Julien E. Forder

Commissioning for Quality: Ten Years of Social Care Markets in England

The introduction of social care markets was one of the main planks of the Conservative governments community care reforms of 1990. The Labour government, whilst emphasising collaboration rather than competition, has not sought to reverse this policy. What have been the consequences? We discuss a decade of market-related change under five heads: purchasers, providers, commissioning, care planning and delivery, and users and carers. There have been quite substantial changes effected by social care markets in each domain, in turn generating a number of pertinent questions for the future success of social care policy in England. One is the very suitability of market-like arrangements in social care. Another is whether transaction costs are too high. More generally, are social care markets structured in a way that will generate the efficiency improvements that successive governments expect of them? Fourth, to what extent will price competition damage quality of care? Finally, will commissioning arrangements mature so as to achieve a better balance between competitive and collaborative modes of working?

An assessment of the construct validity of the ASCOT measure of social care-related quality of life with older people

BackgroundThe adult social care outcomes toolkit (ASCOT) includes a preference-weighted measure of social care-related quality of life for use in economic evaluations. ASCOT has eight attributes: personal cleanliness and comfort, food and drink, control over daily life, personal safety, accommodation cleanliness and comfort, social participation and involvement, occupation and dignity. This paper aims to demonstrate the construct validity of the ASCOT attributes.MethodsA survey of older people receiving publicly-funded home care services was conducted by face-to-face interview in several sites across England. Additional data on variables hypothesised to be related and unrelated to each of the attributes were also collected. Relationships between these variables and the attributes were analysed through chi-squared tests and analysis of variance, as appropriate, to test the construct validity of each attribute.Results301 people were interviewed and approximately 10% of responses were given by a proxy respondent. Results suggest that each attribute captured the extent to which respondents exercised choice in how their outcomes were met. There was also evidence for the validity of the control over daily life, occupation, personal cleanliness and comfort, personal safety, accommodation cleanliness and comfort, and social participation and involvement attributes. There was less evidence regarding the validity of the food and drink and dignity attributes, but this may be a consequence of problems finding good data against which to validate these attributes, as well as problems with the distribution of the food and drink item.ConclusionsThis study provides some evidence for the construct validity of the ASCOT attributes and therefore support for ASCOTs use in economic evaluation. It also demonstrated the feasibility of its use among older people, although the need for proxy respondents in some situations suggests that developing a version that is suitable for proxies would be a useful future direction for this work. Validation of the instrument on a sample of younger social care users would also be useful.

A comparison of the cost-effectiveness of sertraline versus tricyclic antidepressants in primary care

There has been considerable debate concerning the cost-effectiveness of selective serotonin re-uptake inhibitors (SSRIs) versus tricyclic antidepressants (TCAs) thus far using crude prescription price comparisons or reductionist decision-analytic models. This paper employs a retrospective quasi-experimental design where data on service utilisation, use of medication and informal care were collected for two groups of patients in general practice settings. The mean cost of treatment was marginally greater for those people receiving TCA medication due to greater use of psychiatric services. Factors such as age, previous depression and concomitant physical illness are all associated with greater treatment costs. Further analysis using a prospective design is recommended.

Measuring the outcomes of long-term care

How should we measure the value of long-term (social) care? This paper describes a care-related quality of life instrument (ASCOT) and considers aspects of its validity. In particular the aim is to assess whether ASCOT is better suited to measuring the impact of long-term care services than the EQ5D health-related quality of life measure. Long-term care services tend to be more concerned with addressing the day-to-day consequences of long-term conditions. As such, a quality of life measure should not be overly focused on the potential impact of services on personal ability and should instead consider how services directly help people to function in everyday life. Construct validity was judged by assessing the degree to which measured quality of life improvement was consistent with the theorised positive correlation between quality of life and the use of home care services. In a 2008/9 sample of people using care services in England, we found that the impact of service use was significant when measured by ASCOT, but not significant when using EQ5D. The results support our hypothesis that ASCOT has greater construct validity in this case.

Long-term care and hospital utilisation by older people: an analysis of substitution rates

Older people are intensive users of hospital and long-term care services. This paper explores the extent to which these services are substitutes. A small area analysis was used with both care home and (tariff cost-weighted) hospital utilisation for older people aggregated to electoral wards in England.Health and social-care structural equations were specified using a theoretical model. The estimation accounted for the skewed and censored nature of the data. For health utilisation, both a fixed effects instrumental variables GMM model and a generalised estimating equations (GEE) model were fitted, the later on a log dependent variable with predicted values of social care utilisation used to account for endogeneity (bootstrapping was used to derive standard errors). In addition to a GMM model, the social-care estimation used both two-part and tobit models (also with predicted health utilisation and bootstrapping).The results indicate that for each additional pound1 spent on care homes, hospital expenditure falls by pound0.35. Also, pound1 additional hospital spend corresponds to just over pound0.35 reduction on care home spend. With these cost substitution effects offsetting, a transfer of resources to care homes is efficient if the resultant outcome gain is greater than the outcome loss from reduced hospital use.

Competition in the Mixed Economy of Care

The 1990 National Health Service and Community Care Act introduced sweeping changes to health and social welfare services. The reforms to community care were dominated by the introduction of markets for social care. We argue that the new markets cannot be guaranteed to deliver the range of services required to meet community care objectives. When they began to assume their new responsibilities, few key purchasers had a basic understanding of the functioning and imperfections of markets. Consequently, they were poorly equipped to anticipate or ameliorate the sources of market failure that we identify. Like any other relatively ill-informed purchaser, local authorities risk being unable to buy what they want on behalf of their residents and at an appropriate volume, cost and quality. We discuss where and how market imperfections are likely to occur. In this context, we offer an economic framework to help in the shaping and managing of social care markets.

The impact of competition on quality and prices in the English care homes market

This study assesses the impact of competition on quality and price in the English care/nursing homes market. Considering the key institutional features, we use a theoretical model to assess the conditions under which further competition could increase or reduce quality. A dataset comprising the population of 10,000 care homes was used. We constructed distance/travel-time weighted competition measures. Instrumental variable estimations, used to account for the endogeneity of competition, showed quality and price were reduced by greater competition. Further analyses suggested that the negative quality effect worked through the effect on price – higher competition reduces revenue which pushes down quality.

Residential and nursing home care of elderly people with cognitive impairment: Prevalence, mortality and costs

Cognitive impairment among residents has considerable resource implications for both individuals and those responsible for publicly funded care. Two linked surveys were carried out in England: (1) a longitudinal study followed 2500 admissions to publicly funded care up to 42 months after admission; and (2) a cross-sectional survey of 618 homes collected information about 11,900 residents. Information was collected about cognitive impairment using the Minimum Data Set Cognitive Performance Scale. Cognitive impairment was associated with source of funding and type of home. Although level of cognitive impairment has some effect, fees and costs were most influenced by type of home. At the same level of impairment, self-funded residents were more likely to be located in relatively low-cost settings than publicly funded residents. In independent homes fees were lower for publicly funded than for self-funded residents. Overall median length of stay of publicly funded admissions was 18 months. For the most part length of stay was not associated with level of cognitive impairment on admission. It is concluded that more information is needed about the effect of quality of care on people with cognitive impairment in different settings. If the same quality of care can be achieved in residential and nursing homes, the evidence would suggest that changes in placement policies could result in potential savings to the public purse.

Consequences of local variations in social care on the performance of the acute health care sector

This article uses 2 years worth of data from 150 English local authorities to quantify the extent to which local variations in social care resources are associated with variations in performance of the acute sector, and particularly on the rates of hospital delayed discharges and hospital emergency re-admissions. Results indicate that social care services play a significant role in explaining local variations in acute sector performance.

Personalization in the health care system: do personal health budgets have an impact on outcomes and cost?

Objectives In England’s National Health Service, personal health budgets are part of a growing trend to give patients more choice and control over how health care services are managed and delivered. The personal health budget programme was launched by the Department of Health in 2009, and a three-year independent evaluation was commissioned with the aim of identifying whether the initiative ensured better health- and care-related outcomes and at what cost when compared to conventional service delivery. Methods The evaluation used a pragmatic controlled trial design to compare the outcomes and costs of patients selected to receive a personal health budget with those continuing with conventional support arrangements (control group). Just over 1000 individuals were recruited into the personal health budget group and 1000 into the control group in order to ensure sufficient statistical power, and followed for 12 months. Results The use of personal health budgets was associated with significant improvement in patients’ care-related quality of life and psychological wellbeing at 12 months. Personal health budgets did not appear to have an impact on health status, mortality rates, health-related quality of life or costs over the same period. With net benefits measured in terms of care-related quality of life on the adult social care outcome toolkit measure, personal health budgets were cost-effective: that is, budget holders experienced greater benefits than people receiving conventional services, and the budgets were worth the cost. Conclusion The evaluation provides support for the planned wider roll-out of personal health budgets in the English NHS after 2014 in so far as the localities in the pilot sample are representative of the whole country.