WHY MOVE TO OUTCOMEBASED COMMISSIONING – OUT
OF HOSPITAL CARE?
Discussion led by Professor John Bolton
The way in which social care is
delivered makes a big difference?
•  Supporting recovery or Building Dependence?
Research from University of McMaster, Ontario, Canada 2000s
Markle-Reid M, Browne G, Weir R, Gafni A, Roberts J, Henderson S. Seniors at risk: The association between the 6-month
use of publicly funded home support services and quality of life and use of health services for older people. Canadian
Journal on Aging. 2008; 27(2);207-224
“A little bit of care may be bad for you”
•  Challenging a person or colluding with their current state?
•  The benefits of reablement/recovery/rehabilitation/frailty
•  Aston University research into Extra Care Housing/ Work of University of Newcastle –Centre for
Ageing (ADL Smart Care)
• 
ExtraCare Project - Aston University www.aston.ac.uk/lhs/research/centres-facilities/archa/extracare-project/A research project between
Aston Research Centre for Healthy Ageing (ARCHA) and the ExtraCare Charitable Trust.
•  Help a person through a crisis or respond quickly?
My work on out of hospital care
Aci7viesofDailyLifeHierarchy
TacklingFrailtyInOlderPeople
Re-able
Compensate
Care
Timesincestar7ngon‘curve’
©2016 Professor Peter Gore CEng
FIMechE
Variations in outcomes for citizens
IntheUnitedKingdomthereisasix-foldvaria7onasto
whereyouliveandthelikelihoodthatyouwouldbe
placedinolderpeople’sresiden7alcarefundedbythe
localauthority(notrelatedtolevelsofdepriva7on)
IntheUnitedKingdomthereisatwelvefoldvaria7on
astowhereyouliveandthelikelihoodthatyouwould
beplacedinaresiden7alcarehomeforadultswitha
learningdisability
IntheEnglanditistwiceaslikelyinsomeplacesthat
yourproblemscanberesolvedwithouttheneedfor
formalcarewhenyouseekhelp
Thenumberofhoursofcareapersonisassessedas
needingalsovariessignificantlye.g.inextra-care
housingbetween15hoursand36hoursrequiredat
highestlevel
Theimpactofdomiciliarycarereablementvaries
between25%and75%ofolderpeoplewhowill
recover
Over-proscribed care?
Thereissignificantover–
proscribingofsocialcare
Lowlevelcare–tacklingsocialisola7on
orjustchecking
Dischargefromhospital1in5packages
Partnershipwithcarers
Carecanbedeliveredinawaythatfurther
incapacitatestherecipientoritcanbe
enhancingandsuppor7ve–a“dollopof
care”canincreasesomeone'sneedsby
120%
Unmetneedsatlowerlevelsdon’tleadto
poorwell-being
h]ps://www.ipsos-mori.com/researchpublica7ons/publica7ons/
1885/Unmet-social-care-needs-and-wellbeing.aspx
Managing demand in social care
b
a
Diversion–
Community
NHS
c
e
d
RecoveryandRecupera-on
NewInterven-ons
6
What is an outcome?
Apersonishappy/pleasedwith
theservice/gecngtheirneeds
met?
Contentment
OR
Apersonismakingprogress
andneeds“less”longerterm
careandsupport?
Challengedbutfulfilled
Hospital Discharges
Coventry City Council
•  Providers of domiciliary care who support hospital
discharges are required to maximise an older person’s
independence as part of the contract.
•  The measure used is that 66% of those people receiving
help require no further help after 6 weeks.
•  Service supported by Occupational Therapists but
delivered by independent/private sector care providers
•  This is about contract compliance – no reward just an
expectation
•  Variations of the approach used in Glasgow, Scottish
Borders, Nottinghamshire, Carmarthenshire,
Pembrokeshire, Bridgend, Monmouth, Newport…..
Other approaches…….
•  Single biggest challenge for places – securing stability in
the care market prior to moving to outcomes
•  Different from Wiltshire where the outcome is for each
individual and the price set according to the agreed
interventions – and all domiciliary care is reablement
based – did achieve 66% in first 6 weeks but since fallen?
•  Leicestershire – 2 week rule – review after 2 weeks to see
if care still required (about 50%)
•  Reducing budget in Nottinghamshire for adults with
learning difficulties
•  Glasgow contracts with Voluntary Sector
Measuring outcomes from health and
care system - over 65s?
•  Prevention – falls, incontinence, dementia….
•  % of those who have had a fall who received recovery advice after first fall –
over 90%
•  % of those who are incontinent who have received advice and support to
manage the condition – over 90%
•  % of admissions from residential care homes
•  % of re-admissions to acute hospital from a care homes within 6 weeks – less
than10%
•  % of re-admission to hospital
•  % of re-admissions to hospital from those discharged in previous 10 weeks –
less than 5%
Measure impact of out of hospital
care system
•  Speed of response to needing care– within 24 hours
•  % of people needing care and support who could receive that help within 24
hours – 90%
•  % of permanent admissions to residential care direct from
acute hospital
•  % of new permanent admissions to residential care should be less than 5%
•  % receiving of those requiring help being supported with
their recovery through community or bedded facilities
•  % of people who recovered through short-term residential intermediate care –
75% of people were able to be discharged to their own home
•  % of those recovered – “outcome of the system”
•  % of people who were helped at home who required no further assistance
after 8 weeks – over 66%
Outcomes from Reablement –
Variables – who is accountable for the outcome?
•  How are people assessed for the service?
•  How focused is the service on the range of different interventions that
are required for different conditions?
•  How much training is offered by reablement workers for customers:
•  To Manage their condition
•  To use equipment provided (including telecare)
•  To link to local community
•  How well supported is the service by nurses and therapists?
•  Is the demand for the service understood?
•  How does it fit with other Intermediate Care Services?
•  How are people assessed for longer term?
•  Are other client groups helped?
Supporting a person to remain in their
own home assessments/interventions
•  Short-term recovery (domiciliary care reablement versus self-
managed recovery) – hospital discharges?
•  Longer term recovery (evidence at which point do people
recover and who will benefit)
•  Helping a person to live with / manage a long-term condition (or
more likely set of long-term conditions)
•  Helping a person live with /manage having memory loss or
dementia
•  Helping a person receive end of life care
•  Supporting a carer who is helping any of the above
•  Supporting a person with health care
•  Helping people who experience social isolation
•  Helping a person/family with anxiety and worries
How might we measure success?
•  Percentage of people who completed short-term
reablement but were assessed as still requiring a service
after 8 weeks – less than 33%
•  Percentage of people whose needs are reduced within
first year of receiving the service – over 20%
•  Percentage of people whose needs either remain the
same or reduce over time 70% (do not increase)
•  Percentage of people who are admitted to residential care
who are in the service – less than 10%
•  Percentage of people who are admitted to hospital within
2 years of receiving the service – less than 15%
•  Percentage of people who have to visit GP?
People receiving auxiliary
nursing
People receiving palliative care
•  Percentage of people who
•  Percentage of people who
do not need to see a
District Nurse except for
discharge– over 75%
•  Percentage who are not
readmitted to hospital –
over 95%
died in their own home –
over 80%
Some other challenges
•  How do we jointly commission an out-of-hospital care
system?
•  Who should be held to account for the outcomes –
Providers? How much trust – who assesses a person
needs no more care?
•  How do we overcome the other variables?
•  How do we address the shortage of therapists/community nurses?
•  How do we ensure that risks are managed and that we build the
resilience and capacity within older people – challenging but
supportive?
•  How do we ensure that clinical staff don’t pre-empt recovery?
Conclusion
•  We should state the standards we require from providers
in relation to outcomes and pay accordingly
•  Each customer should have a stated set of goals to which
they aspire – these should be challenging
•  We should reward those providers who can assist people
to progress to a greater degree of independence – where
that is feasible
•  We should ensure that all providers focus on helping
people to remain in their own homes – where that is
feasible
•  From hospital we should ensure both speed of response
and outcome from service – managing the flow
More Information
•  Papers on Managing Demand and Outcome Based
Commissioning:
•  http://ipc.brookes.ac.uk/publications/
•  John Bolton
•  [email protected]
•  07789748166
Professor John Bolton
•  Qualified Social Worker - 1974
•  Former Director of Social Services and Interim Director – four
authorities (2002/07; 2010/14)
•  Former Director of Joint Reviews (Audit Commission/DH) (1999/2001)
•  Former Strategic Finance Director at Department of Health (2007/10)
•  Visiting Professor at Oxford Brookes University – Institute of Public
Care (2010- present)
•  Advisor to Local Government Association Productivity Programmes
•  Senior Advisor to Newton (Europe) – efficiency in adult care (2010..)
•  Independent Consultant on cost effective care across United Kingdom
•  Author of papers on prevention, promoting independence, managing
demand and outcome based commissioning in adult care
•  http://ipc.brookes.ac.uk/publications