Lessons from the UK and abroad Anne Mason

Senior Research Fellow Centre for Health Economics, University of York, UK

CHESS, Helsinki, 26 November 2015

Integration and efficiency in health and social care

Hitting the headlines…

Real-terms budget cuts of 31% over five years.. hard evidence of crisis…the social care system is starting to give way and the impact is being felt by the NHS

..more than 5,000 patients in England were occupying beds, even though they could have been discharged…

“the most difficult winter for 30 years…There is now clear evidence that the cuts to social care are not only devastating for the lives of vulnerable older people, but are

having a knock-on effect on the NHS.” Heidi Alexander, shadow health secretary

Overview

England’s health & social care systems Evidence - mostly from England

Effects of primary care services on utilization of specialist care

Effects of care home supply on hospital discharge

Financial mechanisms for integrating funds across health & social care

Policy implications Note that these are my personal views

Familiar challenges?

Good news - increased longevity People living with long-term conditions Complex health and social care needs

Healthcare systems designed to cater for acute episodic disease

Current initiatives to help integrate care include: Better Care Fund (£3.8bn) Integrated Care Pioneers (n=25) Vanguards (n=50) Devolution of health & care budgets

England’s health & social care systems

What do we mean by ‘social care’? Support to deal with consequences of cognitive

or physical impairment In England, health and social care systems are

separate and rarely jointly co-ordinated i.e. administration, staff, culture, finances

Integration important if services are interdependent / interrelated e.g. both health and social care needed for

recovery from hip replacement

NHS structure – official view

152 Local Authorities (LAs)

£14bn – adult social care

SOCIAL CARE HEALTH CARE

Informal (unpaid) carers

Local authorities

Voluntary, community and social enterprise (VCSE) organisations

Private providers

NHS Trusts

155 acute 56 mental health 18 community +

others

209 Clinical Commissioning Groups (CCGs)

£70bn – health care

Independent sector

850 For-profit /

not-for-profit organisations

NHS / social care – simpler view

NHS England £102bn

English electorate

8000 GP practices Specialist services Prison services etc.

Partnership working

Health Act 1999 s.31, NHS Act 2006 s.75 Legislative enabling framework ‘Flexibilities’ to support partnership working

between health bodies and health-related LA services E.g. pooled budgets, lead commissioning,

integrated provision £200m investment for partnership working 2015: proposals to extend partnership

arrangements to primary care

Effects of primary care services

Quality and Outcomes Framework (QOF) Covers most chronic conditions amendable to

primary care, but is still partial picture Focuses where capacity to benefit is greatest Regularly updated / revised P4P scheme or complex intervention?

Financial incentives Computerized prompts, decision support Encourages team-based care Reputational effects

Effects of primary care services

One aim of the QOF is to reduce emergency hospital admissions

Emergency admissions for QOF conditions =11% total – so partial solution at best

Annual payments are £1bn = 25% general practice income

What is the evidence on the QOF? Systematic review: 94 studies Selected studies published since this review

Review of QOF – Gillam 2012 Effects Studies Key findings

Effectiveness 47 Better recording, better processes QOF conditions: better intermediate outcomes esp. for diabetes Non-QOF conditions: not improved, worsened in latter years Modest mortality reduction: 11 lives per 100,000 people per year (across all QOF indicators)

Efficiency 5 Limited evidence of lower admission rates and hence costs for some conditions. Cost-effectiveness – only for subset of indicators and ignoring administration costs linked to QOF

Equity 25 Some reduction in inequalities in process of care for deprived Improvements in care for older groups (narrowing gap) Gender disparities persisted or even increased Ethnic variations reduced

Patient experience

7 No changes in communication, nursing care, coordination, or overall satisfaction Continuity of care worse – see usual doctor less often

Professionals and Team Working

6 Improved team working and practice organisation Enhanced role for nurses, increased internal surveillance Regrets loss of relational continuity and patient-centeredness Care more ‘biomedical’ ?

Selected studies on primary care

Study Condition No. GP practices

Years Key findings

Dusheiko et al. (2011a)

Diabetes 8223 2001-2007

Small decrease in emergency admissions

Dusheiko et al. (2011b)

10 chronic conditions

8200-8300

2004 -2007

Small decrease in emergency admissions and OP visits, but only for stroke or composite measure

Dusheiko et al. (2015)

10 chronic conditions

8200-8300

2004 -2007

Small decrease in mortality for stroke or composite measure

Selected studies on primary care

Study Condition No. GP practices

Years Key findings

Harrison 2014

All QOF conditions

6975 1998-2010

Emergency admissions for QOF conditions decreased compared with admissions for non-QOF conditions

Kasteridis et al 2015

Dementia 8034 2006-2010

Small decrease in emergency admissions linked to annual dementia review

Gutacker et al 2015

Serious mental illness

8234 2006-2010

Small increase in psychiatric admissions linked to annual review

Dusheiko 2011b

Effects of primary care for 10 chronic conditions asthma, CHD, CKD, COPD, dementia,

diabetes, hypertension, hypothyroidism, mental health, stroke

Outcomes: admissions, outpatient visits, costs, mortality

Linked data: demographic, hospital, practice, local health authorities

10% sample of national population data i.e. 5 million observations

Dusheiko 2011b

No independent effect for 9 conditions Quality of stroke care improved by 10% on

average between 2004 and 2007 £130m (€185m) lower hospital expenditure on

stroke in 2007 ≈ 5% total annual NHS stroke costs Cost savings mostly due to lower rates of

emergency admissions & outpatient visits ‘Savings’ take no account of QOF payments,

treatment / drug costs, co-ordination costs etc. Finding does not imply reduced lifetime care

costs

Primary care – summary

QOF targets chronic conditions most amenable to primary care and with greatest capacity to benefit

QOF associated with modest reductions in emergency admissions for some conditions

Apart from mortality, little assessment of health outcomes e.g. quality of life – so the value for money of QOF has not been demonstrated

Limited evidence suggests the QOF may have had detrimental effects on continuity of care

Processes of care for non-incentivised conditions have not improved and may even have worsened

Effects of care home supply

Care homes: residential institutions in the community that provide social and (sometimes) nursing care

Effects: focus is on ‘bed blocking’ = Delayed discharge / delayed transfer of care Patient medically ready to be discharged from

hospital, but appropriate care services unavailable

Potentially inefficient: hospital bed is a more costly substitute for a care home bed / home care

Delayed Discharges Act 2003

Community Care (Delayed Discharges) Act 2003 Reimbursement (cross charging) for delays in

discharging patients from hospital where local authorities are responsible

Monthly census day for all hospitals Number of patients delayed that month Total number days delayed per month Reason for delay: NHS / social services / both

NHS plan (2000): £900m investment in community-based health and social care services

Fernandez & Forder 2008

Effects of social care on acute health care 2 years study: 1998-1999 150 LAs, 99 Health Authorities Population: people 65+ Social care: care homes; home care

Higher supply of social care related to Lower delayed discharges Lower emergency readmissions Shorter length of stay Higher hospital throughput

Social care supply important for explaining variation in hospital performance – confirms there is interdependence

Forder 2009

Impact of long-term care on hospitals 1 year study: 2004/5 7640 electoral wards, 247 NHS trusts,

‘numerous’ care homes Population: people 75+

Return on investment: £1 invested in care homes associated with

£0.35 less in hospitals – and vice versa Efficiency depends on net change in outcomes

Gaughan 2015

Delayed discharges: effect of care home supply 5 year study: 2009-2013 146 local authorities, 18,000 care homes Population: people 65+ ‘Spatial’ effects across authorities

Effects “modest” within the average local authority: 10% increase in care home beds linked to

6% - 8% fewer delayed discharges per month Spill-over effects from neighbouring LAs

10% increase in care home beds linked to 28% - 43% fewer delayed discharges per month

Care homes - summary

Increase in supply of care home beds linked to small reduction in delayed discharges Unlikely to be cost reducing Cost effectiveness unclear

Not assessed health outcomes / QoL

Wider system effects Change in readmissions, LoS, throughput Need to consider cross-boundary impacts

What happens in one area has knock-on effects for its neighbours – and vice versa

Integrating H&SC funds

Mason et al, 2015: systematic review of the international literature

Funded by a grant from the English Department of Health to the Policy Research Unit in the Economics of Social and Health Care (ESHCRU)

Financial mechanisms for integrating resources across health and social care

Evidence of effectiveness or cost-effectiveness and barriers to their use

Methods

8 databases, websites, bibliographies Inclusion criteria

H&SC funding streams Empirical evaluation English language Adults

Exclusion criteria Studies from low-income countries Personal budgets

Overview of the evidence base

38 schemes in 8 countries UK (4); Australia; Canada; Sweden; USA

Schemes used integrated funds to support integrated care

Details of financial integration often unclear especially in ‘programme’ type schemes

In controlled studies, the comparator was ‘usual care’, which was often poorly described

Added effect of financial integration not assessed

Study designs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Randomisedcontrolled trials

Quasi-experimental(non-randomised

controls)

Analysis ofroutine data

Mixed methods(within a single

study)

Qualitative Uncontrolled

Kaavion otsikko All schemes (N=38)

English schemes (N=13)

Findings - summary

Potential Impact What does evidence show?

Improve access to care

Largely positive. But provider autonomy and eligibility policies can undermine budget-holders’ ability to facilitate access.

Increase community care (health and social care)

Evidence is positive to some degree for community services

Reduce unplanned re/admissions

Positive for some groups; negative in others (i.e., increased admissions).

Reduce total costs Mostly neutral; costs higher where unmet need uncovered

Improve outcomes Neutral or positive

Improve the quality of care

Few studies measured the quality of care, and they employed different measures of quality, with mixed results.

Reduce length of stay

Cross charging and pooled funding may reduce delayed discharges in the short term

Reduce residential care

Equivocal: relatively few studies assessed this outcome, and findings were very mixed

Improve patient and user experience of care

Positive largely although some negatives. There was no standardised measurement across schemes

Australian Coordinated Care Trials

CCT1 – round 1 CCT2 – round 2 Years 1997-1999

2002-2005

Funding for coordination

AUS$120m

AUS$33m

No. trials 13 trials (9+4) 5 trials (2+3) Aims Improve health / wellbeing;

Cost neutral Improve outcomes Improve service efficiency

Components • Comprehensive assessment

• Care plan • 3 models of primary care

1. GP coordinator 2. GP coordinator +

service coordinator 3. non-GP coordinator

• Financial integration

Same as for CCT1 + risk-based capitation model

Barriers – Australian CCT1

GPs solely responsible for service substitution, but had no control over admissions or discharges

GPs did not receive information on pooled expenditure and were not liable for overspend

Some services identified in the written care plan were accessible only if clients met pre-existing eligibility criteria …so money did not follow the patient…

Australian CCT2

Team Care Health II: 2 year RCT, 12m intervention Population: 50+ with chronic and complex conditions

Cardiovascular, musculoskeletal, endocrine / metabolic, psychological, respiratory

2720 patients randomised 2 : 1 Integrated management with pooled funds

Model 2: GP care coordinator + service coordinator AUS$ 21.5m pooled funds + $2.6m for care

coordination ≈ $8000 per person Risk-based capitation budget ≈ cost of usual care

Effects – Team Care Health II

Intervention participants had significantly better general health, less depression, higher quality of life

Some service substitution achieved - less inpatient care, more primary care

Intervention participants had significantly higher total costs

“Had the trial progressed for longer, evidence suggests that it would have been at least cost neutral in achieving these outcomes, even after incorporating the cost of care coordination…”

Barriers – Australian CCT2

GPs agreed that unless the financial reimbursement system was simplified and co-ordinator support was continued, care planning …would be unlikely to occur in future

“While flexible funding arrangements were

pursued by all trials neither of the mainstream trials achieved a true pooling of funds…”

Integrated funding - summary

Few schemes improved health outcomes and fewer still reported cost savings

Some succeeded in improving access to care, and shifting care into the community

Despite substantial resourcing, the Australian coordinated care trials did not succeed in delivering improved outcomes within ‘usual care’ budgets

But there were signs that cost neutrality could have been achieved in the longer term – had the trials continued

Integrating finances is difficult; it is likely to require legal, institutional and cultural changes

Policy implications - 1

Better quality primary care for people with LTCs can reduce emergency hospital admissions Care can be shifted closer to home

Increasing the supply of care home beds can reduce delayed hospital discharges, free up beds and so increase hospital throughput If vacated beds are filled by other patients, total

costs are likely to rise, not fall Integrating finances is difficult; but integrating

care within and across different professional groups may be even more difficult!

Policy implications - 2

No ‘magic bullet’ for improving care for people with chronic / complex care needs

Benefits of integration are rarely assessed; so its cost-effectiveness is unknown

Does integrated care resonate with our core values – is it worth doing in its own right?

Look for health and social care interdependencies – focus efforts here

Beware / be aware of wider system effects / unintended consequences

Expectations need to be realistic

References Dusheiko, M et al. 2011a. Does Higher Quality of Diabetes Management in Family Practice

reduce Unplanned Hospital Admissions? Health Services Research 46: 27–46. Dusheiko, M et al. 2011b. Does better disease management in primary care reduce hospital

costs? Evidence from English primary care. Journal of Health Economics 30: 919–32 Dusheiko, M et al 2015. Quality of disease management and risk of mortality in English

primary care practices. Health Services Research;doi:10.1111/1475-6773.12283 Fernandez JL & Forder J. 2008. Consequences of local variations in social care on the

performance of the acute health care sector. Applied Economics;40(10-12):1503-18 Forder J. 2009. Long-term care and hospital utilisation by older people: an analysis of

substitution rates. Health Econ. 18(11): 1322-1338 Gaughan J et al 2015: Testing the bed-blocking hypothesis: does nursing and care home

supply reduce delayed hospital discharges? Health Econ. 24 (S1): 32-44 Gillam SJ et al. 2012. Pay-for-performance in the United Kingdom: impact of the quality and

outcomes framework: a systematic review. Ann Fam Med;10(5):461-8. Gutacker N et al. 2015. Does the quality and outcomes framework reduce psychiatric

admissions in people with serious mental illness? A regression analysis. BMJ Open; 5(4):e007342

Kasteridis P et al. 2015. The influence of primary care quality on hospital admissions for people with dementia in England: a regression analysis. PLoS One.10(3): e0121506

Mason A et al. 2015. Integrating funds for health and social care: an evidence review. JHSR&P. 20(3):177-188.

Any questions?