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BGS Commissioning Workshop London, 25 th November 2008 Better can be cheaper: from postcode lottery to cost-effective, system-wide care?

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BGS Commissioning Workshop London, 25 th November 2008 Better can be cheaper: from postcode lottery to cost-effective, system-wide care?. Colin Currie Consultant Geriatrician, NHS Lothian Special Adviser on Health and Social Care, Policy Unit, Prime Minister’s Office. Outline .

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BGS Commissioning WorkshopLondon, 25th November 2008Better can be cheaper: from postcode lottery to cost-effective, system-wide care?

Colin Currie

Consultant Geriatrician, NHS Lothian

Special Adviser on Health and Social Care,

Policy Unit, Prime Minister’s Office

outline
Outline
  • The post-code lottery in care of older people – facts and figures
  • Why a post-code lottery? – ‘the fault-line of 1948’
  • Tackling the post-code lottery – across a political minefield?
a few numbers from scotland
A few numbers from Scotland

Multi-Agency Inspection of Services for Older People (MAISOP): Tayside 2006

Probability of multiple admissions (>2 p.a.) of >85’s per 1000 population?

  • Angus: 50
  • Perth and Kinross 54
  • Dundee 71
  • PS: Edinburgh: 83!
a bit more about scotland
A bit more about Scotland…
  • All-Scotland data now available
  • Gross divergence in key indicators: e.g. occupied bed-days for multiple admission of >75’s
  • Trend data on above highly informative
  • Scottish Health Dept, Health Boards, and Audit Scotland increasingly interested
english data from cqc shows a similarly indefensible postcode lottery in care
English data from CQC shows a similarly indefensible postcode lottery in care
  • Probability of multiple admissions of >75s* ranges from 2.5% to 9.5% across English PCTs
  • Bed-days for these multiple admissions per 1000 >75s range from <1000 to >3000 p.a.
  • Probability of acute admission of >85s resulting in care home admission ranges from 5% to 20%
  • Numbers of LA-funded >65’s/1000 in care homes vary from 2.4 to 12.2

*>75s – 7.7% of population – account for c. 29% of HCHS costs

why a post code lottery
Why a post-code lottery?

Multi-Agency Inspection of services for Older People (Scotland):

‘.. a striking inverse correlation… between the observed volume and quality of collaborative health and social care provision in localities and the use of acute sector care – in the form of multiple admissions and delayed discharge – by older people from those localities’.

Care Quality Commission (England):

‘Initial impressions from high- and low-performing PCTs appear to confirm the inverse correlation identified by the MAISOP inspection process in Scotland.’

one contributing factor a post code lottery in the funding of social care
One contributing factor: a post-code lottery in the funding of social care

Adult social care as % of total LA budget varies from:

  • 21% to 43% in Metropolitan Authorities
  • 25% to 40% in London Boroughs
  • 30% to 53% in County LAs
  • 28% to 42% in Unitary LAs

Proportion spent on care home care for older people varies

  • From 71% to 25% (national average 51%)
  • (i.e. the proportion spent on care at home varies from 29% to 74%)

Proportion of gross expenditure derived from client contributions varies from 29% to 5% (average 14%)

why is collaboration difficult
Why is collaboration difficult…?

A culture of separatism between health and social care: a legacy of ‘the fault-line of 1948’ with:

organisational, political, financial, cultural and professional divisions:

  • that delay and fragment care, and add costs
  • and – at the highest level – frustrate strategic thinking and obscure the overall costs of late-life care
the darker side of separatism
The darker side of separatism..

Separatism entrenches demographic denial

  • in social care
  • in acute sector care

Result: no ownership of the main challenge for both sectors: the care of older, frailer people

why a post code lottery in health and social care is now intolerable
Why a post-code lottery in health and social care is now intolerable:
  • Over-65s account for:
    • 60+% of acute sector costs
    • c. 60% of social care spend (total c. £30Bn)
  • Care of older people is the main task of both health and social care…
  • ….is wastefully and inequitably delivered..
  • … and is now subject to the twin pressures of demography and funding constraints
many many projects but few real answers
Many, many projects….. …..but few real answers?
  • The problems of ‘projectitis’
  • single-diagnosis schemes for a multi-pathological population?
  • limited generalisability of local projects?
  • problems of evaluation/economic evaluation?
  • methodological rigour irreducibly at odds with service – and political – needs?
  • What matters is what works: for the untidy requirements of late-life and end-of-life care – and works system-wide
effective collaboration focussed on the frailest provides maximum impact
Effective collaboration – focussed on the frailest – provides maximum impact
  • 95% of >65s live at home – and want to stay there
  • A focus on those most at risk of unnecessary acute or care home admission is the most cost-effective approach
  • Accessible, flexible and seamless health and social care – responding to changing dependency, varying clinical acuity, and increasing frailty/cognitive loss – is the goal
  • Such care not widely provided at present…
but effective collaboration is not impossible
But effective collaboration is not impossible…
  • Recent CQC trend data has highlighted PCTs achieving major reductions in bed-days for multiple admissions (>75s and >85’s)
  • High-performing PCTs/local authorities are already providing cost-effective system-wide care…
  • …despite the system.
special adviser tourism a very short report 1
Special adviser tourism: a very short report (1)

Camden

  • strong joint commissioning
  • good geriatric medicine inputs/resource in PCT
  • (young population..)
  • occupied bed-days (>75s) down 16%
special adviser tourism a very short report 2
Special adviser tourism: a very short report (2)

Torbay

  • Care Trust structure
  • pragmatic piloting (Brixham)
  • roll-out to five teams – with one phone number!
  • focus on ‘Mrs Smith’
  • favourable evaluations
  • occupied bed-days (>75s) down 24%
    • 850/1000 vs. quintile average of 1837/1000
special adviser tourism a very short report 3
Special adviser tourism: a very short report (3)

Isle of Wight

  • no over-arching plan
  • evolution of multiple PCT/LA collaborations – that added up to a ‘strategy’ for frailer elderly
  • free personal care at home for frailest – to avoid care home care
  • LA care home spend falling: from £10M to £2.7M
  • occupied bed-days (>75s) down 35%
    • 853/1000 vs. quintile average of 1623/1000
a last reflection on special adviser tourism
A last reflection on special adviser tourism…
  • Isle of Wight and Torbay already have cost-effective system-wide services for older people
  • Isle of Wight and Torbay already have…
  • ………the demography of UK c. 2048!!
so what are we really trying to do
So what are we really trying to do?

Establish for older people – nation-wide – services that:

  • offer risk-managed admission avoidance
  • provide early supported discharge and rehab at home following acute care
  • minimise care home outcomes from acute care
  • for the frailest at home, defer/avert care home care
  • for the dying, provide palliative care at home to those who wish it
  • (the majority!)
some useful side effects
Some useful side-effects?
  • Better job satisfaction – in a less absurd world?
  • Better acute sector care for older people who really need it?
  • Enhanced acute sector efficiency – with resource shift?
  • A robust platform for specialist outreach services:
    • COPD/CCF
    • PD, etc, etc
making it happen
Making it happen?

‘We will bring together the National Health Service and local care provision into a new National Care Service….’

The Prime Minister: 29th Sept 2009

now the debate service integration by collaboration or by structural reform
Now the debate: service integration by collaboration? – or by structural reform?

A debate dominated by provider interests:

  • NHS: ‘Oh no, not another upheaval…’
  • Social care: ‘This looks like medical dominance or even takeover…’
  • Public/user interests?
    • poorly represented, little heard
a rough sliding scale of integration
A rough sliding-scale of integration?
  • Worst-practice inertia? – as seen in CQC data
  • Patchy projectitis? – with all its limitations
  • Good joint commissioning – cf. Camden?
  • Cohabitation? – cf. Isle of Wight?
  • Care Trust model – cf. Torbay?
  • PCTs to take over adult social care? (The nuclear option?)
an achievable goal however achieved for example by
An achievable goal – however achieved….? For example, by:

Strong local community teams combining front-line health and social care staff?

  • serving populations of 30-40k (c.16% >65; c. 1-2% higher-risk old)?
  • establishing protective ‘ownership’ of frailest elderly at home?
  • and thus able to support them there better and for longer?
  • in line with currently achievable best practice?
summary
Summary
  • Older people wish to remain at home, avoiding unnecessary hospital or care home admission
  • Responsive, flexible, collaborative health and social care at home can enable them to do so
  • Overall costs of late-life care can be reduced, and its quality raised
  • Economic, humane and political goals converge
  • So what’s stopping us?
acknowledgements
Acknowledgements
  • Scottish colleagues in MAISOP & ISD
  • Richard Hamblin, Director of Intelligence, CQC
  • No. 10 Research and Information Unit
  • DH & DCLG colleagues
  • Peter Thistlethwaite and Chris Ham
  • BGS colleagues
  • Kings Fund
  • Nuffield Trust
  • Camden, Torbay and Isle of Wight PCT/LA staff
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