1. BGS Commissioning Workshop London, 25 th November 2008 Better 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 Kinross54 Dundee71 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 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: 29 th 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? 1.Worst-practice inertia? – as seen in CQC data 2.Patchy projectitis? – with all its limitations 3.Good joint commissioning – cf. Camden? 4.Cohabitation? – cf. Isle of Wight? 5.Care Trust model – cf. Torbay? 6.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