BGS Commissioning WorkshopLondon, 25th November 2008

Better can be cheaper: from postcode lottery to cost-effective, system-wide care?

Colin Currie

Consultant Geriatrician, NHS LothianSpecial Adviser on Health and Social Care,

Policy Unit, Prime Minister’s Office

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

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…

• 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

• 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?

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 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…?

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..

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:

• 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?

• 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

• 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…

• 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)

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)

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)

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…

• 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?

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?

• 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?

‘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?

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?

1. Worst-practice inertia? – as seen in CQC data

2. Patchy projectitis? – with all its limitations

3. Good joint commissioning – cf. Camden?

4. Cohabitation? – cf. Isle of Wight?

5. Care Trust model – cf. Torbay?

6. PCTs to take over adult social care? (The nuclear option?)

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

• 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

• 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