Early days for Popp schemes

THE RESEARCH

Title: National Evaluation of Partnerships for Older People Projects: Interim Report of Progress.
Authors: The National Evaluation Team comprises Karen Windle, Richard Wagland, Kathryn Lord, Angela Dickinson, Martin Knapp, Julien Forder, Catherine Henderson, Gerald Wistow, Roger Beech, Brenda Roe and Ann Bowling.
Institutions: University of Hertfordshire, Personal Social Services Research Unit, University of Keele, John Moores University and University College London.

ABSTRACT

This report presents interim findings and key lessons emerging from the Department of Health-funded Popp programme (Partnerships for Older People Projects). Twenty-nine local authority-led projects have been funded to deliver and evaluate innovative schemes for older people. The central objective is to target early interventions in the community in order to promote independence, health and well-being for older people and to prevent or delay the need for residential alternatives.

OBJECTIVES

This interim report highlights emerging findings from the national evaluation of the Popp programme, commissioned by the Department of Health. The evaluation examines the extent to which the aims of the Popp programme are being met, and shares the findings more generally. It is anticipated that in the longer term the national evaluation will contribute to the “evidence base on the effectiveness of ­initiatives aimed at promoting independence and prevention”.

FINDINGS

The Popp programme is the focus of considerable and long-standing interest – the 2004 spending review provided ring-fenced funding of £60m (£20m in 2006-7 and £40m in 2007-8) for councils with social services responsibilities to establish innovative pilot projects in partnership with primary care trusts, the voluntary, community and independent sector. The pilots are intended to bring about “large-scale system reform across health and care services to deliver improved outcomes for older people through greater investment in prevention”. In particular, the pilots were set up in the expectation that they would facilitate the release of funding across the system for reinvestment in preventive approaches in the form of:

● More low-level support to prevent or delay the need for higher intensity and more costly care.

● Reducing avoidable emergency admissions and/or bed days for older people.

● Supporting older people to live at home or in supported housing rather than in long-term residential care.

The Popps schemes were selected from a competitive bidding process, and many of the councils that failed to win a share of the money will be watching with particular interest. The interim report identifies the following key messages:

● Early indications are that Popp pilot sites are having a significant effect on reducing hospital emergency bed-day use compared with non-Popp sites.

● Pilot sites are reporting improved access for excluded groups through proactive case finding, greater publicity and links with the voluntary sector.

● Partnerships between statutory organisations and the community and voluntary sectors have improved compared with the situation prior to Popp.

● Pilot sites are reporting improved engagement of older people within steering groups, commissioning, recruitment, provision and evaluation processes.

● Older people’s health and well-being needs are becoming better integrated within the wider strategic agenda.

The Popps programme is a substantial initiative. The first year of operation (the 19 Round 1 Popp sites) from May 2006 to April 2007 saw more than 36,000 older people “in contact with or referred to” Popp projects. Some 65% of these people received a service through the programme most of these people (almost two thirds) were aged at least 75, and a quarter were aged 85 or over. The published findings do not indicate anything about the 35% of referrals which did not lead to any service, or the reasons why this was the case, and more information at this stage would have been helpful.

The value of Popp in the longer term will depend critically on two factors: sustainability and cost-effectiveness. It was a ­precondition of Popps funding that projects should have a life beyond the project funding. As the 2006 circular stated, all pilots are expected to have an exit strategy “to demonstrate how, and to ensure that, successful outcomes for older people are sustained when the grant funding ceases”. This is often one of the most challenging aspects of any special project development initiatives are fine so long as the funding lasts, but struggle to find alternative support in the longer term. As of July 2007, 161 of the 245 projects (66%) developed at the Popp sites were reported to have secured mainstream funding beyond the period of the grant. This is impressive as far as it goes, but the report does not make clear the basis for this estimation, and sustainability will only be properly judged over a longer time scale.

The interim report identifies the role of local area agreements as a “central mechanism” in continuing project development, although it fails to provide any further information on how this is operating at this stage. Other strategies are also being pursued, and the report identifies sites making use of national policy levers (such as practice-based commissioning, payment by results and Health Act flexibilities) to address sustainability issues. Some pilot sites (although how many is not stated) are reported to be concentrating on empowering communities to take projects forward using a social enterprise model. An overall finding across the sites is the recognition that negotiations with commissioners and partner organisations need to take place “at a very early stage in any project evolution if sustainability is to be achieved”.

Cost-effectiveness of Popp projects will be judged in part by their success in reducing the inappropriate use of hospital bed-days. A further short report published by the evaluation team provides further illumination of the data and focuses on data collected from the 19 first round sites over a period of nine months. The evaluation used a “difference-in-difference” statistical model to remove as far as possible any confounding effects of other variables. Analysis indicates that:

“Overall, the initial findings show Popp appears to have a significant effect on hospital emergency bed-day use. The results show reductions against trend that produce potential cost savings on bed-days in the order of about £1 saved for £1 spent on Popp.”

The analysis is not able to determine exactly what factors in the Popp projects contribute to the bed-day reductions, and the report cautions that it is early days and it is yet unclear whether the effects will persist, strengthen or weaken.

Without a randomised control trial it is not possible to be definitive about the effects of Popp, although statistical techniques do reduce the chances of other factors explaining the observed deviations. As the authors also observe, where the cost savings are less, pound for pound, an assessment of cost-effectiveness “will also depend on the differences in well-being and health outcomes between Popp and hospital”.

Moreover, reduced emergency admissions are unlikely to lead to released resources so much as diversion to meet other demands. This means that savings in bed-days are likely to benefit the providers and “only if excess demand is exhausted would commissioners really see significant benefits, or if commissioners could agree with providers to share the savings”.

ANALYSIS

The interim findings from the national evaluation of Popp are welcome, but there are some significant frustrations with this report. Any major initiative such as this which is subject to reporting processes and central evaluation suffers from the same tension. People are eager to get hold of the messages and conclusions, but these take time to emerge. Despite this caveat it is surprising and frustrating that the totality of the efforts of the pilot sites, and of the large and impressive evaluation team, should so far have produced so little. The interim report is notable as much for what it does not address as for what it does, and the document is thin in its discussion of the findings. Nonetheless, there are some tantalising glimpses of achievements to date.

The findings so far are largely a collection of bullet points that raise many questions. It is not clear, for example, what the “increased recognition” of the need for low level services to “sit within the overall health and social care economy” actually means, or whether this is translating into active development of such services.

The interim report is – in many ways – a hostage to fortune, and raises multiple questions that will demand answers in the full evaluation report in October 2008. While the difficulties of identifying interim findings within a tight timeframe are recognised, some areas of greater detail at this stage would have been beneficial, particularly for the non-Popp localities also endeavouring to develop strategies to support independence for older people. The report needs to be seen alongside other material emerging from the Popps initiative, and practitioners and managers alike will find value in the Popps newsletter produced by the Department of Health (Issue 1, September 2007) which provides greater detail on individual Popps schemes.

Melanie Henwood is an independent health and social care consultant

LINKS AND RESOURCES

● The interim report of progress with the national evaluation of Popps (National Evaluation of Partnerships for Older People Projects: Interim Report of Progress) 

● The background to the Popps initiative and details on the schemes are contained 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.

● A further report on the cost-effectiveness of Popps is available from the same source. National Evaluation of Partnerships for Older People Projects Briefing Paper: Cost-Effectiveness – Measuring Effects: Emergency Bed-Day Use, October 2007.

● Popp News: The newsletter of the Partnerships for Older People Projects, Care Services Improvement Partnership, Department of Health.

➔ A conference for social care staff interested in research takes place on 28 November in London. Details of Adult Social Care Researchers Day: Focus on Methods can be found at pssru@lse.ac.uk or 020 7955 6238.