (DH), 2001). This represents five per cent of the total population aged 65 and over, rising to 20 per cent of the population aged 80 and over. By 2026, the num ber of sufferers is expected to grow to , and to have reached 1.2 m illion by The prevalence of dem entia increases with age. I t is 0.1 per cent for people aged 40 60, around two per cent for the age group, and up to 20 per cent for people over the age of 70 (Melzer et al., 1994). Alzheim er s disease is the m ost comm on form of dem entia, causing up to 60 per cent of cases of dem entia (DH, 2001). Vascular dem entia and dem entia with Lewy bodies causes up to 20 per cent and 15 per cent of dem entia cases respectively. The prevalence of dem entia is m uch higher am ong older adults with learning disabilities than in the general population NCCSDO

18 (21.6 per cent as opposed to 5.7 per cent; reported in Elliott et al., 2003). People with Down s syndrom e are at a particularly high risk of developing dem entia, with an age of onset som e years earlier than the general population. The m ajority of older dem entia sufferers are cared for at hom e by a relative or friend (Watkins and Redfern, 1997). The average age of inform al (unpaid) carers is between 60 and 65 years, and m any are m uch older. Caring for som eone with dem entia is different from caring for people affected by other types of disability. This is because of the com plex, unpredictable and progressive nature of the illness (Alzheim er Scotland, Action on Dem entia, 1995). Dem entia has a profound em otional and psychological im pact on sufferers them selves, leading in turn to stress on carers. Carers of people with dem entia are likely to have higher than norm al levels of stress and burden, and report higher levels of depression (Wills and Solim an, 2001). Consequently, carers practical needs for support, as well as needs in relation to relieving the em otional stress of caring, are especially high (DH, 1999a). A num ber of policy initiatives, including the National Strategy for Carers (DH, 1999a), the Carers and Disabled Children Act 2000 and the National Service Fram eworks (NSFs) for Mental Health (DH, 1999b) and for Older People (DH, 2001), aim to support carers and im prove carers services. The national strategy docum ent, Caring about Carers, sets out the governm ent s aim s to help carers take a break from caring (DH, 1999a). An accom panying docum ent, A Real Break, provides a guide for good practice in the provision of breaks for carers (Weightm an, 1999). Breaks can be provided in the hom e or in other settings. Care at hom e m ay include day and night sitting services, or input from a support worker or nursing assistant. Care away from hom e m ay include day centres, weekend respite schem es, m obile centres in rural areas, holiday respite care or short - term respite care in residential or nursing hom es, hospital or specialist short - stay units or fam ily break schem es. Som e schem es enable the carer and care recipient to have a break away or a night out together. Service providers include health and social services, and the voluntary and independent sectors. There is no consensus regarding the overall aim of respite care and short - term breaks. I n the past, such services have served different purposes including to give carers a break from caregiving, to prepare carers and care recipients for the latter s entry to long- term care and to prevent institutionalisation. I n the UK, the governm ent endorses the view that the prim ary objectives of respite care are to relieve carers of caring responsibilities in the short - term, while offering a positive experience for the care recipient (Weightm an, 1999). Carers are now entitled to an assessm ent of their needs (even if the person they care for refuses an assessm ent them selves) under the Carers and Disabled Children Act This offers the opportunity for respite care and short -term breaks to be used as a preventive m easure rather than being not provided until a crisis situation has developed (Jewson et al., 2003). NCCSDO

19 As part of the national strategy for carers, the governm ent introduced the Carers Special Grant in efforts to prom ote independence through the prevention of illness, disability or disease (DH, 1999c). The Carers Special Grant m ade ring- fenced m onies available to local authorities for the enhancem ent of services to allow carers to take a break from caring. The grant totalled 140 m illion for England over three years ( 20 m illion in 1999/ 2000; 50 m illion in 2000/ 2001; 70 m illion in 2001/ 2002), and has since been renewed on a regular basis. The current extension is up to 2006, and the level of funding has been increased to 185 m illion. However, the ring- fencing elem ent was rem oved in April The Carers Special Grant was designed to stim ulate diversity and flexible provision to m eet individual needs, and in this way provide supportive services to help carers m aintain their health and relieve stress. However, studies from the King s Fund (2001), Carers UK 2 (Macgregor, 2000) and Crossroads Caring for Carers (2000) suggested that the Carers Grant did not lead to a significant increase in the range and quality of breaks provided in its first two years of operation. Whereas the Grant went som e way towards prom oting and realising flexible breaks for carers, local im plem entation varied and relatively few carers were benefiting com pared with the probable unm et need (King s Fund, 2001). Furtherm ore, research showed there was a particular gap in relation to developm ents for respite services targeting carers from black and ethnic - m inority com m unities (Hepworth, 2001). At the tim e of the present review, the Carers Special Grant has been available for over three years. The Com m unity Dem entia Support Service in Sheffield (Ryan et al., 2002) is an exam ple of a new respite care developm ent that reflects the requirem ent for person- centred care, as set out in the NSF for Older People (DH, 2001) and the new governm ent standards for respite provision (DH, 2000). Under the provisions of the Carers and Disabled Children Act 2000, local authorities were given the power to develop voucher schem es from October The intention was that local authorities could issue vouchers so that carers, care recipients and those with parental responsibility for disabled children could have short - term breaks. Vouchers can have either a tim e or m onetary value to allow m axim um flexibility, and are seen as being halfway between direct paym ents and direct services provided by or on behalf of the local authority (DH, 2003). As yet, voucher schem es are not fully developed in m any social services departm e nts, and pilot schem es are reported to be running into difficulties due to a lack of services against which vouchers can be redeem ed (Revans, 2001). Respite care is regarded as one of the key form al support interventions to alleviate the stress of caring ( Rudin, 1994; Strang and Haughey, 1998); it is also a service that carers have identified as critical to their caring efforts (Cotrell and Engell, 1998). Contradictorily, respite and short - term breaks are known to have low utilisation rates (Cohen- Mansfield et al., 1994; Toseland et al., 2002). This m ight reflect the fact that carers and care recipients often feel 2 Formerly the Carers National Association. NCCSDO

20 they have little choice in what is available (Social Services I nspectorate, 2000). Furtherm ore, som e carers see conventional respite services as illsuited to the needs of the care recipients (Frost, 1990; Katbam na et al., 1998; Jewson et al., 2003). Given the growing num bers of people with dem entia, the im portant role of respite services and the policy em phasis on im proving these services, the identification of service m odels that provide beneficial breaks from caring for carers of people with dem entia is essential. 1.3 Aim s and objectives of the study The overall aim of the present review is to establish the current state of knowledge about the effectiveness and cost - effectiveness of respite services or short -term breaks for carers for people with dem entia. Within this overall aim, the study has six key objectives. To identify the full range of respite services for carers for people with Alzheim er s disease and other form s of dem entia, including younger people with dem entia. To exam ine the evidence from published and grey literature (both national and international) about effective and cost - effective respite services for carers for people with dem entia. To ensure that the views of key stakeholders are central to the literature- review elem ent of the study and inform its findings and recom m endations. To further develop existing conceptualisations of effectiveness and costeffectiveness specifically in relation to respite services for carers for people with dem entia. To identify exam ples of good practice of respite care and short - term breaks in health and social services, as well as the voluntary and independent sectors, for carers for peop le with dem entia. To advise the SDO which areas should be a priority for further research, having identified key gaps in the evidence base. This report docum ents the findings from the literature review and the consultation. The review is based on evidence from 45 studies, reported in a total of 52 different articles and/ or books (see Section 3 for an explanation of the discrepancy in the figures). Based on the evidence from the review and the accounts collected during the consultation with professionals and focus groups with carers, the report provides an in- depth analysis of available evidence on respite care and short - term breaks, as well as identifying areas of good practice and areas where further research is required and how these areas m ay be addressed. The findings will provide substantive knowledge that can be dissem inated within the UK, and in particular to those working in health and social care services, and the voluntary sector. NCCSDO

21 1.4 Challenges Undertaking evaluation studies of the effectiveness and cost - effectiveness of respite care and short - term breaks for carers for people with dem entia is challenging. At this point, it is useful to identify som e of the com plexities involved. I n particular, contextual issues relating to service provision, carers and care recipients, and the disease itself present a m yriad of challenges that need to be kept in m ind when assessing the evidence base on respite support for the carer. As noted above, respite services often lack clearly defined objectives, m aking evaluation difficult, and it is not always clear whether the service is intended to benefit carers and/ or care recipients or indeed other stakeholders. Carers them selves are very different, and it is erroneous to talk about carers as if they were one hom ogeneous group with sim ilar needs and living in sim ilar circum stances. Generally, they com prise the care recipient s relatives and/ or friends, so the outcom es of any form of support need to be assessed in the light of these relationships. As Mason (2003) states the relationship between carer and patient is a close one, reflected by the term inology for the partnership, the (carer patient) dyad. Dem entia can im pair people s ability to judge what is in their own best interests, so choices about preferred care can be problem atic to elicit. As a result of the carer patient dyad, the values and interests of the two parties m ay be interdependent. Deciding what works best for whom is not clear-cut. There are a num ber of different types of dem entia, as pointed out earlier, and the clinical picture on dem entia is com plicated by the fact that the disease process is varied. Different care recipients are likely to be at different stages of the disease trajectory, and service provision for the person with dem entia should reflect this. What is certain though, is that dem entia is a chronic condition and, at this point in tim e, irreversible. No effective treatm ents exist and pharm aceutical approaches do not present a panacea; however, the effects of m edication m ay im pact on the effectiveness of social care support in this population. I n the absence of definitive evidence on the benefits of m edications, nonpharm aceutical approaches, including the quality of the environm ent in which people with dem entia live, gain m ore im portance (Keen, 1992). Potentially, respite care and short - term breaks have a key role to play in sustaining the health, well- being and quality of life for the carer and the care recipient. However, outcom es of respite care (and other support services) m ay be influenced not only by the intervention itself, but also by the way in which it is delivered. The relationship between interventions and outcom es is rarely based on well- specified pathways, and instead can be m ore like a black box. Moreover, respite care is often just one com ponent part of a com prehensive support package, so potentially the im pact of the service on the carer and/ or the care recipient is open to yet m ore confounding influences. As well as challenges reflecting the context within which short -term breaks are provided, there are also a num ber of m ethodological difficulties for researchers trying to assess the im pact of short -term breaks on carers and care recipients. Previous reviews of respite program m es and/ or individual NCCSDO

22 respite services report that the results of studies are am biguous, or that they do not consistently show positive effects relating to carers health or wellbeing (Deim ling, 1991; Flint, 1995; Zarit et al., 1998; Roberts et al., 2000). However, it is acknowledged that not being able to dem onstrate that respite can help carers m ay be a reflection of weaknesses in the research design and/ or m easurem ent (Zarit et al., 1998). A detailed critique focusing on evaluations of respite services and short - term breaks is provided by Zarit et al. (1998), points that are all reflected extensively in the wider literature. Criticism s by Zarit and colleagues (1998), and other com m entators, relate to the following m ethodological issues, elaborated below: outcom e m easures; control groups; study sample; baseline m easurem ents; prior/ other service use. Outcom e m easures. I nstrum ents are not always sensitive enough to detect the psychological effects of respite care, and/ or changes in effects over tim e. A related point is that the range of outcom e m easures used m ight not be broad enough to capture all the effects of respite care. For instance, som e studies m ay em ploy only instrum ents that m easure carer stress, whereas others m ay use ones that m easure psychological well- being, and yet others m ay em ploy bot h types. Control groups. I f no control groups are included in an evaluation, then studies are not able to assess changes in, say, carers levels or stress and well- being that could have occurred without the treatm ent. When control groups are included, however, it is som etim es the case that carers in the control group are in receipt of services sim ilar to those used by the study group. To give an exam ple, in Lawton et al. s (1991) study of the Multi- Service Respite Service Dem onstration Project based at the Philadelphia Geriatric Center, designed specifically for fam ilies caring for people with Alzheim er s disease and related disorders, som e carers in the control group were using respite services under their own initiative in am ounts very sim ilar to those being used by carers in the study group. 3 The resulting com parison between the study group and the control group was then diluted in term s of showing large differences in stress and well- being. Study sam ple. I f sam ple num bers are low, they m ay be too sm all to detect any statistically significant findings or to m ake m eaningful sub- sam ple com parisons. Sam ples m ay be prone to selection bias, for exam ple white carers, fem ale carers, highly educated carers, carers linked into particular support networks, such as national or local Alzheim er s groups, or carers from one geographical area. There can be high attrition rates in longitudinal studies due to carers stopping using the service, institutionalisation or the death of the care recipient. Baseline m easurem ents. St udies m ay not assess carers stress, well- being and other psychological states before the start of the use of respite services and short -term breaks. Consequently, there is no baseline m easurem ent against which to determ ine the am ount of change that has occurred as a 3 Carers in the study group averaged ten days of day care over the 12-month study period, 63 hours of in-home respite and 11 days of nursing home respite. A substantial number of families did not use respite services at all. NCCSDO

23 result of using respite care. Furtherm ore, studies m ay not include patient m easures such as their illness severity stage. Prior/ other service use. Som e studies do not take into account the level of services used by carers (or people with dem ent ia) prior to participation in the respite service under evaluation. This m eans that the effects of service use m ight have already got underway, and it is hard to disentangle the effects of the different services. Likewise, respite care is often just one com ponent in a com prehensive package of com m unity care and studies m ay not necessarily try to disentangle the im pact of the different elem ents m aking up the support package. Clearly, the challenges of undertaking evaluation studies are considerable, yet that is not to say that they should no longer be com m issioned. Here, it is worth drawing on the scoping study on services to support carers of people with m ental health problem s (Arksey et al., 2002a). This literature- review report discussed key points about effectiveness and cost - effectiveness that had a bearing on future research com m issioning, and which have relevance when applied to the narrow field of dem entia. We do not intend to rehearse those issues in detail again, suffice to say that the analysis high lighted the com plexity of both defining and operationalising these two concepts in evaluation research. 4 Briefly, the scoping study cam e to the conclusion that questions to be considered when designing (cost- )effectiveness studies include: whose perspect ive is to be prioritised: m ultiple stakeholders are involved carers, care recipients, health and social care professionals and views about effectiveness are likely to differ accordingly. This feeds back into the related question of whose perspectives should be included in the design of interventions them selves. which specific aspects of service delivery are to be evaluated: a concentration of the final outcom es of services can be at the expense of learning m ore about the positive and negative features of the structure and process and of the intervention. what is the duration of follow-up for the study: carers, and care recipients, have different and/ or changing needs that m ay or m ay not be m et, depending on tim escales. whether the intervention adopts a needs-based approach: the effectiveness of a generalised service is determ ined by the individual characteristics and circum stances of the carer and/ or care recipient. whether the intervention provides value for m oney: resources used and costed, as well as relevant effects, differ according to the perspective of the analysis. Sound m ethodological principles on which to base new econom ic evaluations were provided in the scoping study. We return to these com plex issues in the final section of this report (Section 6), where we draw on the findings from the present review to m ake 4 For readers who are interested in the issues raised and ideas discussed, see Section 6 of the literature-review report (Arksey et al., 2002a) and also Mason (2003). NCCSDO