GM Health and Social Care: Dementia Care

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1 GM Health and Social Care: Dementia Care Executive Summary The number of people with dementia is set to double to 1.4 million in the next 30 years and the costs are expected to treble. The size of the challenge for health and social care commissioners is considerable. 1 What this means for Greater Manchester (GM) is that the number of people with dementia will increase rapidly from 30,000 to 40,000 over the next 12 years. Given that a quarter of acute hospital beds at any one time are occupied by people with dementia, the vast majority admitted non-electively and with much longer lengths of stay than their peers without dementia, the demands of this group on acute services will rapidly become unsustainable organisationally and financially. Nationally and across GM we devote large amounts of resource to crisis management for people with dementia. And yet we have clear evidence of how such crises can be prevented, not only representing a better use of resource but delivering much better outcomes for people with dementia. Currently people with dementia are disproportionately represented in acute hospitals they are much more likely to be admitted as an emergency and stay much longer than people of the same age with the same condition but without dementia. But for those with dementia the outcome of a hospital admission is very often loss of independence leading to admission to residential care. Early identification and preventive management by the GP and primary care can prevent this type of crisis occurring. There is a close link between the physical health of a patient with dementia and their mental state. The majority of admissions for people with dementia have a medical cause and often it is the compounding of an infection or a fall with the corresponding deterioration in mental state that provokes a crisis that leads to the admission. Therefore a high proportion of such admissions are preventable and primary care, community services and social care have a key role to play. The health and social care theme report argues that we need to retain a holistic and not condition specific approach to the development of integrated services. Improving and supporting the response of mainstream services to meet the medical and social needs of people with dementia who occupy a quarter of acute hospital beds at any one time and make up two thirds of those in care homes 2 3 is core business for health and social care services. This business case set out the proposition behind supporting activity to improve outcomes for people with dementia across GM, and in so doing move the focus of investment towards targeted and planned interventions, and away from reactive provision. It outlines the rationale behind focusing on three linked areas of activity: 1. Improved identification and management in primary care to maintain independence and reduce non-elective admissions. 2. Memory services provision to support diagnosis, treatment and care planning to maintain independence and prevent non-elective admissions. 3. Hospital-based later life mental health liaison to support management of people with dementia by acute services, reducing length of stay and readmissions. Each one of these is dependent on being able to refer into effective and comprehensive social 1 Dementia Care in London (IPPR briefing, March 2011, quoting Goodchild 2009) 2 Counting the Cost (Alzheimer s Society, 2010) 3 Improving Services and Support for People with Dementia (National Audit Office, 2007) 1

2 care pathways. The evidence demonstrates considerable savings to be made to acute trusts and health commissioners through reducing length of stay. Additional savings to health service providers and commissioners could be made through reducing admissions and readmissions. 4 There is also potential for adult social care savings based on delaying admissions to residential care, as modelled in the cost benefit analysis (CBA). It is not possible to model all the potential savings due to the limited evidence available; for example, in relation to admissions avoidance from primary care management or memory service care planning. The approach taken is to implement in line with government policy. In order to reduce risk, robust evaluation has been built in to the process. 1 Aims and objectives The big idea The proposition is to maintain independence for people with dementia by enabling mainstream services to meet their needs effectively. As will be described in more detail in this proposal, there are already 30,000 people with dementia in GM; this number will rise rapidly with growth in the elderly population. People with dementia have complex health and social care needs. The particular focus of this proposal is to ensure that primary and acute health care supported by social care meets the needs of this group through implementation of evidence-based interventions. Business as usual is not working. Evidence gathered nationally and for GM demonstrates that those who have a secondary diagnosis of dementia are much more likely to be admitted to acute care for the same primary medical cause as those without dementia; they stay on average ten days longer, are much more likely to be readmitted, and much more likely to be discharged to residential care. And yet the ideal setting for people with dementia is the familiarity of their own home where possible, or whatever is their normal place of residence. Once admitted to hospital they rapidly lose their independence and ability to function. Across GM there is considerable good practice already implemented or under development. However, provision within this existing state of business as usual is far from comprehensive and at times neither effective nor cost-effective. The idea of the new delivery model (NDM) for dementia is to adopt a systematic approach to implementation of evidence-based interventions. This involves agreeing standards for what constitutes effective and comprehensive care focusing on primary care, memory services and later life mental health liaison, supported by effective community and social care pathways; to map provision across GM against this, and to develop investment and commissioning options for Clinical Commissioning Groups (CCGs) as already agreed by their chairs. The dementia NDM can go further in those areas using an integrated care approach to develop an investment agreement. In that context it can provide supporting evidence for investment in prevention to improve outcomes for people with dementia. 4 With Money in Mind (NHS confederation, 2011) 2

3 Aims and objectives The aims of the dementia NDM are: To maintain maximum independence for people with dementia through early intervention and crisis prevention by supporting them and their carers in their own homes or normal place of residence. To shift resources to early intervention and prevention of crisis. The objectives are: Reduced non-elective admissions in >65s per population >65s. Reduced non-elective bed days in >65s per population >65s. Reduced non-elective re-admission rate within 28 days >65s. Reduced non-elective re-admission rate within 90 days >65s. Reduced proportion of people >65 discharged directly to residential care from hospital. Reduced permanent admissions to residential/nursing care in >65s per population >65s. Increased patients >65 dying in their usual place of residence (in line with their own wishes). Fit with Greater Manchester strategy and government policy Drivers for improvement are: The National Dementia Strategy. 5 Clear evidence and guidance on how effective service provision can improve outcomes for people with dementia and their carers. 6 The imperative to maintain independence and reduce avoidable acute and residential care costs where more affordable alternatives can deliver better outcomes within the AGMA public sector reform agenda. A significant proportion of the dementia care programme target cohort will be at high risk of hospital admission. The key contribution to the GMS lies in reducing the burden on the economy health and social care spend accounts for one third of total public sector expenditure in GM. The dementia care programme is based on the evidence for how we can reduce demand and invest in more cost effective, evidence based interventions. The Prime Minister s challenge 7 (March 2012), building on the National Dementia Strategy, commits to improving dementia diagnosis rates through regular checks of over 65s: from April 2013, there will be a quantified ambition for diagnosis rates across the country, underpinned by robust and affordable local plans. We will ensure GPs and other health professionals make patients aged 65 and older aware of memory clinics and refer those in need of assessment. GM and national dementia CQUINS for will increase demand on existing later life mental health liaison and memory services. The national dementia CQUIN requiring acute trusts to identify, assess and refer over 75 year olds for dementia is also likely to increase demand on primary care. 5 DH,

4 2 Case for change What is the problem we are trying to fix? There are an estimated 29,500 people with dementia in GM. Predominately elderly, they commonly have complex health and social care needs, and the numbers are rising the over-85s will increase by 85% between 2002 and 2026, and up to a quarter of these will have dementia. People with dementia are over-represented in acute care. They occupy up to a quarter of hospital beds at any one time. Compared to those with the same diagnosis but without a dementia coding, those with a secondary dementia coding have longer lengths of stay and poorer outcomes, rapidly losing their ability to function and their independence People with dementia also have a higher chance of being discharged directly to residential care. The root of the issue is that mainstream services health and social care often fail to meet the physical and social needs of people with dementia and their carers. This means that preventable crisis situations often develop for example the deterioration in mental condition provoked by an uncontrolled infection in a person with dementia, or the physical or mental breakdown of an unsupported carer. Frequently, admissions to acute care are a response to crisis because no more appropriate alternative is available. Analysis of 2011 admissions data for GM shows that dementia is poorly coded, representing 4% of discharges compared to the expected figure of 25%. 11 People with dementia codings are much more likely to be non-elective admissions (91% compared to 34% for all admissions), average length of stay is nine days longer for those with a dementia coding compared to all patients, and the average tariff is considerably higher ( 3,043 compared to 1,814). If the 4.2% of patients with a secondary coding and dementia could be treated and costed the same as other patients then the potential difference in tariff could be approximately 15 million in a calendar year. 12 Patients with dementia account for 10% of hospital bed days, 13 and wider evidence suggests that 30% of elderly patients with dementia who come to acute hospitals from their own homes are discharged to care homes. 14 Why focus on this issue There is clear evidence on how this situation can be improved. Good practice is set out in the National Dementia Strategy 15 and involves early identification, care planning and support for people with dementia, built on clear and effective local multi-agency care pathways. The care pathway for people with dementia (based on NICE) is attached at Appendix 1. It shows the desired pathway where the pathway does not function optimally this leads to avoidable hospital admissions, re-admissions, increased length of stay, and/or admission to residential care. This business case focuses on primary care support, memory services, and later life mental health liaison, which represent key drivers of improved outcomes across these areas, supported by integrated health and social care pathways. 8 Counting the Cost (Alzheimer s Society, 2009) 9 Royal College of Psychiatrists, Improving Services for People with Dementia (National Audit Office, 2010) 11 ibid 12 Report by AQuA 2012, based on analysis of 2011 NHS secondary user service data. 13 Review of Dementia Care Admissions (NHS GM, 2011) 14 RAID Supporting Evidence (Birmingham and Solihull NHS Trust, 2011) 15 DH,

5 There is also clear evidence on the benefits in terms of better outcomes for people with dementia and savings in terms of reduced use of acute and residential care. Admissions avoidance is achieved through: primary care support; memory service identification and care planning; pathways of integrated and coordinated care, promoting independence and maintaining function; and end of life care planning. Reducing length of stay is achieved through good discharge planning supported by training for acute services by later life mental health liaison services. Reducing readmissions is achieved through good discharge planning supported by later life mental health liaison services, alongside pathways of integrated and co-ordinated care. The existing delivery models and business as usual Currently, provision of memory services and later life mental health liaison is variable across GM, as is the presence and effectiveness of supporting pathways. Identification and management of dementia in primary care (both nationally and across GM) is at 40-60% of predicted levels. Consequently, the number of unplanned admissions is high, and people with dementia stay longer in hospital and are more likely to be readmitted poor outcomes for the individuals concerned, and poor use of scarce public resources. Recent developments All areas of GM have an existing partnership dementia strategy and action plan based on the National Dementia Strategy. 18 The NHS Greater Manchester Dementia Commissioning Strategy, endorsed in December 2011, has enabled the development of GM CQUINS (contract incentives) for covering patient and carer experience and action planning to improve dementia care across all NHS providers. For acute and mental health trusts, the CQUINs also incentivise improved discharge planning and more appropriate prescribing of anti-psychotics. These are complemented by a national CQUIN which incentivises identification, assessment and referral of over-75s with dementia. The dementia CQUIN is 5% of the total GM CQUIN value, representing about 160,000 to an average district general hospital. Ten hospital-based demonstrator sites have been developed across GM, covering, for people with dementia: end of life care; identification and management in primary care; long term conditions; standards in care homes; intermediate care; later life mental health liaison; and community-based pathways. Why outcomes have not already improved Good practice in dementia care is evident in pockets across GM, based in evidence on effective care for people with dementia as set out in the National Dementia Strategy. However, provision is variable, and a more integrated, whole system approach is required for example, ensuring that later life mental health services provide training for acute trust staff and that memory services ensure care planning as well as diagnosis. It is also essential to undertake more preventative work and less reactive so, in addition to later life mental health liaison delivered to people in hospital, we must stop people getting into hospital in the first place, for example by improving primary care management of the medical needs of people with dementia, and end of life care to support people with dementia to die at home rather than in hospital. 16 Improving Services for People with Dementia (National Audit Office, 2010) 17 Counting the Cost (Alzheimer s Society, 2009) 18 National Dementia Strategy (DH, 2009) 5

6 Although progress has been made, there is insufficient capacity for later life mental health liaison, memory and primary care support services to meet increasing demand, both from the requirement on primary care for increased identification of people with dementia as a result of the national and GM CQUINS, and the ongoing demographic challenge. In addition, the social care sector needs to focus on carers strategies, telecare, community-based pathways, support for care homes, and staff training readmission to hospital will only be avoided if effective and accessible community-based support is in place. It is anticipated that cross-agency support for the dementia programme under the Community Budget umbrella will further prioritise the dementia work and allow implementation at scale across GM. The cost of today s delivery model Work is underway to map current dementia care activity across GM, and the costs associated with it. As a first step, however, basic standards need to be established to define what later life mental health liaison and memory service provision encompasses (and what it does not), with common agreement over the nature of activity a necessary precursor to assessing the scale of current delivery. At the current time, accurate data on dementia care funding streams and costs were not available. The 11 dementia demonstrator sites across GM have benefited from 77k in NHS funding for The main NHS costs to business as usual relate to avoidable use of acute care leading to poor outcomes. As already described, people with dementia codings are much more likely to be nonelective admissions (91% compared to 34% for all admissions), average length of stay is nine days longer for those with a dementia coding compared to all patients, and the average tariff is considerably higher ( 3,043 compared to 1,814). Patients with dementia account for 10% of hospital bed days, 19 and wider evidence suggests that 30% of elderly patients with dementia who come to acute hospitals from their own homes are discharged to care homes. 20 Controlling for age, sex and method of admission, the minimum savings to be achieved across GM by reducing length of stay for people with a dementia coding to the equivalent for those with no dementia coding are estimated to be 11 million. 21 What are the problems with business as usual? As already described and despite the existing implementation of much good practice and new developments across GM the problem with business as usual is that there is currently a lack of consistent application of evidence-based systems of crisis prevention and early intervention across health and social care in GM. This means that people with dementia and their carers do not consistently receive the support they need from primary care, social care or in the acute setting to prevent (further) crises through early intervention. The default is admission into acute care, and this results in poor outcomes for this group. In addition, the demographic growth of older people will bring a projected 50% increase in the number of people with dementia over the next 13 years. Given their likelihood of non-elective admissions, their longer lengths of stay and the higher costs of their care, business as usual will rapidly become an unsustainable model. 19 Review of Dementia Care Admissions (NHS GM, 2011) 20 RAID Supporting Evidence (Birmingham and Solihull NHS Trust, 2011) 21 Improving Outcomes for People with Dementia: Report to Clinical Strategy Board (NHS GM, June 2012) 6

7 3 New service propositions / new delivery models (NDMs) Overview of the new delivery model The NDM represents an integrated approach to improving dementia outcomes across GM. It constitutes the following elements: Increase levels of identification and management of dementia in primary care, and increase capacity and skills in primary care to manage the physical and mental health needs of people with dementia. Ensure that memory services are commissioned to agreed standards of quality, costeffectiveness, capacity and accessibility across GM, to support early diagnosis and care planning of those identified as suffering from dementia. Ensure that later life mental health liaison services are commissioned to agreed standards of quality, cost-effectiveness, capacity and accessibility across GM, to support acute care management and discharge planning, including staff training and support. Better integration with adult services, ensuring join up between acute, primary and local authority services. These core strategies will be underpinned by: Working with adult social care to ensure that the required community support and pathways are in place: carers strategies; use of telecare; clearly understood communitybased pathways, including voluntary sector support, support for care homes, and training for domiciliary and residential care staff in meeting the needs of people with dementia. Improving end of life care for people with dementia (linking with the End of Life Care Community Budget exemplar). Commissioning framework / service delivery framework The draft GM Dementia Strategy Group Delivery Plan is embedded below. Draft GM Dementia Strategy Group Delivery Plan.xls Greater Manchester Clinical Strategy Board which includes the chairs of the 12 CCGs has recognised the importance of primary care identification and management of dementia. They have agreed the following: Development and use of the GM Long Term Conditions dashboard to include dementia. This gives CCGs as clinical leaders the opportunity to identify inter-practice variation in the proportion of those with dementia who are being identified and managed by the practice; whether those with dementia are getting the care they need for long term conditions, and the rates of related emergency admissions to hospital (to be launched to clinical leads in November 2012). Identification of dementia clinical leads to provide the necessary leadership (achieved). 7

8 A standards-based approach to commissioning effective memory services to support diagnosis and care planning, and later life liaison services to support acute trusts in effective discharge and avoiding readmissions. Standards are designed with clinical input and based on NICE and other guidance. Standards-based service mapping is in progress and will enable CCGs to identify unmet needs for services and consider commissioning options. To investigate the potential to develop increased generalist and specialist capacity in primary care to manage dementia an approach already developed in Stockport and other areas. This approach forms part of the primary care and long term conditions work streams of Healthier Together. Size of the cohort The cohort of patients with dementia is set out below. Assumptions for estimating the numbers are set out in the Cost Benefit Analysis (CBA), as outlined in Section 6 of this Business Case. Primary care. Those benefiting will be: i) people with dementia on the practice register who have not yet received a diagnosis (around half); and ii) patients identified with a diagnosis of dementia who are not currently receiving regular comprehensive reviews of their physical, mental and social care needs. Memory services. Those patients who are referred for diagnosis to memory services, which is the majority of those who are identified in primary care (some patients with severe dementia or with severe physical health issues may not be referred for diagnosis as this would not be relevant to their care plan). Later life mental health liaison services. This provision is for patients who are admitted to acute care and who need a specific assessment and care plan provided by the services. There will also be a benefit to those with dementia who are admitted to an acute setting and are not referred to the services. This will be achieved through training and development for acute ward staff in managing the needs of people with dementia. Geography The dementia programme operates on a 10 and 1 basis, combining locally shaped delivery in the ten GM districts with standards and support being developed at a sub-regional level. The final product in March 2013 will be the delivery of ten locality commissioning proposals, based on mapping against standards and developed with local dementia commissioning and clinical leads, setting out the need for service redesign, developments and investment, for consideration by CCGs and Health and Wellbeing Boards. How are cases referred This work will be supported by the development of pathways to clarify who can refer to what services according to defined criteria. These pathways will be based on NICE guidelines, local need, local provision and resources. Referral into the pathways can be via self-referral, carer referral, or from health, social care or voluntary agencies. Delivery Delivery is via a range of agencies, notably primary care, acute care, specialist mental health services, adult social care and the voluntary sector. Most of these are represented on the Greater Manchester Dementia Steering Group. 8

9 Performance management and monitoring As detailed above, a set of target outcomes has been identified, against which performance will be monitored and evaluated, drawing on the methodology used to evaluate the Birmingham RAID project. 22 Given the difficulty in identifying a control group immune to the influence of RAID, 23 a pragmatic (and cost-effective) approach was adopted, drawing on retrospective data from a pre- RAID group. The GM dementia programme has gained support from Manchester Academic Health Sciences Centre (MAHSC) and Northwest Advancing Quality Alliance (AQuA) for the evaluation. The development of a shared outcomes framework will ensure a consistent approach with the other GM Community Budget exemplars, and in particular will secure a strong fit with overarching outcome indicators on which all of the health and social care projects will be focused. The objectives listed in Section 1 are entirely consistent with these overarching outcomes. Governance and accountability Dementia initiatives in GM are governed by a multi-agency Greater Manchester Dementia Strategy Group, chaired by the Chair of GM Association of Directors of Adult Social Care (ADAS). This group will take formal responsibility and accountability for the three work streams outlined in this business case, with more detailed operational decisions taken by the locality dementia leads who form a subgroup of the steering group. The Strategy group reports to: NHS Greater Manchester Clinical Strategy Board; AGMA health commission/health and wellbeing board; GMADAS. The Strategy group monitors delivery quarterly against milestones through a governance system that includes key risks and mitigating actions. 4 Changes required Proposed differences between the new delivery model and business as usual In order to implement the NDM successfully, the following reforms or shifts are required: Finance the ability to identify savings made by commissioners and providers in the cost of acute and residential care, and to develop an investment model to support communitybased prevention and early intervention. A key element to work through in this regard is the cashability of projected savings, in terms of the diverse incentives for commissioners and providers, and the potential to decommission services. A move towards outcomefocused commissioning would support this. Moving beyond organisational and thematic (e.g. health vs. social care) silos to develop clear pathways for identification and management of people with dementia across GM, including those in residential care. Consistent implementation of evidence-based strategies including telecare, carers strategies, and end of life care. 22 See 23 Benefits from the project were not limited to immediate participants in RAID services, as other people also benefited from improved provision by hospital staff trained under the wider RAID initiative. 9

10 Training in meeting the needs of people with dementia, for staff in primary care, acute, domiciliary and residential care. National changes required to make a scaled up model reality This business case is submitted as part of an overall theme report that recognises that although there are already flexibilities in tariff and competition arrangements that could be deployed, we may wish to secure support in building confidence in local systems to move towards new models of commissioning. Potential for reducing or decommissioning services As set out in Section 2, if those patients with a secondary coding of dementia could be treated and costed the same as other patients then the potential difference in tariff could be approximately 15 million in a calendar year. 5 Delivery plan for implementation Implementation Implementation will be led by the NHS Greater Manchester dementia programme lead working in close partnership with the dementia strategy group, primary care, adult social care, mental health and dementia commissioning leads to deliver in line with the timeline set out in Appendix 2. This sets out dates and key milestones. Key risks and mitigating actions are outlined in the risk register below. Timeline Please refer to Appendix 2 for an outline timeline. Risk management A number of high-level risks associated with the project are identified in the table below, along with mitigating actions. Risk Implementation implementation may be slowed through the timescale imposed by the governance arrangements. Capacity there may be issues with commissioning capacity due to health service reforms and pressure on local authority budgets. Action Accept that sustainable change will be achieved through using the correct governance arrangements but ensure that momentum is not lost and realistic timescales are understood and accepted. Ensure that dementia is a high priority across the system and that the economic benefits of developing effective and comprehensive services are clear. 10

11 Identifying unmet need the high profile of dementia plus the expectation on CCGs to improve identification and management will increase demand. Evidence for cost and benefit drivers whilst national evidence (where it exists) and local management insight have been used to determine initial cost and benefit assumptions, they remain estimates. Cashability of savings both the nature of the costs (predominantly semivariable and fixed costs) and the ability to reduce future demand need to be tested within the NDM. Develop robust monitoring and evaluation with support from MAHSC and AQuA. Demand will be tracked as part of the evaluation process and will be factored into the financial monitoring process. Ongoing tracking of costs and benefits will enable forecasts to be replaced with real delivery data to determine the actual CBA over the lifetime of the proof of concept phase. This work will be done within the context of a wider integrated working programme. The cashability of savings needs to be taken in the round alongside the Healthier Together programme within the Proof of Concept phase. Any savings realised may be re-invested in response to rising future demand. 6 Cost-Benefit Analysis The CBA is based on the available data, but the evidence is limited (for example there is limited evidence available on the potential for hospital admissions avoidance through primary care support and memory services provision). Due to this lack of evidence, we have not been able to model all of the benefits; however, robust evaluation is built in to the implementation process, supported by MAHSC and AQuA, and this should help us to capture the wider impact of the three work streams. The programme will be implemented in line with Department of Health (DH) guidance including the National Dementia Strategy and the Prime Minister s Challenge as already described and risk reduced by evaluating its effectiveness as it is implemented. As detailed above, work is underway to map existing dementia care activity and costs. In addition to the challenges resulting from a lack of common standards, this task is complicated by the fact that much dementia care funding falls within wider NHS block contracts, adding to the difficulty in identifying business as usual expenditure (and, particularly, disaggregating spend across the three work streams). The absence of robust data on the scale and cost of current dementia care delivery across GM makes it very challenging to assess the relative cost of the NDM. For this reason, the CBAs for the memory services and later life liaison work streams have drawn upon population and cost data sourced from the DH Dementia Commissioning Pack Toolkit, 24 from which savings for each work stream have been derived using the GM CBA model. Relevant evidence outlined in the DH tools has also been used at various stages of the CBAs, particularly concerning the impact of interventions. In addition, the analysis has drawn upon secondary evidence from other sources, including an evaluation of the RAID later life liaison intervention in Birmingham /?OpenDocument. Note that data for all of the PCTs within GM have been used, but the boundaries of some of these (e.g. Tameside and Glossop) extend beyond the footprint of the ten GM local authorities. 11

12 The target objectives for the NDM (and the current GM demonstrator sites) are outlined earlier in this document. Reflecting these objectives, the CBAs focus on the following outcomes: reduced admissions; reduced readmissions; reduced bed days (below trim point); reduced excess bed days; and reduced residential care admissions. Findings from the initial draft CBAs were tested at a recent workshop that brought together partners from across the health and social care sector in GM to challenge the assumptions in the analysis. The workshop highlighted the importance of accounting explicitly for the fiscal disbenefits that will form a counterbalance to some of these benefits for example, increased take-up of home care, intermediate care and reablement packages, as a result of shorter length of stay in hospital and delayed admission into residential care. The current CBAs incorporate these balancing costs within the Costs worksheet. The modelling has also been subject to scrutiny by DH analysts, including the team that developed the Dementia Commissioning Pack Toolkit. The CBAs focus on fiscal benefits, and do not capture the wider economic and (particularly) social benefits that will flow out of the interventions undertaken. 25 The conservative nature of the model should also be stressed, with allowance made for optimism bias by scaling up costs and reducing benefits. The analysis is based upon delivery costs expended during a single year (year 1) on an initial cohort, with the benefits modelled over a five year period. Savings from the majority of the outcomes modelled are anticipated to be in-year (i.e. realised during year one), with the exception of savings from delayed residential care admissions, which due to the long-term element of residential care extend over the five years. The balancing costs related to residential care savings (see below) have also been modelled across the five year period. Gaps remain to be filled in the CBAs, particularly around the extent of deadweight associated with the interventions. As the NDM moves from a theoretical concept into on-the-ground intervention, we will fill such gaps with real data emerging from delivery, and test and revise the assumptions that underpin the current preliminary analyses. Primary care support The DH Primary Care toolkit models primary care support as referrals from primary care practitioners to a specialist dementia community support team. The vision in GM is considerably broader, looking to improve skills and capacity within the primary care support to identify and manage dementia more effectively. As the fit between the DH approach and that under development in GM is poor, it was decided not to use DH tool input data as a starting point for the modelling. Due to a lack of intelligence on the scale and cost of the GM NDM, CBA has not been undertaken for this work stream. Memory services The cohort for memory services provision under the NDM has been taken from data provided in the DH Memory Assessment Services toolkit. For a cohort of an estimated 15,925 people with dementia who could be referred to memory services across GM each year, the DH toolkit estimates that an investment of 12.6m per annum 26 would fund memory service provision around early referral and diagnosis, plus drugs prescription to a sub-set of the cohort. The CBA indicates that this investment could result in annual fiscal savings relating to reduced residential care weeks of an estimated 25 The only exception is modelling of the economic benefit flowing to people with dementia who self-fund their residential care, who will benefit financially if their entry into care is delayed as a result of memory services and/or later life liaison provision m when scaled up by 15% to account for optimism bias. 12

13 7.9m, accruing to local authority adult social care services. However, balancing costs relating to increased home care requirements for the additional weeks that beneficiaries may remain out of residential care need to be taken into account (estimated at 3.8m, before optimism bias correction), as does the additional cost of housing benefit that is not paid to people when in care (a further 2.5m). Bringing these costs alongside the investment to support NDM activity under this work stream effectively outweighs the projected savings, particularly when optimism bias corrections of -40% are applied to the benefits and +15% to the costs. The benefit cost ratio (BCR) is 0.36, indicating that for every one pound spent, an estimated thirty six pence will be saved. The need for a whole system approach to implementing the delivery model is evident, with the local authorities, CCGs and the Department for Work and Pensions (DWP) as investing agencies, but the sole beneficiary being the local authorities. The imbalance between investors and beneficiaries clearly demonstrates the rationale behind developing an investment agreement to support enhanced memory service provision across GM. It is important to note that in only considering the estimated savings to be derived from reduced residential care expenditure, the DH tool does not explore outcomes around the reduction in hospital admissions that can result from memory services provision (wider evidence suggests that a diagnosis supported by effective care planning will significantly reduce unplanned admissions); the average non-elective admission cost is 2,384, a significant sum. If evidence was available on which to model these outcomes, the BCR would be considerably improved. Furthermore, the social benefits that will accrue to individuals and wider society from memory service activity have not been modelled. Such social benefits include general health and well-being improvements amongst the cohort and family/friends who are their carers, and wider life satisfaction (for example, associated with increased independence). Although we have not been able to include such benefits in the analysis, if they were quantifiable in terms of QALYs (Quality Adjusted Life Years), a significant social return on investment would be identified. As discussed previously, the only economic benefit to be modelled is the proportion of savings from delayed residential care admissions that will be self-funded by private individuals; based on these savings, the economic BCR for the memory services CBA is 0.17, and 0.10 for the later life liaison CBA. In addition, there are likely to be significant economic benefits to informal carers of working age who experience lost employment, lower earnings and reduced pension entitlement as a result of their caring responsibilities, and to the wider economy through lost GVA (Gross Value Added). Similar economic benefits may be associated with people suffering from early on-set dementia, although this is only a small proportion of the total cohort. Taken in isolation, the fiscal BCR does not provide a compelling financial case for the NDM around memory services. However, it is important to recognise the limitations of the modelling in not capturing the full range of fiscal savings, and in not considering the wider economic and social benefits, which are likely to be substantial. Viewed in the round, the case for change is much stronger than the CBA would suggest. Hospital-based later life mental health liaison services The DH Hospital Mental Health Liaison Service toolkit estimates that 80,482 elderly patients in GM hospitals could benefit from mental health liaison services each year; of these, an investment of 2.3m per annum would enable 15,292 people to access provision. The CBA model estimates an 13

14 ensuing annual fiscal benefit of 12.0m, 27 across all five of the key outcomes modelled, with a BCR of 1.56 (indicating that for every 1 invested, 1.56 in benefits is estimated to result) and a pay-back period of one year. As with memory services, balancing costs have been applied to account for increased demand for home care, intermediate care and reablement, along with Community Mental Health Team (CMHT) activity and additional Housing Benefit costs. Once again, there is an imbalance in the money flows demonstrated between the agencies involved: the CCGs and local authorities are the principal investing agencies, with the CCGs as the main beneficiary; the acute trusts are anticipated to derive significant benefit despite little or no initial investment. In addition, evidence from evaluation of the Birmingham City Hospital RAID project suggests that further positive outcomes (and associated cost savings) were achieved for people with dementia who did not directly access later life mental health liaison services whilst in hospital, but who benefited from interaction with staff who had received training under the wider RAID initiative. 28 Net benefits There is likely to be some overlap between the cohorts for the three work streams that make up the NDM. In reality, the overlap between memory services and later life liaison (the two work streams that have been modelled) is unlikely to be large, given that memory service provision will be focused largely on people with dementia with relatively mild needs, and later life liaison focused on people with more severe needs. The only common outcome between both CBAs is reduced residential care admissions, on which there is potential for the double-counting of benefits. However, the estimated savings are premised upon delaying entry into residential care for a defined length of time, which varies according to the intervention; if someone benefits from both memory service activity and later life liaison, this is simply likely to result in them enjoying a more extended delay/diversion from becoming institutionalised. For this reason, the findings from the two CBAs can be aggregated without adjustment to come up with net figures the net costs from memory service and later life liaison are 29.4m (after optimism bias correction), and the net annual fiscal benefit 19.8m (also adjusted for optimism bias), giving a net BCR of A further consideration is the extent of duplication between the dementia care exemplar and other projects within the GM Health and Social Care theme, and projects under the three other Community Budget themes, Early Years, Transforming Justice and Troubled Families. These themes have very little focus on the dementia care elderly cohort, and in any case are generally modelling different outcomes. There might be some overlap between the sub-set of the memory services cohort that suffers from early onset dementia, but the numbers are very small (around 2% of all people with dementia). There is greater potential for overlap between dementia care and the Integrated Care and Fire and Falls projects, both of which focus on an elderly cohort and model common outcomes such as excess bed days, hospital and residential care admissions. Some 8% of elderly people have dementia, so any overlap will be relatively small, particularly because neither the Integrated Care or Fire and Falls delivery models specifically target dementia sufferers. The exact proportion will be tested on implementation of the NDMs, but is likely to be a maximum of 5%. In aggregating savings across the projects, some discounting of savings may be appropriate. 27 This comprises: savings from reduced readmissions of 3.1m, accruing to the CCGs; savings of 2.2m from reduced admissions, also accruing to the CCGs; savings from reduced bed days below trim point of 2.9m, accruing to the acute trusts; savings from reduced excess bed days of 2.1m, accruing to the CCGs; and savings from reduced residential care admissions of 1.7m, accruing to local authority adult social care services. 28 See RAID Supporting Evidence (Birmingham and Solihull NHS Trust, 2011) and Economic Evaluation of a Liaison Psychiatry Service (Centre for Mental Health, 2011). 29 Note that this calculation does not take account of the spread of costs and benefits over the five year period, which in the CBA model are adjusted by a discount rate of 3.5% to produce Net Present Values (NPVs). This adjustment will make a small difference to the overall net BCR quoted here. 14

15 Sensitivity analysis The significant optimism bias corrections 30 that have been applied to both CBAs have a considerable impact in reducing the BCR. The analysis has been re-run to exclude these corrections, resulting in a combined BCR across both of the models of Whilst this figure does not include a reduction in estimated savings due to deadweight (which will be modelled once further evidence becomes available), it indicates the extent to which the model adopts a conservative stance, and the impact this has on the CBA findings. As the assumptions within the modelling are replaced by actual data derived from delivery experience, the level of optimism bias correction should reduce, thereby increasing the BCR towards or beyond break-even point. Assumptions and caveats Common assumptions that are applicable to both CBAs are outlined below, followed by assumptions and caveats that are specific to the individual analyses. Many of the assumptions draw on the approach adopted in the DH tools, with others based upon evidence from the Birmingham RAID project evaluation. Both CBAs The following unit costs are used in both the memory services and later life liaison CBAs: o GM average gross weekly expenditure per person on supporting older people in residential care (Personal Social Services Expenditure Unit Cost, ), 464 o GM average gross weekly expenditure on home care per older person receiving home care at 31 March 2011 (Personal Social Services Expenditure Unit Cost ), 200 o Housing Benefit average weekly award, >65s (DWP, May 2012 data), 77 o Local Authority Housing Benefit management cost, per award per week (Bury Adult Services of Housing Benefit award), 12. In general, optimism bias corrections of +15% have been applied to the cost areas, and -40% to the benefits. Two-thirds of residential care costs are assumed to be funded by the local authorities, and the remaining third privately funded by individuals; savings derived from delayed entry into residential care are allocated according to these proportions (DH tool). Similarly, for home care, we have assumed that two thirds of the cost is covered by the local authority, and a third by the (more affluent) individual. We have assumed that housing benefit is paid to two-thirds of the cohort being diverted from residential care. 30 In both the memory services and later life liaison CBAs, all of the costs have been uplifted by 15% to account for uncertainty in the data, and the fiscal savings for all but one of the target outcomes reduced by 40% (evidence relating to savings from reduced hospital admissions as a result of later life liaison provision is more robust, and hence a 25% optimism bias correction has been applied to savings against this outcome). 31 The total costs across the two CBAs are 25.6m, and the total savings 32.3m. The individual BCRs come out as 0.68 for memory service provision, and 2.88 for later life liaison. As with the calculation for the net BCR that includes optimism bias corrections, the spread of costs and benefits over the five year period of analysis will make a small difference to the BCR quoted, due to discounting to produce NPVs. 15

16 Most savings will be realised in-year. However, although the majority of savings from reduced residential care admissions are in-year, the remainder may extend into later years to take into account the long-term element of residential care. The following proportions have been used: 60% year 1; 20% year 2; 10% year 3; 5% years 4 and 5. The same proportions have been applied to the distribution of balancing costs relating to reduced care admissions (i.e. home care, intermediate care, reablement and CMHT provision, and housing benefit costs) across the five year analysis period. Memory services CBA Following the approach adopted by the DH tool, savings are modelled in two areas: savings from use of Alzheimer's drugs; and savings from increased awareness (increased patient and carer knowledge of the dementia condition and prognosis due to early detection and prevention). We have not modelled savings from the reduced length of hospital stay that is likely to result from memory services provision, through awareness that a patient has dementia upon admission. Similarly, we have not modelled savings from reduced reliance upon anti-psychotics, resulting from increased awareness of dementia diagnosis on admission to residential care. Drawing on national evidence quoted in the RAID evaluation, we have assumed that 30% of people with dementia will enter residential care. We have assumed that 100% of people with dementia whose entry into residential care is delayed or diverted as a result of memory service intervention will remain at/ return home and require home care. As memory service intervention is not likely to keep severe dementia cases out of residential care (and memory services tend to see mild and moderate rather than severe cases), we have assumed that none of the cohort will require reablement provision, intermediate care or CMHT support. Note that these assumptions are based on uncorroborated expert judgement, made in the absence of relevant hard evidence, and need substantiating. All people who are eligible to be referred to memory service provision are referred, and 95% of those referred progress to follow-up having received a diagnosis (DH tool). Sixty per cent of people attending memory services receive a diagnosis of dementia. Forty per cent of dementia patients have Alzheimer s and are prescribed drugs (a proportion of these will not continue with drug treatment after a few months the DH tool uses an average of 13 prescriptions dispensed by the memory service). Use of these drugs results in an average one and a half month delay in entry to residential care; an additional month of home care provision will be needed (DH tool). All patients (and carers) who receive memory service provision are assumed to benefit in terms of increased awareness, and a better understanding and ability to plan for the impact of dementia. Along with the consequently improved home and primary care support patients should receive, these benefits are estimated to delay entry into residential care by three months; an additional two months of home care provision will be required (DH tool). An additional cost to DWP is identified relating to the need to pay out housing benefit to people with dementia benefiting from memory services provision who are diverted from residential care to home or an intermediate care setting (housing benefit is not paid to people in residential care). Following the DH tool assumptions over the length of delay to institutionalisation (as above), this is estimated at additional housing benefit payments for 16

17 1.5 months relating to reduced residential care resulting from memory service prescription of Alzheimer's drugs, and three months relating to reduced residential care resulting from increased awareness. Housing benefit management costs to the local authority have also been modelled as a balancing cost against the savings derived from reduced residential care admissions. The time period over which these costs will be incurred has been calculated in the same way as the DWP housing benefit costs. Mental health later life liaison CBA The following unit costs are used in the later life liaison analysis: o mean cost per bed day, mental health services, elderly patients (Unit Costs of Health and Social Care, 2011), 319 o median tariff cost for excess bed days (NHS tariffs, 2011), 228 o average non-elective admission cost (NHS 2010/11 reference costs - all HRGs), 2,384 o average cost per day of bed-based intermediate care provision in a residential home (National Audit of Intermediate Care, 2012), 136 o median cost per week of home-based intermediate care provision (National Audit of Intermediate Care, 2012), 513 o average cost of a reablement package per service user (Unit Costs of Health and Social Care, 2011), 2,083 o average cost per case per CMHT team member per annum (Unit Costs of Health and Social Care, 2011), 2,142. Only the 20% most severe dementia cases in hospital are referred to the later life liaison team, 95% of which are seen. It is assumed that 20% of all over-65 hospital admissions have dementia (DH tool). 80% of people with dementia whose entry into residential care is delayed or diverted as a result of later life liaison provision will remain at/return home and require home care; of these people, an estimated 50% (40% of the total beneficiary cohort) will receive reablement support. It is assumed that the remaining 20% who do not remain at/return home will enter intermediate care. Note that these assumptions are based on uncorroborated expert judgement, made in the absence of relevant hard evidence, and need to be substantiated. A balancing cost for six weeks home care and six weeks CMHT provision has been apportioned against the savings derived from reducing residential care admissions by six weeks as a result of later life liaison activity (DH tool, see below). It is assumed that 30% of the beneficiary cohort (the most severe cases) will require CMHT provision. A balancing cost has also been introduced to account for the increased need for home care and CMHT provision due to reduced length of hospital stay (bed days below trim point/excess bed days) as a result of later life liaison provision. This is based upon the average two days reduction in length of stay used in the benefit calculations (see below). It is assumed that 75% of people whose length of stay is reduced will require home care and 30% will require CMHT support (given to the most severe cases) for the additional days they are out of hospital. 17

18 The balancing cost relating to the need for intermediate care on discharge from hospital is based upon unit costs derived from the National Audit of Intermediate Care (2012), and average length of provision (27.6 days, from the same source). It is assumed that half (10%) of the 20% of beneficiaries requiring intermediate care will receive bed-based care in the community, and half (10%) home-based care. Data from the National Audit has been used to apportion these costs by agency, with 73% falling to the CCGs, and 27% to the local authorities. A proportion of the cohort that benefits from reduced residential care admissions as a result of later life liaison provision will require reablement services. A balancing cost has been calculated based upon a national unit cost for standard length provision and an estimate that 50% of the beneficiary cohort will require reablement provision. As with memory services, an additional cost to DWP is identified relating to the need to pay out housing benefit to people diverted from residential care to home or an intermediate care setting. Following the DH tool assumptions over the length of delay to institutionalisation, this is estimated at additional housing benefit payments for six weeks. The time period over which local authority housing benefit management costs have been modelled has been calculated in the same way to the DWP housing benefit costs. Evidence from the RAID evaluation suggests that later life liaison activity results in a two day reduction in length of stay (assumed that one day is below trim point, and one an excess bed day). RAID also found that, under business as usual, 19% of patients with dementia who are admitted to hospital will subsequently be readmitted, but for patients receiving the RAID intervention this reduced to 5%. RAID evidence has also been used to model impact on reduced admissions. Following receipt of RAID services, 25% of patients with dementia were not admitted to hospital, compared to 17% under business as usual. We have drawn upon national evidence quoted in the RAID evaluation that 30% of people admitted to hospital with dementia will subsequently enter residential care. The DH tool suggests that on average 33% of people with non-elective hip fractures were able to stay in the community having received later life liaison provision, rather than being admitted to residential care; it also assumes that the average delay in admission to care is six weeks. Note that the approach is a conservative one, with the assumptions based solely on dementia patients sustaining hip fractures in reality, people with dementia will also enter residential care for a range of other reasons. In addition, savings are likely to be underestimated as they only take into account people diagnosed with dementia, and not those who remain undiagnosed. In line with the approach adopted in the DH tool, savings that might result from psychiatric liaison activity leading to reduced reliance upon anti-psychotic medicines have not been modelled. 18

19 7 Financial plan Sources of investment Once the NDM and cohort size is finalised, consideration will need to be given to how the significant up-front investment might be sourced. There is a good rationale for encouraging agencies that are net beneficiaries to support up-front investment (e.g. acute trusts and CCGs for later life liaison activity, and local authorities for memory services). Adult social care providers might invest in such areas as telecare, carers support and crisis response teams. Health commissioners should be persuadable around all three work streams, once the potential benefits are clearly articulated. There may also be a case for obtaining pump-priming investment from other sources, to be repaid by outcome-related payments made by beneficiary agencies, as articulated in an investment agreement. The investment agreement would also help to address issues around the time-lag in achievement of cost savings relating to residential care admissions, and the requirement to support related balancing costs for home care, CMHT, intermediate care, reablement and housing benefit provision across an extended period (see the tables at the end of this section). Such a time-lag can represent a further disincentive to invest in early intervention and preventative activity. Reinvestment / repayment strategy Decisions over which savings will be reinvested or retained will depend upon conversations initiated by the CBA findings; such decisions will be outlined in an investment agreement. The distribution of savings from dementia care provision under the NDM across the agencies involved, and the extent to which these savings will prove cashable, are important yet complex considerations in this regard. For example, savings relating to a reduction in excess bed days (i.e. over the tariff) accrue to the commissioner (the CCGs). However, if the reduction in bed days falls below the trim point, savings accrue to the provider (the acute trusts). Incentives are attached to readmission rates, and may vary by locality some of the savings from a reduction in readmissions will accrue to the commissioner, and some to the provider. Providers can also accrue additional resources if they achieve targets under the national and GM CQUINS, which incentivise trusts to reduce length of stay. Specifically, the mental health CQUIN incentivises the development of later life liaison services. As an indicative example, the CBAs for the two work streams attribute the benefits as follows: 100% of the savings from the following outcomes accrue to the CCGs (currently the PCTs): reduced excess bed days; reduced admissions; reduced readmissions. 100% of the savings from reduced bed days (below trim point) accrue to the acute trusts. 100% of the savings from reduced residential care admissions accrue to the local authorities (adult social care services). 32 The extent to which acute trust savings are cashable can be dependent upon latent demand, which can simply result in newly freed-up beds being filled by other patients. It is only when beds and (particularly) wards and hospitals are closed permanently that savings are realised. If provision is spot purchased, savings to local authority adult social care services from reduced admissions to residential care may be more immediately cashable, as surplus activity can simply be 32 Although note that in calculating the estimated savings from reduced residential care admissions that will accrue to local authorities, the CBA assumes that local authorities fund two-thirds of social care services, with the remaining third funded by private individuals paying for their own care. Savings from the latter are economic (benefiting the individual) rather than fiscal (benefiting the public purse). 19

20 decommissioned. However, the situation with regard to local authority-run care homes is more complicated cashability will depend on the scale of reduction in demand for residential care, which may need to be sufficient to close a home. NDM COSTS 2013/ / / / /18 000s 000s 000s 000s 000s CCGs 17, Acute Trusts Local authorities 5,290 1, DWP 1, Totals 24,729 2,352 1, NDM BENEFITS 2013/ / / / /18 000s 000s 000s 000s 000s CCGs 7,341 Acute Trusts 2,927 Local authorities 5,743 1, DWP Totals 16,011 1, CASHABLE SAVINGS 2013/ / / / /18 000s 000s 000s 000s 000s CCGs 1,468 Acute Trusts 585 Local authorities 2,872 1, DWP Totals 4,925 1, INVESTMENT REQUIRED 2013/ / / / /18 000s 000s 000s 000s 000s CCGs 11,338 Acute Trusts 4,521 Local authorities 8,870 2,352 1, DWP Totals 24,729 2,352 1,