HEU’s Phil Kinghorn reflects on the challenges of conducting research in adult social care, and introduces some of the research being conducted by the Health Economics Unit.
A thirst for (the right?) knowledge:
We don’t need to look very far to illustrate the pressures facing local authorities (151 of which have responsibility for adult social care in England): Birmingham City Council hit the headlines in September last year for issuing a Section 114 notice (effectively declaring itself bankrupt). In order to fill a £300m budget shortfall at Birmingham City Council, ‘savings’ of £23.7m on adult social care have been proposed.
Those in leadership roles in adult social care often speak of a desire to establish an evidence-base to inform (and justify) their decisions and defend specific models for the provision of services. Economics also seems to be a hot topic for research funders. But at the same time, there is a tendency for those working in local authorities to conflate cost-effectiveness with cost-saving, and funding panels need to have a sensible expectation of what data can realistically be gathered or obtained in a social care context to feed into economic analysis.
We are not alone:
The combination of under-developed infrastructure to support research, the lack of an established research culture, severe budget pressures, and difficulty translating health economics methods easily across to adult social care makes research in this area challenging (if you will excuse the understatement!). These issues were all discussed in a paper presented at the Health Economists’ Study Group (Norwich, Summer 2019). But in HEU we are grappling with and seeking to overcome the challenges, building up an increasing portfolio of research on adult social care. And we are not alone! The Social Care Economics Network (SCENE) is a fantastic new initiative by Professor Helen Weatherly, Dr Magda Walbaum and others; it is bringing together over 50 academic (health?!) economists undertaking social care related research.
Residential care:
Several academic staff in HEU lead and/or contribute to NIHR funded research on adult social care. University of Birmingham is a core member university of the NIHR’s School for Social Care Research (SSCR). An SSCR funded project exploring what happens for those self-funding residential care in England when the “money runs out” (known in the sector as Capital Depletion) concluded at the end of March. But it’s not just School for Social Care Research that is funding this burgeoning research theme, HEU’s Tracy Roberts is a co-Investigator for an NIHR Programme Grant (led overall by University of Birmingham’s Professor Jon Glasby) and leads the economics work package for that project, exploring the costs and consequences of care home closures. Research on residential care is a slight shift of direction for me after several projects exploring strengths and asset-based approaches in adult social care. In supporting Tracy with the “Achieving Closure” project (which HEU’s Ayesha Iqbal is also contributing to), there are fantastic opportunities to transfer learning across to and from my SSCR funded project on Capital Depletion.
What does happen when the money runs out?
It is estimated that 372,035 people were resident in a care home in England in 2022/2023, with 37% of these residents self-funding. HEU’s Rebecca Ince and I have been told in qualitative interviews how those self-funding their care are often turned away from local authorities in England with little support or guidance, told to come back when their savings and assets fall below £23,250. Even when they become eligible for financial support from the local authority there can sometimes be delays arranging the financial and needs assessments, which are two necessary first steps in transitioning to local authority support.
Early guidance could result in self-funders making better informed decisions. Decisions that are made when arranging care have a significant influence both on when capital depletion occurs and how easily it can be managed. At the point of capital depletion, local authorities explore alternative care home placements for the resident (considering value for money). The prospect of being moved can be hugely distressing to residents and their family members. We observed a perception from some stakeholders that outcomes can be too dependent on how willing and able residents, families and care providers are to fight for what is in the (perceived) best interests of the resident. We are exploring our findings in terms of asymmetric information and principal-agent relationships.
Achieving Closure:
A total of 1,578 care homes in the UK closed their doors between 2015 and 2020, affecting 48,600 individuals with care and support needs. Little was known about what actually happens when care homes close; our scoping review indicated that whilst there isn’t consistent evidence to suggest that care home closures will have a long-term detrimental impact on the health of residents, a sizeable proportion of the monetary costs of care home closures is likely to fall on the public sector (mainly the local authority). By mapping out closure pathways and populating them with estimates of costs and outcomes, we are seeking to address the current gap in evidence and inform cost-effective strategies to manage closures in the future.