Background

ObjectivesTo examine links between clinical and other characteristics of people with Alzheimer's disease living in the community, likelihood of care home or hospital admission, and associated costs.DesignObservational data extracted from clinical records using natural language processing and Hospital Episode Statistics. Statistical analyses examined effects of cognition, physical health, mental health, sociodemographic factors and living circumstances on risk of admission to care home or hospital over 6 months and associated costs, adjusting for repeated observations.SettingCatchment area for South London and Maudsley National Health Service Foundation Trust, provider for 1.2 million people in Southeast London.ParticipantsEvery individual with diagnosis of Alzheimer's disease seen and treated by mental health services in the catchment area, with at least one rating of cognition, not resident in care home at time of assessment (n=3075).InterventionsUsual treatment.Main outcome measuresRisk of admission to, and days spent in three settings during 6-month period following routine clinical assessment: care home, mental health inpatient care and general hospital inpatient care.ResultsPredictors of probability of care home or hospital admission and/or associated costs over 6 months include cognition, functional problems, agitation, depression, physical illness, previous hospitalisations, age, gender, ethnicity, living alone and having a partner. Patterns of association differed considerably by destination.ConclusionsMost people with dementia prefer to remain in their own homes, and funding bodies see this as cheaper than institutionalisation. Better treatment in the community that reduces health and social care needs of Alzheimer's patients would reduce admission rates. Living alone, poor living circumstances and functional problems all raise admission rates, and so major cuts in social care budgets increase the risk of high-cost admissions which older people do not want. Routinely collected data can be used to reveal local patterns of admission and costs.

:The National Institute for Health and Clinical Excellence (NICE) provides guidance to the National Health Service (NHS) in England and Wales on funding and use of new technologies. This study examined the impact of evidence, process and context factors on NICE decisions in [2004][2005][2006][2007][2008][2009]. A data set of NICE decisions pertaining to pharmaceutical technologies was created, including 32 variables extracted from published information. A three-category outcome variable was used, defined as the decision to 'recommend', 'restrict' or 'not recommend' a technology. With multinomial logistic regression, the relative contribution of explanatory variables on NICE decisions was assessed. A total of 65 technology appraisals (118 technologies) were analysed. Of the technologies, 27% were recommended, 58% were restricted and 14% were not recommended by NICE for NHS funding. The multinomial model showed significant associations (p < 0.10) between NICE outcome and four variables: (i) demonstration of statistical superiority of the primary endpoint in clinical trials by the appraised technology; (ii) the incremental cost-effectiveness ratio (ICER); (iii) the number of pharmaceuticals appraised within the same appraisal; and (iv) the appraisal year. Results confirm the value of a comprehensive and multivariate approach to understanding NICE decision making. New factors affecting NICE decision making were identified, including the effect of clinical superiority, and the effect of process and socio-economic factors.

This article aims to explore the concept of choice in public service policy in England, illustrated through findings of the Individual Budgets (IB) evaluation. The evaluation tested the impact of IBs as a mechanism to increase choice of access to and commissioning of social care services around the individual through a randomised trial and explored the experiences and perspectives of key groups through a large set of interviews. The article presents a reexamination of these interview data, using three 'antagonisms of choice' proposed in the literature -choice and power relations, choice and equity, and choice and the public nature of decisions -as organising themes. The randomised trial found that IB holders perceived they had more control over their lives and appreciated the extra choice over use of services, albeit with variations by user group. However, problems of power relations, equity and the constraints implied by the public nature of decision-making were complicating and limiting factors in producing the benefits envisaged. The focus on choice in policy, especially as implemented by IBs, emphasises an individualistic approach. The findings suggest that addressing broader issues relating to power, equity and an understanding of the public nature of choice will be of value in realising more of the benefits of the policy.

Cash-for-care schemes offering cash payments in place of conventional social services are becoming commonplace in developed welfare states; however, there is little evidence about the impact of such schemes on older people. This paper reports on the impact and outcomes for older people of the recent English Individual Budget (IB) pilot projects (-). It presents quantitative data on outcome measures from structured interviews with  older people who took part in a randomised controlled trial and findings from semi-structured interviews with  older people in receipt of IBs and with IB project leads in each of the  pilot sites. Older people spent their IBs predominantly on personal care, with little resources left for social or leisure activities; and had higher levels of psychological ill-health, lower levels of wellbeing, and worse self-perceived health than older people in receipt of conventional services. The qualitative interviews provide insights into these results. Potential advantages of IBs included increased choice and control, continuity of care worker, and the ability to reward some family carers. However, older people reported anxieties about the responsibility of organising their own support and managing their budget. For older people to benefit fully from cash-for-care schemes they need sufficient resources to purchase more than basic personal care; and access to help and advice in planning and managing their budget.KEY WORDSolder people, personal budgets, individual budgets, cash-for-care, choice and control.Cash-for-care schemes offering cash payments in place of conventional social services to older and disabled people are increasingly commonplace throughout developed welfare states. However, there is little evidence about the impact of such schemes on older people, and less still that gives voice to older people and to their individual experiences of cash-for-care schemes. This paper reports on an evaluation of a recent English cash-forcare scheme, the Individual Budget (IB) pilot projects (the IBSEN study). It highlights the impact and outcomes of IBs for older people through survey data; semi-structured interviews with a sub-sample of older IB users and their proxies; and semi-structured interviews with the IB project lead in each of the  IB pilot sites.Cash-for-care schemes that offer older and disabled people cash payments or access to a specified cash resource, instead of allocations of services in kind, are increasingly common in parts of Europe, Australia, Canada and the United States of America (Da Roit and Le Bihan ; Doty, Mahoney and Simon-Rusinowitz ; European Commission ; Glendinning and Kemp ; Leece and Leece ; Lord and Hutchison ; Timonen, Convery and Cahill ; Ungerson and Yeandle ). In some countries, such schemes are available to older people as part of arrangements for funding long-term care; elsewhere cash payments are only available to younger disabled people as part of moves to support independent living; in other countries cash-for...

Keywords pilot projects; pulmonary disease, chronic obstructive; randomised controlled trial; selfcare; self-management; patient education as topic; primary health care.

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In recent years, there has been significant concern, and policy activity, in relation to the problem of delayed discharges from hospital. Key elements of policy to tackle delays include new investment, the establishment of the Health and Social Care Change Agent Team, and the implementation of the Community Care (Delayed Discharge) Act 2003. Whilst the problem of delays has been widespread, some authorities have managed to tackle delays successfully. The aim of the qualitative study reported here was to investigate discharge practice and the organisation of services at sites with consistently low rates of delay, in order to identify factors supporting such good performance. Six 'high performing' English sites (each including a hospital trust, a local authority, and a primary care trust) were identified using a statistical model, and 42 interviews were undertaken with health and social services staff involved in discharge arrangements. Additionally, the authors set out to investigate the experiences of patients in the sites to examine whether there was a cost to patient care and outcomes of discharge arrangements in these sites, but unfortunately, it was not possible to secure sufficient patient participation. Whilst acknowledging the lack of patient experience and outcome data, a range of service elements was identified at the sites that contribute to the avoidance of delays, either through supporting efficiency within individual agencies or enabling more efficient joint working. Sites still struggling with delays should benefit from knowledge of this range. The government's reimbursement scheme appears to have been largely helpful in the study sites, prompting efficiency-driven changes to the organisation of services and discharge systems, but further focused research is required to provide clear evidence of its impact nationally, and in particular, how it impacts on staff, and patients and their families.