HEALTH AND SOCIAL CARE
October 2016
SOCIAL NEED
Elderly care • Dementia prevalence to triple by 2050 • 51% more people aged 65 and over in England in 2030 compared to 2010
Mental Health • In 2011/12 over 1.25 million adults accessed NHS services for severe or enduring mental health problems. • Almost one in four British adults and one in ten children experience a diagnosable mental health problem at any given time
Physical health • Average difference in disability- free life expectancy is 17 years between areas of different deprivation • Over 50% more people with three or more long-term conditions in England by 2018 compared to 2008. Examples of long term conditions include high blood pressure, depression, dementia and arthritis
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COMPLEX AND CHANGING SYSTEM £118bn Department of Health
Department for Communities and Local Government £6bn
£££
Healthwatch England
Public Health England
£3.4bn
Local authorities Director of Adult Social Care
NHS England
NICE
Commissioning Support Units Health and Wellbeing Boards
£105bn
£69bn
209 Clinical Commissioning Groups (CCGs)
£££ AHSNs
Director of Public Health
£17bn
Elderly care
Central strategic funds
£69bn £7bn
Public health services
£10bn
Services for people with Disabilities
Community Services
Mental health services
Hospital services
GPs, Dentists, Opticians
£16bn Specialist services
New organisation from Apr 2013
UNDER GREAT FINANCIAL STRAIN
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DELIVERING MIXED OUTCOMES •
Increase in demand but reduction in budgets
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Inconsistent and often poor quality of care o
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In the lowest performing GP practices, only 25% of patients report being able to see their doctor
Reactive rather than preventative o
34% of patients visiting A&E last year only needed advice
o
24,000 people with diabetes die each year from avoidable causes related to their condition
•
Disjointed services and support to individuals
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Variation in access to care across the country o
¾ of people with depression and anxiety receive no treatment
o
85% of LAs restrict publicly funded care to those with substantial and/or critical needs
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RECENT REFORMS IN HEALTH AND SOCIAL CARE 50 new vanguards: • Multispecialty community providers (MCPs), Integrated primary and acute care systems (PACS) • Models of enhanced health in care homes • Urgent and emergency care (UEC) vanguards • Acute care collaborations Devolution of health and care • Manchester • Cornwall Use of capitated budgets and rise of Accountable Care Organizations Boost to primary care
7 day services Living wage Flexibility in council tax rate to fund social care provision
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SOCIAL SECTOR PLAYS AN IMPORTANT ROLE IN DELIVERY OF HEALTH AND SOCIAL CARE •
8% of social enterprises and 22% of charities operate in health and social services
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Have potential to improve service user outcomes o
Focus on prevention
o
Collaboration with service users
o
Close working with communities
o
Expert knowledge of local needs and preferences
o
Engagement with volunteers building social capital
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SOCIAL SECTOR PLAYS AN IMPORTANT ROLE IN DELIVERY OF HEALTH AND SOCIAL CARE •
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National service provider charities o
Charities are delivering > £1.8bn of health contracts and >£4.6bn of social service contracts
o
Large asset base
o
Many organisations with revenue >£10m (for e.g. 10 largest charities providing elderly care have combined income >£1bn )
Spin outs o
Health Spin outs have total turnover > £500m and growing
o
Most are employee owned
o
Diversifying away from reliance on single contracts and have recently won a number of large contracts from CCGs
o
Often asset poor
Community-based VCS organisations o
•
More locally grounded and mixed appetite to expand geographically
Tech Social Enterprises o
Make use of emerging digital interventions to improve outcomes and lead to system change
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THE ROLE OF SOCIAL INVESTMENT IN IMPROVING OUTCOMES
Developing new models of care to shift spending away from acute services and into preventative services focusing on outcomes
Enabling health and social care charities access to property in which to deliver care services
Supporting income generation and scaling innovative new services
• SI used to provide risk finance for delivery of outcome based contracts • Increase in number Social Impact Bonds that focus on preventative services with potential for long term cash savings • SI to scale of community based care models that commonly reduce demand for formal care
• Use of SI to develop new facilities to accommodate care users • This may include (1) new property purchase on balance sheet or (2) property funds providing long term leases to social sector organisations delivering community based care.
• Supporting innovation in service delivery • Use of SI to access new revenue streams from commissioners either alone or in partnership • Use of SI to adapt to increasing use of personal budgets to purchase care
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SUPPORTING PEOPLE WITH LONG TERM CONDITIONS TO MANAGE THEIR CARE
Investors £1.65 Investment into SIB programme
SIB SPV (Ways to Wellness)
Consortium of: • • • •
Mental Health Concern Changing Lives First Contact Clinical Health Works Newcastle
Social prescribing to those with an expressed willingness/ability to change.
1800 patients (aged 40-75) improve selfcare and positive behaviour change leading to increased likelihood of returning to work and reduced burden on health provision
Payments triggered by outcomes represent a % of cost savings
Newcastle West Clinical Commissioning Group (CCG)
Payment metric: 1. Reduced secondary care usage 2. Improved wellbeing based on the Outcomes star
Ways to Wellness Commissioner: Newcastle West Clinical Commissioning Group (CCG) Investors: Bridges Social Impact Bond Fund (£1.65m) Delivery body: Consortium of four local charities Intervention: Social prescribing through Link workers assigned by an individual’s GP. The link workers will work with each person one and one and recommend nonmedical interventions to enable the patient sustain a more healthy lifestyle.
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MOVING CARE INTO THE COMMUNITY
Shared Lives
Kent Shared Lives - Karl and Clare with Shared Lives carers Blossom and Mike, at their wedding, before moving to live independently
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Alternative model of care in which host families provide home and community-based care arrangements for vulnerable adults in need of support
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Provides flexible and person-centred care and is estimated to save local authorities up to £26,000 per person each year compared to traditional service
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Social investment up-front supports growth and will be repaid as a proportion of the management fee that the Shared Lives schemes receive from local authorities for each Shared Lives arrangement that they establish.
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ENABLING PEOPLE WITH MENTAL HEALTH NEED ACCESS SUPPORT DERIC
PROBLEM
SOLUTION
People with mental health issues, or experiencing emotional or psychological distress, may avoid sharing their feelings with friends, family or healthcare professionals due to stigma.
Big White Wall is an anonymous digital mental health and wellbeing service where people who are experiencing mild to moderate mental health issues can talk freely about their problems and self-manage their own mental health.
Of the one in four who experience a mental health problem, the majority will not receive treatment.
REVENUE MODEL
IMPACT
Big White Wall is a subscription service.
Big White Wall members get instant access to 24/7 support, are supported to self-manage their mental health without recourse to further help, with 95% of users reporting improvements in their wellbeing.
The investment is repaid through subscribing organisations, including NHS providers, government departments, the armed forces and universities, as well as individuals.
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INVESTING IN ACCOMMODATION FOR VULNERABLE PEOPLE SANDWELL COMMUNITY CARING TRUST
PROBLEM
SOLUTION
Many people with dementia and physical or learning disabilities are unable to live completely independently.
Sandwell CCT provides high quality, personal residential care for older people with dementia and supported living for people with physical and learning disabilities. Social investment was used alongside a loan from Unity Trust to help it acquire a 62-bed residential care home for £4.25 million to expand its operations.
REVENUE MODEL
IMPACT
Sandwell CCT’s services are used by a mixture of private individuals and local council commissioners.
More than 700 vulnerable people from in and around the Black Country are looked after by Sandwell CCT.
The income generated from these services is used to repay the investment. 13
WHERE WE’VE GOTTEN TO IN HEALTH AND SOCIAL CARE INVESTMENTS •
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• •
MARKET CHAMPIONING
£37m of investments (115 by number) made into organisations working to improve health and wellbeing outcomes (16% of total by number, 8% by value according to latest transparency data release)
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Influence into the Winterbourne View work
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Role in the DH/PHE/NHS England VCSE Advisory Board
3 funds with a focus on health and social care (DERIC, Shared Lives, and Care and Wellbeing Fund, with a total £14mm of funds available).
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Strong relationships with largest charities and spin outs
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Some relationships with opinion shapers e.g. King’s fund and Health Foundation
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2 pieces of research published (AgeUK and report on Winterbourne View)
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Numerous awareness raising roundtables (supported living, mental health, health and social care contract providers and others)
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Limited influence into CCGs
All unsecured funds have made an investment into these outcome areas to date 2 SIBs up and running
BSC PRIORITISED PROJECTS Drivers
Potential partners
Success in 6 month- 1 year
Channelling social investment into social sector organisations delivering primary care
Central NHS push to scale primary care Increased pressure for consolidation and growth Social enterprise models of primary care
Nuffield Trust Health Foundation Care and Wellbeing Fund
Increased deployment of existing funds into primary care Scope for a specialist fund
Identifying models of using social investment to scale community based models
Push for avoidance of acute settings
Community Catalysts Power to Change Coalition for Collaborative Care AgeUK
Investment into 1-2 partnership models
Catalyse outcome based commissioning and use of SI by CCGs
Increased number of models of social investment used to catalyse delivery of outcomes
AHSN SW AHSN Network NHS England
SIFI capital channelled to support SSO delivery of larger outcome based contracts in health
Identifying partnership models in health and social care service delivery
Increase in contract size Bottom up innovation in models
Health and Wellbeing Partnership AHSN SW
Partnerships Insights Paper
THEORY OF CHANGE
THE PROBLEM • Information barriers - lack of understanding of available services and suitable treatments, for example: o Elderly: Older people are the most frequent users of healthcare services but also least likely to complain about poor care. Arguably the biggest barrier is not knowing how to complain and who to complain to (Ombudsman, 2015). The problem is exacerbated as more and more information are moved online (Age UK, 2015) o Hospital patients: Only 52% of in-patients felt they were as involved in decisions about their care as they wanted (Kings Fund, 2012) ACCESS o Long-term conditions: Less than 50% of people with diabetes were given the opportunity to discuss their own goals for self-management (Kings Fund, 2012) • Physical barriers - physical disabilities or lack of local support to access healthcare services, for example: Barriers that o Learning disabilities: people with LD have poorer health than their non-disabled peers, that are to an extent avoidable (Northern Ireland Assembly, 2013) prevent access to o Elderly: More than a million people who have difficulties with the basic activities of daily living, such as getting out of bed, washing and dressing, now receive no formal or informal and use of help at all. That is an increase of 100,000 in one year alone (Nuffield Trust, 2016) healthcare o Geographical inequalities: In Scotland, mortality rates for asthma and cancer are worse in rural areas due to later diagnose and intervention (RCN, 2012) services • Nature and severity of illness - insufficient focus on preventative care and long-term needs, for example: o Prevention: On average around 3% of national health sector budgets are currently spent on public health and prevention (WHO, 2016) o Long-term non-critical needs: 90% of local authorities were limiting help only to those with ‘substantial’ or ‘critical’ needs (Nuffield Trust, 2016)
QUALITY Challenges to provide high quality healthcare services
• Inability to provide person-centered services, for example: o People with long-term conditions and multiple, complex needs too often report that their interactions with the health and social care system feel confusing and poorly coordinated. Typical problems including dealing with a range of care professionals who have not shared information with them, poorly scheduled appointments etc. • Inability to provide equal services, for example: o Health inequalities: in England, people living in the poorest areas will die an average of 7 years earlier than richest areas; 11 years for people living in Scotland , and 8 years for people living in Northern Ireland (ONS, 2014) • Inability to provide effective services, for example: o Poor record of preventing and treating ill health compared to other developed countries: high rates of smoking, harmful alcohol consumption and obesity, which are all above the OECD average (OECD, 2015) 82% of women in the UK survived over five years with breast cancer, compared with 87.4% in Sweden (Quality Watch, 2015) • Inability to provide timely services, for example: o GP waiting time:14.2 million patients waited a week to see their doctors, or did not manage to get an appointment at all in 2015 (Labour, 2016) o Surgery waiting time: The waiting time for seven key procedures in England now ranges from 91 days, for gallstone removal, to 107 days, for a knee replacement (NHS, 2015) o Mental illness: people experiencing mental ill health waiting almost twice as long for a consultation as people with physical ailments (Nuffield Trust, 2015)
• Lack of coordination among healthcare providers, for example: o Long-term conditions: Co-ordination of care for patients with complex needs and long-term illness is currently poor (The King’s Fund, 2011), and those with long-term conditions have a lower quality of life (Department of Health, 2011) Poor • Lack of knowledge transfer among healthcare providers, for example: intermediation o Delayed transfers: Escalating numbers of delayed transfers now appear to be symptoms not simply of insufficient money but also of problems of workforce and service capacity as among healthcare well as poor co-ordination and information sharing between different parts of the system (Nuffield Trust, 2016) providers SYSTEM
• Insufficient and ineffective allocationof funds to meet societal needs: o Funding gap: The NHS in England will struggle to meet the requirement, set by the Five Year Forward View, to save £22 billion by 2020. Even if hospitals and other NHS providers made cost savings of 2% a year, year after year, the funding gap would still stand at around £6 billion by 2020–21 (Nuffield Trust, 2016) o Shrinking public spending: By 2015-16, NHS providers were being paid £925 in cash for the same procedure they would have been paid £1,000 to perform in 2009-10: the Policies fail to equivalent of a real-terms cut of 20% to just £800 (Nuffield Trust, 2016) channel funding o Pressure on commissioners: Demand for hospital and other NHS services is currently growing at 3.1% a year – considerably faster than commissioners’ ability to pay for it. There is to respond to a risk that commissioners will resort to curtailing growth through crude service rationing e.g. by raising the threshold for treatment and access to certain services; or they might attempt healthcare needs to do it indirectly e.g. by shutting services and hoping that patient and clinicians’ expectations for care and treatment will wane (Nuffield Trust, 2016) POLICY
THEORY OF CHANGE Problem
Activities
Intermediate outcomes
Final outcomes
Information and guidance Information barriers
Self-management training
Receive accurate, personalised and timely advice
Peer-to-peer support ACCESS
Barrier-free goods and services
Barriers that prevent Physical barriers access to and use of healthcare services
Care homes
Social prescribing
Community-based care and support Non-personcentered services
Challenges to provide high quality healthcare services Ineffective services
Health insurance Primary care for underserved communities Outcome based commissioning
Receive person-centered health and social care
Improved support to access suitable healthcare services
More people maintains a healthy lifestyle
Receive equal health and social care Greater focus on delivering positive health outcomes
Lack of coordination Lack of knowledge transfer
POLICY Insufficient and Policies fail to ineffective channel funding to allocation of public respond to funds healthcare needs
Healthy and physically active people in communities
Improved quality of healthcare services
Reduce bureaucracy
Improved capacity for providers to provide highquality healthcare services
Consolidation e.g. GP federations SYSTEM Poor intermediation among healthcare providers
Positive experience and attitude toward own physical and mental health
Professional training Equipment upgrade
Untimely services
Receive support and training to maintain healthy lifestyle
Self-management and training Income support
Unequal services
Reduced physical barrier to access health and social care
Home-based care and support Behavioural / lifestyle change programmes
Nature and severity of illnesses
QUALITY
Increased level of independence and perception of control
Networks and Platforms among / between stakeholders (patients, caretakers, providers, policy makers etc.) Spin-off mutuals
More effective communication among stakeholders
Reduced pressure on public health funding
Research / Think Tank Advocacy Media as watchdog
Good support and quality of life in relation to physical and mental health
More effective design and delivery of health and social care
Public policy and expenditure that supports good physical and mental health = SI opportunities
THEORY OF CHANGE Problem Information barriers ACCESS Barriers that prevent Physical barriers access to and use of healthcare services Nature and severity of illnesses
Non-personcentered services
Activities
Examples of SSOs and SI
SI Opportunities
Information and guidance
Unforgettable* (Impact Ventures UK)
Self-management training
HeLP Diabeties* (Numbers for Good)
Investing in SSOs that deliver preventative care
Peer-to-peer support
Big White Wall* (Impact Ventures UK)
Barrier-free goods and services
HCT Group (SASC)
Care homes
Country Court Care (Cheyne Capital)
Home-based care and support
Care and Share Associates (Big Issue Invest)
Behavioural / lifestyle change programmes
Oomph (Nesta)
Social prescribing
Ways to Wellness SIB (BSC)
Community-based care and support
DERiC (BSC)
Investing in SSOs that deliver care to people with mental illness Investing in SSOs that deliver health and social care to elderly, people with LD
Scaling community-based models
Self-management and training Income support
QUALITY
Unequal services
Challenges to provide high quality healthcare services Ineffective services
Health insurance Primary care for underserved communities Outcome based commissioning
Care and Wellbeing Fund SIB (BSC)
Catalysing outcome based commissioning and use of SI by CCGs
Professional training Equipment upgrade
Untimely services
Reduce bureaucracy Consolidation e.g. GP federations
SYSTEM Poor intermediation among healthcare providers
Lack of coordination Lack of knowledge transfer
POLICY Insufficient and Policies fail to ineffective channel funding to allocation of public respond to funds healthcare needs
Networks and Platforms among / between stakeholders (patients, caretakers, providers, policy makers etc.)
Hospify* (Bethnal Green Ventures) Konnektis* (Bethnal Green Ventures)
Spin-off mutuals
Chime CIC (SASC)
Identifying partnership models in health and social care service delivery
Research / Think Tank Advocacy Media as watchdog
* Technology-enabled solutions
Enabling innovative technologyenabled solutions
