• Amy Swan, Project Manager (Health Partnerships), National Housing Federation

• David Mcdaid, Research Fellow at LSE and Editor of Eurohealth,

Exploring housing’s place in the local health economy

Understanding the NHS and the housing association offer

‘The NHS needs no more unresourced sticking plasters. Neither will it benefit in the long run from

“handouts”, however generous.’Alastair McLellan, editor of HSJ

‘We are about to run out of cash in a very serious fashion.’

Tim Kelsey, NHS England's Director for Patients and Information

http://www.housing.org.uk/publications/browse/routes-into-health

Demand outstripping supply

NHS begging bowls

• £30 billion gap in funds• Better Care Fund• Diversion of funding

from acute sector• Demands for more staff

and the workforce crisis

Priorities for health commissioners

• Persistent health inequalities

• Ageing population• Unmet mental

health needs• Premature deaths• Complex conditions

• Prevention• Health promotion• Self-care• Shifting resources

out of hospitals• Designing

integrated services• Early intervention

Show me the money!

NHS providers

Lottery funding

DH innovation fundingSmall CCG grants

CCG healthcare contract

Public health tenders

A clear vision

Joint venture or partnership with an

NHS provider

Host NHS services or co-locate with health

Monitoring, health checks, and signposting

So how can economics help strengthen case to invest in housing for health?

Economic arguments have long been embedded into NHS decision making

Immediate funding pressures

Economic arguments embedded

Since 1999 the National Institute for Health and Care Excellence has assessed case for investing in health care interventions

2005 – extended to health promotion and public health

2013 – extended to social care

Interventions need to be shown not only to be effective but also cost effective

Cost effectiveness

also a concern for

local government

commissioners

Economics can be one

important input into decision

making process

Resources are not unlimited;

economic information can

help determine how best to

make use of resources but……

Cannot be used in isolation;

many other factors (fairness,

equity, political concerns etc)

influence decision making

Econ

om

ics

What types of economic issues do housing associations need to be aware of?

Cost of hip fractures from falls in Ireland

27%

1%

35%

6%

21%

10%Hospital costs

Primary Care

Long- term care

Informal Care

Poor Quality ofLifeDrug Costs

6,813 fracture hospital admissions85% from falls€260 million€38,000 per case

O’Shea and Gannon, Irish Medical Journal, 2008

Valuing the socio-economic contribution of older people in the UK (2011)

• In 2010 positive net contribution to UK economy £40 billion rising to £77 billion by 2030.

• Costs: takes account of pension, welfare, health costs.

• Benefits: Tax revenues, Consumer Spending, Provision of Care, Volunteering

http://www.goldagepensioners.com/Uploads/PDF/main-report.pdf

The costs of action

• The costs of action: What would it cost to intervene by providing a preventive measure or treatment delivered by a housing association?

• Estimating the resource requirements, staffing, equipment, premises etc required to deliver a service by a housing association

• Could compare this with cost of same service delivered by other providers

• Can services be delivered more efficiently?

The cost effectiveness of action

• The cost-effectiveness of action: What is the balance between cost of intervention and better outcomes, e.g. health status, improved quality of life, educational performance etc?

• Important to identify benefits of housing interventions

• Interventions can cost more money but they must then achieve better outcomes

• Is it worth the extra cost to achieve this benefit?

Economics is about choice

CCGBudget

More Mental Health Services

More Hip Replacements

Economic evaluation

The effectiveness question:

Does this intervention work?

The economic question:Is it worth it?

Two Basic Needs: (A) Costs and Outcomes; (B) 2+

Alternatives

Outcomes e.g Quality of Life Years (QALYs); Independent living; delayed entry to nursing homes

Costs of usual intervention

Costs of Housing Association intervention

Outcomes (e.g Quality of Life Years (QALYs); Independent living; delayed entry to nursing homesTraditionally NICE

considered cost per QALY circa £30,000 considered good value; But budgetary impact important

Cost-Effectiveness Possibilities

CNew >

COld

New housing intervention is less effective and more costly

New housing intervention is less effective but less costly

New intervention is more effective but also more costly

New intervention is more effective and less costly

ENew > EOld

CNew <

COld

ENew < EOld

The ‘no go’zone?

Cost-saving 0

No right or wrong answer: Each society must decide how much it is willing to pay for additional benefits

?????Uncertainty

So … is it worth it?

What do we know about the economic case for investing in housing to promote and protect health?

Limited but growing evidence base on effectiveness

Health commissioners most influenced by large scale, well designed studies (usually randomised controlled trials)

Limited but growing examples of interventions that could be delivered by housing sector

Economic outcomes attached to some of these studies

Limited but growing evidence base on effectiveness

Some examples:

Extra care housing

Reablement services

Floating support services

Independent housing for people with mental health needs

Financial advice services

Home adaptation, insulation schemes

er

High chance of being very cost effective

Baumker et al 2011

Reablement: Long term returns

How can housing associations make use of this evidence?

Making use of economic evidence

• When making a case refer to published studies on the costs of poor health

• Report resources required to deliver housing intervention and how this compares with current service costs if possible

• Helpful to refer to any published studies on value for money of intervention – doesn’t have to be delivered by housing association

• The more rigorous the study – the more credibility it will have with commissioners

• Focus on quality of outcomes as well as costs

Where to look for economic evidence

• Three useful starting points

• NHS Economic Evaluation Database

• US National Library of Medicine (Medline) database

• NICE website – guidelines on interventions

• Work with economists to model cost effectiveness – opportunities for the housing sector to partner universities in housing and health research

NHS EED http://www.crd.york.ac.uk/CRDWeb/

How to present the economic case: some tips

Presentation Tips

• Refer to robust evidence on effectiveness

• Apply local unit cost data when estimating costs of service delivery

• Be transparent on strengths and weakness of evidence

• Be conservative and cautious on strength of evidence

• Present information on the economic case for reaching specific population groups

Presentation Tips

• Focus on impact on quality rather than on arguments that interventions will reduce costs to the NHS

• Present some information on the costs of the status quo

• Tailor the economic argument to different stakeholders

• Look at budgetary impacts as well as cost effectiveness

• Commit to ongoing monitoring of a service

Questions?

• @natfedamy • @dmcdaid

• website@housing.org.uk