THE ESSENCE PROJECT

Assessing needs

Case studies

Read the full case study for 'Person-centred support for people living with dementia in care homes: economic evidence' here (PDF)
Michela Tinelli, Renee Romeo, Martin Knapp, Danielle Guy 2019

KEY POINTS

  • Almost all (95%) of the average cost of care home residence (£792 per week) is accounted for by room and board charges. Hospital contacts contribute the largest proportion of the additional healthcare costs. The absence of an association between cost and needs emphasizes the importance of a more needs-based service system which could result in clinical and economic advantages.
  • Person-centred, integrated, and in-reach care home services responding to the needs of individual residents may improve health outcomes and quality of life at reasonable costs.
  • Interventions providing good value for money, similar to the Wellbeing and Health for People with Dementia or Enhanced Care Home Outcomes interventions are good value for money.

Read the full case study for 'Transition into and from hospital for people with social care needs: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

  • Interventions that seek to improve the transition between hospital and other settings include: comprehensive geriatric assessments; specialist dementia / delirium unit; short-term early discharge home care and rehabilitation packages; early supported discharge with multidisciplinary community care; multi-professional palliative care.
  • Each has been linked to some positive outcomes – although for specialist delirium/ dementia unit and for multi-professional palliative care outcomes referred to small changes in mood, satisfaction or symptom control rather than to changes in health-related quality of life.
  • Early supported discharge programmes that include a rehabilitation-focused community care package are likely to be cost-effective from a combined health and social care perspective. The evidence refers to older people and people with stroke.
  • Comprehensive geriatric assessment and short-term rehabilitation provided to older people in hospital units may be cost-effective from a hospital perspective, but the wider impacts are unclear.
  • Multi-professional palliative care might be cost-effective; evidence refers to people with multiple sclerosis and people with breathlessness; there might cost savings for people with multiple sclerosis due to reductions in hospital and primary care.
  • A specialist delirium/ dementia unit was not cost-effective based on health-related quality of life but might importantly improve experiences of people using it and their carers.
  • Various national initiatives have been recently implemented to support development of innovative services to integrate care between hospitals and other settings.

Evidence

An introduction to economic evaluation in occupational therapy: cost-effectiveness of pre-discharge home visits after stroke (HOVIS)
Sampson C, James M, Whitehead P, et al British Journal of Occupational Therapy, 77, 330-335. 2014

Introduction: Occupational therapy interventions, such as home visits, have been identified as being resource-intensive, but cost-effectiveness analyses are rarely, if ever, carried out. The authors sought to estimate the cost-effectiveness of occupational therapy home visits after stroke, as part of a feasibility study, and to demonstrate the value and methods of economic evaluation. Method: The authors completed a cost-effectiveness analysis of pre-discharge occupational therapy home visits after stroke compared with a hospital-based interview, carried out alongside a feasibility randomised controlled trial. Their primary outcome was quality-adjusted life years. Full cost and outcome data were available for 65 trial participants. Findings: The mean total cost of a home visit was found to be £183, compared with £75 for a hospital interview. Home visits are shown to be slightly more effective, resulting in a cost per quality-adjusted life year of just over £20,000. Conclusion: The author’s analysis is the only economic evaluation of this intervention to date. Home visits are shown to be more expensive and more effective than a hospital-based interview, but the results are subject to a high level of uncertainty and should be treated as such. Further economic evaluations in this field are encouraged.

Autism Spectrum Disorder in Adults: Diagnosis and Management [CG142]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers diagnosing and managing suspected or confirmed autism spectrum disorder (autism, Asperger’s syndrome and atypical autism) in people aged 18 and over. It aims to improve access and engagement with interventions and services, and the experience of care, for people with autism.

In August 2016, 2 research recommendations were removed from this guideline.

Recommendations
This guideline includes recommendations on:

identification and assessment
interventions for autism
interventions for challenging behaviour
interventions for coexisting mental disorders
assessment and interventions for families, partners and carers
organising and delivering care
Who is it for?
Health and social care professionals (including those in the independent sector)
Commissioners and providers
Adults with autism and their families, partners and carers

Related NICE guideline:
APPENDIX 18:HEALTH ECONOMIC EVIDENCE – EVIDENCE TABLES OF PUBLISHED STUDIES Authors not listed

Building Community Capacity: Making an Economic Case
Knapp M, Bauer A, Perkins M Personal Social Services Research Unit, London. 2010

Our aim in this small study was to develop simple ‘models’ of interventions that can contribute
to local community development programmes by examining some of the possible impacts. We
could not look at all impacts because of data limitations. These are necessarily simplified
representations of reality, because of the availability of evidence. But this is a pragmatic
approach, using published, unpublished and experiential evidence, and working closely with local experts, and was the most helpful way to go forward given time constraints. We
calculated the costs of three particular community initiatives – time banks, befriending and
community navigators for people with debt or benefits problems – and found that each
generated net economic benefits in quite a short time period. Each of those calculations was
conservative in that we only attached a monetary value to a subset of the potential benefits.

Care and Health Improvement Programme: Efficiency Project
Local Government Association Local Government Association, London. 2018

This report provides practice examples from ten councils who took part in the Care and Health Improvement Programme during 2016/17. It describes the innovative approaches they took to achieve greater efficiencies from their adult social care budgets and draws conclusions as to what other councils might learn from them. The examples cover three main areas: managing demand for social care by offering residents a different type of service; more effectively using the capacity in communities to help find new care solutions; and working closer with partners in the NHS to reduce pressures in the care and health system. They highlight the importance of councils dealing with people effectively at their first point of contact; the benefits of using strength-based approaches; that developing social enterprises can be a cost effective way of meeting demand and reducing shortage of supply; and the potential of collaboration between councils to reduce costs and demand for services. The 10 councils are: Bristol City Council, Poole Borough Council, Swindon and Wiltshire Councils; Norfolk County Council; Waltham Forest Council; Somerset Council; Newcastle City Council; Nottingham City Council; and Nottinghamshire County Council.

Care and Support of People Growing Older with Learning Disabilities [NG96]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers care and support for adults with learning disabilities as they grow older. It covers identifying changing needs, planning for the future, and delivering services including health, social care and housing. It aims to support people to access the services they need as they get older.

We have produced an EasyRead version and video to explain this guideline, which are available from information for the public.

Recommendations
This guideline includes recommendations on:

overarching principles
organising and delivering services
identifying and assessing care and support needs
planning and reviewing care and support
identifying and managing health needs
end of life care
staff skills and expertise
Who is it for?
Providers of social care, health and housing support for people growing older with learning disabilities
Practitioners in social care, health and housing who work with people growing older with learning disabilities and their families and carers
Commissioners and people with a strategic role in assessing and planning local services
Practitioners in other related services, including older people’s services, adult learning disability services, employment, education and criminal justice services
People with learning disabilities, their families, carers and advocates

Related NICE guideline:
Appendix C2: Economic report Bauer A and Knapp M

Challenging Behaviour and Learning Disabilities: Prevention and Interventions for People with Learning Disabilities Whose Behaviour Challenges [NG11]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers interventions and support for children, young people and adults with a learning disability and behaviour that challenges. It highlights the importance of understanding the cause of behaviour that challenges, and performing thorough assessments so that steps can be taken to help people change their behaviour and improve their quality of life. The guideline also covers support and intervention for family members or carers.

NICE has produced an easy read version for people with a learning disability.

Recommendations
This guideline includes recommendations on:

general principles of care
support and interventions for family members or carers
early identification of the emergence of behaviour that challenges
assessment
psychological and environmental interventions
medication
interventions for coexisting health problems and sleep problems
Who is it for?
Healthcare professionals, commissioners and providers in health and social care
Parents, family members or carers of children, young people and adults with a learning disability and behaviour that challenges

Related NICE guideline:
Appendix T: Health economic evidence – economic profiles Authors not listed

Commissioning Cost-Effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill-Health
McDaid D, Park A, Knapp M Public Health England, London. 2017

A return on investment resource to support local commissioners in designing and implementing mental health and wellbeing support services.

Cost effectiveness of pilot self-assessment sites in community care services in England
Clarkson P Australian Health Review, 37, 666-674. 2013

OBJECTIVE:
Self-assessment has been advocated in community care but little is known of its cost effectiveness in practice. We evaluated cost effectiveness of pilot self-assessment approaches.

METHODS:
Data were collected from 13 pilot projects in England, selected by central government, between October 2006 and November 2007. These were located within preventative services for people with low-level needs, occupational therapy, or assessment and care management. Cost effectiveness, over usual care, was assessed by incremental cost-effectiveness ratios (ICERs), in British pounds per unit gain in assessment satisfaction. A public-sector perspective was adopted; the provider costs of the agencies taking part.

RESULTS:
At 2006-07 prices, including start-up and on-going costs, only three pilots demonstrated cost effectiveness. Two pilots in assessment and care management had ICERs of £3810 and £755 per satisfaction gained, well below a benchmark from a trial of usual assessment of £18296 per satisfaction gained. When extrapolating uptake to numbers accessing assessments over 1 year, one occupational therapy pilot, of £123/satisfaction gained, also fell below this benchmark in sensitivity analysis. There was less evidence for preventative services.

CONCLUSIONS AND IMPLICATIONS:
Most pilot projects were not cost effective. However, self assessment is potentially cost effective in assessment and care management and occupational therapy services. Better quality cost data from pilot sites would have permitted more detailed analysis. Measuring downstream effects in terms of users’ well being from receipt of self-assessment would also be beneficial.

Dementia care costs and outcomes: a systematic review
Knapp M, Iemmi V, Romeo R International Journal of Geriatric Psychiatry, 28:, 551-556. 2013

Abstract
OBJECTIVE:
We reviewed evidence on the cost-effectiveness of prevention, care and treatment strategies in relation to dementia.

METHODS:
We performed a systematic review of available literature on economic evaluations of dementia care, searching key databases and websites in medicine, social care and economics. Literature reviews were privileged, and other study designs were included only to fill gaps in the evidence base. Narrative analysis was used to synthesise the results.

RESULTS:
We identified 56 literature reviews and 29 single studies offering economic evidence on dementia care. There is more cost-effectiveness evidence on pharmacological therapies than other interventions. Acetylcholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease were found to be cost-effective. Regarding non-pharmacological treatments, cognitive stimulation therapy, tailored activity programme and occupational therapy were found to be more cost-effective than usual care. There was some evidence to suggest that respite care in day settings and psychosocial interventions for carers could be cost-effective. Coordinated care management and personal budgets held by carers have also demonstrated cost-effectiveness in some studies.

CONCLUSION:
Five barriers to achieving better value for money in dementia care were identified: the scarcity and low methodological quality of available studies, the difficulty of generalising from available evidence, the narrowness of cost measures, a reluctance to implement evidence and the poor coordination of health and social care provision and financing.

Dementia: Assessment, Management and Support for People Living with Dementia and their Carers [NG97]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers diagnosing and managing dementia (including Alzheimer’s disease). It aims to improve care by making recommendations on training staff and helping carers to support people living with dementia.

Recommendations
This guideline includes recommendations on:
• involving people living with dementia in decisions about their care
• assessment and diagnosis
• interventions to promote cognition, independence and wellbeing
• pharmacological interventions
• managing non-cognitive symptoms
• supporting carers
• staff training and education

Who is it for?
• Healthcare and social care professionals caring for and supporting people living with dementia
• Commissioners and providers of dementia health and social care services
• Housing associations, private and voluntary organisations contracted by the NHS or social services to provide care for people living with dementia
• People living with dementia, their families and carers

Related NICE guideline:
Appendix J:Health Economics Authors not listed

Demonstrating the Health and Social Cost-benefits of Lifestyle Housing for Older People
Housing Learning and Improvement Network Housing Learning and Improvement Network, London. 2017

This report, commissioned by Keepmoat Regeneration/ENGIE, sets out the evidence for the benefits of developing specialist retirement housing for people aged over 55, including cost savings. It focuses on the benefits of age restricted retirement housing or sheltered accommodation, care villages and specialist extra care housing with services and care on-site. Part one lists key facts and figures on the health and social care cost-benefits of lifestyle housing for older people. Part two provides more detailed findings of the potential benefits including the areas of: social connectedness and reducing loneliness; life expectancy, keeping couples together and supporting informal carers, financial savings in adult social care and the NHS, and preventing the need for institutional care. References and links are listed at the end of the document.

End of Life Care for Adults in the Last Year of Life: Service Delivery [GID-CGWAVE0799]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London.

In development

Related NICE guideline:
In development In development

Going Home Alone: Counting the Cost to Older People and the NHS
Royal Voluntary Service Royal Voluntary Service, Cardiff. 2014

Assesses the impact of home from hospital services, which focus on supporting older people in their homes following a stay in hospital and seek to reduce the likelihood that they will need to be readmitted to hospital. The report brings together the findings of a literature review (as well as discussions with relevant experts), the results of the survey of 401 people aged 75 or over who had spent at least one night in hospital on one or more occasions within the past five years, and the outputs from a cost-impact analysis using national data and results from the survey. It sets out the policy context in England, Scotland and Wales, with its focus on preventive care, better integration of health and care services, and on shifting care away from the hospital into homes and communities. It then discusses the demand drivers for these schemes, including the ageing population, the growth in hospital readmissions, and decreasing length of stay. The report examines the experiences of older people after leaving hospital, looking at admissions, discharge, need for support following discharge, and type and duration of support. It suggests that home from hospital schemes can help to improve the well-being of their users and to reduce social isolation and loneliness and the number of hospital readmissions, as well as demand for other health and care services. The results of the cost-impact analysis suggest that, were home from hospital schemes appropriately targeted and effective in addressing ‘excess admissions’, they may produce a saving for the NHS of £40.4m per year

Health at Home: A New Health and Wellbeing Model for Social Housing Tenants
Peabody Peabody Group, London. 2018

The report from Peabody is based on research with some of their general needs residents aged 50 and focuses on helping them to improve their understanding and confidence around managing their own health. It looked at how:

services can be delivered effectively at lower cost?
self-care can be encouraged for the most vulnerable customers and reduce dependency on direct support?
partnerships with other agencies can ensure a coordinated response to support residents’ complex and multiple health needs?

The report shows how housing associations can play an important role in empowering residents to stay healthy and also demonstrated the value of a person-centred approach to build more system resilient.

Home from Hospital: How Housing Services are Relieving Pressures on the NHS
Copeman I, Edwards M, Porteus J National Housing Federation, London. 2017

This report shows how housing services are helping to relieve pressure on the NHS by reducing delays in discharging people from hospital and preventing unnecessary hospital admissions. It features 12 case studies to show the positive impact these services have on people’s lives and the cost benefit to the NHS. The case studies highlight services that will benefit people most at risk of delayed discharge, such as older people, people with mental health problems and people experiencing homelessness. The case studies also demonstrate a diversity of housing and health services including: ‘step down’ bed services for people coming out of hospital who cannot return to their own home immediately; hospital discharge support and housing adaptation services to enable timely and appropriate transfers out of hospital and back to patients’ existing homes; providing a new home for people whose existing home or lack of housing mean that they have nowhere suitable to be discharged to; and Home from Hospital services to keeping people well at home who would otherwise be at risk of being admitted or readmitted to hospital. The report also considers the impact and additional savings that could be made by housing providers if this work were to be scaled up.

Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster randomised controlled trial.
Ballard C, Corbett A, Orrell M, et al Public Library of Science: Medicine, 15, e1002500. 2018

Abstract
Background

Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost.
Methods and findings

This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory–Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen’s D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI −7.39, −1.15; Cohen’s D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI −7.07,−2.02; Cohen’s D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen’s D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group.
Conclusions

These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting.
Trial registration

ISRCTN Registry ISRCTN62237498
Author summary
Why was this study done?

People with dementia living in care homes often experience agitation and other symptoms that are difficult to treat and distressing for the individual.

What did the researchers do and find?

We tested the WHELD programme, which combined staff training, social interaction, and guidance on use of antipsychotic medications, in 69 UK care homes in a 9-month clinical trial.
We showed that care homes receiving the WHELD programme saw improvements in quality of life as well as other important symptoms including agitation, behaviour, and pain in people with dementia.
The WHELD programme was also shown to be cost-effective.

What do these findings mean?

The findings show that the WHELD approach is beneficial for people with dementia living in care homes.
WHELD could be provided in an affordable way to improve the lives of these individuals, who often do not receive the care they need.

Integrating assessments of older people: examining evidence and impact from a randomised controlled trial
Clarkson P, Brand C, Hughes J, et al Age and Ageing, 40, 3, 388-391. 2011

SIR—The needs of older people are often multiple, complex and are at times experienced in combination, which require closely targeted services [1] and necessitate the collaboration of several professional groups. However, care has often been disjointed and compartmentalised [2]. One response to this has been a call for integration, between health and social care. Integrated care can operate at the organisational level, in terms of structures [3, 4] or the professional level, in terms of shared working arrangements, multidisciplinary teams and case management [5, 6]; an issue being that integrated structures, although conducive to inter-professional working, do not necessarily guarantee it [7].

Integration is assumed to produce benefits in terms of better co-ordination of services, better outcomes and greater efficiency [8]. Integration remains an aim pursued by successive governments [9]. Policies in several countries call for integration at the assessment stage; a key phase in terms of ensuring care closely matches older people’s needs [10, 11]. In England, examples are the single assessment process (SAP), offering a common structure through shared tools and processes [12], and the common assessment framework (CAF) for adults, advocating technical solutions for information sharing [13]. However, while evidence identifies potential benefits of integrating assessment information from different professionals [5, 14] and of more comprehensive geriatric assessment [15], there remains a need to examine the cost-effectiveness of such approaches to guide future policy.

We reanalysed data from a randomised controlled trial of integrated assessment between specialist clinicians and social services care managers in England [14] to offer evidence of the costs and benefits of integration. We evaluated the experiment’s impact on changes in functioning, admissions to care homes and use and costs of health and social services for frail older people at risk of entering care homes

Investing in Recovery: Making the Business Case for Effective Interventions for People with Schizophrenia and Psychosis
Knapp M, Andrew A, McDaid D, et al Rethink Mental Illness, London. 2014

This study provides economic evidence to support the case for investing in effective, recovery-focused services for people with schizophrenia and psychosis. Drawing on a wide range of data, it sets out the evidence for the cost-effectiveness for a range of interventions and service. Those discussed are: Early Detection (ED) services; Early Intervention (EI) teams; Individual Placement and Support (IPS); Family therapy; Criminal justice liaison and diversion; Physical health promotion, including health behaviours; Supported housing; Crisis Resolution and Home Treatment (CRHT) teams; Crisis houses; Peer support; Self-management; Cognitive Behavioural Therapy (CBT); Anti-stigma and discrimination campaigns; Personal Budgets (PBs); and Welfare advice. For each intervention the report provides information on the context, the nature of the intervention, the evidence on effectiveness and cost-effectiveness, and the policy and practice implications. The report finds evidence to suggest that all of the interventions contribute to recovery outcomes, reduced costs and/or better value for money. Examples of the savings incurred through particular interventions are also included. The study was undertaken by a team from the Personal Social Services Research Unit (PSSRU), at the London School of Economics and Political Science (LSE), the Centre for Mental Health, and the Centre for the Economics of Mental and Physical Health (CEMPH) at King’s College London.

Mental Health Problems in People with Learning Disabilities: Prevention, Assessment and Management [NG54]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers preventing, assessing and managing mental health problems in people with learning disabilities in all settings (including health, social care, education, and forensic and criminal justice). It aims to improve assessment and support for mental health conditions, and help people with learning disabilities and their families and carers to be involved in their care.

Recommendations
This guideline includes recommendations on:

organising and delivering care
involving people in their care
prevention, including social, physical environment and occupational interventions
annual GP health checks
assessment
psychological interventions, and how to adapt these for people with learning disabilities
prescribing, monitoring and reviewing pharmacological interventions
Who is it for?
Healthcare professionals
Social care practitioners
Care workers
Education staff
Commissioners and service providers
People with learning disabilities and their families and carers

Related NICE guideline:
Appendix S: Health economic evidence –economic profiles Authors not listed

Micro-enterprises: Small Enough to Care?
Needham C, et al University of Birmingham, Birmingham. 2015

Outlines the findings of an evaluation of micro-enterprises in social care in England, which ran from 2013 to 2015. The report focuses on very small organisations, here defined as having five members of staff or fewer, which provide care and support to adults with an assessed social care need. The research design encompassed a local asset-based approach, working with co-researchers with experience of care in the three localities. Twenty seven organisations took part in the study overall, including 17 micro-providers, whose performance was compared to that of 4 small, 4 medium and 2 large providers. A total of 143 people were interviewed for the project. The study found that: micro-providers offer more personalised support than larger providers, particularly for home-based care; they deliver more valued outcomes than larger providers, in relation to helping people do more of the things they value and enjoy; they are better than larger providers at some kinds of innovation, being more flexible and able to provide support to marginalised communities; and they offer better value for money than larger providers. Factors that help micro-providers to emerge and become sustainable include: dedicated support for start-up and development, strong personal networks within a localities, and balancing good partnerships (including with local authorities) with maintaining an independent status. Inhibiting factors, on the other hand, include a reliance on self-funders and the financial fragility of the organisation. The report makes the following recommendations: commissioners should develop different approaches to enable micro-enterprises to join preferred provider lists; social care teams should promote flexible payment options for people wanting to use micro-enterprises, including direct payments; social workers and other care professionals need to be informed about micro-enterprises operating close-by so that they can refer people to them; regulators need to ensure that their processes are proportional and accessible for very small organisations; and micro-enterprises need access to dedicated start-up support, with care sector expertise, as well as ongoing support and peer networks.

Money Matters: Reviews of Cost-effective Initiatives
Institute of Public Care The Institute for Research and Innovation in Social Services, Glasgow. 2011

This set of eight case studies, produced by the Institute of Public Care on behalf of IRISS (the Institute for Research and Innovation in Social Services), provides detailed analysis of the cost-effectiveness of a series of recent social care initiatives, ranging from nationwide and relatively high-profile schemes such as individual budgets to those thus far unique to one country, city or local authority area in the UK.

In each case, the report provides an overview of the initiative – its origins, including previous variants of the scheme, who it is intended to help, and how it works in practice – before justifying claims of cost-effectiveness by reference to detailed comparative costings, using one illustrative implementation of the scheme where the initiative is nationwide. Based on the analysis, the report sets out the initiative’s applicability to other settings as well as potential impediments to broader implementation.

The eight initiatives scrutinised are:

A study of Shared Lives schemes in south east England for providing care in the carer’s own home for individuals placed there by the local authority.
An extra-care housing scheme completed in Bradford.
Health in mind – social inclusion support for people with mental health needs in Bradford based round a series of mental health “well-being cafes”.
LinkAge Plus – analysis of nationwide DWP-funded pilot schemes for an holistic approach to provision of services for older people.
The Rapid Response Adaptations Programme – a Welsh initiative for providing adaptations such as ramps to let people return to their own homes.
A project in north west England to guide older people with low-level needs through a self-assessment process.
Analysis of various pilot sites taking different approaches to individual budgets, based on a broader evaluation conducted in 2008.
A project in two acute trusts in London to reconfigure hospital discharge procedures to emphasise rehabilitation.

Older People with Social Care Needs and Multiple Long-term Conditions [NG22]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers planning and delivering social care and support for older people who have multiple long-term conditions. It promotes an integrated and person-centred approach to delivering effective health and social care services.

Recommendations
The guideline includes recommendations on:

identifying and assessing social care needs
care planning, including the role of the named care coordinator
supporting carers
integrating health and social care planning
delivering care
preventing social isolation
training health and social care practitioners

Who is it for?
Health and social care practitioners
Providers of care and support in health and social care services
Older people with social care needs and multiple long-term conditions (including both physical and mental health conditions), and their carers.
Commissioners should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
Appendix C3: Cost-consequence and cost-utility analysis of an outpatient geriatric multidisciplinary assessment and case management intervention: the ‘GRACE’ model of care Trachtenberg M and Fernandez JL

People Powered Recovery: Social Action and Complex Needs. Findings from a Call for Evidence
Turning Point All-Party Parliamentary Group on Complex Needs and Dual Diagnosis, London. 2018

The UK All-Party Parliamentary Group (APPG) on complex needs and dual diagnosis was established in 2007 in recognition of the fact that people seeking help often have a number of over-lapping needs including problems around access to housing, social care, unemployment services, mental health provision or substance misuse support. This report sets out the findings from a call for evidence on how social action can improve outcomes and develop more responsive services for people with complex needs or a dual diagnosis. Social action is about people coming together to tackle an issue, support others or improve their local area, by sharing their time and expertise through volunteering, peer-led groups and community projects. The report provides examples of how social action can support recovery, self-worth and confidence, boost employment prospects and skills, reduce stigma, better shape services to meet people’s needs, contribute to better health and wellbeing and save money. It also looks at how to overcome some of the challenges and barriers to developing social action focused around complex needs. These include resources, stigma, procedural issues, leadership, commissioning structures and demonstrating benefits.

Social care in prison: emerging practice arrangements consequent upon the introduction of the 2014 Care Act
Challis D, Tucker S, Hargreaves C, et al British Journal of Social Work, 48, 6, 1627–1644. 2018

This research will give local authorities’ a framework of evidence to inform the delivery of social care for prisoners, both while in prison and on release. In particular it will provide information on the nature and extent of prisoners’ social care needs and the range and cost of the services required to meet these. As such it has the potential to help councils deliver the Care Act reforms in an efficient manner and improve prisoners’ independence, well-being, rehabilitation and risk of re-offence. The overall study has three main strands. Strand 1 will scope prisoners’ social care needs via interviews with approximately 350 inmates in Lancashire. Stand 2 will use a Balance of Care approach (a strategic planning tool) involving staff workshops and cost modelling to identify the options for service provision. Strand 3 will constitute a national survey of local authorities in England to identify the arrangements councils have put in place to meet their responsibilities for prisoners under the Care Act, including how they identify prisoners with social care needs, deliver assessments, develop care and support plans and provide/procure services. The findings will be shared with a wide range of stakeholders via a multi- faceted knowledge exchange programme.

Targeting, care management and preventative services for older people: The cost-effectiveness of a pilot self-assessment approach in one local authority
Clarkson P British Journal of Social Work, 40, 2255-2273. 2010

As social services councils face a more constrained economic environment and as eligibility criteria tighten, the issue of targeting becomes increasingly relevant. This paper presents findings from a pilot project in one local authority that aimed to target access to assessment for older people with low-level needs who would normally have fallen under eligibility thresholds. Self-assessment was used as a tool whereby these older people could identify, with assistance, their preferences for a range of preventative services. Via a randomised design, the study evaluated the costs and benefits, in terms of reported satisfaction, of the approach compared with the usual care management assessment. Although self-assessed cases were offered more advice as to a wider range of preventative services, which generated greater costs, total costs were lower for this group. This cost saving arose from the use of staff with a lower unit cost who also spent less time on administrative duties and gathering information. Satisfaction with self-assessment was comparable to a professional assessment, therefore representing a cost-effective approach. The project offers evidence of how councils can target resources through assessment and how self-assessment approaches may be appropriately configured to offer value for these users whilst also generating resource savings.

Technical Guide: Building a Business Case for Prevention
Social Finance Social Finance, London. 2014

This guide sets out the issues that need to be considered when developing a business case to invest in preventive services and to ensure that any decision are based on robust and reliable data. The guide focuses on the following arguments: the importance of ‘investing to save’, arguing that prevention is cheaper in the long term; promotion of service innovation; placing the focus of commissioning on outcomes rather than outputs; and managing a shift in spending from acute to prevention to reduce demand over time. The guide outlines key four activities required to build a business case: understanding needs; understanding current costs; assessing possible interventions; and deciding how to measure the value and outcome of the interventions. It also provides a summary business case for prevention and using a Social Impact Bond (SBI) to finance a business case for prevention. An example case study of making a business case for prevention services in early years services in Greater Manchester is included.

The UTOPIA Project: Using Telecare for Older People in Adult Social Care. The Findings of a 2016-17 National Survey of Local Authority Telecare Provision for Older People in England
Woolham J, Steils N, Fisk M, et al Social Care Workforce Research Unit, King's College London, London. 2018

This report describes how electronic assistive technology and telecare are used by local authorities in England to support older people. It is based on an online survey of local authority telecare managers to identify local authority’s aims when offering telecare to older people, the methods they use to assess whether their objectives are achieved, and how telecare is operationalised and delivered. It also aimed to explore why the findings of the earlier the Whole System Demonstrator project – which found no evidence that telecare improved outcomes – have been overlooked by local authorities and policy makers, and whether there is other evidence that could account for WSD findings. The survey results found a third of local authorities used research evidence to inform telecare services and half were also aware of the Whole System Demonstrator. It also found that telecare is used in most local authorities to save money. Although there was some evidence of monitoring, there was no evidence of local authorities adopting agreed standards. The final section of the report provides suggestions for improving telecare service practice. They include the areas of using telecare as a substitute for social care; expanding the focus on telecare beyond risk management, safety and cost reduction; the impact of telecare on family members, carrying out effective assessments, and training

Total Transformation of Care and Support: Creating the Five Year Forward View for Social Care
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2017

Adult social care has repeatedly demonstrated its capacity for transformation: pioneering de-institutionalisation, personal budgets and more recently, asset-based approaches.Health and care systems will not provide good services that meet rising demand without realigning around people and communities.There are five areas where transformation needs to take place: 1Helping all people and families to stay well, connected to others and resilient when facing health or care needs.2Supporting people and families who need help to carry on living well at home.3Enabling people with support needs to do enjoyable and meaningful things during the day, or look for work.4Developing new models of care for adults and older people who need support and a home in their community.5Equipping people to regain independence following hospital or other forms of health care. If the sector scales up promising practice, economic modelling shows that outcomes can be improved and costs reduced.The sector needs to have difficult, challenging and creative local conversations involving people who use services and others, which create space to move forward together. Further research and economic modelling is needed on the promising practices to build a business case for proper and effective investment in truly integrated care and health.

Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Needs [NG27]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people’s experience of admission to, and discharge from, hospital by better coordination of health and social care services.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
The guideline includes recommendations on:

person-centred care and communication and information sharing
before admission to hospital including developing a care plan and explaining what type of care the person might receive
admission to hospital including the establishment of a hospital-based multi-disciplinary team
during hospital stay including recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge
discharge from hospital including the role of the discharge coordinator
supporting infrastructure
training and development for people involved in the hospital discharge process.
Who is it for?
The guideline is for health and social care practitioners; health and social care providers; commissioners; service users and their carers (including people who purchase their own care).

Related NICE guideline:
Appendix C3 Bauer A and Fernandez JL

Transition Between Inpatient Mental Health Settings and Community or Care Home Settings [NG53]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers the period before, during and after a person is admitted to, and discharged from, a mental health hospital. It aims to help people who use mental health services, and their families and carers, to have a better experience of transition by improving the way it’s planned and carried out.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
This guideline includes recommendations on:

overarching principles for good transition
planning for admission and discharge
out-of-area admissions
support for families and carers
Who is it for?
Providers of care and support in inpatient and community mental health and social care services
Front-line practitioners and managers in inpatient and community mental health and social care services
Commissioners of mental health services
People who use inpatient and community mental health services, their families and carers

Related NICE guideline:
Economics, economic modelling, appendix C3.2 Cost–utility analysis of a 2-year multi-staged psychological intervention for bipolar I patients with their first, second or third hospitalisation vs Generic outpatient treatment of bipolar affective disorders (active treatment as usual) Trachtenberg M and Knapp M

What Works in Community Led Support?
Bown H, Carrier J, Hayden C National Development Team for Inclusion, Bath. 2017

This report has been written to share the findings, learning and examples of impact identified from working with 9 authorities across England, Wales and Scotland who are working differently to improve the lives and support of local people.

It is essentially an evaluation report on the authorities’ progress towards the outcomes and longer-term aims of community led support over the last 18 months, but we believe it is more than that.

We hope the learning shared here will help demonstrate what’s possible when applying core principles associated with asset based approaches at the same time as tackling hard systemic and cultural issues around speed of response, ease of access, changing the nature of ‘assessment’, reducing waiting times and lists, turning eligibility criteria on their heads and making the best use of local resources for people with a wide range of support needs.

 Back to Organisational Framework


NIHR School for
Social Care Research