Colin Currie

1. SPIF Seminar: Public Service Reform – delivering personalised care RCPE, 26th October 2011Cost-effective system-wide care of older people Reflections from a Jekyll-and-Hyde job plan Colin Currie Consultant Geriatrician, NHS Lothian,1979-2010 Special Adviser, Policy Unit, No.10 Downing St, 2008-2010

2. Cost-effective, system-wide care of older people • Background: • MAISOP inspections • Policy work in central government • Data on local ‘care economies’ • A post-code lottery in the care of older people ….. and what can be done about it?

3. Service provision and in Tayside: a MAISOP pilot inspection Angus Rural/small town; robust primary care Interface services v. good; acute beds lost! Perth and Kinross Urban/rural; big DGH Robust primary care; interface services OK Dundee Small city/big teaching hospital Meagre interface services

4. Service provision and service use in Tayside: a MAISOP pilot inspection – and some data from ISD!! 2 or more emergency admissions in 2006 (aged 85 and over, per 1000 population) Angus Rural/small town; robust primary care Interface services v. good; acute beds lost! 50 Perth and Kinross Urban/rural; big DGH Robust primary care; interface services OK 54 Dundee Small city/big teaching hospital Meagre interface services71!!

5. MAISOP– and after…. • Care Quality Commission interest: 2007 • interesting numbers emerging • occupied bed-days/1000 at risk – a diagnostic metric? • Policy Unit work: 2008-2010 • part-time Special Adviser • the Whitehall village • the fault-line of 1948 • a financial crunch coming… • DH priorities?

6. What are our strategic priorities? Putting People First Live independently Have the benefit of the best possible quality of life, irrespective of illness or disability Sustain a family unit which avoids children taking on inappropriate caring role Exercise maximum control over their own life and/or lives of family members Participate as active and equal citizens, economically and socially Stay healthy and recover quickly from illness Retain maximum dignity and respect Ensuring information is Available and accessible for all to support decision-making and access to care services, irrespective of people’s social circumstances and eligibility for statutory services Focussing on prevention, early intervention and enablement, rather than crisis management, to bring long-term benefits to individuals’ health and wellbeing Supporting people to maintain or improve their well-being and independence within their own homes and local communities and through avoiding unnecessary admission to hospital Improving people’s health and emotional well-being by enabling them to live as independently as suits them Enabling people to make choices and be in control of their own care to deliver successful outcomes first time. Promoting shared decision making to encourage ownership LAC 2008(1): Transforming Social Care Designing systems that build on the capacity of individuals and their communities to manage their own lives, confident that they have access to the right information and interventions at the right time should they need more support Strategic working with NHS partners to enable people with long term conditions to manage their health and wellbeing more effectively Providing quality care that promotes dignity, and is safe, effective and available when and where people need it Our Health, Our Care, Our Say Improved quality of life Exercise choice and control Making a positive contribution Economic wellbeing Improved health and wellbeing Maintaining personal dignity and respect Freedom from discrimination and harassment High Quality Care for All Effective – improving people's health, wellbeing and quality of life Personalised – responding to individual needs and preferences Fair – treating people with equity and dignity at all times Safe – making sure people are not put at risk of harm Every Child Matters Enjoy and achieve Make a positive contribution Achieve economic wellbeing Be healthy Stay safe Supporting People Carers will have access to integrated and personalised services to support them in their caring role Carers will be able to have a life of their own alongside their caring role Carers will be supported so that they are not forced into financial hardship Carers will be supported to stay mentally and physically well and treated with dignity Carers’ Strategy Disabled people who need support to go about their daily lives will have greater choice and control over how support is provided Disabled people will have greater access to housing, transport, health, employment, education and leisure opportunities and to participation in family and community life. Independent Living Strategy Valuing People Independence – Services provide the support to maximise independence Choice - A real say in where they live, what work they should do and who looks after them. Inclusion – enabling people to do ordinary things, make use of mainstream services and be fully included in the local community. Legal and civil rights – Treat people as individuals with respect for their dignity, and challenge discrimination on all ground. CSCI domains Leadership Commissioning and Use of resources Healthy, independent living and quality if life Access to services A good experience for people Improving outcomes for people Value for money Safe Dimensions of Quality (CQC)

7. Data from CQC: an astonishing – and indefensible – postcode lottery in care • Probability of multiple (2 or more/yr) admissions of >75s* ranges from 2.5% to 9.5% across English PCTs • Bed-days for multiple admissions per 1000 >75s range from <1000 to >3000 p.a. • (Costs/1000: ranging from c. £5M to c. £20M…?) • 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

8. 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

9. Some more contributing factors Social care spend 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%)

10. And a few more factors…? A culture of separatism between health and social care… …a legacy of ‘the fault-line of 1948’ ….that delays and fragments care, adds costs… ..…and – at the highest level – frustrates strategic thinking, fragments the policy debate ………..and blocks any overall scrutiny of quality and costs of late-life care

11. The darker side of separatism.. Demographic denial, separatism, ageism? Social care – ‘We prefer stable dependency…’ Acute sector – ‘We prefer the interestingly ill…’ Result: no ownership of the main challenge for both sectors: the care of older, frailer people

12. 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 >£30Bn: England) • Care of older people is the main task of both health and social care… • ….is wastefully and inequitably delivered.. • … and now subject to the twin pressures: …demography and funding constraints

13. But effective system-wide collaboration is not impossible… • CQC trend data 2003-2008 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 – which embeds structural disincentives to collaboration…)

14. Special adviser tourism: a very short report (1) Torbay • Care Trust structure • pragmatic piloting (Brixham) • roll-out to five teams – but only one phone number! • focus on ‘Mrs Smith’ • favourable evaluations

15. Special adviser tourism: a very short report (2) Isle of Wight • no over-arching plan • evolution of multiple PCT/LA collaborations – that added up to a ‘strategy’ for frailer elderly • from 2007, free personal care at home for frailest – to avoid care home care • overall LA spend on home/care home care down £1.7M • private spend down too

16. Evidence of effective service change (1) % change in bed-days: 2003 -2008 >75s >85s Torbay: - 24% - 32%(Dep. Quintile 3) (-9%) (-9%) Isle of Wight: - 35% - 47%(Dep. quintile 2) (-2%) (-4%)

17. Evidence of effective service change (2)2008 bed-days/1000 at risk >75s >85sTorbay: 850* 1197**(Dep. Quintile 3) (1837) (2829) Isle of Wight: 853** 1134*(Dep. quintile 2) (1623) (2619)*lowest in England ** 2nd lowest in England

18. A last reflection on special adviser tourism… • Isle of Wight and Torbay already have cost-effective system-wide services for older people – using different approaches • Isle of Wight and Torbay already have… ………the demography of UK c. 2048!!

19. Effective collaboration – focussed on the frailest – provides maximum impact • 95% of >65s live at home – and want to stay there • So focus on those most at risk of unnecessary acute or care home admission – 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 • A third force? • moderating the adverse consequences of: • unredeemed social care • and an over-mighty acute sector …not working very well together

20. 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!

21. Ways of measuring progress? • Occupied bed-days for multiple admissions of >75s per 1000 at risk • a measure of both admission avoidance and support available on discharge • Rates of discharge from acute care to permanent care home care • Rates of care home use; mean length of care home stay • Ratio of deaths at home to deaths elsewhere • Systematic serial feedback on local services from users and carers?

22. Savings – and reform?? • Savings • Administrative: reduced back-office costs • Operational: more and better care at home; less time in expensive unnecessary care elsewhere • Saving £2Bn? (England) • Shifting the balance of care – and money, and power? • reducing unnecessary acute care • providing better, more cost-effective care elsewhere • An answer (at last?) to the 60-year NHS problem of acute sector dominance?

23. The good news? • ‘Looking after older people well is cheaper than looking after them badly’ The less good news? • Provider resistance – reflecting entrenched organisational, political, financial, cultural and professional divisions – still makes bad, expensive care the easy option widely across the UK

24. 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 • Political will the determining factor now? Ref. Currie CT (2010) Health and Social Care of Older People: could policy generalise good practice? Journal of Integrated Care18 (6) 20-27

25. Acknowledgements • Prof. James Williamson, CBE FRCPE • Scottish colleagues in MAISOP & ISD • Richard Hamblin, Director of Intelligence, CQC • Andy McKeon, Head of Health, Audit Commission • Finbarr Martin, Former National Director, Older People’s Care, DH • No.10 Research and Information Unit • DH & DCLG colleagues • Peter Thistlethwaite and Chris Ham • King’s Fund & Nuffield Trust • Torbay and Isle of Wight PCT/LA staff

27. Many, many projects….. …..but few useful 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

28. Bringing health and social care together: an urgent but achievable priority? 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?