The National Evaluation of Partnerships for Older People Projects suggests nearly all are cost effective, while there was particular success with the provision of practical help, finds social care consultant Melanie Henwood
Authors: Karen Windle; Richard Wagland; Julien Forder; Francesco D’Armico; Dirk Kanssen; Gerald Wistow
Institutions: London School of Economics, University of Kent, University of Southampton
The Partnerships for Older People Projects (Popp) initiative was funded by the Department of Health (£60m overall) to develop services for older people to promote their health, well-being and independence, and prevent or delay their need for higher intensity or institutional care. Twenty-nine councils in England were involved as sites for the pilots, which ran from 2006 to 2009.
Popp was focused on improving health and well-being for older people through local projects and services. These were to be person-centred and integrated, featuring strong partnerships between local organisations and involving older people. From the outset, evaluation was built into the programme.
Each site had a local evaluation team, and in addition an overarching national evaluation was established to collate and analyse core data and to assess how well the projects met the objectives of the programme.
Most readers of Community Care will have some awareness of the Popp programme. The interim report of the evaluation has been previously discussed and the publication of the evaluation report in January 2009 was reported (see Links and Resources at the end of this article), highlighting the experience of Popp projects in Bradford and Tameside (Community Care, 4 February).
The 29 sites set up 146 local projects. Two-thirds of these were directed primarily at reducing social isolation and exclusion, or promoting healthy living.
The other third were focused on avoiding hospital admission, or facilitating discharge from acute or institutional care. A further 530 small “upstream” projects were commissioned from the third sector. In total, 522 organisations were involved with the projects across the statutory, private and third sectors.
Some 264,000 people using services were involved with the pilots over the course of three years, with a mean age of 75.
Overall, 81% of respondents agreed that improvements had been delivered in the quality of life and well-being of older people using services, and a similar proportion (78%) agreed that a greater range of services was being offered to older people as a result of Popp. The outcome that fewest respondents (39%) believed to have been delivered was improved responsiveness of services to the needs of ethnic minorities.
The impact of the programme on older people was also explored in a questionnaire before and after the Popp intervention, covering health-related quality of life and overall quality of life. Assessing the impact of projects on people’s quality of life is difficult, however, because older people are likely to experience a natural deterioration in well-being while other variables, including poverty, illness or bereavement, can also have a major impact.
Health-related quality of life explored perceptions on mobility, self-care, ability to undertake usual activities, levels of pain or discomfort, and anxiety or depression.
The greatest improvements (12%) were reported by older people receiving practical help: there was “a far higher change in their [health quality of life] than might be expected from such simple focused services. It could be argued that those services that provide simple aids and adaptations can change the ease of self-care. A grab-rail attached to a lavatory, bath or shower can make washing easier. Similarly, providing gardening services or making simple repairs can reduce user anxiety.”
An equivalent level of improvement was reported following interventions providing exercise, while smaller improvements (3-4%) were found among people using projects offering community support, proactive case co-ordination and specialist falls programmes. Projects that were focused on people with long-term conditions and complex needs showed small positive changes, but the analysis argued strongly that, in fact, the interventions maintained healthy quality of life and showed better outcomes than the comparative sample.
Quality of Life
When asked to rate their quality of life as a whole, people reported a very small deterioration. However, factors including levels of deprivation and age were found to have an impact on such judgements. Thus people living in the most deprived areas were more likely to report some overall deterioration in their quality of life, as were younger people, while people older than 85 were more likely to report that their quality of life had remained the same or improved since the intervention.
As the authors acknowledge, it is “questionable whether the projects, measured over the short term and given their range, would have a perceived impact on the quality of life. The multi-variant nature of quality of life is unlikely to be measured through a single question.”
The evaluation explored other aspects of outcomes, including the impact on joint-working (“reasonably successful”), the involvement of older people in design and implementation of Popp projects (which strengthened over time), and expenditure and savings.
The 29 pilot sites spent nearly £51m between them, and the cost of interventions per user per week varied from £4 for primary prevention to £7 for tertiary prevention. Such costs are low by comparison with other health and care interventions. Similarly, the impact of Popp projects on hospital emergency bed use was significant and the evaluation concluded that every £1 spent on Popp services saved £1.20 on emergency bed days.
The authors are cautious in making evidence-based claims but conclude that “within the context of this research, Popp projects can be recommended as a cost-effective policy option”.
However, considered as a whole, there was a high probability (86%) that the Popp programme was cost-effective compared with usual care. Projects focused on practical help, small housing repairs, gardening, limited assistive technology or shopping indicated a 98% probability of cost-effectiveness for an extra spend of £5,000 a person (£96.15 a week). Here, the authors state with more certainty that “commissioners putting in place such projects could be reasonably confident that only around 0.2 projects in 10 would not be cost-effective”.
The findings from the Popp evaluation are of great interest. At more than 300 pages, it is not the easiest of reads nor the most accessible of reports, but that is perhaps inevitable, given the sheer complexity of the task. The summary of the main report provides an admirably concise overview of the findings, despite the many caveats on extrapolating from the evidence.
The relevance of this work is obvious. Policy in health and social care for older people has, for some years, emphasised the importance of partnership working, integration, prevention of ill-health and promotion of wider well-being.
The Putting People First agenda continues to place great weight on the contribution of early intervention, development of social capital, and engaging local people in the design and operation of local services. Although there has been “an underlying assumption that such a service shift would eventually bring cost savings” there has been, until now, little evidence to back this up.
The findings of the programme provide valuable evidence that early interventions can deliver improved outcomes and greater satisfaction and reduce the need for hospital and other higher dependency services.
The authors believe the approach of Popp should be continued and that the learning should be used to target further investment to secure even greater returns. However, the benefits of cost-effectiveness will only be realised by decommissioning and reinvestment strategies.
At a time of political churn and the prospect of a change of administration, it is vital that the lessons from policy implementation and evaluation are not lost. There is an opportunity to build on the foundation of major policy innovation and evaluation in this and related areas (most notably that of individual budgets). It will be increasingly important that health and care commissioners understand the potential for system-wide change that offers a win-win both to the health and care systems and, above all, to the lives of older people.
Melanie Henwood is a health and social care consultant and adviser on older people’s issues to the Joseph Rowntree Foundation
Links and Resources
● The background to the Popps initiative is set out in two circulars: LAC(2006)7 Partnerships for Older People Projects (Popp) Grant 2006-08 Round 1 Popp Pilots, and LAC (DH) (2007)3, Partnerships for Older People Projects (Popp) Grant 2007-08: Round 2 Popp Pilots.
Prevention and Early Intervention
Prevention and early intervention programmes can make a major difference to the lives of older people. Small services providing practical support (which have often been viewed pejoratively as ‘low level’) can significantly affect health and well-being.
Funding and performance management
Partnerships require appropriate funding and performance management to succeed.
Savings must be reinvested
The Popp projects were pump-primed with special funding, but the cost-effectiveness of interventions requires savings to be released and reinvested. Some decommissioning will be required in parallel to new investment and changed configuration if the benefits are to be maximised.
Engage with stakeholders
New programmes, particularly when they involve multiple partnerships, take time to get established. Projects need adequate preparation time and support. Engaging with stakeholders at an early stage is critical to sustainability. Providers should also realise that the pay off is likely to be longer term and quick wins cannot easily be demonstrated.