How do you measure value in a complex clinical care setting? This is the challenge we have been grappling over the past few months working on behalf of the clinical homecare industry.
We hear a lot about value or units of value and how healthcare can be measured in terms of outcomes divided by cost. But often examples are given in terms of simple pathways. In diabetes for example, commissioners might measure unplanned admissions to hospital or limb amputations, for elective knee surgery it is whether the patient returns to usual mobility and is able to play sport or garden pain free. But for complex patients with long-term conditions or multiple morbidities it’s a much more difficult process.
Clinical homecare is notable in its absence from NHS England’s Five Year Forward View as a new care model. This might be because, until now, the sector has failed to define clinical homecare or to collectively demonstrate its value and contribution to the health system. In June 2015 at the NHS Confederation annual conference, Healthcare at Home announced their intention to convene a market inquiry to bring together leading thinkers in this field to do just that.
ZPB was asked to convene and manage a panel and synthesise all their deliberations into a report. We were delighted to work very closely with panel chair Christine Outram, who chairs the Christie NHS Foundation Trust and drew on her experience of leadership roles in local and national commissioning organisations.
Today the panel launches its first report, Building the case for clinical care in the home at scale, at an event at the House of Lords. The UK homecare market is worth $6.2bn or over £4bn in the UK but there is still more that could be done by NHS trusts to deliver treatment such as chemotherapy that is traditionally administered in hospital in a patients’ own home. Research has showed that there are considerable psychological and person–centred benefits in doing this.
The panel’s first report focuses on the more clinical end of the market, which they describe as clinical care in the home and defined it as:
Integrated care, treatment and support that takes place in a person’s home or place of residence. This can directly reduce the need for or prevent an overnight or inpatient stay in hospital or a day case or outpatient visit. This can include patients with more severe conditions and those with long term conditions. Normally, the hospital or NHS provider retains responsibility for patient care.
They then focussed most of their time defining the units of value that the different models of clinical homecare can deliver. Value that is recognised by the NHS, pharma and of course, patients. These fell into four broad categories:
Care in the home can lead to better adherence and a reduction in non-clinical medication drop-off. It can mean that patients suffer fewer relapses, fewer re-admissions and recover faster.
Care in the home can lead to reablement and improved quality of life. It is more likely to fit around the patient, allowing them to recover more quickly or have a better chance of living well with their condition. It gives them the best chance to return to a routine, including returning to work for those who wish to, that is best for them and their wellbeing. In turn this reablement can reduce pressure on hospitals and free capacity.
Care in the home can activate patients, by which we mean take responsibility for self-management. It gives them the best environment in which to self-manage their conditions. This includes self-administration of medicines and control of treatment choices, times and places. Patient activation will be a key enabler for health and care systems to meet demand.
Care in the home can yield financial savings. Our analysis is provisional and needs more investigation but initial findings indicate that the services outlined in this report comfortably meet the three per cent efficiency savings prescribed in the Five Year Forward View.
The panel’s first call to action is for all local leaders to explore how to make clinical care in the home work in their area and deliver expert and efficient care that improves quality of life.
Christine will be re-convening the panel early next year to explore how to measure these units of value. This is when we will really be able to define clinical care in the home’s worth.