An Older People's Pathway
Edinburgh Integration Joint Board, 2023 - 2024
Background
The Integration Joint Board is a statutory body responsible for health and social care services in Edinburgh. It is a partnership of the Lothian Health Board and the City of Edinburgh Council, established in 2015.
The Board comprises elected members of the Council; independent citizen, trades union and voluntary and community sector representatives; and clinicians and non-executive members of the NHS Lothian.
The Board governs a Health and Social Care Partnership (EHSCP) with a £0.9BN annual budget, which is delegated from the Council and NHS Lothian.
The Partnership commissions, operates and procures sub-acute hospitals and care homes; home care and supported living; reablement and rehabilitation; community nursing and primary care; specialist mental health and learning disability services; and voluntary and community services.
Waiting for care, scarcity and inflation
In June 2023, EHSCP saw persistent demand and costs for care that exceeded the budgets delegated from its partners. Waiting times and fees for residential and dementia care were notable among them.
The Board directed a strategic commissioning exercise about older people's bed-based services by appointing an external commissioner. It wanted an independent study of the City's subacute hospitals and care homes, with recommendations for immediate savings and long-term commissioning plans. James was appointed to lead the programme, called the "Older People's Pathway" as the substantive deliverable of his term as Edinburgh's Lead Commissioner.
Approach
The programme worked closely with the Partnership's commissioners, the NHS Lothian Executive, clinical leaders and the City's care homes, to agree a plan to rebalance bed-based care, divesting from services in hospitals and older care homes and reinvesting in modern care homes and enhanced domiciliary services, with a special focus on acute dementia and palliative end-of-life care.
The reconfiguration was designed to provide affordable care in the community, helping older people leave hospital for the right setting at the right time. It released the site of the Liberton Hospital to be redeveloped for much-needed housing. It found a new, modern home for the Lothian region's Infectious Disease Unit. The reconfiguration was cost-neutral to the Partnership and yielded significant savings to NHS Lothian.
Conclusions
The programme concluded with proposals for new care homes to meet projected long-term growth in the incidence of acute dementia and conditions that need complex nursing care. This required long-term investment by the Council and by independent care providers. It would be repaid with adequate, affordable care in coming decades.
Reports
Read our findings and see our presentation to the Board, February 2024
See the Board's decision to close Liberton Hospital and reinvest savings in nursing and dementia care in Council care homes and a new end-of-life care home service, June 2024
See the Board's decision to replace a general medicine ward at Western General Hospital with enhanced domiciliary and rehabilitation services, August 2024
Fair Cost of Care
Gloucestershire County Council and NHS Gloucestershire, 2023
In 2023, the Department of Health and Social Care prepared to reform funding for social care by executing dormant provisions in the Care Act (2014).
Background
In 2014, the Care Act reformed the way social care is planned and delivered in England. It meant to reform funding, too, but it did not. Funding reform has been deferred by successive governments since 2015.
Among the dormant reforms in the Care Act was a provision to narrow the difference between fees that local councils pay for those they fund and the fees paid by people who fund for their own care.
The problem of cross-subsidy
Most people who pay for their own care do so because they have more income and assets than the state allows. This is decided by a means test that local councils perform on everyone who needs care and wants the state to pay for it.
It is a commonplace of social care policy in England that people whose care is not funded by the state pay more per unit (per week in a care home, per hour of care at home) than the state pays for the same unit. This is due in part to "monopsony," which allows local councils to negotiate lower fees with care providers because they are the single largest purchaser of care in their area. This leads to a popular theory that the state's means test for social care causes inequity: people who do not qualify for state funding not only pay for their care, they pay higher fees for it than the state would pay.
The intended effect of means-testing is that people with some, albeit modest, income and assets don't benefit from state funding despite paying, or having paid, taxes.
The unintended effect is that the state pays less than the real cost of care because it gets discounts for the quantity of care it buys. On aggregate, this would mean that state-funded care is uneconomic. Only because self-funders pay higher fees can the state fund sufficient care from its current budget. (This assumes, controversially, that state spending on care meets need.)
If cross-subsidy is endemic, it is unintended and unfair but the care system depends on it.
Fair Cost of Care
The Government's 2023 Fair Cost of Care programme was part of a government policy to reform the funding of social care by executing dormant provisions in the Care Act. Among the policy aims was to reduce cross-subsidy by funding local councils to close the gap between their fees and fees paid by self-funders. Gloucestershire County Council commissioned Sphere Advisory as a trusted, independent intermediary to estimate the cost of filling the gap.
To do so, we needed first to establish if cross-subsidy was real in Gloucestershire and, if it was, what it would cost to eliminate it.
The scope of this Fair Cost of Care programme included care home and home care services for older people because this is the population most likely to be affected by means-testing and cross-subsidy. The programme required local councils to survey care providers to find out what it costs to provide care, irrespective of price and who pays. Preparatory research indicated that if there was cross-subsidy in Gloucestershire, it would affect care homes more than home care. The credibility of the care home survey, which is more complex than the home care survey due to the capital costs of care homes, depended on accurate, statistically significant results.
Approach
Sphere Advisory played a pivotal role. We acted as an independent intermediary, engaged care providers, facilitated survey completion, and delivered accurate, actionable insight to the Council, NHS and government.
Sphere was effective because we had the commercial maturity to act as an independent intermediary between the Council and care providers under a legally binding confidentiality agreement; and the systems to produce actionable results and analysis quickly and accurately.
We ensured that the survey was fair, transparent, and accurate; and that providers were confident that their survey data were processed safely and that no home's results could be identified by the Council nor by any other state agency or care provider.
Results
The survey was a success. It represented care homes operating about half of the care home beds for older people in Gloucestershire. We produced statistically significant results which showed that cross-subsidy was real in Gloucestershire, but less-so in home care than in care homes. The data were sufficient to support a plan for preferential fee-uplifts for dementia and nursing care, which evidence from provider engagement and from data about waiting times showed were the most scarce.
Because we estimated the unit-cost of care, indifferent to the price and who paid, we were able to estimate the cost of a subset of services commissioned by NHS Gloucestershire.
The results allowed NHS Gloucestershire to match the Council's Fair Cost of Care fee-uplift. This avoided the potential that Council fee-uplifts for nursing care would create a fee-gradient, with the Council unintentionally out-bidding NHS for services for Continuing Health Care. This risked reducing the stock of beds for people at the end of their life and most in need of rapid access to care.
Report
Read our Technical Report on Fair Cost of Care for care homes in Gloucestershire, October 2023.