Costs of alternative care options (see Chapter 3, Activity 4.1)

The estimated costs of the community care arrangements deemed most appropriate by local practitioners to meet the needs of the nine marginal care home case types identified in Chapter 4 are detailed in Table 28, alongside those of their actual residential care placement. Further information about their constituent elements is given in Box 8. A number of the alternatives involved moves to ECH (variously specialist or generic). Other commonly employed resources included home care (again both specialist and generic) and support from specialist mental health services [predominantly community mental health nurse (CMHN) and psychiatrist input]. Considerable use was also made of telecare, including pendant alarms and smoke, gas and fall detectors. Where more than one alternative was provided these are presented in the table.

TABLE 28

The estimated costs of the original and alternative options for the marginal care home case types: practitioners proposals (£s per week), site X only

BOX 8

A comparison of the alternative care packages proposed for the marginal care home case types CMHN, community mental health nurse; DN, district nurse; OT, occupational therapist; SW, social worker.

Taking a comprehensive costings approach, the total predicted costs of the alternative plans exceeded those of care home placement in every case. However, some were relatively more expensive than others. Additional expenditure per service user ranged from £31 to £1188 per week, with a mean difference of almost £320 per week. Much of this can be attributed to the increased private (personal) costs associated with the alternative packages, which averaged £195 per week more than for residential care placement. In comparison, public expenditure varied less. Seven community packages increased public costs and seven decreased them. There was also a clear shift in the distribution of public expenditure, with NHS and other government costs typically higher for alternative options and social services costs generally higher for care home options.

Although these figures are best or central estimates, the upper and lower bounds in Table 28 represent the possible extremes of any cost differences, allowing for uncertainty in the quantity and cost of resources and the representativeness of vignettes. These, understandably, introduce much more variation into the model. Nevertheless, even after such adjustments, the alternative care packages for case types 6 and 9 remain considerably more expensive than their original care home placements.

Outcomes of alternative care options (see Chapter 3, Activities 4.2–4.4)

A marked lack of relevant literature comparing the relative outcomes of people with similar needs supported at home, in care homes or ECH was identified. Furthermore, although a number of publications addressed the outcomes of older people with mental health problems cared for in particular settings, none provided enough detail about their samples to match them to this study’s case types. Although mostly originating from small, descriptive studies, there is, however, a growing body of evidence to suggest that social well-being and quality of life (QoL) in ECH are generally good.^164–166 In one recent study, people who moved into ECH reported significantly improved levels of QoL and decreased levels of unmet need compared with people living at home.¹⁶⁷

The search for secondary data sets containing comparative information about the outcomes of older people supported in different settings similarly proved unfruitful. Even the English Longitudinal Study of Ageing included relatively few older people who received formal mental health support, and fewer still who had entered a care home. This may reflect the relatively young age of the study’s participants. However, even if the numbers had been larger, the data would have required considerable manipulation to be suitable for our purposes.

The attempt to collect primary data (matched cohort study) about the relative outcomes of care home entrants and older people living at home with CMHT support also encountered difficulties. Not least of these was the Council in site Z’s unexpected late decision not to participate in the study. Both the achieved care home sample and the number of people represented by the care home case types were considerably smaller than anticipated, and the degree of empirical overlap between the two samples was also less than expected.

The plan to investigate the outcomes of people in one or two matched case types was thus abandoned and a broader approach taken in which all potentially marginal care home entrants (i.e. all case types commonly found in both samples) were considered for follow-up. In effect, this amounted to all care home entrants who were less than ‘very dependent’ (Barthel > 40) and less than ‘severely cognitively impaired’ (CPS score < 4) so long as they did not have complex challenging behaviour (behaviour score < 9) and were appropriate for interview (e.g. could express their basic needs). Comparable CMHT clients were then chosen using a manual ‘nearest neighbour’ approach that took into account individuals’ age, gender and diagnostic group as well as case type. As the study progressed, however, additional individuals just outside the margins of care were included in an attempt to boost numbers.

Despite these actions, the number of achieved interviews remained disappointingly small (Figure 6). Only 16% of the care home entrants and 13% of the CMHT clients the study attempted to recruit participated in this exercise. Forty-four per cent of the selected care home entrants and 58% of the CMHT clients were deemed ineligible by their keyworkers, while no response was received for a further 22% and 14% respectively. Of those service users who were considered eligible, however, 73% were happy to be approached by the research team, and 66% were interviewed (11 care home entrants and 12 CMHT clients).

FIGURE 6

Flow diagram of matched cohort study recruitment. (a) Care home arm; and (b) CMHT arm.

Bearing in mind the small numbers and our intention to capture people with similar needs, the interviewed care home entrants were significantly older than the CMHT clients (mean age 87.8 years compared with 78.8 years, t-test: 3.41, df = 21, p = 0.003). They also needed more help with activities of living, with 9 of 11 care home entrants compared with just 1 of 12 CMHT clients unable to manage stairs (chi-squared: 12.68, df = 2, p = 0.002). Consequently, though matches were achieved for six of the care home entrants, the study lacked community clients to match those admissions with more dependent profiles.

Perhaps unsurprisingly, no statistically significant differences were found in the two samples’ outcomes with regard to QoL or satisfaction, which were generally said to be good. However, when asked if they were basically satisfied with their lives, two CMHT clients but no care home entrants said ‘no’, and the same number indicated that they were not getting enough help. Asked to name the best thing about their current situation, care home entrants typically spoke about security and food, while the worst aspects of care home life were the lack of stimulation and the manner of certain carers. Correspondingly, those interviewees supported at home most frequently praised the help they received from different agencies, whereas any negative comments were particular to individual circumstances.

The incorporation of the cost and outcome data into the balance of care analysis (see Chapter 3, Activities 5.1 and 5.2)

When presented with the details of the marginal care home case types identified by practitioners, their original care home placements and suggested alternative care packages, the site X RAM Panel opted to support all nine cases in the community. As shown in Box 8, however, they did not necessarily agree with the proposed care plans, particularly where these involved moves to ECH. Indeed, the only situation in which this was endorsed concerned a case type whose home was described as physically unsuitable to meet their needs, such that a change of residence was, at least in the short-term, inevitable. They were also inclined to make more use of day care and considerable use of telecare, including the ‘Just Checking’ system.

Although typically lower than the costs of the practitioners’ plans, the estimated costs of the packages of care the Panel recommended exceeded those of care home placement for eight of the nine case types (Table 29). Furthermore, even using the most extreme plausible values, the costs of the alternative care packages for case types 6 and 9 exceeded those of residential care.

TABLE 29

The estimated costs of the original and alternative care options for the marginal care home case types: RAM Panel proposals (£s per week)

As shown in Table 30, much of this difference was again attributable to the greater private costs associated with the enhanced packages, which averaged £153 more per week than those of care home placement. However, even taking a purely public expenditure approach, the alternative package costs for seven case types were similar to, or higher than, those of a care home. Nevertheless, a clear financial incentive remained for the Social Services Department (SSD) to maintain certain groups of service users in the community, as direct savings were predicted for five of the nine case types.

TABLE 30

The estimated difference between the original and the alternative care options for the marginal care home case types by cost type: RAM Panel proposals (£s per week, alternative option minus original option)

Qualitative analysis of the panels’ decision-making process identified six main themes (Box 9), of which perhaps the most pervasive was their strong desire to maintain people at home. Their explanation to the research team was:

BOX 9

A summary of the main themes identified in the RAM Panel discussion Can the person’s needs be met at home?

. . . and our key brief and our key principle is that we will always try and support someone in their own home, taking into account the risks that they would actually face in doing that, before we would agree any form of residential care . . .

Indeed, the other five domains could be interpreted as adjuncts to this. The minimisation of risks, for example, seems a necessary step in making home care viable, while the possibility of the service user improving over time may be viewed as strengthening the case for maintaining them at home.

There was surprisingly little discussion of costs, which were only mentioned in relation to one case type. Potential outcomes were also only discussed at a very general level (that staying at home would be in the service user’s ‘best interests’). There was, however, some debate about the best time to enter ECH, acknowledging that for certain individuals it might be better to move while they were still able to adjust to a new environment (although, in only one instance did they opt for such care). Furthermore, the provision of specific evidence about the likely social benefits of ECH compared with care at home, and the advantages of care home placement over ECH for people with advanced dementia, made no difference to the Panel’s decisions. Thus, in the first instance they reiterated that:

Our decision-making will always be, if the person can be supported where they are in their own home and that’s where they would like to be, then that will be our starting point.

They were also inclined to feel that the evidence would not apply to the case type in question, thus relying on maintenance at home as the priority.

Athough the last quote suggests that account was taken of service users’ preferences, the weight given to these appeared dependent on setting. Thus, where service users expressed a positive desire to remain at home, this was seen as justification for maintaining them in the community, whereas if they or their family expressed concerns about staying at home, the Panel tried to find ways of alleviating/overcoming these. Indeed, as one member of the panel put it, although they always tried to:

. . . consider somebody’s wishes . . . in terms of making a decision as to whether or not we can use the public purse to support someone in residential care . . . (we would) differentiate between want and need.

The panel did, however, acknowledge that it could be very difficult for front-line staff to promote the case for home care in the face of strong family opposition, and that for many carers the admission of their relative to hospital served as a ‘tipping point’. The pressure to discharge people from hospital before they had reached their full potential also increased pressure on staff to arrange short-term care home placements, a proportion of which inevitably became long-term. This was particularly true if their stay became protracted, they lost skills or confidence, they or their carers did not engage with plans to return home, and/or the care home wished to keep them.

The validation of local practitioners’ decisions (see Chapter 3, Activities 6.1 and 6.2)

The majority of older people’s groups (34 participants) who reviewed the plans proposed by the RAM Panel favoured the suggested community care packages over care home placement (Table 31). Indeed, the sole exception to this concerned case type 14 (MMM), where opinion was divided. However, complete consensus was only achieved for one case type (9, LHH), while in a number of instances it was felt that the depicted ‘clients’ would need a higher level of community support than had been recommended, including more day care, carer support and telecare services.

TABLE 31

Review of marginal care home cases: older people’s and experts’ preferred placement options

Expert opinion was similarly divided among the seven participants. Although for every case type the majority of experts favoured the alternative option, six of the seven experts advocated residential care in at least one instance. As with the older people, many proposed additional resources, echoing the call for more carer support and stressing the value of experienced social work input, the importance of meeting people’s social care needs, and the benefits of short-term placement in a dedicated assessment and rehabilitation unit. When the decisions made by the older people, carers and national experts were included in the logisitic regression analysis presented in Chapter 4 (see Tables 22 and 23), the model suggested older people and carers were considerably more likely than local staff to favour care home placement, whereas experts were also somewhat more likely to support residential care (albeit each individual looked only at a subset of cases).

When asked to state the main reason for preferring community care, both older people and experts stressed their desire to respect service users’ wishes, and a belief that community services could meet people’s needs. The experts also highlighted the need for further assessment at home before care home entry and the desire to avoid potentially debilitating moves, whereas the older people were more likely to point to the potential financial implications of care home entry for service users. Conversely, care home entry was typically predicated on the need for more care than could be provided at home (particularly at night) and the risks service users posed to themselves and others.

Costs of alternative care options (see Chapter 3, Activity 4.1)

Box 10 details the packages of care local practitioners’ believed would meet the needs of the five most marginal inpatient case types. Interestingly, all three plans for care home residents involved input from a specialist care home support team (CHST), whereas those for people admitted from home drew on an intensive mix of primary care and mental health expertise, including frequent mental health support worker input to assist people with their diet, medication, personal and social care needs.

BOX 10

The alternative care packages proposed for the five least appropriate inpatient case types ABC, antecedent, behaviour, consequences; CBT, cognitive–behavioural therapy; CHST, care home support team; CMHN, community mental health nurse; DN, district (more...)

The estimated mental health and social care costs of the alternative arrangements are set out in Table 32, suggesting that in every case the predicted costs of the proposed community care packages were lower than those of hospital admission. Indeed, the mean weekly difference was £1873. Even allowing for considerable uncertainty in the quantity and cost of resources and the representativeness of vignettes, the general picture remained unchanged. The vast majority of this difference was attributable to the relatively low costs of providing community as opposed to inpatient mental health care, even where this involved multiple staff and frequent input. Furthermore, in contrast to the care home entrants modelling, there was no obvious trade-off between health and social care costs.

TABLE 32

The estimated costs of the original and alternative care options for the marginal inpatient case types (£s per week) (all sites)

The validation of local practitioners’ decisions (see Chapter 3, Activities 6.1 and 6.2)

As shown in Table 33, although national experts tended to support the commuity care of three of the above case types (26, 28a and 31), including both those representing care home residents (26 and 31), they were less inclined to support the alternative community care arrangements suggested for case types 6 and 10. Indeed, although the local appropriateness ratings for these two case types were 26.2% and 28.3%, respectively, the corresponding experts’ scores were 56.2% and 43.8%, with some perceiving them as entirely appropriate for admission, and others completely inappropriate. This may in part reflect the necessarily limited amount of information it was possible to include in the vignettes, for a number of experts commented that it was sometimes difficult to make such judgements without knowing more about the people’s circumstances, including their life and medical history; current and past medication; and wider informal network.

TABLE 33

Review of marginal inpatient cases: experts’ views of appropriateness

When asked to indicate the most appropriate care packages for case types 6, 10, 26 and 28a (see Box 10), the majority of experts favoured option B in every case. However, almost without exception, additional, different, or more timely resource inputs were proposed. Recurrent themes included the desirability of experienced social work and primary care support; the need for earlier consultant psychiatrist involvement; the importance of ruling out physical causes for changes in presentation; the need for detailed behavioural and functional analyses of individuals’ behaviour as the basis for person-centred intervention strategies; and the relative advantages of intensive home treatment/CHSTs over multiple professionals from different organisations. The main reasons for favouring community care were the potentially negative effects of inpatient admission and the limited chance of acquiring any new insights in hospital. Correspondingly, where inpatient admission was advocated, this was typically predicated on the need to provide a place of safety and/or more intensive care than was available at home.

Marginal care home cases (see Chapter 3, Activity 7.1)

In Table 34 the aggregate annual costs of providing the alternative care arrangements proposed by the RAM Panel have been compared with the costs of their original care home placement (site X only). The key variables in this table are the number of service users represented by each case type (projected over a 12-month period assuming those admissions for whom no baseline data was obtained had the same case type distribution as the achieved sample) and the anticipated number of months it might prove possible to divert each case type (based on experts’ degree of confidence in the alternative care packages as reported in Table 31). Thus, although Table 29 shows that the additional estimated weekly costs of supporting case type 2 (LLM) in the community were less than those for case type 6 (LMH), in view of the higher number of service users represented by case type 2 and the longer expected diversion period, the aggregate cost implications are greater.

TABLE 34

The estimated annual cost differences of diverting the marginal care home case types: site X only (£s per year)

Focusing solely on costs to social services, the biggest potential savings (albeit modest) would seem to come from supporting case types 5 (LMM) and 14 (MMM) in the community, where savings of approximately £45,000 and £42,000 per year might be made. Indeed, the maximum annual saving that social services could make is predicted to be just over £140,000 (achieved by maintaining all service users in case types 5, 6, 14, 17 and 23 in the community for the specified period), while the corresponding increase in private and total costs is in the order of £201,000 and £197,000 respectively. If it proved possible to divert all 134 marginal care home entrants, the corresponding figures would be around £110,000, £556,000 and £1,130,000 respectively.

It is, of course, unlikely that even with the benefit of enhanced community services, it would be possible to maintain 100% of marginal care home entrants in the community for the full diversion periods. This population has changing needs and with increasing mental or physical incapacity, some would inevitably need earlier care home placement. In light of this, Figures 7 and 8 show the effect of different diversion success rates on total costs (e.g. the effect of maintaining 10%, 20%, 30%, etc., of each case type in the community). These illustrate the almost equal trade-off between health and social care costs as agencies divert more care home entrants. For case types without significant one-off costs, they may also be viewed as proxy indicators of the costs of diverting 100% of service users for 10%, 20%, 30%, etc., of the specified time period.

FIGURE 7

Marginal care home analysis. The effect on different cost types of different diversion rates: site X only (£s per year). NGO, non-governmental organisation.

FIGURE 8

Marginal care home analysis. The effect on public and private costs of different diversion rates: site X only (£s per year).

There are several reasons why the overall cost implications of the above analysis are likely to be more complicated. As shown in Chapter 4 (see Table 8), 42.6% of service users on the active social services caseload who lived at home, and were not known to the specialist mental health service, were in one of the nine marginal care home case types. In addition, 39.8% of the site X CMHT caseload who lived at home were similarly in one of the nine case types. Furthermore, another 17% of the active social services sample who lived at home were in one of the five non-marginal (i.e. most appropriately placed in a care home) case types. At any time, there are thus substantial numbers of older people with mental health problems living in the community who are on the verge of care home entry, but who (again based on information from Chapter 4) are unlikely to receive the substantial care packages necessary to maintain them at home. There are also a number of older people living at home for whom care home placement may be a more appropriate option.

Marginal inpatient cases (see Chapter 3, Activity 7.1)

Echoing the approach described above, Tables 35 (all sites) and 36 (site X only) detail the estimated annual aggregate costs of providing enhanced community care packages for the five most marginal inpatient case types compared with those of inpatient admission. These are based on the locally formulated care packages preferred by the experts, and focus solely on costs incurred by mental health and social services. The key variables are the expected number of patients represented by each case type (projected over a 12-month period), the estimated number of inappropriate admissions each individual might experience a year (based on information from the baseline data collection), the anticipated length of inpatient stay (based on the inpatient discharge data collection), and the number of days the intensive community care package might need to be employed (based on information from the practitioner care planning exercise). If it were possible to divert all of these five case types, local agencies might expect savings in the region of £2M. Even focussing only on the three case types which experts concurred were inappropriate (i.e. case types 26, 28a and 31), savings of more than £1.5M might still be achieved.

TABLE 35

The estimated annual cost differences of diverting the marginal inpatient case types: all sites (£s per year)

TABLE 36

The estimated annual cost differences of diverting the marginal inpatient case types: site X only (£s per year)

As with the marginal care home case types, however, it is not realistic to believe that it would be possible to keep all 81 people out of hospital and Figure 9 shows the effect of increasing diversion success rates on the different cost elements. There is, furthermore, a difference between the funds that would accrue to the SSD on diverting people from care homes and those that might be realised by trusts in preventing admissions. If, for example, just one or two care home placements a year were prevented, local authorities might expect to make modest savings. By contrast, the avoidance of a few inpatient admissions would only release very limited resources. Although small reductions in admissions might enable higher quality of care for other patients (e.g. by staff spending more time with each patient), the number of hospital admissions prevented would need to reach a critical mass before fixed costs could be reduced to allow any transfer of monies.

FIGURE 9

Marginal inpatient analysis. The effect on different cost types of different diversion rates: all sites (£s per year).

Taking the implications for site X as an example, if it only proved possible to keep half of the people in case types 5, 10, 26 and 28a at home, the trust would divert just 12 individuals a year, probably below the critical threshold noted earlier. If, however, they were able to divert all cases, potential savings might approach £700,000.

Methodological considerations/lessons for future studies

A number of assumptions were built into this work. Perhaps the most significant of these was that the overall level of health and social services expenditure on older people with mental health problems was unlikely to vary a great deal from year to year, and that the age structure and associated needs for care of the local population would change little in the short-term. Inevitably, there was also a degree of uncertainty about service costs, such that the results constitute estimates of expenditure. The main findings, however, appear robust, and sensitivity analysis helped understand how different factors might influence future costs and their distribution. Furthermore, in taking account of the empirical variability of costs within case types (rather than simply average costs) the study was able to test out the implications of group-based placement decisions. Like previous published analyses, however, no account was taken of the transaction costs that might be incurred in reallocating resources between settings or the creation of new services.

Although the achieved study samples at the baseline data collection stage fell short of expectations, compared with related studies^89,117,118 they were still large. Furthermore, the data suggested that the study had reached saturation in the development of case types. The smaller than expected CMHT and care home samples did, however, have consequences in reducing the pool of people from which individuals could be recruited for the matched cohort study.

Other limitations include the pragmatic identification of older people with mental health problems within the social services samples. This may have captured some people without a formal mental illness, including those with cognitive impairment attributable to other causes and people with subthreshold depression. However, mild depressive symptoms are often clinically significant,^168,169 and feedback from practitioners suggested the study did accurately identify those older people with mental health problems who commonly present to social services. An unavoidable weakness of the sampling process was that it only captured those older care home entrants known to social or specialist mental health services. As such, the findings take no account of the potential for diverting those self-funded care home entrants who currently have no such contact with services.

A key lesson concerns the importance of the vignettes. These were based on real individuals (see Chapter 3) and (although limited to one side of A4, so as to not overload the reader) contained a wealth of information about factors known to be significant in determining the most appropriate locus of care. Furthermore, participants were told to assume anything not mentioned was non-problematic. However, although feedback on the vignettes was overwhelmingly positive, suggesting participants could easily picture the service users depicted, some staff would have liked more detail and a few commented that this impaired their ability to make informed judgements about optimal care settings.

Perhaps the most important limitation of the study, however, was its failure to identify or collect sufficient data on the relative merits of different service options for specific groups of people on the margins of care. The research programme aimed to generate objective evidence of absolute and relative benefits of alternative care options. This would have been invaluable in making decisions on the cost-effectiveness of alternative care packages for marginal cases. It is simple to assess cost-effectiveness where benefits are greater and costs lower than alternatives. Where, however, both costs and benefits are greater, sound knowledge of the magnitude of the difference in benefits becomes critical to sound resource allocation. Lacking this intelligence, the reader is thus left to assume that in determining where service users were best placed, participants will have made some form of normative judgement about their best interests.^30,97,102

Given this, the presentation of more general evidence to the RAM Panel should be viewed as a simulation/pilot of one way of exploring whether knowledge of likely outcomes makes a difference to service manager decision-making. One cannot, however, conclude from this exercise that it has little effect, for more account may have been taken of evidence that specifically related to the relevant case types. Furthermore, the real situation is likely to be much more complicated than this study was able to model, with any one particular setting delivering relative improvement in some outcomes, but worse performance in others.

If this study found that robust information on the relative outcomes of specific groups of older people with mental health problems supported in different settings is urgently needed, it also suggested that this will not be easy to generate. To obtain the target numbers for the planned cohort outcome study, this exercise would have had to run for 12 times longer than the allotted period, or included 12 times the number of teams. Other possibilities to improve recruitment might have included further relaxing the inclusion criteria to encompass service users with higher needs levels (albeit this may have decreased the overall recruitment rate further); undertaking proxy interviews with informal carers; and/or expanding the recruitment process to people living at home in the social services sample (although this was of itself a small sample). In retrospect, however, the main problem with this element of the study was the requirement to recruit service users via practitioners, which led to a complicated process, outside the research team’s control.

Feedback from practitioners identified a number of disincentives to participation in recruitment, including concerns that they would be seen as responsible if users had negative experiences, damaging trust; their already heavy workloads; and the lack of any direct benefit to themselves, while other studies have faced similar problems.¹⁷⁰ Thus, despite the suggestion that those practitioners who participated in this study would be more receptive to future research involvement, we would echo calls to test new ways of quantifying staff impact on the recruitment process and the possibility of linking this to tangible rewards.^170,171

Implications for local service providers

This study suggests that services for older people with mental health problems in site X do not always correspond with their needs and preferences, and identifies a shared aspiration to shift care towards the community. It also identifies a number of building blocks that might need to be put in place to achieve this. These include the growth of a range of community services; a clarification of the role of ECH; a more timely response to the needs of people on the cusp of acute mental health inpatient admission; and improvements in hospital discharge planning. None of these proposals are radical. They are not concerned with new or novel ideas, but rather concentrate on doing important things well, on increasing efficiency and on strengthening existing arrangements.

When asked to identify appropriate services for marginal care home case types, local practitioners recommended a mix of generic and specialist home care, community mental health staff input and telecare. Managers, older people and experts also advocated the use of more day care, carer support services and dedicated assessment/rehabilitation beds. Packages of care deemed best for marginal inpatient case types similarly relied substantially on community mental health services (including mental health support worker input), primary care and specialist CHSTs. Indeed, an important point about care home support services, whatever form they take, is that the resources invested in preventing one admission, might arguably also prevent future admissions as care home staff gain skills in caring for this client group.

Although most, if not all, of these services were theoretically available in the catchment area, feedback from staff and service users raised doubts about the quality of some (including certain home care services) and the quantity of others. The input of mental health support workers, for example, was said to be time-limited, while traditional day care services were seen as closing consequent on the introduction of personal budgets and the deconstruction of block contracts. This raises questions about how to stimulate markets to meet individual need. A need for 24-hour, rather than 9–5 community services was also identified, with the suggestion that workforce flexibility had not kept pace with changes in care requirements and settings. There was a general recognition of the need for more mental health training for staff and the development of funding arrangements able to support more flexible services.

The specific roles that generic and specialist ECH might play in any future service configuration perhaps needs particular thought. Although practitioners identified this as a more appropriate option for many marginal care home entrants, in practice relatively few vacancies arise each year. Moreover, at present there is no facility for potential tenants to try ECH on a short-term basis, as is possible with care home placements. These factors suggest a move to ECH is more likely to be a planned change than a response to immediate needs, and perhaps explain why RAM Panel members failed to sanction many such proposals. However, the question of exactly when in the care trajectory ECH is the best option did not appear to have been resolved. The place of capital resources in a context of revenue resource dominated community care is complex.^172,173

If adequate capacity of community services for the needs of older people with mental health problems is clearly vital, the study also suggests the timeliness of such provision may be equally important. This was particularly evident with regard to the marginal inpatient case types, where the data suggested approximately four-fifths of patients had some involvement with the mental health service before their admission. Although some appeared to be relatively new referrals at a point of crisis, others were longer-term clients, with existing care packages. In both situations, however, what was striking was the large discrepancy between the intensity of the enhanced community support felt necessary to keep them out of hospital and the amount of support they were actually receiving before their admission, suggesting higher levels of input may be needed sooner.

Similarly, the data suggest that some three-quarters of marginal care home entrants were already known to social services (although in many cases data on this aspect of the study were missing). There was once again a large discrepancy between the packages of care many actually received and those thought necessary to divert them from care home placement. As with the inpatient sample, there may be many reasons for this, including a sudden change in circumstances (resulting from say a fall or stroke) and service refusal. That said, the data from the social services domiciliary sample would seem to suggest that at any one time there are a number of people in the community with considerable ongoing care needs who receive relatively little formal support. In the light of evidence that specialist integrated assessment may potentially defer the care home admission of older people at risk,¹⁷⁴ the fact that more than half of care home entrants had not been seen by specialist mental health services was also noteworthy.

Finally, perhaps one of the most striking findings from this study was the very high proportion of marginal care home entrants admitted from general hospital wards or at unacceptable risk of falls. This illustrates the complex morbidity of this client group, and also highlights the number of placements arranged in the context of crises, as identified elsewhere in the literature.¹⁷⁵ This made assessment of individuals’ potential functioning more difficult, and gave little time to organise home care packages or garner support from informal carers. In recognition of this, the SSD has recently commissioned a number of beds in the local community hospital for assessment purposes, as suggested by the experts in this study. As seen with the mental health inpatient data, however, it is important to ensure that any such beds are used only for those people who really need them, and also that the efficiencies to be gained in the discharge planning process to prevent delayed discharge are achieved. Indeed, the data suggest that as many as 834 inpatient bed-days may have been lost across the three sites over the 6-month data collection period.

Wider implications

Although one of the perceived strengths of the BoC approach is the particular relevance of its results to local decision-makers, it is anticipated that many of the challenges facing care providers in this study will be echoed across the country. Indeed, the settings investigated are both generic and ubiquitous. The findings also raise some important issues for national policy-makers.

One obvious question is how the continuing promotion of community care fits with drives to reduce public expenditure, for the study suggests that diverting greater numbers of older people from care home admission will actually raise total public costs. Although there was some potential for site X LA to achieve modest cost savings through the reduction of long-term placements, these would be more than offset by increases in other public expenditure. Indeed, the current system of parallel services (and budgets) would seem to encourage the continuation of such cost shifting. The common perception of a hierarchy of costs (in which community care is cheapest) running in parallel with one of choice (in which care at home is the preferred option) may now need revising, although it would still seem to hold compared against hospital admission.

Another question in light of the above is ‘What is now driving the desire among staff to keep people at home?’. Older people themselves were markedly more likely to favour residential care than were practitioners, with the latter expressing a lack of confidence that care homes can meet the needs of this client group, an issue explored further in Chapters 12–14. Indeed, if there were to be a shift towards the greater use of care homes, local practitioners suggested it would be necessary to increase the amount of funding attached to care home placements, so facilitating improvements in the quality of care provided.

One final lesson concerns the potential utility of the BoC approach as a way of capturing uncertainty in the service planning process. As well as facilitating communication between diverse stakeholders by creating a shared representation of the whole system at a time of considerable change in the provision of health and social care services, the application reported here has the advantage of ‘tempering perspectives that overestimate the reliability of prediction’ and ‘bringing uncertainty into the open’.¹⁷⁶ Based on this work, the research team are thus currently developing a BoC workbook complete with cost modelling templates that will enable other health and social care decision-makers to apply the framework independently.