PHREE Spring Conference 2014

1. Evaluating health and social
care interventions in a CCG
Jo Broadbent
Director of Integration & Innovation, NHS NEE CCG
Consultant in Public Health, Essex County Council

2. Overview
1. Why evaluate at a local service level?
2. Case study 1 – Evaluation of Stroke
Pathway Improvements
3. Case study 2 – MDT Case Management
Evaluation (“Virtual Wards”)
4. A note on Information Governance
5. Challenges and Pitfalls
6. Conclusion

3. Why evaluate at a local service level?
• “Integration Fever”
– Lack of evidence of impact of integrated health & social care
interventions on quality, demand and cost
• “Innovation Fever” / Reality Check
– How robust and how generalisable are ‘best practice’ results?
• Economic challenges & Value for Money
– Stewardship of limited public finances
– Informing monitoring of ongoing cost / effectiveness
• Managing expectations
– Increasing gap between public & professional expectation vs.
effectiveness & affordability
– Scepticism & making the case for change: “Can it work here?”
• Pragmatism
– Short-term funding and Pilot-itis

4. CASE STUDY 1 – EVALUATION
OF STROKE PATHWAY
IMPROVEMENTS IN NE ESSEX
HYPOTHESIS – IMPROVED CLINICAL
STROKE CARE MAKES SAVINGS TO
SOCIAL CARE

5. Overview of Stroke in NE
Essex
• c. 600 acute stroke admissions p.a. in NEE; average admission cost
£5,032 (Essex-wide cost; SUS)
• c. 17% stroke mortality rate across Essex (SUS)
• c. 170 high risk TIAs treated p.a. in NEE (SUS)
• No. known stroke / TIA survivors = 6,625 (2.0% of population; QOF
2011/12)
• 33-bed hyper/acute stroke unit with 10 rehab beds in Kate Grant
Unit, Clacton Hospital
• c. 55% of patients have Early Support Discharge (ESD / rehab at
home) in their own home
• Post-stroke social care costs an average of £18,458 p.a. (Essex
County Council)

6. Milestones in Pathway
Development
2007/8 Developing acute care & introduction of thrombolysis
2008/9 AF screening introduced at Flu Clinics
2009/10 Primary Care Local Enhanced Service introduced – to increase diagnosis
and improve management of cardiovascular conditions
March 2010 “As is” pathway mapping workshop with clinicians, patients & carers
May 2010 Patient Listening Exercise
Essex Cardiac & Stroke Network Peer Review of Rehab
Pathway redesign workshop with clinicians, patient reps, voluntary sector
& commissioners
September 2010 ESD Procurement started
March 2011 GP TIA awareness training
2011/12 Multi-provider Joint Care Planning CQUIN
October 2011 ESD Service admits first patients
December 2011 Decommissioning of rehab beds in acute sector
February 2012 Process to switch grant-funded Voluntary Sector Patient & Carer Support
to commissioned basis starts
Befriending for post-stroke patients funded
2012/13 Midlands and East Stroke Review
May 2012 Extended access to ESD access to >50% by lowering clinical thresholds
January 2013 Commissioned Life After Stroke voluntary sector service replaces grant-
funded services

7. Stroke Spells in NE Essex (SUS)

8. Linking Health & Social Care Data
SAFE HAVEN

9. Data Manipulation and Cleaning
Specific social care records were attributed to a stroke using the
following rules:
•A social care package that was active at the date of discharge – length
of stay (i.e. date of admission) was classed as a “pre-stroke package”.
This was so that we could estimate potential increases in packages
attributable to the stroke.
•A re-ablement package that was started within 5 days of discharge or
whilst the patient was still in hospital was attributed to the stroke.
•Any other package that was stared within 5 days of discharge or whilst
the patient was still in hospital was attributed to the stroke.
•Any other package that was stared within 7 weeks of discharge was
attributed to the stroke.

10. Impact - Quality of Patient Care
2009 2012
Patients diagnosed with AF 5,409 6,423
Spending 90% of stay on stroke unit 61% 79%
High risk TIAs treated in 24 hours 25% 96%
Stroke HSMR 108 <80
Patients supported by Early
Supported Discharge
0 60%

11. Impact - Pathway Efficiency
Oct 2010-Sept
2011
(n=629)
Oct 2011–Sept
2012
(n=510)
No. Rehab Beds in System 20 10
Average Annual Cost of Social Care
Package
- £18,458
% patients receiving re-ablement 4.3% 1.0%
% patients receiving new or amended
post-stroke domiciliary care package
1.9% 0.8%
% patients newly entering Residential
or Nursing Care
2.7% 0.2%

12. What was the impact of
increasing ESD in NEE?
• A 75% reduction in need for social care packages post-
stroke in NEE following the introduction of ESD
• ESD-attributable reduction in social care demand
estimated at 57%
Oct 10 – Sept 11 Oct 11 – Sept 12 Difference
No. Stroke patients 629 510 119 / -18.9%
% Stroke Patients receiving
ESD
0% 47% +47%
Baseline No. / % (95% CI)
Patients receiving Social
Care Package
56 / 8.9% (6.9-11.4%) 14 / 2.7% (1.6-4.6%) -42 / -75%
Upper Estimate No. / %
Patients receiving Social
Care Package
93 / 14.8% (12.2-17.8%) 23 / 4.6% (3.0-6.7%) -70 / -75%
Reduction in Packages Due
to -
No. /% of the observed
reductions -
Reduced Incidence of Stroke 8 / 18.9%
Reduced Need / Supply 10 / 23.8%
ESD 24 / 57.3%

13. So What?
• A 57% reduction in post-stroke social care demand, due
to ESD, could save:
• £172k - £572k pa in NE Essex
• £977k - £3,243k pa across Essex
• Essex County Council agreed to use s256 Sustainability
funding for dedicated social workers for each acute
stroke unit & stroke pathway in Essex, to facilitate timely
discharge and support for domiciliary ESD
• A case for using the Better Care Fund to fund improved
stroke care?

14. CASE STUDY 2 – MULTI-
DISCIPLINARY CASE
MANAGEMENT EVALUATION
HYPOTHESIS - COMMUNITY
“VIRTUAL WARDS” IMPROVE CARE
QUALITY BUT REDUCE DEMAND ON
HEALTH & SOCIAL CARE SERVICES

15. What is a Community “Virtual Ward”?
Multi-agency, integrated assessment and
case management
Offered to –
Patients with multiple, complex needs including
long term health conditions
Staffed by –
A team or ‘ward’ of nurses working closely with
a patient's GP and other health, social care
and voluntary sector staff.
Core team: GP, community matron, social
worker, ward clerk
Wider support: social care, voluntary sector,
district council, COTE consultant, Specialist
Community Nurses
Pilot Virtual Wards were first
established in the Clacton area
in January 2011, covering 9 GP
practices.
Evaluation period = 12 months

16. Who is Admitted to the Community Virtual Ward?

18. Aims of the Virtual Ward Project
DoH LTC QIPP workstream aimed to:
“reduce unscheduled hospital admissions by 20%, reduce length of stay by 25% and
maximise the number of people controlling their own health through the use of supported
care planning.”
NE Essex aims:
“to enhance care for people with multiple long term conditions and/or those at high risk of
acute admission in NE Essex, through –
•building on the current clinical case management role of Community Nurses;
•using risk prediction software to increasingly focus activity on preventing exacerbation
and avoidable acute admissions;
•admitting high risk patients to “Virtual Wards” run by Clinical Case Managers;
•establishing multi-disciplinary teams (MDT) across health and social care, which link
to Local Authority and voluntary sector services, and have Case Manager at centre;
•Case Managers directly drawing support for patients from MDT, Local Authorities and
Voluntary Sector.”

19. Evaluation Objectives
(after Maxwell)
Effectiveness
Service usage and LTC risk factor
management. This will address –
•Quality
•Adding value
•Reduction in unscheduled admissions
Cost-Effectiveness
Additional costs incurred by the Virtual
Wards will be collated. These will be
compared with costs/savings from change
in service usage and impact of risk factor
control changes. This will address –
•Sustainability
•Delivering savings (QIPP)
Acceptability / Experience
A before and after survey of the
experience of patients, family/carers,
practice staff and virtual ward staff will be
undertaken. This will address –
•Quality
•Adding value
•Effectiveness of joint teams
•Empowerment of patients
•Sustainability
Appropriateness
•For NE Stakeholders
•For commissioners to decide if and how
to expand the service

20. Impact – Improved Patient Experience
“If I didn’t have this help to
look after me … I’d have to
go in a home. Which I
don’t want to do because
you get so lonely.”
“Excellent idea having
Community Matrons.
Community Matron is able
to pull thing together and
liaise with everyone.”
“Myself and family feel this
is an excellent service and
since being on the ward
have not been in hospital”
“When Community Matron
got involved everything
went smoothly”
“Very happy with
Community Matron who is
kind and explains things to
me”

21. Impact – High Quality of LTC Care
• 72% of GPs and 100% of Community
Matrons report that virtual wards have
improved LTC patient care
• High quality of care found by clinical audit
(individual level QOF-based vs wider
population)

22. Fewer AVOIDABLE ambulatory care sensitive (ACS) hospital
admissions – through better Community-based care
Impact - Reducing Avoidable Admissions
19% reduction in ACS
admission rate
= 20 fewer admissions / 1000
patients pa.
= saving of c. £58,000 pa. per
1,000 patients case managed
40% significant reduction in
ACS bed days
= 400 bed days / 1000 patients pa

23. Impact - Reducing Avoidable
Admissions (System-Level)
Rate of increase in all NEL
admissions for all >65s was three-
fold lower at GP practice level in
practices supported by a VW than
in all other GP practices in
Tendring:
All NEL admission rate –
VW Practices = 4.73% increase
vs non-VW = 14.11%
ACS Admission rate –
VW Practices = 20.66% increase
vs non-VW = 28.42%

24. Addressing Unmet Social Care Needs / Early Social Care Intervention
•20% of virtual ward patients have been found to have unmet social care needs
and are now receiving small preventive packages of care
– eg next day initiation of domiciliary care (eg personal care, meals and
medication support), home and furniture adaptations, and benefits
assessment and advice.
•45% of contacts involved some form of carers’ provision (either advice or
services)
Reducing Social Care Package Cost
•Published evidence suggests that net residential care cost avoidance of
£44,722 p.a. were made (not evaluated directly)
•Pre-existing packages of care were reduced on average by £10 per person per
week (= £16k p.a. in the pilot phase)
•NET social care savings of around £6k should be made in 2013/14,
increasing to £127k in 2014/15 IF numbers of patients increase
Impact - Impact on Social Care

25. Impact – Increased Integration of Services
85% of GPs report improved communication with Community Health and
Social Care teams
•42% of GPs report that the single greatest impact on patient wellbeing
is from having a social worker embedded in the team
Close working with the voluntary sector is a key feature of NE Essex
virtual wards
•Voluntary Sector organisations commissioned to provide a range of support
essential to health and wellbeing include:
– Mental Health First Aid training for staff – MIND
– Befriending & Outreach - Clacton Family Support, Age UK, Tendring Specialist
Stroke Services
– A ‘Message in a Bottle’ for all patients - The Lions Club
– Voluntary Services Directories - CVSs
– Support literature – St Helena Hospice & Epilepsy Action

26. So What?
• Multi-disciplinary care planning delivers a good patient
experience, but has limited impact on service demand
• “Everyone Counts” and the Better Care Fund are
pushing health and social care into integrated
commissioning and delivery – on the premise that this
will release efficiencies. Lack of evidence of ability to
realise large scale efficiencies may provide a reality
check to scale of savings achievable?

27. Information Governance
• These evaluations were carried out pre-
April 2013, when Regulations on access to
Patient Identifiable Data changed.

28. HOW COULD THE
EVALUATIONS HAVE BEEN
IMPROVED?

29. Challenges and Pitfalls
1. INFORMATION
GOVERNANCE
2. Limitations in routinely
collected data (content /
completeness /
timeframe / costing)
3. Identifying meaningful
controls / comparators
4. Selling the benefits of
evaluation to delivery
teams
5. Producing a balanced
review of quality & cost
5. Linking datasets (high %
mismatch)
6. Attribution of cause and
effect
7. Over-interpretation of
limited data
8. Wide confidence
intervals
9. Managing expectations
of decision-makers
10.Inconclusive results
make decisions difficult

30. CONCLUSION
Evaluation in a service environment will not be
perfect and will not go to plan.
The “science” of public health evaluation in a
service context is to deliver something sufficiently
robust for the evaluation purpose.
The “art” of public health evaluation is
understanding the needs of decision-makers, and
knowing when ‘good enough’ is good enough!