Seraphim Rose Patel explains, with a colleague, how a whole person, whole system approach can reduce NHS and social care costs.
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Health is too big an issue for the NHS alone to deal with. No matter how good the treatment of illness, people may have multiple underlying social, housing or personal issues that lead them to enter and re-enter hospital care unless identified and dealt with effectively.
The Audit Commission report Joining up health and social services says that we need to look at the whole system of health and social care. Particularly the unnecessary use of the most expensive forms of institutional care like emergency hospital care including ambulance, acute beds, nursing care home beds, residential care beds and more effective use of less expensive preventive community services like re-ablement, domicilliary care and personal budgets.
The Commission proposes six outcome measures that enable localities to see how they use these resources locally and make changes to prevent unnecessary entry or re-entry to the most expensive forms of hospital care – and fund and develop local community and voluntary support services. Table 1 (in document, attached right) shows results for three neighbouring localities in London
The Personal Social Services Research Unit costs of health and social care 2011 shows the average cost of various types of care (see table 2, in document attached right). Intensive hospital care is highest. If people are unnecessarily using very expensive forms of care then that is a major drain on the resources of the local health and social care system.
Investment in preventive community care, re-ablement and effective self-management of long term conditions – including telecare and carer support is therefore of benefit to all – and care in their own homes is generally preferred by patients and families.
Quality of care in hospitals varies enormously and that many older people or people with learning disabilities or mental health problems who find themselves in institutional care may not always be treated with the respect and dignity they should expect.
Shortage of resources through inefficient usage may make this worse by reducing the amount of money that should be available for improving the quality of care and outcomes – rather than throughput and activity. The current system of payment by activity rather than outcome may be a major factor in this misuse of scarce resources – and a barrier to integration around the patient.
In view of these factors, it is not surprising that the Future Forum said “it is clear the health service now needs to drive integration in a way that has simply never happened to date.” To be fully effective it the NHS must work with councils and voluntary and community organisations to maximise management of care at home in each locality and develop preventive options that prevent unnecessary use of expensive care options. We need to look at how we spend every penny of public money
The whole person approach
Recent major reviews of evidence on integration and reducing hospital admissions conclude that to be effective we need a whole person approach.
The Future Forum report on integration says that we need to “integrate around the patient not the system”.
This follows from the comprehensive King’s Fund/Nuffield Trust review of evidence on integration which says that “the service user should be the organising principle of integrated care” and that it should focus on joining up care around the needs of patients.
It also says that “integrated care without care coordination cannot lead to integrated care”. And that ‘integrated care is most effective when population based and takes into account the holistic needs of the patients. Disease based approaches ultimately lead to new silos of care’.
The Future Forum report confirms that “integration is not about structures, organisations or pathways – it is about better outcomes for patients. The entire health and social care system should embrace a definition of integration that truly puts people at the centre.
“Integrated services work best for frail older people, to those living with long term chronic and mental health illnesses and those with medically complex needs or requiring urgent care.”
Whole person-centred tools for integration
Recent research suggests that the main person centred care approach - care management (or case management or care coordination) – “where it is implemented effectively… has improved the experiences of users and carers, supporting better care outcomes, reducing the utilisation of hospital- based services and enabling a more cost effective approach to care”. It works best if part of a wider programme of care (such as a locally integrated whole system of care).
To work effectively, care management should be targeted on people most at risk of heavy use of hospital and institutional care homes and who could benefit most (“case finding”); should consider the whole range of needs so assessment is not restricted to health needs only – a problem with some NHS care management pilots; should empower the user to be more independent and self managing; provide an element of continuity of care; needs close collaboration between health and social care (and housing and voluntary sector) staff who need to be able to draw on a range of resources and services in the community.
Case example: as part of the London Older Peoples Service Development Programme, 24 health and social care projects aimed at applying case finding and case management using the Castlefields model across London, one case management project identified an elderly lady who had over 10 emergency hospital attendances (all by ambulance) and a similar number of GP emergency call outs in a year. On assessment it was found that she had a heart condition but also dementia, extreme social isolation and lack of carers – which made her anxious and liable to panic. Each problem was dealt with and the lady was happier and less isolated and the number of unnecessary call outs greatly reduced. (LOPSDP 2002)
There have been endless pilots of care management in the UK but the economic situation may mean that we now have to use the evidence built up to develop services.
Personalisation: the ultimate whole person approach
Personalisation is at the heart of transforming health and social care services. Following an assessment of needs with the user, the cost of care is determined and then the user (or carer) is given the budget that would have been spent by health or social care services and therefore can exercise choice and control over which services are best to meet their individual outcomes. Like case management this has been implemented in social care for far longer than the in the NHS.
Evidence suggests that recipients of direct payments are more satisfied and report better outcomes including greater choice and control (IBSEN). However, Councils also appear to differ on the amount of money, degree of freedom of choice or level of bureaucracy involved in the process (In Control).
The introduction of personal budgets with individual outcomes enables services to measure service effectiveness for the first time ie the activity and cost and outcome rather than just the old limited efficiency measure of unit costs – which ignores the actual outcomes or quality of the costed activity.
The new NHS and adult social care outcomes are welcomed for including a major element of user and carer self reported satisfaction and quality of life and outcome measures. Joint NHS and social care outcome measures have already been successfully piloted for mental health services.
The new personal budgets and individual outcomes will allow an unprecedented ability for health and social care communities to identify the cost of services for each individual, the individual outcomes and the overall balance of care in the locality. If implemented correctly it would give us the ability to measure the effectiveness and quality of each service or combinations of services on individuals and groups of people – which has been conspicuously absent from current health and social care data.
In the US individual billing gives health companies the ability to maximise profit and make cost reductions to improve their competitive position. Unfortunately it also seems to add to the overall cost in terms of cost/GDP where the NHS is one of the most efficient performers.
Evidence shows that we need a whole person, whole system approach to develop services effectively and make integration work. Individual outcomes and costing/budgets and whole system indicators will enable detailed analysis of individual and system costs, quality and outcomes across services in a locality.
It may be the time to stop the constant piloting; use the known evidence to develop effective services; design performance and audit systems to measure individual outcomes costs and quality so we can see how effective each service is; use the outcome information to continuously monitor whole system use of resources, identify services with the best outcomes/cost, and use any money gained through efficiency to improve quality and develop more preventive community care options. The one thing we can’t do is do nothing.