1. Prevention for older people: context, policy and economics Julien Forder

2. Overview Consider the prevention agenda for older people Discuss findings and conclusions of the Wanless Social Care Review –What is prevention? –Policy context –Is there any evidence? –How can the evidence-base be improved? Conclusions

3. Policy context 2006 White Paper – –2 of its main aims: better prevention services with earlier intervention more support for people with long-term needs –Achieved by: Shifting resources away from acute health More care outside hospital Better joined up local services 2004 Spending Review –LTC and people supported at home PSA –Specific initiatives: e.g. £60m on POPP Older people’s NSF and NHS Plan: –Intermediate care Long-term conditions agenda –Case management

4. Policy context Marked shift in policy rhetoric since 1990, which emphasised targeting of resources on those with most need (e.g. Griffiths Reports) Changing needs: –Ageing populations –Importance of chronic diseases and long-term conditions

5. What is prevention? The term prevention covers a lot of ground – sometimes over-used and misapplied in the policy rhetoric Two concepts: –(1) public health and (low-level) services preventing or delaying the long-term need for social care services by reducing people’s dependency, disability and ill health –(2) Up-stream services preventing inappropriate use of more intensive, downstream services for people with given dependency, disability and ill health. But inevitably inter-twinned…

6. (1) Preventing poor health and disability Services targeted at people with low-level (or no) needs Aim to reduce the chance of, or delay, onset of more significant disability Health focused: –Primary prevention: this could include exercise programmes, smoking cessation, etc. –Secondary prevention: this could involve screening and case finding to identify individuals at risk of specific conditions or events (such as falls or stroke); –Tertiary prevention: aimed at minimising disability or deterioration from established diseases. Main function: to delay inevitable deterioration

7. (2) Preventing inappropriate use of up-stream services A spectrum of services… Services overlap: locating people with complex needs –Too intensive: high costs and intermediate outcomes –Not intensive enough: poor outcomes, risk

8. Where does prevention fit? The future cost of social care –Numbers of people with care needs: Population health is improving but evidence suggests healthy life expectancy is growing slower than total life expectancy –What services people receive Older people not requiring care (5.5m) +44% Older people with low needs (1.4m) +53% Older people with high needs (0.9m) +54%

9. Where does prevention fit? Prevention can potentially: –Reduce numbers of people with needs i.e. improve population health and well-being –Use of upstream services might improve cost- effectiveness i.e. given the person’s impairment or poor health, provide lower cost services that offer a better improvement in outcomes per £ than existing services.

10. The trade-off: Money for prevention services targeted on population with low- level needs Money for care services provided to people with high- level needs Implications of more low-level prevention

11. The trade-off: Low-cost services for a large number of people to prevent a small number of people needing intensive services High-cost services to support a small number of people with high-level needs Good population outcomes… but high population expenditure? For same expenditure, improved outcomes for people with high needs – overall better population outcomes or not?

12. Targeting is key… Prevention is more cost-effective if better targeted –E.g.: new grab-rails installed in every person’s home who otherwise would have fallen in next year… But how to target? –… Install grab-rails in homes of all people over 75 (3.9m people!) Need targeting indicators –E.g. older people with conditions affecting balance, in poor housing, etc…

13. Evidence – low-level prevention What are they? –Help with everyday tasks e.g. laundry, cleaning and shopping –Services to promote social inclusion –Home adaptations; Assistive technology –Services to promote physical activity Why? –Investment now could lead to future cost savings –Improves quality of life now e.g. living in own home, self-esteem, social participation (Is this prevention?) Context –Significant reduction in low-level home care in recent years

14. Evidence – low-level prevention Evidence-base –No large-scale quantitative studies –But a number of qualitative studies Main findings –Appear to improve quality of life and well- being outcomes, prevent/delay institutionalisation –… but little on costs or the value and size of benefits

15. Condition or service specific Falls –More robust evidence base Include: exercise, education, environmental modification, medicines management, eye sight, hip protectors etc… –Many studies considered effectiveness In most cases falls were reduced significantly –Fewer studies looked at cost-effectiveness Some weak evidence of CE

16. Condition or service specific Stroke –Include: lifestyle (smoking, diet, exercise); cardiovascular medicines (e.g. Statins) –Many studies indicate good effectiveness, but few consider cost- effectiveness Evidence of CE mixed, but positive on balance Intermediate care –no consensus between papers about cost effectiveness. IC leading to longer lengths of stay but with the positive impact that patients are discharged with a high level of physical functionality. IC can be effective in saving bed days in acute hospitals but this is dependent upon intermediate care being available on discharge –Timeframe of studies and model of IC appear critical in determining IC

17. Evidence – preventing inappropriate hospitalisation Evidence-base is poor –POPP and Innovations Forum results are needed Statistical analysis suggests that people using social care show a reduced use of inpatient care –E.g. £1 spent on SC implies 30p to 70p reduction in inpatient spending –But difficult to know what happened to patient outcomes Many studies of improved health and social care integration show shift of resources to social care and a reduction of intensive service use –Most suggest modest cost-effectiveness

18. Impact of home care on hospital use Source: (Fernández and Davies, 2002)

19. Problems in developing the evidence What outcomes How to measure outcomes Attribution of effects Long time horizons

20. Conclusions Significant policy emphasis on prevention agenda Wide variety of interpretations of the term prevention Evidence-based is under-developed –Indications of effectiveness but cost-effectiveness is not really known Prevention could be the solution… … but in the meantime increasing spending on prevention is taking resources away from services for people with real and immediate needs (where there remains significant unmet need)