Cuts to council social care budgets are often cited as a cause of pressure on NHS urgent and emergency care services. Much of the evidence supporting this link, however, is anecdotal. We set out to try and quantify the effect of cuts to social care on older people’s use of emergency healthcare services, and our research has just been published in BMJ Open;
Eligibility for publicly funded social care has been tightened as council budgets have been cut during a decade of austerity. This is reflected in the fall in numbers of older people receiving publicly funded social care – down by 40% between 2008 and 2014.1, 2 At the same time demand for urgent and emergency care among the older population has been increasing – the number of people aged 65 years and over attending Accident and Emergency departments in England climbed by 64% between 2008 and 2015.3 In this environment, it is understandable that some commentators have expressed growing concern that under-supply of social care is at least partly behind the increased pressure seen in urgent and emergency care.
We investigated the extent to which reductions in social care spend on older people, following the 2008 financial crisis, led to increases in emergency hospital admissions.4 We did this by exploiting regional variation in social care spending by local government and differences in the size of subsequent cuts but found no evidence to support the view that reductions in spend have led to increases in emergency hospital admissions for older people. This counter-intuitive finding is out of step with the perceptions of those working in acute hospitals. It also presents a challenge to recent policies that are predicated on the expectation that closer working between health and social care will ease pressure on emergency services.
The nature of health and social care services suggests that the utilisation of social care will have an impact on the demand for health care and vice versa. But the existence of what health economists refer to as a substitution effect (at the margin) is an under-researched area.5 We found only a small number of papers that have addressed this important question.6, 7, 8
From a researcher’s perspective, one side-effect of local government cuts in social spending was to create a form of natural experiment – although reductions in spend were widespread and sustained there was significant variation in the scale of cuts enacted in different parts of the country. Such geographic variation in exposure is helpful when attempting to identify a potential impact on hospital admissions.
However, despite using a panel dataset that included data on spending and admissions for 132 English councils over the period 2005-2016 we found no significant relationship between changes in the rate of government spend on social care for older people within councils and our primary outcome variable, emergency hospital admissions (IRR 1.009, 95% CI 0.965 to 1.056) or our secondary outcome measure, admissions for ambulatory care sensitive conditions (IRR 0.975, 95% CI 0.917 to 1.038).4
In the paper we explore possible explanations for our finding. Recent evaluations of interventions that aimed, but failed, to reduce emergency admissions for older people have highlighted the possibility that increased contact with health service workers may lead (especially in the short term) to the identification of urgent needs for health care that might otherwise have remained unmet or unidentified.9
Secondly, changes in emergency department admission thresholds mean some patients who would previously have been admitted are now being managed in A&E without the need for admission.10 Without these threshold changes, the number of emergency admissions over the period we looked at would have been notably higher. Recent work conducted by the Institute for Fiscal Studies appears to lend credence to this explanation. The IFS research, which looked at the impact of cuts to local authority funding for social care on A&E visits, reported evidence of a modest spillover between spending on public social care and A&E visits – almost an additional A&E visit for every ten people over the age of 65 but no significant effects on inpatient care or delayed discharges.11
Thirdly, social care services in the UK operate in a mixed economy. Our analysis examined government funded social care provision, but substantial levels of care are privately funded by individuals or provided informally by friends, family and neighbours. The most recent evidence suggests that the level of informal care provision has increased at the same time as the level of government funded care has been pared back.12, 13, 14
Importantly, for the future, it seems likely that individuals who have been affected by reductions in social care spend to date are those whose need levels are closest to eligibility thresholds and may therefore have the lowest ability to benefit. Consequently, it does not necessarily follow that further reductions in levels of publicly funded social care will not lead to increases in emergency hospital admissions. We also caution against our finding being interpreted as a wider problem with the effectiveness of social care, for example regarding its capacity to improve the quality of life of users of social care.
Our study was an ecological study – meaning data were analysed at the population level – ideally future research will be built on individual level datasets. As health and social care organisations transition toward a population health management approach the requirement to better understand the relationships and interactions across multiple care and service settings will become ever more important.
- Paul Seamer, the Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit.
- Simon Brake, Warwick Medical School, and NHS Walsall Clinical Commissioning Group.
- Patrick Moore, Institute of Applied Health Research, University of Birmingham.
- Mohammed A Mohammed, the Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, and Faculty of Health Studies, University of Bradford.
- Steven Wyatt, the Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit.
NHS Digital (2008). Community Care Statistics, Referrals, assessments and packages of care for adults – England, 2007-2008, National summary. Available at: https://digital.nhs.uk/catalogue/PUB01519.
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Seamer P, Brake S, Moore P, Mohammed M, Wyatt S (2019). Did Government Spending Cuts to Social Care for Older People Lead to an Increase in Emergency Hospital Admissions? An Ecological Study; England 2005 to 2016. BMJ Open 2019;9:e024577. doi: 10.1136/bmjopen-2018-024577.
Thorlby R (2015). ‘Fact of Fiction? Social care cuts are to blame for the “crisis” in hospital emergency departments’, Nuffield Trust, 29 January. Available at: https://www.nuffieldtrust.org.uk/news-item/fact-or-fiction-social-care-cuts-are-to-blame-for-the-crisis-in-hospital-emergency-departments.
Forder J (2009). Long-term care and hospital utilisation by older people: an analysis of substitution rates. Health Economics, 18(11), pp.1322-1338.
Gaughan J, Gravelle H, and Siciliani L (2015). Testing the Bed-Blocking Hypothesis: Does Nursing and Care Home Supply Reduce Delayed Hospital Discharges? Health Economics, 24, pp.32-44.
Holmas T, Islam M, and Kjerstad E (2012). Interdependency between social care and hospital care: the case of hospital length of stay. The European Journal of Public Health, 23(6), pp.927-933.
Lloyd T, Brine R, Pearson R, Caunt M, and Steventon A (2018). Briefing: The impact of integrated care teams on hospital use in North East Hampshire and Farnham. Available at: https://www.health.org.uk/publications/impact-integrated-care-teams-hospital-use-north-east-hampshire-and-farnham.
Wyatt S, Child K, Hood A, Cooke M, and Mohammed M (2017). Changes in admission thresholds in English emergency departments. Emergency Medicine Journal, 34(12), pp.773-779.
Crawford R, Stoye G, and Zaranka B (2018). The impact of cuts to social care spending on the use of Accident and Emergency departments in England. Available at: https://www.ifs.org.uk/publications/13070.
Department for Work & Pensions (2018). Family Resources Survey: financial year 2016/17. Available at: https://www.gov.uk/government/statistics/family-resources-survey-financial-year-201617.
Office for National Statistics (2016). Changes in the value and division of unpaid care work in the UK: 2000 to 2015. Available at: https://www.ons.gov.uk/economy/nationalaccounts/satelliteaccounts/articles/changesinthevalueanddivisionofunpaidcareworkintheuk/2000to2015#changes-in-the-division-of-unpaid-care-between-2000-and-2015-part-2-adult-care.
Office for National Statistics (2016). ‘Home produced “adultcare” services’ in Household satellite accounts: 2005 to 2014. Available at: https://www.ons.gov.uk/economy/nationalaccounts/satelliteaccounts/compendium/householdsatelliteaccounts/2005to2014/chapter3homeproducedadultcareservices#gross-value-added-of-informal-adult-care.