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13th December 2012 

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News and Comment from Roy Lilley

Challenging accepted wisdom can be tricky. There is a little questionette that's been niggling me. I don't want to show myself up but it's nearly Xmas, so here goes. 'Is looking after people in the community really cheaper?'


Before your swipe your keyboard onto the screen and whiz-off a 'Lilley you've lost yer last marble' billet-doux, bear with me. I'm not saying it isn't better (although I have another little niggle about that), I just want to know if it really is cheaper.


Let's start with conventional wisdom 'hospitals are expensive'. Really? A night in a Premier Inn is about �90, including breakfast. I can think of lots of reasons why we expect hospital is more expensive, but are you sure? If we nail, to the cost of every bed, a share of the hydrotherapy pool, the staff car park, the MRI scanner and the chairman's cocktail cabinet, it might be. But if we do apples with apples; that is, 'the cost of looking after someone in their own home compared with the actual cost on a medical ward', you can do the numbers in a very different way.  How costs are allocated is pivotal. I know the FDs reading this will have fingers hovering over the delete button, but hold on. Isn't service line accounting supposed to reveal all?


This is important because we are blithely shoving more people and their needs and aliments into largely unprepared, under pressure community services which must be more expensive. If they are not it means Tesco have got it wrong and the high street is cheaper. Better, maybe? Cheaper, no.


For a start there is duplication of all back office costs. HR, accounting, supplies and purchasing, managers, Boards and bog-rolls. Everything a community service needs to run and operate, a hospital already has. There's more. What about the actual services.


Here is my 'come-to-mind' list of what it takes to run a service looking after someone in their own home:


Safety supervision, risk analysis, falls assessment, transport. Socialisation, cognitive stimulation, clinical monitoring, cooking, housekeeping, shopping, laundry services, ambulatory assistance, dressing, positioning in chair or bed, transfers between bed and chair. Rising and twilight services. Wheelchair or walking aid assessment, provision and assistance.  Bathing and showering. Bed baths, grooming, shaving. Oral hygiene, toilet and incontinent care. Chiropody and podiatry. Light exercise programme development. Meal planning, nutrition planning. Cooking, meal delivery, cutlery, washing up and waste. Medication reminders, set up and administration and safety supervision. I.V. and related therapies, Insulin injections and administer. Wound care; dressing changes, catheter care, Ostomy/Colostomy care. Tube feeding assistance. And.... trips back and forth to hospital, to where all of the above already exists.­­­­­


I suspect you'll tell me there's stuff I've missed out. I've thought of about 30 headings. Thirty services with thirty interfaces giving us the possibility of 30 to the power of 30 likelihood of a cock-up. Well, at least the patient's bed comes free? Don't bet on it. Often a different bed or adaptations are needed. Meaning; assessment, inventory, delivery, safety checks, maintenance, cleaning and retrieval.  The home is free?  No, not if you take benefits and allowances into account. 


There's a further complication. Some services are provided by the NHS, some Social Services. Others will be voluntary sector. Oh and some provided by the big hospital on the hill with the machines that go beep. I guess in the middle of all this there will be somebody making sure it works on time, every time. They will no doubt be in a position to tell us if and what and which of these services are supplied under tariff, contract, partnership money, AQP, tendered for or perhaps not even accounted for at all.


To get all that working in the same place at the same time takes coordination, timetables, worksheets, days on, days off and cover, offices, computers, mobile phones, voicemail and text, recruitment, CRB vetting, transport, expense claims, parking and vehicles off the road. Back to my accounting favourite; 'costs-in-flow'; there is a huge amount of money swirling around this.


I know people like to be in their own home. I would. But is it cheaper? It can't be and if it's not we've got some really wrong policy assumptions. Instead of talking hospital closure wouldn't it be better, for some, to remodel them into bespoke eldercare facilities? 


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