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Background Since 2010, adult social care spending has fallen significantly in real terms whilst demand has risen. Reductions in local authority (LA) budgets are expected to have had spill over effects on the demand for healthcare in the English NHS. Motivation If older people, including those with dementia, have unmet needs for social care, their use of healthcare may increase. Methods We assembled a panel dataset of 150 LAs, aggregating individual-level data where appropriate. We tested the impact of changes in LA social care resources, which was measured in two ways: expenditure and workforce. The effects on people aged 65+ were assessed on five outcomes. 1. Rates of emergency hospital admissions for falls in people with dementia aged 65 and over. 2. Rates of emergency hospital admissions for fractured neck of femur in people 65 and over. 3. Extended length of stay in people with dementia, 7 days and over 4. Extended length of stay in people with dementia, 21 days and over 5. Rates of NHS Continuing Healthcare (NHS CHC) Outcomes (utilisation) data were derived from the Hospital Episode Statistics (1, 2, 3 and 4), the Public Health Outcomes Framework (2), and publicly available datasets from NHS Digital (5). Datasets varied in the timeframes available for analysis. Planned analysis of the effects of social care cuts on delayed transfers of care in mental health trusts, and on deprivation of liberty safeguards were not undertaken because of data quality concerns. We tested the effect of two separate explanatory variables: adult social care gross current expenditure (per capita 65 and over) adjusted by area cost; and adult social care workforce staff (per capita 18 and over). Workforce measures distinguished LA and independent sector employees and included professional and non-professional staff providing direct social care. We ran negative binomial models and linear models, and controlled for a range of confounding factors, including deprivation, ethnicity, age, unpaid care, LA class and year effects. To account for potential endogeneity (‘reverse causality’), we also tested the Area Cost Adjustment (ACA) as an instrumental variable and ran dynamic panel models. Sensitivity analysis explored the effects of the additional effects of the Better Care Fund. Results The level of social care expenditure on older people was not significantly related to emergency admission rates for falls in people with dementia or for fractured neck of femur. Extended stays of 7 days or longer were significantly and positively related to the level of social care spend, but this association was no longer significant when additional spend from the Better Care Fund was taken into account. There was no significant relationship between the level of social care spend and hospital stays of 21 days or longer or between spend and uptake of NHS CHC. We also tested the effect of four social care workforce measures. LAs employing higher rates of social care staff (especially professional staff) had significantly higher levels of NHS CHC, but there was no significant relationship between LA staffing levels and the remaining four outcomes. LAs with higher levels of independent social care staffing had significantly lower rates of extended stays, but there was no association with either emergency admissions or on NHS CHC. The effect of ‘full time’ ii CHE Research Paper 174 unpaid care on outcomes was mixed, with tentative evidence of a protective effect on admissions for falls, and on extended stays of 21 days or longer. When the Area Cost Adjustment was used as an instrument in place of expenditure, results were largely consistent with the main analysis: there were negative effects on NHS CHC but no effect on any other outcome. The dynamic panel models found a positive relationship between spend and emergency admissions for falls, but the effect on other outcomes was statistically insignificant. Conclusions The study found no consistent evidence that reductions in social care budgets led to the expected rises in hospital admissions, hospital stays or uptake of NHS CHC. However, findings suggest that public sector staff providing direct social care, particularly professional staff, may be instrumental in facilitating access to NHS CHC. In addition, the study found tentative evidence that extended hospital stays are partially offset by social care provision by the independent sector and by unpaid carers providing intensive care. To test the validity and robustness of these findings, future research using linked individual-level health and social care data is needed.

Background Serious mental illness (SMI), including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with SMI are treated in primary care by general practitioners (GPs), who are financially incentivised to meet quality targets for patients with chronic conditions, including SMI, under the Quality and Outcomes Framework (QOF). The QOF, however, omits important aspects of quality. Objective(s) We examined whether better quality of primary care for people with SMI improved a range of outcomes. Design and setting We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, Accident & Emergency (A&E) attendances, Office for National Statistics mortality data, and community mental health records in the Mental Health Minimum Dataset. We used survival analysis to estimate whether selected quality indicators affect the time until patients experience an outcome. Participants Four cohorts of people with SMI depending on the outcomes examined and inclusion criteria. Interventions Quality of care was measured with: i) QOF indicators: care plans and annual physical reviews ;and ii) non-QOF indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by GPs). Main outcome measures Several outcomes were examined: emergency admissions for i) SMI and ii) ambulatory care sensitive conditions (ACSCs); iii) all unplanned admissions; iv) A&E attendances; v) mortality; vi) re-entry into specialist mental health services; vii) costs attributed to primary, secondary and community mental healthcare. Results Care plans were associated with lower risk of A&E attendance (Hazard ratio (HR) 0.74, 95%CI 0.69-0.80), SMI admission (HR 0.67, 95%CI 0.59-0.75), ACSC admission (HR 0.73, 95%CI 0.64-0.83), and lower overall healthcare (£53), primary care (£9), hospital (£26), and mental healthcare costs (£12). Annual reviews were associated with reduced risk of A&E attendance (HR 0.80, 95%CI 0.76-0.85), SMI admission (HR 0.75, 95%CI 0.67-0.84), ACSC admission (HR 0.76, 95%CI 0.67-0.87), and lower overall healthcare (£34), primary care (£9), and mental healthcare costs (£30). Higher GP continuity was associated with lower risk of A&E presentation (HR 0.89, 95%CI 0.83-0.97), ACSC admission (HR 0.77, 95%CI 0.65-0.92), but not SMI admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or A&E presentation. None of the quality measures were statistically significantly associated with risk of re-entry into specialist mental healthcare. Limitations There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences. Conclusions Better performance on QOF measures and continuity of care are associated with better outcomes and lower resource utilisation and could generate moderate cost savings. Future work Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Supplemental material, Appendix_3_online_supp for Modeling the Economic Impact of Interventions for Older Populations with Multimorbidity: A Method of Linking Multiple Single-Disease Models by Ji-Hee Youn, Matt D. Stevenson, Praveen Thokala, Katherine Payne and Maria Goddard in Medical Decision Making

OBJECTIVE: To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI). DESIGN, SETTING, PARTICIPANTS: Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database. OUTCOMES AND ANALYSIS: Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC). RESULTS: Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews. CONCLUSIONS: Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.