New opportunities for the voluntary sector and the NHS

September 2013

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Improving Care

Phil Hope and Kieran Brett

Committed to improving the lives of vulnerable and older people

Helping health and social care organisations develop excellent and sustainable services

At the forefront of developing Social Impact Bonds in the UK

Visit our website to download our report “Creating Sustainable Health and Care Systems in Ageing Societies”

www.improvingcare.co.uk

The population is set to grow from 63.2 million to 72.1 million over next 20 years. If the NHS budget remains fixed the real-terms impact is a reduction of 12.4% for each person in the UK

2012-13 2022-3 2032-3£1,400

£1,450

£1,500

£1,550

£1,600

£1,650

£1,700

£1,750

Sources: ONS (population projections); DH (NHS Budget)

10 million 18.3 million1995

2000

2005

2010

2015

2020

2025

2030

2035

2040

The number of people aged over 65 is projected to increase by

83%. NHS costs for retired households are nearly double that

for non-retired households (Source: Government actuary)

2011 20500

1

2

3

4

5

6

7

8

9

Population aged over 80

Millions

The oldest old will more than double by 2050 from 3 million

to 8 million. Patients aged over 85 cost three times

higher than a person aged 65-74

(Source: Parliament.UK The Ageing Population)

These cost pressures will only increase over time

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Our health and care systems need radical reformDesigned for an age when acute – not chronic – conditions were the greatest burden of disease

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Emergency admissions have risen dramatically across the NHSRepresenting poor patient care and an unsustainable system, (Nuffield Trust graph, 2010)

7

High emergency admissions in Leicester City represent an opportunity for better care

Leicester City CCG has a high emergency admission rate compared to other CCGs (Health Service Journal, Dec 2012)

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Hospital use can and should be reduced

“Emergency hospital admissions are undesirable for the individual patient concerned and are expensive to the NHS, costing over £1,000 per admission, on average. However, it is commonly accepted that many unplanned admissions can be prevented if the optimal care is in place.” The Nuffield Trust, 2011

5700 fewer hospital beds would be needed if all parts of the NHS achieved the rate of admission and average length of stay for over 65s as those with the lowest use The King’s Fund, 2012

Other health systems, like Kaiser Permanente, make far less use of hospital beds than the NHS does Ham et al, 2003

There is huge variation in different parts of the NHS and internationally

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Best practice shows that integrated care can reduce admissionsKaiser has far fewer admissions for some common chronic conditions than the NHS (Ham, 2003)

0

100

200

300

400

500

600

700

800

900

COPD Bronchitis/asthma Angina

Inp

ati

en

t ad

mis

sio

ns (

per

100 0

00 p

op

ula

tio

n)

in o

ver

65s

NHS

Kaiser

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Health systems that make less use of hospital deliver integrated care

“Areas that have well-developed, integrated services for older people have lower rates of bed use.” The King’s Fund, 2012

“The NHS can learn from Kaiser's integrated approach” Ham et al, 2003

“The [Veterans Health Administration's] transformation was based on the creation of regionally based integrated service networks in place of a fragmented hospital-centred system.” Curry and Ham, 2010

In Torbay, “the results of integration include reduced use of hospital beds, low rates of emergency hospital admissions for those aged over 65, and minimal delayed transfers of care” Thistlethwaite, 2011

The evidence is clear that integrated care makes a difference

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Invert the care pyramid for better outcomes at lower cost

Acute episodes

Best practice escalation

management

Nurse care co-ordination

Supported self-care

Self-care

Acute episodes

Poor escalation management

Low level intermediate services

Low level of supported care

Self-care low

Existing model of care

Future model of care

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Two broad opportunities for the voluntary sector in health care

We have worked with over 70 local voluntary sector organisations to help them reshape their thinking to provide services for the NHS

We are developing a Social Impact Bond to deliver integrated care for older people in partnership with NHS commissioners, providers and the voluntary sector

NHS contracts and Social Impact Bonds

HomeHospita

l

GP

Home

Care navigators in A&E to prevent admissions

Reduce length of stay e.g. nutrition support

Home from hospital service discharge

Reablement support to reduce readmissions

Care planning

Support in the community to reduce use of GPs and acute care e.g. medicines management, nutrition care,

GP care navigators

Integrated care to prevent avoidable admissions

NHS contracts: there are big opportunities for new services by local voluntary organisations to improve health outcomes, improve patient satisfaction and reduce unnecessary costs

Support at home to prepare for planned admissions

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The voluntary sector can act as care “integrators”

What this means for Wendy

Wendy and her

daughter

Peer support worker/ voluntee

r Anticipato

ry care plan

Agreed goals and

shared decision

s

Working as part of

an integrated team

GP support

and escalatio

n plan

Condition support

group and communit

y resilience

Access to appropriate housing, benefits

and equipment

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Integrated Care: Creating successful integrated care services requires certain conditions

1. Resources to avoid double-running hospital and community care services

2. The alignment of incentives for all parts of the health economy to drive the shift to activity from the acute sector to care at home

3. New services need to be in place before existing services are reconfigured

There are three conditions that need to be created

Social Impact Bonds are a vehicle for creating these conditions

Social Impact Bonds can catalyse system transformation because they align incentives and add traction

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• Ethical external investment from organisations which care about better outcomes for older people

• Investment could come from the public sector

Creating a sum for investment in

services

• New integrated care services based on the best performing systems in the world

• Reshaping health and care services to help deliver savings or new services which help to meet rising demand within a fixed budget

• Services commissioned backed by contracts and rigorous performance management

A programme of action

• The Investor takes the financial risk if emergency admissions are not reduced

• Significant surpluses can be generated for the NHS and other local partners, once the investor has been repaid

Creates surplus for NHS and repays the

investor

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An integrated care Social Impact Bond delivers benefits for patients and taxpayers

For patients and carers For taxpayers

Improved self-management

Support to remain independent at home

Fewer hospital admissions and less demands on GPs

Better co-ordination of care among providers

Increased satisfaction among patients and carers

Expensive hospital care replaced by higher quality lower cost community care

Health system financially sustainable for the future

Initial investment never paid back if outcomes are not achieved

Up-front funding means no reshaping of hospital services until community services in place

Reducing hospital activity improves care and reduces costs

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Our pathfinder service with Age UK is showing promising early results

Drawing on world-class best-practice, we have developed integrated care pathways with local and national clinicians and are testing these in Newquay

100 older people with chronic conditions such as COPD and diabetes are enrolled in the project

Initial outcomes from a small subset of patients show an increase of 26% in well-being and a potential reduction of 30% in admissions

We plan to scale up the service to 1000+ and develop new integrated care services around the country

100 older people are part of a pilot in Cornwall