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:
Demand for healthcare - Workstream 1
1.1 - Demand for Community Health Services and Interaction with Hospital Services
↴Background:
Community health services (CHS) provide important care for people living in their own homes who have a range of health conditions requiring nursing or therapy services. These services can play a valuable role in promoting independence, preventing hospital admission and expediting hospital discharge. Focusing on CHS for adults, this project will provide evidence to inform policy development.
Aims and objectives:
The key aim is to explore how services vary by age, gender, ethnicity, health condition (broadly defined) and features of the patient’s area of residence, such as how rural or urban, or how disadvantaged it is. We will examine the use of the CHS by hospital inpatients and outpatients with health conditions for which community services are important. We will produce projections of demand for CHS for adults nationally and locally for the next 10 years.
Methods:
We will conduct analyses of linked data from the NHS Community Services Data Set (CSDS) and Hospital Episodes Statistics (HES) for 2019/20 to 2021/22. These datasets contain individual patient data for most NHS providers of CHS in England and all NHS providers of hospital care in England (plus NHS patients treated by independent sector providers). We will build a simulation model to produce projections of future demand for CHS. We will consult public advisers, commissioners and providers throughout the project.
Policy relevance and dissemination:
The project will provide evidence to inform Spending Reviews, policy development and planning of CHS at national and local level, including identifying ways for the CHS to address health inequalities and improve the interface between hospital and community health services. We will promote our findings through presentations to the Department of Health and Social Care, NHS England and relevant professional and voluntary sector organisations. We will also disseminate findings through accessible research summaries, journal papers and conference presentations.
1.2 - Avoidable drivers of falls and injuries among older people: Housing quality and characteristics
↴Background:
Older people have the highest risk of falling. However, falls by older people are often preventable. Reducing them is important for maintaining people’s health, wellbeing and independence. Falls can also lead to costly yet avoidable use of health and care services.
Aims and objectives:
The main aim of this study is to explore whether older people experiencing poor housing conditions (e.g. with poor lighting, lack of space, cold temperatures) and/or living in unsuitable homes (e.g., with accessibility issues) are more likely to fall than those living in better quality / more suitable homes.
We will also identify the range of key housing-related drivers of falls by older people and how these differ between groups (e.g. by ethnicity, age, etc.), and estimate the current cost of the services used as a consequence of a fall.
Methods:
We will use data from a nationally representative survey of older people which includes individual information on falls, individual characteristics of people who have fallen such as age, gender and ethnicity, housing tenure such as owned or rented, housing conditions (including housing quality and adaptations), care needs and service use (formal and informal care services). We will use statistical analyses to investigate the extent to which there is an association between housing characteristics and quality and falls.
Policy relevance and dissemination:
This research has the potential to help identify strategies for reducing costs for the health and social care systems and to identify interventions which reduce falls among older people, thereby improving older people’s quality of life, and which also offer good value for money. The analysis will also identify which groups of older people have the highest risk of falls.
Findings and policy messages will be shared, as they emerge, with policy makers, academics, older people and older people’s organisations and broader audiences (such as local authorities and practitioners).
1.3 - Future health care demand and the compression or expansion of morbidity
↴Background:
Frailty and chronic health impairment are associated with ageing. As we live longer and populations age, there are concerns that increased ill-health and disability will place additional pressures on health care services.
One view is that progress in preventing or delaying the start of chronic health problems and disabilities as we age may not keep pace with increasing length of life. This could mean that, although we are living longer, we might experience health issues for a greater proportion of our lives. This is referred to as an `expansion of morbidities’.
However, the above description is open to question.
An alternative view suggests that medical progress, improved lifestyles, and better socio-economic conditions don’t just extend length of life but also delay the onset of health issues to older ages. Consequently, the period during which chronic diseases and disabilities are experienced is shorter and concentrated in later years of life. This is known as `compression of morbidities’.
Aims and objectives:
This project aims to investigate healthy population ageing in England.
Methods:
We use survey data from England to explore how life expectancy, ill-health and disability have changed over time. This allows us to determine whether the number of years lived with certain health conditions increases (expansion of morbidities) or decreases (compression of morbidities). Where possible, we will consider how healthy ageing varies across socio-economic groups and geographical regions.
Policy relevance and dissemination:
The above two positions have very different implications for projections of population health, health care use and associated expenditures. They might also affect the ability of people to work. If people are living longer and retiring later in life, but are also experiencing more health problems, it might become harder for them to stay productive in the workplace.
Our research will help predict how much health care will be needed in the future and how it might affect people’s ability to work and stay productive.
Supply side efficiency - Workstream 2
2.1 - What is the impact of changes in funding of long term care on delayed discharge, costs and outcomes for critical care patients?
↴Background:
The delays critically ill patients face when moving from the intensive care unit (ICU) to a regular hospital ward are important. Imagine someone seriously ill, receiving life-saving care in the ICU. Once the crisis has passed and they are stable, they should move to another hospital ward to continue recovery. However, this often doesn’t happen as quickly and smoothly as it should. Around 39% of ICU patients wait between 4 to 24 hours for a standard hospital bed, and 16% wait longer than a day.
Aims and objectives:
The team will: find out how people are affected by ICU delays and how much these cost the NHS, in order to understand how big the problem is; consider how delays affect patients after they leave the ICU in terms of health outcomes and costs; investigate if some patients face longer delays than others and whether this leads to unequal health outcomes; explore how funding for long-term care affects these delays.
Methods:
We shall calculate the cost of delays, taking account of the patient’s illnesses. We will analyse the relationship between costs and outcomes including death in hospital and changes in how well patients return to their daily lives. We will also consider the link between delayed transfers from ICU and long term care funding.
Policy relevance and dissemination:
This research aims to shine a light on the ripple effects that delayed ICU discharges have on patients and hospitals, with the hope of finding solutions to improve the system for everyone involved.
We shall share this work with a wide audience, including the general public, through the LSE Department of Health Policy’s blog series and Health Talks podcast. We shall also present the work to medical and academic audiences, and publish scientific papers.
2.2 - The effect of advancements in medical technology on health care expenditure
↴Background:
Medical technologies keep improving. They can include drugs, implants like pacemakers that help the heart beat steadily, or digital ways to read tests like scans faster. Every year new technologies get adopted into clinical practice in the English NHS. These technologies may change how, where, and when care is provided.
There are long-standing concerns about how much NHS expenditure keeps growing. Does spending increase because of a) new technologies and how they are used; or b) England’s population is older and less healthy than in the past?
Aims and objectives:
We want to understand how much of the growth in NHS expenditure for a given health condition is because of changes in medical technology and how it is used.
Methods:
Our study will use hospital data that have already been collected in the English NHS. We will study health care expenditure for people who experienced a major health shock (for example, a heart attack) in a given year. We will compare these people against others who are similar in age, sex, where they live and their other health problems but who experienced the same health shock 10 years earlier. Because the patients will be very similar, any differences in health spending will tell us about the effect of technology changes.
We will also look to understand if people living in less affluent areas were affected by technological change in the same way as those living in more affluent areas.
Policy relevance and dissemination:
The government wants to know what drives increases in healthcare spending, year-on-year. We will share our results with the Department of Health & Social Care to show the separate financial impacts of an aging population and technology change. This evidence will help to budget and plan for future healthcare spending.
2.3 - Tests and treatments: the link between diagnostic procedures and inpatient care
↴Background:
The NHS uses ever-growing amounts of healthcare services. The fastest growth is in imaging and diagnostic tests like CT scans or colonoscopies. The government wants to know if this big increase in testing leads to more people who need treatment in-hospital. If it does, the government needs to plan so everything is in place to provide the treatment.
Aims and objectives:
Does using more diagnostic procedures mean in-patient treatments for conditions like cancer and heart disease increase or decrease? Do they help people get treated and improve their health outcomes? Do they make existing inequalities better or worse for people who need treatment?
Methods:
Phase One: Months 1-4
We are focusing our research on tests and treatments for cancer, heart or stomach and bowel problems. We will review clinical literature and guidelines. We will ask clinical experts about links between certain diagnostic tests and inpatient care for these health problems to understand better how to focus our research project.
Phase Two: Months 5-16
We will use NHS datasets for each hospital in England. We will identify particular types of hospital treatment (eg bowel cancer surgery, heart surgery) associated with particular diagnostic procedures (eg colonoscopy, chest CT scans. Then we will use statistical models analyse the links between them.
Phase Three: Months 17- 24
We will look in the data to see where tests for one condition (eg cancer) may lead to treatment for a different condition (eg other stomach problems), and for changes in the types of patients being treated and their health outcomes.
Policy relevance and dissemination:
We will share our results to show if and how more diagnostic testing affects the need for inpatient treatments. This will provide a basis for future policies to make diagnostic testing widely available and help plan for hospital capacity where it’s needed.
Organisation, incentives and regulation - Workstream 3
3.1 - Integrated Care Systems Collaboration and Incentives Framework: A Primary Care centric perspective
↴Background:
In recent years, there have been major reforms in how the NHS provides care, with the aim of improving coordination between services. The role of newly formed Integrated Care Systems (ICSs) is to bring different service providers together on a large scale to ensure patients receive the care they need swiftly and effectively. On a smaller scale, Primary Care Networks (PCNs) aim to improve coordination among GP practices and other primary care providers like pharmacies.
Aims and objectives:
We want to understand and summarise how primary care and other healthcare services work together and relate to each other in providing care for patients and how money flows within ICSs. We then want to see where patient experience is impacted by differences in the way care providers relate to each other, for example, through waiting times. We will also examine if care coordination impacts some patients more than others, namely if more deprived patients are impacted differently.
Methods:
We will first summarise how relationships between primary care and other healthcare providers change over time. This will highlight the potential for better coordination to reduce bottle-necks in patient care. We will use this information to guide statistical analysis to examine patients’ pathways through the healthcare system. We will use differences between PCNs to understand the degree and types of coordination within primary care and how these affect care delivery and outcomes in other parts of the system (e.g. waiting time). We will also look at how fair these outcomes are for different groups of patients.
Policy relevance and dissemination:
Our results will provide evidence about the coordination of primary care providers and its benefit for patients. These findings can be used to share good practice and highlight where additional resources could be most beneficial to patients. Our results will be disseminated to healthcare professionals, policymakers, and the public.
3.2 - Drivers of hospital length of stay and its interface with quality of care
↴Background:
Following the COVID-19 pandemic, hospitals are under pressure to treat more patients. There is a renewed policy effort to discharge patients from hospitals as quickly as it is clinically safe to do so, which is reflected in the Where Best Next campaign, the NHS Long Term Plan and the Guide to Reducing Long Hospital Stays.
Reducing patients’ length of stay in hospitals can generate additional capacity that is much needed to treat additional patients at a time of unprecedented pressure for the NHS to ensure adequate access to care.
Aims and objectives:
Patient length of stay is a key driver of efficient use of hospital beds. This project aims to advance our understanding of the determinants of length of stay and the relationship between length of stay and hospital quality.
The aims are to identify healthcare treatments where length of stay is longest; to identify best practice by comparing length of stay across hospitals and Integrated Care Systems; to assess whether length of stay has increased after COVID-19; to explore whether hospitals with shorter length of stay have higher or lower clinical quality and waiting times and to measure inequalities in length of stay between patients differing in socioeconomic status, ethnicity, personal circumstances, availability of social care homes and need.
Methods:
The statistical analysis will use data that measure length of stay of each patient and over time from the Hospital Episodes Statistics.
Policy relevance and dissemination:
The project will deliver policy insights and assess the scope for reducing hospital length of stay and generate additional capacity and whether this can be achieved without affecting quality of care or creating healthcare inequalities.
3.3 - NHS care home commissioning, acute care performance and local care markets
↴Background:
A place in a care home can be purchased by private individuals, local authorities (LAs) or the NHS, often to support people with serious health problems or following a hospital stay.
Little is known about how the NHS purchases care home places or how these purchasing decisions impact on local social care prices and care quality. Limited evidence suggests that the NHS purchasing varies geographically and that there are large differences between the prices paid by the NHS and by LAs. These differences could impact how well care markets work across England.
Aims and objectives:
A place in a care home can be purchased by private individuals, local authorities (LAs) or the NHS, often to support people with serious health problems or following a hospital stay.
Little is known about how the NHS purchases care home places or how these purchasing decisions impact on local social care prices and care quality. Limited evidence suggests that the NHS purchasing varies geographically and that there are large differences between the prices paid by the NHS and by LAs. These differences could impact how well care markets work across England.
Methods:
We will use statistical analyses to understand local variations in the amount, price and quality of care places purchased by the NHS. We will link data about LA characteristics and social care services to NHS Continuing Health Care and NHS-funded Nursing Care data, and data from the National Audit of Intermediate Care.
We will interview NHS and LA care home commissioners in two groups of three areas with relatively high/low levels of NHS purchased beds. We will investigate the reasons for the levels of NHS care beds and how much LAs and the NHS co-ordinate their purchasing decisions. We will report findings separately for residential and nursing care.
Policy relevance and dissemination:
The study findings will be fed back to DHSC colleagues through regular project meetings. The results should shed light on the interdependencies between purchasing decisions in the NHS and local authorities, and therefore inform policy decisions for improving the coordination of the commissioning of care across the NHS and local government.
Previous Programmes - 2019-2023
Click here to view our archive of work published between the years of 2019 and 2023. You can see an overview of ESHCRU II’s achievements in this poster.
Demand for Health Care - Workstream 1
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.
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.
1.3 The effect of Covid-19 on healthcare use: understanding the level and variation in displaced demand
↴The Covid-19 pandemic has changed how health care – including hospitals, prescriptions and GP appointments – is accessed and used. This could cause both unmet need and an increased future demand for health care, which we term `displaced’ demand. It is likely that the impact of the pandemic varies by the type of patient, their age, sex and ethnicity. Impacts might also vary across different parts of England and depend on how much disadvantage there is.
Understanding the volume of displaced demand and how this varies across different groups is important for prioritising and managing NHS and social care spending as the impact of the pandemic subsides. We also need to understand how much of this fall in activity is driven by ‘supply’ – availability of doctors, nurses, beds, operating theatres – and how much is due to changes to ‘demand’, e.g., by patients cancelling appointments, or failing to attend an appointment they needed. This project aims to disentangle these issues by answering the following research questions:
- How has the pandemic impacted health care use in England, and how does this vary across different groups of patients and geographies?
- What are the underlying mechanisms that led to displaced demand?
- Has social care acted as a substitute for health care?
- What are the policy implications of displaced demand in terms of prioritising what care to provide, and tackling uneven and unfair health gaps between people?
We will address these questions using both a literature review and data analysis. We will review other studies of the effects of the pandemic on health care use. We will use hospital administrative data to track levels of inpatient and outpatient care from the start of the pandemic to the end of 2021. We will then use household survey data, such as UKHLS and ELSA, to separate out how much displaced activity was due to patients not pursuing care and/or care being cancelled, and whether social care was substituted for health care.
1.4 The long-run effect of COVID-19 risk on A&E demand across different patient groups
↴During the COVID-19 pandemic the number of visits to hospital A&E departments in the UK fell by up to 57%. A&E visits remained at below-normal levels for over one year until May 2021 when they began to return to normal levels. Research suggests that one of the reasons for the fall in visits was due to people’s fears of catching COVID-19 in hospital. We know that people’s risk of catching COVID-19 disease has varied throughout the pandemic in different areas of the country and has been higher at certain times than others. We also know that different types of people, eg the elderly, or those from ethnic minority groups, were more likely to suffer from severe symptoms of COVID-19. In this project we want to understand how people’s decision to attend A&E was affected by their perceptions of risk from COVID-19 and how this effect may translate into changes in A&E visits in the future.
We will analyse data from hospital A&E departments from 2020 to 2022 comparing different areas of the country and different patient groups (eg by age, gender, ethnicity, co-morbidities and deprivation). Our analysis will show if the COVID-19 pandemic contributed to inequalities in use of A&E. For example, did people from low-income areas miss out on treatment more than those from more affluent areas. We will compare the changes in visits for different types of treatment such as mental or physical health conditions as well as urgent conditions (eg a stroke or heart attack) and non-urgent conditions (eg a mild gastrointestinal infection).
This project will help the Government design policies which will ensure people seek treatment from hospital A&E departments when they need it or access alternative sources of care or support when A&E isn’t appropriate. For example, it could shape the design of patient-facing websites and the 111 telephone service.
1.5 Demand for community health services for adults
↴This project will examine the use of the Community Health Services (CHS) by different groups of patients and by geographical area. The CHS are important for the care of people living in the community with a range of health conditions that require nursing or therapy services in their own homes. They can have a valuable role in promoting independence, preventing hospital admission and expediting hospital discharge. The project will explore how service use varies by age, gender, ethnicity and health condition (broadly defined) and also by features of the patient’s area of residence, such as its rurality (that is, if the area is rural or urban) or how disadvantaged it is. This evidence can help policy makers to tackle health inequalities.
The project will also produce projections of demand for CHS nationally and locally for the next 10 years. It will involve analyses of linked data from the NHS Community Services Data Set (CSDS) and Hospital Episodes Statistics (HES) and the production of a simulation model to produce the projections. The projections will reflect official populations projections on the numbers of people by age and gender and will not take account of future changes in policy or future patient preferences.
We will consult public advisers, organisations supporting patients, and commissioners and providers of CHS, as we conduct the project. The findings will provide evidence to inform national and local planning of CHS. They could inform Spending Reviews, policy development and planning of CHS at national and local level, including informing ways for the CHS to address health inequalities. We will promote the impact of our findings through offering presentations and discussions to the Department of Health and Social Care, NHS England and relevant professional and voluntary sector organisations.
1.6 Interaction between community health services and hospital care
↴This project will focus on examining use of the Community Health Services (CHS) by hospital inpatients and outpatients with health conditions for which their use is important. It will also consider the use of adult social care (ASC) by these patient groups by age and gender, drawing on findings from other studies (e.g. work conducted by the Adult Social Care Policy Research Unit – see https://www.ascru.nihr.ac.uk), so that use of CHS and ASC can be compared.
The CHS are important for the care of people living in the community with a range of health conditions that require nursing or therapy services in their own homes. They can have a valuable role in promoting independence, preventing hospital admission and expediting hospital discharge.
The project will involve analyses of linked data from the NHS Community Services Data Set (CSDS) and Hospital Episodes Statistics (HES). It will include consultation with clinical experts and policymakers about the health conditions for which use of the CHS is likely to be especially important to enable people to live in the community, prevent hospital admission and expedite hospital discharge.
We will also consult public advisers, organisations supporting patients, and commissioners and providers of CHS, as we conduct the project. The findings will provide evidence to inform policy developments relating to the CHS, especially policy developments to improve the interface between hospital and community health services. We will promote the impact of our findings through offering presentations and discussions to the Department of Health and Social Care, NHS England and relevant professional and voluntary sector organisations.
Supply side efficiency - Workstream 2
Measuring what is being delivered for the money spent on H&SC to maximise quality of care and improvements in health and wellbeing.
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.
2.4 Costs and outcomes of Discharge to Assess schemes
↴Providing appropriate support for patients after they are discharged from hospital can be crucial to enabling them to leave hospital as soon as possible and to help them have the best quality of life. This study aims to understand how arrangements for discharging patients back into the community (known as Discharge to Assess or D2A) impact on the use of care services and outcomes of the health and social care system.
The study will:
- Describe how discharge services are organised in different local authorities. To do this we will a) carry out a survey of how the discharge process is arranged within these local authorities, and b) interview care professionals responsible for the discharge process.
- Collect and analyse data about the number of patients discharged from different hospitals, their characteristics and the support provided to these discharged patients.
- Understand the use of care services following discharge from hospitals, and how it affects the demand for community health and social care services.
The overall aim of the project is to identify how different ways to arrange hospital discharges affect the costs and outcomes of the care system. These results will help the development of future policy and practice advice regarding hospital discharge arrangements in England. Evidence-based improvements in policy and practice can contribute to improving the support that patients receive following their hospital discharge, to achieve better outcomes and increase efficiency in the use of the health and social care resources.
2.5 Community services for supporting rehabilitation and reablement outcomes. A scoping study
↴Care services often provide community-based reablement and rehabilitation services to help people with health and social care needs to regain and maintain their independence. These services are particularly important for patients discharged from hospital. Understanding how reablement and rehabilitation support is provided to people needing different types of care is therefore very important.
The project aims to:
- Summarise existing evidence about how reablement and rehabilitation services work in England.
- Understand whether it is possible to use data held by local authorities to analyse community-based reablement and rehabilitation support services.
- Understand whether there is a good supply of these services and how they are provided to people with different care needs.
To achieve these objectives, the project includes the following elements:
- Rapid review of the literature on the organisation and impact of reablement and rehabilitation services in England.
- Work with 7 local authorities to understand whether it is possible to extract linked individual-level health and social care records with information about care needs and use of reablement and rehabilitation support.
- If suitable administrative data can be found, to use statistical analysis to understand how reablement and rehabilitation services are used.
- Interview key health and social care professionals to understand challenges and opportunities for improving reablement services post-hospital discharge in England.
We will concentrate our analysis in the London region, but we are seeking to broaden the geographical coverage of the study.
We will summarise the results of the project through:
- a note explaining the potential to extract individual-level evidence about reablement services and their potential use for analysing how the care system works
- a report of the results of the rapid literature review and the findings from the interviews with professionals involved in the provision of community reablement and rehabilitation support
- a report analysing the patterns of use of reablement and rehabilitation services and their association with care needs and other health and social care services.
2.6 Going beyond health opportunity costs: exploring the potential effects of publicly funded Adult Social Care on net production
↴Social care aims to improve the quality of life of service users, but it can also have wider benefits for the economy and for society. For example, by supporting people of working age, either those receiving care or their unpaid carers, social care can help these to be more productive at work or to start a paid job. Social care may also reduce the amount of hospital services used; for example, hospital patients recovering from surgery can be moved home more quickly if supported by social care. Currently, there is very limited evidence about these wider effects of social care on the broader economy.
This project aims to address this lack of evidence by investigating how publicly funded social care services affect individuals’ net production, which is what individuals produce after taking account of what they consume, either as part of the paid economy (e.g. by being employed or by buying goods and services) or as unpaid service (e.g. by providing or receiving unpaid care). This evidence can support policy makers in their decisions about how to spend funds within the social care sector and across the public sector more broadly. Information on these wider effects provides a more complete picture of the ‘opportunity costs’ of investment decisions: the benefits that would be lost if funds were not invested in the public social care sector. For example, it can help decision makers to judge whether a new social care intervention provides value for money, which is the case if the wider benefits it offers exceed the benefits that would have been produced if the money were left invested in existing services.
Organisation, incentives and regulation - Workstream 3
Designing the organisation of health and care systems to make the best use of resources to deliver joined-up care for the population.
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.
3.3 Impact of waiting times on health outcomes, utilisation and resource use for a selection of common conditions
↴The COVID-19 pandemic has diverted NHS resources away from planned care (such as elective hospital admissions and outpatient consultations), leading to increased waiting times. Longer waiting times delay the health benefits from treatment, can worsen the health of those whilst waiting, reduce the ability to benefit from treatment, and increase emergency admissions and complications. They can also increase the cost of treatment, if patients become more ill while waiting.
Decisions by policymakers over funding, and the efficient and equitable allocation of resources requires knowledge of how waiting times affect health outcomes and costs.
This project will examine the impact of waiting times for hospital treatment on health outcomes, utilisation and costs for a selection of common (urgent and non-urgent) elective conditions and/procedures. We will also investigate the health inequalities of access to planned care, mainly by analysing how the impact of waiting times varies with age, gender, ethnicity, income deprivation and location, and how the impact has changed during the COVID-19 pandemic.
The project will focus on common high-volume conditions and/procedures that affect a significant part of the population, and for which meaningful outcomes can be defined. These will include: hip and knee replacement, cardiovascular diseases (e.g. coronary heart disease of patients requiring coronary bypass or angioplasty) and/or common cancers (e.g. breast, prostate, lung) requiring urgent care, and where delayed treatment can have serious health consequences.
This research will improve knowledge and understanding of the likely impact of waiting list backlogs, by providing evidence on how waiting times affect health outcomes, utilisation and costs. This will help inform funding decisions by policymakers, in the short- and long term; and decisions as to whether reorganisations of services are required to mitigate the effect of long waiting times on patients, particularly those with a high level of need.
Looking at different patient characteristics, such as age, gender, comorbidities, ethnicity, and deprivation will enable policymakers to make decisions in the future which improve outcomes for specific groups of patients and help to reduce health inequalities.
3.4 Waiting time prioritisation and inequalities of elective patients
↴The Covid-19 pandemic has moved NHS resources away from providing common operations, leading to increased waiting times and delaying health improvements from treatment. For a given type of operation, hospitals prioritise patients so that those who benefit most from having the operation, will get treated first. However, we don’t know much about how prioritisation is happening, nor the extent to which this should be further encouraged in the light of the current backlog.
This project will examine waiting time prioritisation for patients having hip and knee replacement operations, looking at how different types of patients experience different waiting times in the years before and during the Covid-19 pandemic. We will look at the waiting times of groups of patients who differ by factors of health need such as pre-operative health status, age, and gender; and socioeconomic factors including deprivation on income and education, and ethnicity. We will also compare how the types of patients being treated changed during the pandemic, and find out how much of the change in prioritisation is due to the change in which patients are coming forward for treatment rather than because of decisions made by hospitals.
The project will also examine the extent of waiting times inequalities for common cancers (e.g. breast, prostate, lung, bowel cancer), taking into account other patients’ characteristics, before and during the Covid pandemic.
This study will show how hospitals are choosing which patients to treat first (prioritising) and how changes in prioritisation have affected equity in access to common operations, and help the government decide which policies may further encourage prioritisation based on need and ability to benefit. Our project’s results will also identify when prioritisation is going wrong and some patients are unfairly missing out on treatment, or having it later. This will help the government to tackle health inequalities by changing or introducing policies which affect how prioritisation happens in the NHS.
3.5 Elective surgery waiting time prioritisation to improve population health gains and reduce health inequalities
↴The NHS in England cannot treat every patient immediately. Patients with urgent health needs will often be seen within hours. Other patients with less urgent needs often wait weeks or months before they are seen by a doctor or receive care. This includes patients waiting for surgery such as hip replacements or eye surgery.
The NHS waiting list for less urgent treatments has grown steadily since the start of the COVID-19 pandemic. There are now several million people waiting for planned surgeries. Planned surgeries are those which can be booked in advance after a patient has seen a doctor who specialises in their health condition. Some patients can expect to wait over a year before they have surgery.
Patients may become unwell when they are waiting for their surgery. This means that some patients may not be able to live a normal life while they are awaiting treatment. Their health condition may also get worse, and treatment may become less effective. But how should the NHS decide which patient groups to treat first?
In this research study we will study how waiting for planned surgery affects patients’ health. We will work out the health effects of waiting for some common forms of surgery. We will study how waiting affects how long patients can expect to live and what quality-of-life they have. We will look at this using information from clinical studies and hospital medical records. We think that the negative effects of waiting are worse for some types of surgery (e.g. heart surgery) than others (e.g. hip replacement). Our research will help NHS managers decide which waiting lists they should tackle first.
R.01 The potential impact of Surgical Hubs and Community Diagnostic Centres
↴During the early months of the pandemic, English hospitals stopped routine surgery and diagnostic testing to free up space for COVID-19 patients. While care services are now getting back to normal, there are still millions of people who are waiting for the operations or diagnostic tests they need.
The NHS has introduced two new types of services to help reduce the backlog of care and reduce the time it takes for patients to be seen:
- High volume low complexity surgical hubs are small NHS hospitals that focus on a small number of planned operations and will only treat patients who are otherwise healthy. This should allow hubs to treat more patients on a daily basis.
- Community diagnostic centres will be located in city centres or other convenient locations and will provide easier and more direct access to the full range of diagnostic tests that patients may need.
Surgical hubs and diagnostic centres are not new ideas. In this study we will review previous research to find out if they are likely to work and what factors will influence how well they work and how fairly they work for different types of patients. We will use ideas from economics to describe how these new types of facilities could work. If we can access the right type of data, we also plan to analyse whether community diagnostic centres – which have been up and running for longer than surgical hubs – are helping to reduce waiting times in practice, and whether these benefits differ between patient groups.
Previous Programmes - pre 2019
Click here to view our archive of work published before the year 2019.
