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Housing associations already deliver a range of services to promote health, wellbeing and independence for many different populations including older people and those with enduring mental health problems. Recent reforms to the health system, including measures to increase co-operation and joint commissioning of services with the social care sector, will both create opportunities for housing associations and have implications for the ways in which housing associations enter into the healthcare market.
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• Amy Swan, Project Manager (Health Partnerships), National Housing Federation
• David Mcdaid, Research Fellow at LSE and Editor of Eurohealth,
Exploring housing’s place in the local health economy
Understanding the NHS and the housing association offer
‘The NHS needs no more unresourced sticking plasters. Neither will it benefit in the long run from
“handouts”, however generous.’Alastair McLellan, editor of HSJ
‘We are about to run out of cash in a very serious fashion.’
Tim Kelsey, NHS England's Director for Patients and Information
Demand outstripping supply
NHS begging bowls
• £30 billion gap in funds• Better Care Fund• Diversion of funding
from acute sector• Demands for more staff
and the workforce crisis
Priorities for health commissioners
• Persistent health inequalities
• Ageing population• Unmet mental
health needs• Premature deaths• Complex conditions
• Prevention• Health promotion• Self-care• Shifting resources
out of hospitals• Designing
integrated services• Early intervention
Show me the money!
NHS providers
Lottery funding
DH innovation fundingSmall CCG grants
CCG healthcare contract
Public health tenders
A clear vision
Joint venture or partnership with an
NHS provider
Host NHS services or co-locate with health
Monitoring, health checks, and signposting
So how can economics help strengthen case to invest in housing for health?
Economic arguments have long been embedded into NHS decision making
Immediate funding pressures
Economic arguments embedded
Since 1999 the National Institute for Health and Care Excellence has assessed case for investing in health care interventions
2005 – extended to health promotion and public health
2013 – extended to social care
Interventions need to be shown not only to be effective but also cost effective
Cost effectiveness
also a concern for
local government
commissioners
Economics can be one
important input into decision
making process
Resources are not unlimited;
economic information can
help determine how best to
make use of resources but……
Cannot be used in isolation;
many other factors (fairness,
equity, political concerns etc)
influence decision making
Econ
om
ics
What types of economic issues do housing associations need to be aware of?
Cost of hip fractures from falls in Ireland
27%
1%
35%
6%
21%
10%Hospital costs
Primary Care
Long- term care
Informal Care
Poor Quality ofLifeDrug Costs
6,813 fracture hospital admissions85% from falls€260 million€38,000 per case
O’Shea and Gannon, Irish Medical Journal, 2008
Valuing the socio-economic contribution of older people in the UK (2011)
• In 2010 positive net contribution to UK economy £40 billion rising to £77 billion by 2030.
• Costs: takes account of pension, welfare, health costs.
• Benefits: Tax revenues, Consumer Spending, Provision of Care, Volunteering
http://www.goldagepensioners.com/Uploads/PDF/main-report.pdf
The costs of action
• The costs of action: What would it cost to intervene by providing a preventive measure or treatment delivered by a housing association?
• Estimating the resource requirements, staffing, equipment, premises etc required to deliver a service by a housing association
• Could compare this with cost of same service delivered by other providers
• Can services be delivered more efficiently?
The cost effectiveness of action
• The cost-effectiveness of action: What is the balance between cost of intervention and better outcomes, e.g. health status, improved quality of life, educational performance etc?
• Important to identify benefits of housing interventions
• Interventions can cost more money but they must then achieve better outcomes
• Is it worth the extra cost to achieve this benefit?
Economics is about choice
CCGBudget
More Mental Health Services
More Hip Replacements
Economic evaluation
The effectiveness question:
Does this intervention work?
The economic question:Is it worth it?
Two Basic Needs: (A) Costs and Outcomes; (B) 2+
Alternatives
Outcomes e.g Quality of Life Years (QALYs); Independent living; delayed entry to nursing homes
Costs of usual intervention
Costs of Housing Association intervention
Outcomes (e.g Quality of Life Years (QALYs); Independent living; delayed entry to nursing homesTraditionally NICE
considered cost per QALY circa £30,000 considered good value; But budgetary impact important
Cost-Effectiveness Possibilities
CNew >
COld
New housing intervention is less effective and more costly
New housing intervention is less effective but less costly
New intervention is more effective but also more costly
New intervention is more effective and less costly
ENew > EOld
CNew <
COld
ENew < EOld
The ‘no go’zone?
Cost-saving 0
No right or wrong answer: Each society must decide how much it is willing to pay for additional benefits
?????Uncertainty
So … is it worth it?
What do we know about the economic case for investing in housing to promote and protect health?
Limited but growing evidence base on effectiveness
Health commissioners most influenced by large scale, well designed studies (usually randomised controlled trials)
Limited but growing examples of interventions that could be delivered by housing sector
Economic outcomes attached to some of these studies
Limited but growing evidence base on effectiveness
Some examples:
Extra care housing
Reablement services
Floating support services
Independent housing for people with mental health needs
Financial advice services
Home adaptation, insulation schemes
er
High chance of being very cost effective
Baumker et al 2011
Reablement: Long term returns
How can housing associations make use of this evidence?
Making use of economic evidence
• When making a case refer to published studies on the costs of poor health
• Report resources required to deliver housing intervention and how this compares with current service costs if possible
• Helpful to refer to any published studies on value for money of intervention – doesn’t have to be delivered by housing association
• The more rigorous the study – the more credibility it will have with commissioners
• Focus on quality of outcomes as well as costs
Where to look for economic evidence
• Three useful starting points
• NHS Economic Evaluation Database
• US National Library of Medicine (Medline) database
• NICE website – guidelines on interventions
• Work with economists to model cost effectiveness – opportunities for the housing sector to partner universities in housing and health research
NHS EED http://www.crd.york.ac.uk/CRDWeb/
How to present the economic case: some tips
Presentation Tips
• Refer to robust evidence on effectiveness
• Apply local unit cost data when estimating costs of service delivery
• Be transparent on strengths and weakness of evidence
• Be conservative and cautious on strength of evidence
• Present information on the economic case for reaching specific population groups
Presentation Tips
• Focus on impact on quality rather than on arguments that interventions will reduce costs to the NHS
• Present some information on the costs of the status quo
• Tailor the economic argument to different stakeholders
• Look at budgetary impacts as well as cost effectiveness
• Commit to ongoing monitoring of a service