How do we integrate health & social care: lessons from research - - PowerPoint PPT Presentation
Green Templeton College, Oxford 18 October 2017 How do we integrate health & social care: lessons from research & practice Martin Knapp Personal Social Services Research Unit, London School of Economics & Political Science &
Martin Knapp
Personal Social Services Research Unit, London School of Economics & Political Science & NIHR School for Social Care Research
Green Templeton College, Oxford 18 October 2017
How do we integrate health & social care: lessons from research & practice
challenges
better?
I. Raise awareness; take responsibility
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Structure
REVENUE COLLECTION
PURCHASER BUDGETS
PROVIDER BUDGETS
A simplified health/social care system
RESOURCE INPUTS
OUTPUTS
urgical operations
NON-RESOURCE INPUTS
taff attitudes
OUTCOMES
elf-determination Person in need COSTS
Fam ily
Health care Social care Housing Education
Crim justice
NHS LAs DCLG DfE MoJ Benefits
Em ploym ent
DW P Firm s Social netw I ncom e CVOs All Mortality I ndiv Genes Fam ily I ncom e Em ply’t
Resilience
Traum a
Phys env
Events Chance
… impacting on potentially many budgets
People w ith needs & assets
Public satisfaction 2016 (no significant changes from 2015):
, highest in NHS
From NatCen Survey 2016 Main reasons for overall satisfaction with the NHS: 1. quality of care, 2. NHS is free at the point of use 3. range of services available Main reasons for overall dissatisfaction with the NHS: 1. long waiting times 2. staff shortages 3. lack of funding
than ever before
spending goes on health
more
spending have slowed
health than other EU countries
with social care
healthcare than social care
Philip Hammond on the Andrew Marr Show, 5 March 2017
Theresa May in Parliament (11 January 2017): "He [Jeremy Corbyn] talks about delayed discharges. S
service locally, have virtually no delayed discharges. S
It tells us that it is about not j ust funding, but best practice.”
h l d h d h h
“Just 24 local authorities account for 50%
all the delayed discharges from the NHS”
A patient is ready for transfer when:
for transfer AND
patient is ready for transfer AND
DTOCs are obviously not the only challenge facing the NHS – but data are readily available and so this topic attracts disproportionate attention. ti t i d f t f h
Delayed transfers of care (DTOCs)
care
and Community Care Act
Biggest changes since November 2010 have been increases in the number of days delay due to patients waiting for a care package to be available either at home (172% increase) or in a nursing home (110% increase).
Awaiting care package in own home
Causes of DTOCs (coded by NHS staff)
What 's behind delayed t ransfers of care? Nuffield Trust February 2017
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 August November February May August November February May August November February May August November February May August November February May August November February May August November 2,010 2,011 2,012 2,013 2,014 2,015 2,016
Delayed Transfer of Care, NHS Organisations, England
NHS Social Care Both % SC reponsibility
90% 7,000 90%
Delayed transfers of care (DTOCs), NHS
Proportion attributed to social care causes went from 32% (Aug 2010) to 24% (Feb 2014) to 37% (Dec 2016)
rising
is propping up care
people
themselves
elf-funders appear to be subsidising councils
councils cope.
unequally distributed across the population
Social care trends and challenges
Projected numbers in E&W aged 80+ by interval-need dependency, 2010-2030
Ageing: implications for care needs
Jagger et al BMC Geriat rics 2011; slide borrowed from Carol Jagger People in E&W aged 80+ by interval-need dependency, 2010
HLE & LE, men at age 65 by national deciles of area deprivation, England 2012-14
Foresight report 2016 – data from ONS (2016)
Projected public expenditure on health & long- term care as %
, 2014/15 to 2064/65
7.3 6.2 6.5 7.1 7.6 7.9 8.0 1.1 1.2 1.4 1.7 1.9 2.1 2.2 0.0 2.0 4.0 6.0 8.0 10.0 12.0 2014-15 2019-20 2024-25 2034-35 2044-45 2054-55 2064-65 % GDP
Long-term care Health
Foresight report 2016; data from OBR (2015)
care of £5 billion by the end of the current Parliament.
Social care trends and challenges
Index of net current expenditure on adult social care relative to 2005/06
Real term figures calculated at 2014/ 15 prices (GDP deflator) S
CIC EX1 and AS C-FR annual returns (expenditure); ONS (mid-year population estimates) – courtesy of Jose-Luis Fernandez
authorities; efforts & resources concentrated on ‘ high-need cases’ .
Social care trends and challenges
Proportion of older people (age 65+) receiving support
0% 2% 4% 6% 8% 10% 12%
2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 Number of service recipients
Residential and nursing care Community-based services
authorities
services
Social care trends and challenges
Home care: local authority– supported contact hours and households (age 65+)
500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Contact hours 100,000 200,000 300,000 400,000 500,000 600,000 Households
Local authority providers Independent sector providers Households
S lide from Jose-Luis Fernandez
authorities
services
but social care workforce is growing.
Social care trends and challenges
Social care self-funders
self-funders; >40%
(Baxter & Glendinning, 2015)
elf-funders often do not think to approach their local council for advice (Wright, 2000) or are deterred by perception of stigma associated with asking the council for help (Putting People First 2011)
elf-funders are the most disadvantaged & isolated people in social care system: care arrangements often owe more to chance than active choice (Henwood and Hudson, 2008).
guarantee greater control over care (Putting People First 2011).
implications of paying for long-term care (NAO 2011).
authorities
services
but social care workforce is growing.
unpaid care
Social care trends and challenges
Sources of social care
Projected demand for, and supply of unpaid care for older people in England
3.0 4.0 5.0 6.0 7.0 8.0 9.0
2015 2020 2025 2030 2035 Millions
Demand, base case Demand, if formal care falls by 10% S upply, base case S upply, 1% pa decline in caring rate for younger carers S upply, 1% pa rise in caring rate for younger carers
Brimblecombe, Fernandez, Knapp, Rehill, Wittenberg (2017) unpublished.
time and money
care
many require intensive, high-cost support
turnover rates
workforce of 1.34 million people
recommendations accepted but never implemented – see later
Other challenges currently facing social care
pressure; increasing numbers of people are not receiving the help they need, which in turn puts a strain on carers.
people can afford – and where they live – rather than on what they need.
NHS services is undermining the policy obj ective
residential care. The Care Act 2014 has created new demands and expectations but funding has not kept pace. Local authorities have little room to make further savings, and most will soon be unable to meet basic statutory duties. S
nder massi e
Kings Fund & Nuffield Trust (2014) on social care for older people in England
Social care
But the issues go much wider …
Health / social care boundaries
Social care Welfare benefits Housing Criminal justice
Education
Labour markets
Immigration policy
Science policy
Pensions
Community develop’t
Tax policy
Competition policy
Food policy Trade & Industry
Environment
Human rights
REVENUE COLLECTION
PURCHASER BUDGETS
PROVIDER BUDGETS
RESOURCE INPUTS
OUTPUTS
urgical operations
NON-RESOURCE INPUTS
taff attitudes
OUTCOMES
elf-determination Person in need COSTS
Fam ily PURCHASER BUDGETS
What is the question to which integration is the answer?
REVENUE COLLECTION
PURCHASER BUDGETS
PROVIDER BUDGETS
Presumably … how can we achieve … ?
RESOURCE INPUTS
OUTPUTS
urgical operations
NON-RESOURCE INPUTS
taff attitudes
OUTCOMES
elf-determination Person in need COSTS
Fam ily
… better assessment of needs, assets & preferences - more holistic, continuous … … better access to services; more flexible & personalised responses to needs & assets … avoidance of wasteful duplication & damaging gaps in service provision … improved cost- effectiveness of care … better outcomes for individuals & families … better coordinated & hence more efficient commissioning
Dimensions
systems (health or other)
social care, housing, etc.
profit, third sector … ) Scope
social care, or hospital and community care systems
integrated teams/ professions
Integration: governance or service organisation?
From individual perspective:
trategies that map j ourneys through services (integrated care pathways)
trategies that support individuals in negotiation with (& access to) services Examples of service integr’n:
j oint care planning
hared guidelines/ protocols
%
Patients/ service users experience services that are more j oined-up (91% ) Quality of care for patients/ service users has improved (91% ) S ervices are now more accessible to patients/ service users (91% ) Quality of life for patients/ service users has improved (86% ) Patients/ service users now able to continue living independently for longer (82% ) Experience of carers has improved (82% ) Patients/ service users now have a greater say in the care they receive (82% ) Patients/ service users now better able to manage their own care & health (77% ) Patients/ services users now have greater awareness of services available (77% ) GPs now at centre of organising and coordinating patient/ service user care (77% ) S ervice providers now able to respond more quickly to patient/ service user (changing) needs (73% ) Number of readmissions to hospital have reduced (68% ) Unplanned admissions have reduced (64% ) % of leads reporting “some” or “substantial” progress
Progress reported by Integration Pioneers
Erens et al Journal of Int egrat ed Care 2017
Barriers identified by Integration Pioneers
% “very” significant by Wave of Integration Pioneer Wave 1 Wave 2 S ignificant financial constraints within the local health and social care economy 63 49 Incompatible IT systems make it difficult to share patient/ service user information 38 64 Conflicting central government policy or priorities 39 42 Lack of additional funding makes it difficult to try out innovative services 39 39 Information governance regulations making it difficult to share patient/ service user information 30 46 Too many competing demands for time or resources reducing the focus on working together 33 36 S hortages of frontline staff with the right skills 27 46 Increased demand for existing services 33 30 Working out realistic savings that could be achieved 31 21 The different cultures of partner organisations 20 36 Erens et al Journal of Int egrat ed Care 2017
More money would be helpful, yes, but clearly we need to think carefully about whose money and how to use it.
Funding
from it and implement if relevant
policy discussion & practice development
care is to be financed
they arise, and ways to address them
What (else) could we do better?
NICE guidance
Child abuse and neglect NG76 October 2017 Intermediate care including reablement NG74 S eptember 2017 Transition between inpatient mental health settings and community or care home settings NG53 August 2016 Transition from children’s to adults’ services for young people using health or social care services NG43 February 2016 Transition between inpatient hospital settings and community or care home settings for adults with social care needs NG27 December 2015 Older people with social care needs and multiple long-term conditions NG22 November 2015 Home care: delivering personal care and practical support to older people living in their own homes NG21 S eptember 2015 Managing medicines in care homes S C1 March 2014
Personalisation of social care has been a strong policy theme for 20 years – to promote choice & control.
Personal budgets & associated support
Individual (personal) budgets have positive effects on quality of life, social care
But outcomes much less positive for older people:
budgets
Level of support influences
Cost-effective Support arrangements are key to success.
Glendinning et al IBS EN report 2008
Evidence on four main types of intervention:
What impacts on:
Carers: review of evidence
Brimblecombe, Fernandez, Knapp, Rehill, Wittenberg (2017) unpublished.
Robust, quantifiable evidence used in our modelling of economic impacts:
increases unpaid care provision and increases employment, possibly combined with other interventions.
improve carer employment outcomes.
intensity unpaid care & decreases higher-intensity caring that is less compatible with employment. Home care, PA support, day care most effective for those caring 10+ hrs per week
S TART: individual programme (8 sessions; 8-14 weeks, delivered by psychology graduates + manual); carers given techniques to:
Livingston et al BMJ 2013; Knapp et al BMJ 2013; Livingston et al Lancet Psych 2014
Caring can be enormously stressful; 40%
people with dementia have depression or anxiety
START: a carer support programme
Evaluation of START over a 72-month period
Pragmatic trial: S TART vs usual support. n=260 family carers of people with dementia, in North London area. Analyses at 8, 24, 72 months after end of intervention.
Livingston et al BMJ 2013; Knapp et al BMJ 2013; Livingston et al Lancet Psychiat ry 2014
Carer health & QOL Mental health gains at 8 & 24 months QALY gains at 8 & 24 months Patient health & QOL No differences in health or QOL Delayed care home admission not sig. Costs (not significant) Increased carer costs at 8m Reduced total service costs at 24 mths Cost-effectiveness £118 per 1-point change on HADS
S TART dominates usual care at 24 mth Now analysing carer mental health, care home admission, costs & cost-effectiveness at 72 months … … the results look encouraging!
Telecare
WSD telecare –
effectiveness
Largest ever RCT of telecare – compared to standard treatment. Cluster RCT design (GP practices) For older people with social care needs. Funded by DH, 2011-14.
use over 12 months (n=2600)
have small benefits on some psychological & HRQOL outcomes (n=1189)
S teventon et al Age & Ageing 2013; Hirani et al A&A 2014; Henderson et al A&A 2014
New analyses of the telecare trial data:
affect social care costs
but can reduce NHS costs (particularly hospital costs) for people living with
Unpublished results from Cate Henderson (LS E)
and much is of modest quality. Too many small, local, short-term, uncontrolled studies, using invalid measures.
but especially in using research: insufficient commitment to participate in, and then implement robust research.
practice, 2 safe staffing guidelines (= 252 in total) …
but only 6 social care guidelines so far.
social care research evidence
Research: volume, quality, capacity
Why is the social care evidence base weak? Some or all of these might be true
to other areas (e.g. health)?
data utilisation & analysis, ambition?
attractiveness? Too few practitioner- researchers?
researchers?
authorities/ providers to participate?
research messages through?
upport costs for research too low?
NIHR School for Social Care Research
Phase 1
E, KCL, Universities of Kent, Manchester & York
coping Reviews Phase 2
E, Universities of Bristol, Kent, Manchester & York
Mission: “ t o develop t he evidence base for adult social care pract ice in England by commissioning and conduct ing world- class research.” Funded by t he Nat ional Inst it ut e for Healt h Research
NIHR School for Social Care Research, 2009-2019
Projected lifetime LTC costs at age 65
S mall minority of people with ‘ catastrophic’ costs A minority of people with no LTC costs Costs paid by users until their funds run out:
England
£- £50,000 £100,000 £150,000 £200,000 £250,000 £300,000
1 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100
Lifetime cost
Percentage of population State Individual
Dilnot (2011) and Care Act (2014)
Dilnot: cap on individual care costs set at £35,000 Care Act: cap on individual care costs set at £72,000 Current situation: awaiting consultation …
“ In theory, the significant financial uncertainties in terms of potential need, intensity and duration of long-term care provide a powerful rationale for sharing this risk across individuals” (OECD 2011 p253). In reality, private LTC insurance coverage is very low. Why?
Private LTC insurance – market failure? 1
hazard) insurers protect themselves by limiting access to coverage
individuals’ future needs are uncertain & a long way
they will cover premium volatility
associated with LTC needs
adulthood ( education, mortgage… )
Private LTC insurance – market failure? 2
Preparing to pay for social care 62%
pay for social care they might need when they are older (% unchanged since 2011) 28% have actually started to prepare to pay for social care services they might need when they are older (% unchanged since 2011)
Concern about meeting the costs 46%
might need when they are older Following Care Act 2014, proportion concerned about meeting social care costs fell (from 59% in 2014 to 44% in 2015), and this was maintained in 2016
social care services they might need in future Responsibility for saving 45% agree it is their responsibility to save so that they can pay towards their care when they are old; 32% do not think it is their responsibility, 22% have no opinion Preparing to pay for social care
Public perceptions of NHS and social care: survey for DH, winter 2016 wave, Feb 2017
Dementia risks
Prevalence: 850,000 in 2015 (UK); >2,000,000 by 2051. There is no known cure. Costs (UK) are already almost £30 billion annually. Risk factors for dementia:
moking, depression, physical inactivity, social isolation, diabetes (lat e-life) Population-attributable risk is 35%
Livingston et al Lancet 2017
S
chool for S
RC)
All views expressed in this presentation are those of the presenter, and are not necessarily those of the DH, NIHR, ES RC or Alzheimer’ s S
I have no conflicts of interest to report that are relevant to this presentation.
Funding, disclaimer, conflicts of interest Thank you m.knapp@lse.ac.uk