BGS Commissioning Workshop London, 25 th November 2008 Better can be cheaper: from postcode lottery to cost-effective,

1. BGS Commissioning WorkshopLondon, 25th November 2008Better can be cheaper: from postcode lottery to cost-effective, system-wide care? Colin Currie Consultant Geriatrician, NHS Lothian Special Adviser on Health and Social Care, Policy Unit, Prime Minister’s Office

2. 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?

3. 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!

4. 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

5. 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

6. 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.’

7. 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%)

8. 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

9. 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

10. 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

11. 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

12. 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…

13. 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.

14. 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%

15. 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

16. 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

17. 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!!

18. 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!)

19. 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

20. 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

21. 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

22. A rough sliding-scale of integration? • Worst-practice inertia? – as seen in CQC data • Patchy projectitis? – with all its limitations • Good joint commissioning – cf. Camden? • Cohabitation? – cf. Isle of Wight? • Care Trust model – cf. Torbay? • PCTs to take over adult social care? (The nuclear option?)

23. 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?

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 • So what’s stopping us?

25. 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