Data to support contracting decisions
4.4.1 Reported activity data
Appendix A.2 shows the names of the variables that were collected as part of the data request. Data quality was found to be highly variable among different PCTs, given that fields such as ethnicity and gender were largely not provided by PCTs we decided to remove these two columns from our analysis.
An issue highlighted during collection related to recording practices of LTC costs. For example, whilst PCTs pay for care costs on a weekly or monthly basis they are often reported in annual terms as there are a number of fixed costs often incurred during a person’s care e.g. the cost of a specialist orthopaedic mattress, and costs can change depending on whether the individual’s condition worsens. Such characteristics of the PCTs reporting practices culminated in a small number of cases having a very high weekly care cost: likely due to them being reported in annual terms.
Although to the best of our knowledge there is no commonly agreed cap on LTC care costs for NHS CHC, we observed through meetings with LTC commissioners that LTC care costs above £5,000 would typically be investigated as a matter of procedure. For this reason we set an upper bound of £5,000 on a weekly basis or £260,000 annually. Similarly, a number of individuals were recorded at zero weekly cost. We assumed that such figures represented costs associated with short respite care or potentially the fact that the individual was in a block contract and hence their cost was captured within an existing commitment. As such costs could have a damaging effect on our analysis we decided to set a lower bound for the weekly care cost of £112 – this corresponds with the average weekly cost of an NHS funded nurse16 over the period considered.
16 http://www.nhs.uk/chq/Pages/what-is-nhs-funded-nursing-care.aspx
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In total we performed 11 additional data cleaning steps17 including: removing data points with no care group specified, removing data with no provision type specified, removing data where weekly rate was greater than £5000 or less than £112, removing data where the provision type was not specified; and removing data where the funding band was not NHS CHC. Finally we inspected the start dates and end dates of care and removed inconsistent cases, those with provision start date after the provision end date, together with those with missing provision start date as we would not be able to identify for how long a patient’s care package had been in place. The data cut of period for our analysis was the 1st of April 2009, as such individuals that had started care but not been given a provision end date were assumed to still be in receipt of NHS CHC at the end of the period. In total the 11 phases of our cleaning process removed a total of 8,152 (59%) cases resulting in 5,548 (39%) cases for analysis.
Data fields
Of the fields collected and available the following fields were selected for analysis: hostpct (Host PCT), commpct (Commissioning PCT), caregroup (Care Group), provisiontype (Provision Type), weeklyrate (Weekly Rate), prov_start_date (Provision Start Date) and prov_end_date (Provision End Date). To aid our analysis we have also included two computed fields, external (External) and days_in_care (Days in Care), which indicate respectively whether or not the care package is funded by the same PCT in which the care takes place and the total number of days in LTC: according to the difference between prov_start_date and prov_end_date. Whilst external is a binary categorical variable, assuming the values 0 or 1, days_in_care is a positive integer.
Graphical overview
Table 4-1 and Table 4-2 provide a cross tabulation of activity by home care and institutional placements respectively. Abbreviations used for the six care groups are as follows; FMH (Functional Mental Health), LD (Learning Disability), OMH (Organic
17 Full details of our data cleaning steps can be found in Appendix A.3
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Mental Health), PAL (Palliative), PDA (Physically Disabled Adult) and PF (Physically Frail). Among the 5,548 care packages taking place 3,908 (~70%) took place within institutions compared with 1640 (~30%) taking place in the home. In the case of home care packages, a higher percentage were hosted within the PCT’s catchment area (79.3%) compared with those taking place externally (20.7%). In contrast with those care packages taking place at home, intuitional placements were observed to slightly more evenly split between being hosted within the commissioning PCT’s own borough (59.6%) compared with those hosted externally (40.4%).
In terms of the distribution of care groups among the provision type, 71.1% of care packages taking place at home were associated with patients in the PAL category. The second highest most prevalent care group in home care was PF (18.7%) followed by PDA (6.7%) in third. In contrast, while institutional placements were too associated with PF (39.9%) and PAL (25%), the ordering was the other way around and OMH (14.8%) played at greater role. FMH represented the least amount of activity taking place at home (0.1%);
the same was true for LD (6.8%) under institutional placements.
In terms of the number of care days taking place, calculated by taking the difference between an individual’s start and end date of care, Figure 4.1 and Figure 4.2 show the total numbers of days spent in NHS CHC by care group and provision type respectively. From Figure 4.1 we find that the PF care group account for the majority of NHS CHC care days (35%) followed by OMH (18%). From Figure 4.2 we find that institutional placements account for the overwhelming majority of NHS CHC care days (84%) versus 16% taking place in the home.
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Table 4-1 - Cross Tabulation of Home Care Packages by Care Group
Home Care
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Table 4-2 - Cross Tabulation of Placements by Care Group
Placements
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Figure 4.1– Days in Care by Care Group
Figure 4.2– Days in Care by Provision Type
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Figure 4.3 shows a histogram of weekly care costs weighted by the number of days in care.
The average weekly care cost was found to be £1005.99 with a standard deviation of
£701.905.
Figure 4.4 and Figure 4.5 provide the distribution of care costs for care days hosted externally and internally respectively. Whilst the standard deviation of weekly cost was roughly the same for both externally and internally hosted care, £700.223 and £701.322, the average weekly care cost was higher for externally hosted care packages (£977.19 versus £1054.37). One possible interpretation of this observation is that in cases where an individual has highly specialist or rare needs, needs that are typically more expensive to manage, a patient is more likely to be placed outside of the commissioning PCT’s catchment area due to a lack of a capability on the behalf of the PCT. At the same time packages hosted externally may be provided by care providers for whom the PCT does not regularly use hence the PCT exhibits less ability to negotiate pricing discounts.
Figure 4.3– Distribution of weekly cost
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Figure 4.4– Distribution of weekly cost for externally hosted care
Figure 4.5– Distribution of weekly cost for internally hosted care
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Figure 4.6– Weekly cost by care groupFigure 4.6 shows a breakdown of weekly care cost for different care groups. We observe that the median care costs for LD are higher than for other care groups. It is also the care group for which, except for outliers, the highest weekly care cost is recorded. In contrast, the median weekly cost of palliative care is found to be the lowest. In terms of spread of weekly care costs, FMH, LD and PDA share a similarly larger interquartile range (IQR) compared with the IQR for OMH, PAL and PF which is substantially smaller.
Figure 4.6– Weekly cost by care group
The distribution of days in care across all care groups and both provision types is shown in Figure 4.7. The mean stay in NHS CHC is found to be circa 472 days and general form of the distribution is characterised by a positive exponential shape that decays rapidly after 1,000 days in care – corresponding with circa 2.7 years in NHS CHC. The sharpest peak in activity is observed at between 0 and 90 days in care, closely resembling the typically stay of less than 3 months for palliative patients. Some of these packages may also relate to respite care. Figure 4.8 breaks down the number of days in care further by distinguishing between those days attributed to either home care or institutional placements. We observe that patients on average stay longer in institutional settings and that length of stay in care
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for home care provision is more homogeneous. Furthermore, a small number of individuals receiving LTC in institutions have been there for in excess of 5 years.
Figure 4.7– Distribution of days in care
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Figure 4.8– Distribution of days in care by provision type
By considering the start and end dates of care for each care package, whilst summing together packages of care that took place simultaneously, we estimated the total volume of daily LTC activity across London. Figure 4.9 reports our findings by showing an extract of LTC activity across London between the 1st of January 2005 and the 1st of January 2008.
From the line graph we are able to observe a linear increase in reported daily activity over the period, rising from about 600 NHS CHC packages taking place in early January 2005 to just over 2,000 packages in early 2008. A notable feature is the slight levelling off in activity from mid-2007. Although we cannot offer a precise explanation, a partial explanation relates to the introduction of the 2007 NHS CHC Framework which standardised the application process by limiting NHS CHC to those whose need for care was based primarily on an underlying medical condition.
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Figure 4.9– No. of LTC Packages Taking Place Over Time