We undertake robust and policy-relevant research, based on the discipline of economics. We use state-of-the-art tools of economic and statistical analysis to address important policy questions about the funding, organisation and delivery of health and social care services. Our five-year programme of work covers three areas:
Understanding changes in the demand for health and social care (H&SC) from different population groups and the implications for how health and care services are provided and funded.
Measuring what is being delivered for the money spent on H&SC to maximise quality of care and improvements in health and wellbeing.
Designing the organisation of health and care systems to make the best use of resources to deliver joined-up care for the population.
Workstream 1: Demand for Health Care
1.1 Drivers of Demand for Health Care and associated activity and spending
Understanding what drives demand for health care (including the interactions with social care) and how demand may change in future is essential to inform long-term workforce and infrastructure planning. The overarching aims of this workstream are to understand the key drivers of demand and to provide projections of future demand. Research is organised within 4 Work Packages (WPs):
WP1 Conceptual / theoretical framework: Evaluations of the drivers of the demand for health care typically infer demand from expenditure and activity. However, this captures only ‘expressed’ demand. The WP will develop a conceptual framework that distinguishes the different types of demand and that informs our understanding of demand drivers.
WP2 Evidence on drivers of demand: This WP will consider evidence on the link between proxies for need and service use, and how these have changed over time. It will build on earlier ESHCRU work examining the drivers of inpatient hospital expenditures and activity. It will examine the rise in expenditures across periods and their determinants through, for example, changes in patterns of morbidity, characteristics of patients and providers. It will also consider evidence on expenditure at the end of life.
WP3 Towards a model of demand for health care: The key challenge for projective future health care demand is recognising that the system is complex, diverse and involves consideration of flows (e.g. hospital admissions) and stocks (waiting times). Potential modelling approaches may include focusing sequentially on different conditions / clinical areas. We will also consider the compatibility of a health care model with the long-term care (LTC) model, ensuring the two models can be integrated into an overall model of health care and LTC demand.
WP4 Variations in supply: This WP will consider systematic variations in the supply of health care services, setting out a conceptual framework and devising empirical strategies for identifying and quantifying variation.
1.2 Development of the long-term projections models
PSSRU (now CPEC) has developed a number of models for producing projections of demand for long-term care and associated expenditure. The models have been used extensively for producing projections for Spending Reviews, reviews of the social care funding system and OBR fiscal sustainability analyses.
This project aims to extend the models to include (a) community health services and (b) a wider range of needs measures.
Community health services: to date, the models have mainly focused on social care. People with long-term care needs may require social care, community health care or combinations of social care and community health care. This project aims to extend the models to cover community health services (CHS), in particular community nursing and therapy services.
Need measures: the models contain as their key measure of need limitations in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Since use of CHS may meet different types of needs and some evaluations of interventions have used different needs measures, we will also extend the models to include more needs variables.
Workstream 2: Supply side efficiency
This Workstream focuses on the interdependence between health and social care (H&SC) services. The overall aims are:
To understand how variations in H&SC service provision affect the care system as a whole, for example due to demand substitutability and complementarity across services and sectors.
To understand and assess different models of service coordination, and the extent to which existing arrangements maximise potential care synergies and achieve truly integrated care.
2.1 Impact of alternative hospital discharge arrangements on lengths of stay
Previous studies have aimed to identify best practice in hospital discharge arrangements. NHS England and NICE have produced recommendations on arrangements to optimise the transition from hospital to social care support. These tend to emphasise system-level processes for care coordination, such as regular management meetings, clear delineation of provider roles and responsibilities, monitoring of pressures, and pooling of resources. At practice level, recommendations cover the establishment of joint local protocols and assessment forms, secure communication methods, up-to-date care directories, single points of access and named contacts.
In practice, the take-up of recommended discharge arrangements has been limited: for example, less than half of hospitals have developed joint or shared patient assessments. Furthermore, there is no quantitative evidence of the impact these different arrangements have on system performance. This project will contribute to the development of good practice in hospital discharge in England by:
- Mapping the range of H&SC discharge coordination arrangements in place across English hospitals.
- Engaging with H&SC stakeholders to understand which factors facilitate (or undermine) the implementation in practice of recommended discharge arrangements.
- Quantifying their impact on post-operative care costs and outcomes for different patients.
2.2 Analysing variability in systems for joint working across LAs and CCGs
Care arrangements for coordinating H&SC services vary significantly across local areas, in terms of the nature and extent of joint funding, care models, managerial structures, and information systems. These variations are likely to influence system performance and the success of future reforms.
Our research aims to map the different H&SC coordination arrangements across England and to explore their consequences on costs and outcomes of the care economy. We will:
- Compile evidence describing local H&SC joint working arrangements.
- Assess what types of integrated care arrangements exist, and how they respond to local characteristics.
- Quantify the impact of different integration arrangements on H&SC expenditure and system performance.
2.3 Impact of social care availability on hospital use
A critical question regarding the integration of the H&SC systems is the extent to which the two types of services substitute for each other, and in particular the extent to which increasing social care support reduces demand for health care. For patients admitted to hospital, greater availability of social care support should facilitate the discharge process and so reduce post-operative length of stay.
Whereas there is some evidence that this substitution effect does take place, this evidence is limited and does not differentiate between different types of patients. Increasing our understanding of these effects should provide critical evidence for optimising resource investment across acute and non-acute service areas.
Our research will aim to understand the extent to which greater supply of community and residential-based social care impacts hospital length of stay and 30-day readmission rates for older patients with different health care conditions. This project will build on analyses of the impact of complexity of discharge arrangements on lengths of stay using Hospital Episodes Statistics linked to the ESHCRU I programme of work, using panel datasets matching HES data to local authority-level data about supply of community and institutional social care.
Whereas we hypothesise a negative relationship between social care supply and hospital lengths of stay, the effect on readmission rates could be either negative (because greater social care support reduces the risk of deterioration post-discharge) or positive (because discharging earlier patients as a result of the availability of social care increases the risk of subsequent readmissions). The analysis will attempt to disentangle these effects.
Workstream 3: Organisation, incentive and regulation
3.1 Analysis of purchaser-provider contracts: modelling risk sharing and incentive implications. The focus of this longer term (3 year) project is on changing purchasing arrangements in the NHS and especially the movement away from purely activity-based payment (such as under the national tariff) towards mixed capitation / activity payment. One very important aspect of that change is how purchasers and providers of care will accommodate risks of activity being higher than anticipated. A second crucial aspect is the incentives that these arrangements give rise to in terms of influencing the volume, quality and cost of health care. The first elements of this project involve reviewing and applying conceptual frameworks for understanding these issues and the trade-offs that emerge (for example an incentive to better control activity but a reduced emphasis on quality of care). The conceptual frameworks imply that the benefits and costs depends on certain key parameters (such as how inherently variable volume is) and we intend to evaluate different payment mechanisms against these frameworks using data from current NHS emergency admissions.
3.2 Paying for health benefits using PROMs data. This is an 18-month project with a specific focus on evaluating the potential benefits and risks of utilising outcome measures (specifically patient reports or PROMs) as a means of conditioning how much payment the providers of services receive. The first strand of this project is to construct a model of an idealised payment scheme based on rewarding the health gains produced from treatment. That model will in particular set out what the key parameters (things that the purchaser can observe and measure) of the idealised payment system are. The model will then be simulated based on data from one or more PROMs elective procedures. It will provide direct estimates of the bonus that might be paid by a purchaser to the providers of services.