Research shows that when integrated care systems (ICSs) spend more on community care, there are lower rates of unplanned A&E admissions. And we know this aligns with what people want: to spend more time with friends and family in a familiar setting. So, if we are all in agreement, what is stopping us?
One major barrier is the difficulty in moving funding and resources from one bit of the system to another. In a financially challenged situation, this is near impossible, especially at a time when demand is overwhelming capacity. Put simply, you can’t have both taps on at full blast at the same time – also known as – the dreaded double-running costs.
There is also understandable reluctance to take a risk on a new or different service when you do not know if it will have the desired impact.
So, what’s the answer? Social investment. The NHS Confederation chief, Mathew Taylor, pointed to social investment as a good option in a speech to the Royal Society of Medicine, calling on all ICSs to use it. Macmillan Cancer Support is pioneering the use of social investment in the NHS and, in 2021, launched its Macmillan Fund for End of Life Care, providing £36 million for transformation in adult end-of-life care services.
What is social investment?
So, what is social investment?
It is the use of capital for a social as well as financial return and can provide up-front and at-risk investment to NHS partners. This is used to fund new or enhanced community provision and is only repaid if agreed outcomes are achieved. The outcomes are based on what people want – such as spending more time with friends and family – and linked to the value that this creates for the system, for example, reducing agency spend for escalation wards. It enables funding to be reallocated in a measured way across several years and with less risk to the system.
The outcome payer can be anyone within the ICS where the benefit of reduced acute activity is felt, such as a foundation trust or integrated care board. No matter who it is, a system-based approach is key. There are no losers; everyone wins by providing better end-of-life care and creating much-needed capacity.
The Macmillan Fund is unique as it provides charitable funding for social investment with no expectation of a financial return. This removes a potential deterrent to public health bodies who may be concerned about the use of private capital. It’s also important to note that the funding model protects the core NHS principle of care that is free at the point of service.
Why end-of-life care?
Too many people at the end of life do not get the care they need at the right time in the setting they want. Without investment into high-quality community care, this will never change. But how can ICSs make this investment when 30% of all acute patients are in their last year of life?
In our work with Macmillan, we have seen social investment used in nine areas across the UK to fund a range of community-based end-of-life care models. People are supported at home and when they do need to attend hospital, they are assessed, treated and discharged once it is safe to do so. To date, over 20,000 people and their carers have been supported to spend less time in hospital in their last year of life. This happens in a variety of ways.
For example, in Hillingdon, north west London, a single point of access and rapid response nursing service was created to tackle the problem of people being unable to die in their preferred place. The service assesses patients quickly – within two hours of referral in a community setting where possible. And the results speak for themselves: 2,275 patients were supported in the community and over 90% of them died in their preferred place compared to a national average of 50%. The social investment ended in 2021, but the service has since been sustained.
In Oxford, a partnership between Oxford University Hospitals, Sobell House Hospice and Macmillan Cancer Support established the Rapid Intervention for Palliative and End of Life Care. It provides enhanced care through a home hospice in the last two weeks of life, a rapid response service for crisis support in the community and for early discharge for those dying in hospital. It also offers a palliative care hub for out-of-hours advice and support. In its first year, the service enabled 500 people in the last three months of life to spend a week less in hospital.
A key benefit of social investment is the flexibility it provides to drive innovation in response to the needs of different areas. We know that the top-down cookie-cutter approach creates a poor experience for patients and a frustrating one for service providers who are wrestling with processes that don’t work for their communities.
The focus of social investment is on the end outcome rather than fixed inputs, which frees up the capacity to adapt along the way rather than stick to a plan that might not be working. As well as delivering value for both people and systems, social investment has a halo effect, encouraging teams to make change happen.
Take the End of Life Care Integrator as an example. It has invested in and supported seven different models of care to ensure that people across the UK can die well. Each site achieved better outcomes for people in the last 12 months of life, but each went about it in its own way. They were enabled and encouraged to take a bespoke approach.
The operational and clinical teams are given the freedom to flex and change the service model, with the outcomes being the only thing set in stone. They can change the workforce model, referral criteria, and hours of operation – anything is possible!
One clinical lead told us: ‘Financial investment is very powerful…it has brought energy and excitement that we can do things, change things, achieve things when a lot of the rest of the NHS feels very constrained…and this is seen in other innovative ideas and approaches team members are taking.’
So, why is social investment not happening more? Despite being used across the UK, social investment remains an enigma to many people in ICSs. And change is hard. It is difficult to adopt new ways of working in the midst of financial and workforce challenges.
But the evidence is staring us in the face. Investment in the community reduces unplanned care; it’s what people want and it’s what systems need. Social investment can be part of the solution.
And the solution can look different depending on local needs. We are working with ICS executive teams to design a social investment innovation: Healthy Partnership Community Funds. These will use charity-powered social investment to drive better outcomes and answer the Hewitt Review’s call for sustained investment to reduce health inequalities.
And building on its success to date, the £36m Macmillan Fund is once again open for applications. Any people and systems that are interested in exploring the potential of the funding for service transformation should get in touch and apply by the deadline of 31 October 2023.