bgs commissioning workshop london, 25 th november 2008 better can be cheaper: from postcode lottery...
TRANSCRIPT
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?