Integrated Resource Framework: clinicians and care professionals event: Stirling, 9 June 2010

Cost-effective, system-wide care of older people: some reflections from north and south of the border

Colin CurrieMAISOP/NHS Lothian

Things we agree about?

• 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• Action now overdue

The problem: an 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 >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.’

Why we need collaboration between health and social care – providing equitable, cost-effective services

• Over-65s now account for – 60% of hospital bed-days– 60% of social care spend

• Care of older people therefore now the main task of both health and social care

• Population is ageing – and public sector cost-effectiveness an urgent priority

Why is collaboration difficult…?

• A culture of separatism between health and social care

• ‘The fault-line of 1948’ with: – organisational, political, financial, cultural,

professional divisions (and IT problems too)– that delay and fragment care, and add costs

• Successful collaboration at present consists largely of conspiring against the absurdities of the status quo

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 at home

But collaboration is not impossible…

Some encouraging lessons from observed variance in England:

• CQC trend data highlighted PCTs achieving major reductions in bed-days for multiple admissions (>75s and >85’s)

• High-performing PCTs/local authorities were already providing cost-effective system-wide care

Special adviser tourism: a very short report (1)

Torbay• Care Trust structure, with social care integrated in PCT• pragmatic piloting (Brixham)• roll-out to five unitary teams – with only one phone

number!• focus on ‘Mrs Smith’• favourable evaluations and outcomes

– e.g. direct transfers from acute care to care home falling

• occupied bed-days (>75s) down 24% – 850/1000 vs. quintile average of 1837/1000

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

• 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!!

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 health and social care – responding to changing dependency, varying clinical acuity, and increasing frailty – is the goal

• But such care not widely provided at present…

Creating a third force in care for older people?

• Recognise realities– acute care focus an expensive failure– traditional – separatist? – social care still

largely suboptimal

• Learn from success: with a ‘third force’– that builds on empirical evidence of what

works– and has care of the frail elderly at home as its

highest priority

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% old; c.

1-2% higher-risk old?)

• Close links with primary and acute care?• Best achieved in new organisations

combining CHP and adult social care?

• cf. Arbuthnot’s Clyde Valley recommendations?

Some benefits?

• Fewer unnecessary acute admissions• Necessary acute admissions shorter• Care home care deferred/averted• Fewer people ‘dying among strangers’

• Specialist outreach working facilitated– COPD, CCF, PD, palliative care, etc

• Provider morale better – as realities are addressed, and we’re not wasting time

and energy ‘fighting the absurdities of the status quo’?

Savings – and reform??• Savings

– Administrative: reduced back-office costs– Operational: more and better care at home; less time

in expensive care elsewhere– Saving £2Bn (England) or £200M (Scotland)?

• Shifting the balance of care – and power?– reducing unnecessary acute care – shifting care – and resources – accordingly

• An answer (at last…) to the 60-year NHS problem of acute sector dominance?

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

The good news?

• ‘Looking after older people well is cheaper than looking after them badly’

The less good news?• Provider resistance – reflecting organisational,

political, financial, cultural and professional divisions – still makes bad, expensive care the easy option widely across Scotland

Acknowledgements

• Prof. James Williamson• Scottish colleagues in MAISOP & ISD• Richard Hamblin, Director of Intelligence, CQC• Andy McKeon, Head of Health, Audit Commission• Finbarr Martin, Acting National Director, 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