Evidence on Care
We held an interesting session last week on evidence around home-based care for older people.
It was jointly hosted with Nuffield Trust, and included many of the leading experts from academia, SCIE, Department of Health (DH) as well as investors like Big Society Capital. Our aim was to map existing approaches against our five stage model of evidence, to show what really works in keeping people healthy, saving money or improving wellbeing.
The background was that many claims are made for new interventions that can reduce unplanned admissions. We're regularly approached by social enterprises, charities, private companies and doctors who claim to have the answer, sometimes with apparently impressive spreadsheets showing the huge savings they can deliver.
But much of the research shows their claims are unfounded, and decision makers often struggle to make sense of what they should do.
The group found it quite easy to place interventions on the scale. Not surprisingly there were very few at levels 4 and 5, partly a symptom of lack of funding for rigorous research around social care (the few included early intervention on dementia and Sweden's medicine managers).
Telehealth and telecare had slowly moved up the scale thanks to thousands of studies, though the Whole System Demonstrator, the largest RCT in the world on telecare and telehealth has had ambiguous results, as did nearly 150 models tried out at part of the Partnership for Older People Projects programme (POPPs). There were many promising examples at level 1 and 2 (where some benefits can be illustrated), often involving social support, and quite a lot of evidence around re-ablement and admission avoidance at around level 3 (where causality can be demonstrated).
There were several interesting conclusions, apart from the general one on how thin the evidence base is. One was how many projects hadn't really mastered level 1 - ie they simply hadn't thought rigorously enough about how they were going to achieve change, and some had jumped to formal evaluations prematurely. Another was that even when there is strong evidence, the barriers to adoption are huge - vested interests in hospitals and clinicians in particular. A third was that the holders of money - in GP commissioning or local government - simply don't have access to easily used guidance on what works and what's promising. The sheer range of variables involved in ageing also make research difficult - and some apparently rigorous research methods may overclaim.
The group also concluded that a lot more experimentation and creativity was needed as well as more evidence - some of the most promising approaches are likely to combine existing elements in new ways, and many expect a lot to be achieved by interventions that focus primarily on well-being as an indirect route to health. Despite huge investment in medical solutions, and in technological ones, there has been surprisingly little systematic innovation around service design. We'll be following up this work with, we hope, both better orchestration of what's already known and more intensive innovation.