Shifting the balance of care: great expectations
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The document discusses the challenges and policies related to shifting care from hospitals to community settings within the NHS, stressing the need for better organization and funding. It analyzes various interventions and their effectiveness in reducing hospital activity and costs, revealing mixed results with some initiatives potentially increasing expenses. Overall, while community care has benefits, the transition may not yield immediate financial savings, highlighting the necessity for a comprehensive strategy and acknowledgment of funding limits.
Shifting the balance of care: great expectations
- 1. Candace Imison, Director of Policy, Nuffield Trust Shifting the balance of care Great expectations
- 2. A long term ambition 2 “The general availability of medical services can only be effected by new and extended organisation, distributed according to the needs of the community. This organisation is needed on grounds of efficiency and cost, and is necessary alike in the interest of the public and of the medical profession.” Interim Report on the Future Provision of Medical and Allied Services (Dawson 1920)
- 3. Multiple policy interventions, little shift 3 2000 2006 2013 2014 “Shift in the centre of gravity of spending.” “Significant expansion of care in community settings.” “Out-of-hospital care needs to become a much larger part of what the NHS does.” “Ease the pressure on hospitals.”
- 4. Multiple policy interventions, little shift 4 2000 2006 2013 2014 “Shift in the centre of gravity of spending.” “Significant expansion of care in community settings.” “Out-of-hospital care needs to become a much larger part of what the NHS does.” “Ease the pressure on hospitals.” £4bn of £22bn
- 5. STP assumptions are variable but hope to bend the demand curve & save money 5 Area No. of STPs Min Reduction Max Reduction Average by 2020/21 Outpatients 19 7% 30% 15.5% Elective Inpatients 22 1.4% 16% 9.6% A&E attendances 26 6% 30% 17% Non-elective inpatients 30 3% 30% 15.7%
- 6. Evidence suggests some initiatives may reduce activity and save money Most Positive Emerging positive Remote monitoring of people with certain LTCs Patients experiencing GP continuity of care Improved end-of-life care in the community Extensivist model of care for high risk patients Condition specific rehabilitation Social prescribing Targeted support for self care Senior assessment in A&E Additional clinical support to people in nursing and care homes Rapid access clinics for urgent specialist assessment Improved GP access to specialist expertise Ambulance/paramedic triage to the community
- 7. Evidence suggests some initiatives may reduce activity and save money Most Positive Emerging positive Remote monitoring of people with certain LTCs Patients experiencing GP continuity of care Improved end-of-life care in the community Extensivist model of care for high risk patients Condition specific rehabilitation Social prescribing Targeted support for self care Senior assessment in A&E Additional clinical support to people in nursing and care homes Rapid access clinics for urgent specialist assessment Improved GP access to specialist expertise Ambulance/paramedic triage to the community
- 8. Evidence suggests some initiatives may reduce activity and save money Most Positive Emerging positive Remote monitoring of people with certain LTCs Patients experiencing GP continuity of care Improved end-of-life care in the community Extensivist model of care for high risk patients Condition specific rehabilitation Social prescribing Targeted support for self care Senior assessment in A&E Additional clinical support to people in nursing and care homes Rapid access clinics for urgent specialist assessment Improved GP access to specialist expertise Ambulance/paramedic triage to the community
- 9. Many initiatives may not save or may cost money Mixed – re £ + activity May cost ££ Case management and care coordination Extending GP opening hours Intermediate care: rapid response services Specialist support from a GP with a special interest Intermediate care: bed-based services Consultant clinics in the community Hospital at Home NHS 111 Shared care models for the management of chronic disease Urgent care centres including minor injury units (not co-located with A&E) Virtual ward Referral management centres Shared decision making to support treatment choices Direct access to diagnostics for GPs
- 10. Many initiatives may not save or may cost money Mixed – re £ + activity May cost ££ Case management and care coordination Extending GP opening hours Intermediate care: rapid response services Specialist support from a GP with a special interest Intermediate care: bed-based services Consultant clinics in the community Hospital at Home NHS 111 Shared care models for the management of chronic disease Urgent care centres including minor injury units (not co-located with A&E) Virtual ward Referral management centres Shared decision making to support treatment choices Direct access to diagnostics for GPs
- 11. Many initiatives may not save or may cost money Mixed – re £ + activity May cost ££ Case management and care coordination Extending GP opening hours Intermediate care: rapid response services Specialist support from a GP with a special interest Intermediate care: bed-based services Consultant clinics in the community Hospital at Home NHS 111 Shared care models for the management of chronic disease Urgent care centres including minor injury units (not co-located with A&E) Virtual ward Referral management centres Shared decision making to support treatment choices Direct access to diagnostics for GPs
- 12. What do systems leaders think? 12 Care in the community is cheaper and provides better care for patients. 38% Care in the community provides better care for patients but is not cheaper. 38% Care in the community is cheaper but does not provide better care for patients. 3% Care in the community is neither cheaper nor provides better care for patients. 7% I am not sure. 14% With regard to moving care out of hospitals, which of the following statements most accurately reflects your view? (n=58)
- 13. 9% 25% 26% 40% Risk stratification: not the whole solution • Regression to mean • Requires holistic view of patient • Patient’s capacity to engage • Need very high impact on those at greatest risk to have impact overall Adapted from: Roland and Abel, 2012 High relative risk (x 5.5) Very high relative risk (X 18.6) Moderate relative risk (x1.7) Low relative risk (x0.5) Case management Disease management Supported self care Prevention and wellness promotion 13 % Total Emergency AdmissionsX Average rate of emergency admission
- 14. The gap between theory and practice “Improvement initiatives are sometimes planned on the hard high ground, but are put into effect in the swampy lowlands.” - Marshall and others, 2016 © Kenneth Allen
- 15. Implementation needs to take wide range of factors into account • Requires rigorous framing of the problem and contextual factors that could influence feasibility and effectiveness • Including influencing professional behaviour such as attitudes to risk Source: Imison and others, 2012 15 Bed use System governance factors • Governance models • Commissioner behaviour/ relationships • Provider behaviour/ relationships • Staff beliefs and values • Leadership Hospital factors (supply side) • Access (rurality) • Internal processes – admission, treatment and discharge Community factors • Primary care supply and capacity • Community care supply and capacity • Local authority care supply and capacity Patient factors (demand side) • Age • Socioeconomic status • Sex • Health needs • Beliefs and values
- 16. Why is it so hard to release savings from shifting care? 16 • Lower unit costs in community does not mean lower costs overall. Price Cost • Additional services supply- induced demand • Care coordination can cost more than it saves • Targeting overuse can expose underuse 0 4 0 2 4 Cost(£) Level of activity
- 18. Community An unequal battle? Hospital 18 No funding to support transition
- 19. Primary and community care facing significant challenges 19 • 1/3 GP practices have a vacancy for at least one partner • 2016 - NHS England identified 20% GP practices as vulnerable • 1/5 district nurse posts vacant
- 20. Will economic impact only be visible when we have whole system change? 20 • A more radical approach needed? • Initiatives have been too small and underpowered? • Unsupported by wider system incentives • Lack of time • Inappropriate measures of success
- 21. Conclusion 21 • The NHS is undertaking the herculean task of changing its modus operandi at the same time as experiencing the leanest years in its history. • Nobody can argue against the principle of better, more appropriate care closer to home. • But we cannot assume that this will save money, especially in the short term. • To succeed, we need a relentless focus on what works • Crucially, to admit when the funding envelope simply isn’t big enough to deliver the transformation needed.
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