There are few clearer measures of societal health than homelessness. On this count, and despite its enormous material wealth, England is in poor shape. Relative to the recent past, and any country we might want to compare ourselves to, we have a problem with homelessness. The causes of homelessness are undoubtedly complex. But the above comparisons show that the problem can be addressed: policy choices make a difference. This was shown in dramatic fashion last March with the Ministry of Housing, Communities & Local Government decision to house people rough sleeping (‘Everyone In’) in response to the first national lockdown. So Lockdown 1 was a period of great policy innovation. It was also a time of radical service innovation as health and social care services responded to a world of social distancing, remote working and PPE. At that time many Strategy Unit projects were focused on what could be learnt from this period of innovation. What changes were being made? Which changes seemed to be an improvement on pre-lockdown practice? Which ones were a step back? Which needed more evidence and further study? We were asked these questions so frequently, we produced a Guide to working through them. It was a great privilege to be asked by NHS England & Improvement to examine these questions in relation to the service response for people experiencing homelessness. Alongside this, we were also asked to look at how data collection and use could be improved. The reports below contain the detailed results of this work. These results resonated strongly with similar projects from Groundswell, St Mungo’s and Crisis. Above and beyond the results set out in the reports, we also found that: Innovation was taking place on the frontline. Changes made by services were pragmatic responses to changes in circumstance; they were not done in response to plans from ‘on high’. Policy is now running to catch up with practice. Existing problems were exposed. Data were patchy and weak; services were often strained (and sometimes unwelcoming). These pre-existing weaknesses came more sharply into focus. The hope is that temporary measures to cope with the crisis – less hiding behind ‘IG’ for example – can be now nurtured into everyday practice. The basic right of access to healthcare, that has too often eluded those experiencing homelessness, is assured. While seeing that standard administrative data was lacking, we found that it was possible to gather near live information from people experiencing homelessness. We joined forces with (the excellent) Groundswell to bring together our work on services’ experiences with their peer-led work looking at people’s experiences of this support. This combination proved powerful and we shared many lessons during a session at our INSIGHT 2020 festival. The NHS can be criticised for its approach to addressing health inequalities. The hope here must be that the inequalities exposed by Covid draws a fuller and better response in future. Recent reasons for this hope include: the content of NHSE/I’s ‘Phase 3 letter’, which focused heavily on inequality; the recent appointment of Dr Bola Owolabi as Director of Inequalities; and the energy shown by Olivia Butterworth, who led NHSE/I’s response to homelessness. Homelessness is a source of shame for our society. The best way to improve outcomes is not to tweak services, but to prevent the problem. But while homelessness remains, the NHS must feel a sense of duty and responsibility to do the best it can do, and to work closely with local government and the voluntary sector in support of this. This work gave us the chance to combine personal interests and passions with professional skills. It was part of the Strategy Unit’s ongoing commitment to addressing health inequalities and we relished the chance to contribute to a significant and vital agenda. We look forward to working with others to do so again in future.

Tacking inequalities in health is a long-standing NHS policy objective. Variation in the experiences and outcomes of different communities during the COVID-19 pandemic served to bring this issue back into focus. In the Summer and Autumn of 2020, as the first wave of the pandemic subsided, concern grew about reduced access to routine hospital care: diagnostics, outpatient care and planned surgery. Waiting lists and waiting times began to grow. The network of Decision Support Units in the Midlands recognised the potential for this issue to exacerbate existing inequalities. They jointly commissioned this analysis to explore the extent, causes and consequences of socio-economic inequalities in access to planned hospital care. The recent NHS Planning Guidance emphasises the importance of identifying and tackling these inequalities. The report has four objectives: To describe socio-economic inequalities in access to planned hospital care To identify where in the patient pathways these, inequalities in planned care emerge To explore potential drivers of these inequalities To explore whether poor access to planned care in some communities leads to increased demand for unplanned care. The report builds on earlier research, advancing our understanding in some key areas. Although further analysis may certainly add benefit, this report is sufficient to support some immediate and targeted actions. We look forward to working with the network of Decision Support Units in the Midlands to improve the outcomes for people living in the most deprived parts of the region.

Risk and reward sharing is a simple and attractive concept, offering a commissioner the opportunity to co-opt and incentivise a provider to moderate growth in healthcare demand by sharing in the savings or cost over-runs. The Centers for Medicare and Medicaid Services (CMS), a US government agency, has established a comprehensive approach to risk and reward sharing for US Accountable Care Organisations: the Shared Savings Program. This paper draws out the central themes from the Shared Savings Program and translates these into an NHS context. The rationale that underpins the development of Accountable Care Organisations in the US and Integrated Care Systems in England is similar: to moderate healthcare costs through service coordination and integration. However, US ACOs and English ICSs are vastly different in scale (on average, US ACOs provide services to c. 19,000 enrolled patients) and operate in radically different political, financial and cultural contexts. In the US, ACOs are required to sign up to one of three risk-sharing ‘tracks’. Track 1 is a one-sided risk-sharing model where providers have the potential to share in savings if priced activity falls below expected levels, but are not required to pay a share of any cost over-runs. Tracks 2 and 3 are two-sided models, exposing providers to an increasing proportion of upside and downside risks. Six years since the first ACOs were established more than 90% of ACOs remain on track 1. This suggests that to date, providers have a limited appetite for risk. It also offers some insight into the level of confidence that US ACOs have in their ability to moderate demand growth. Complexity is a key feature of any robust risk-reward sharing arrangement and is likely to increase transaction costs above those associated with fee-for-service arrangements. The complexity arises as the commissioner or system designer attempts to ensure that the incentives accurately reflect the policy intention, and do not instead reward cost shunting, quality reductions or chance variations in costs. It is possible to extend risk-reward sharing to multiple partners within an Integrated Care System and to organisations outside the scope of an ICS. But these extensions add further complexity. The notion of a ‘counterfactual’ is central to risk-reward sharing. In this context a counterfactual is the price of healthcare activity that might be expected under normal circumstances. It is the benchmark against which priced activity levels are assessed at year end. If priced activity falls below this level, then the provider may be entitled to a reward payment. If it exceeds this level, then a penalty may be applied. There are many approaches to calculating and agreeing counterfactuals, but none are simple. These calculations determine the allocation of significant sums of money. If the NHS is to make best use of risk and reward sharing, then it must be aware of the complexities and hazards inherent in these arrangements as well as the potential benefits.

Dementia is a key priority for NHS England and is estimated to affect around 676,000 people in the country. Our analysis is intended to help understand the need for future dementia diagnosis and treatment services in a specific area and to help commissioners to identify and prioritise interventions.

Commissioned by NHS England, this report describes the status and context of palliative and end of life care services in the six Sustainability and Transformation Partnerships in the West Midlands. The report contains data on trends and forecast numbers of deaths, place of death, palliative care registers, acute healthcare use prior to death, availability of specialist-level palliative care and summarises the results of recent palliative care reviews and audits. The number of deaths in England has reduced year on year since the early 1980’s despite increases in population size. In 2011 there were four hundred and fifty thousand deaths in England, lower than at any point since the NHS was founded, but since 2011 the number of deaths per annum has increased and ONS forecast that this upward trend will continue for the foreseeable future with a 25% increase in annual deaths by 2039. This implies that demand for end of life care has been comparatively low in recent years but will rise considerably in the years ahead. Hospital remains the most common place of death, although all parts of the West Midlands have seen decreases in the proportion of deaths in this setting. There are now five thousand fewer deaths per year in hospital than in 2006. A very large proportion of deaths from frailty and degenerative conditions occur in either a hospital or care home setting. Without service redesign, we might expect these settings to experience most demand pressure as frailty deaths increase rapidly. Palliative care registers are intended to assist GP practices to manage the care of patients in their last 12 months of life and evidence suggests that patients on palliative care registers are more likely to receive well-coordinated care. Despite significant improvements in recent years, the number of patients on palliative care registers in the West Midlands falls well short of the expected number. Acute hospital utilisation increases significantly in the last 12 months of life. Despite unprecedented pressure on hospital beds, patients continue to receive non-beneficial treatments in hospitals in the last months of life. A&E attendances and emergency admissions rise sharply in the last year of life, often peaking in the month of death. In May 2017, there were 52 Consultants in Palliative Medicine working a total of 450 (half-day) sessions per week. One fifth of these sessions were delivered as part of a community palliative care team with the remaining sessions shared between hospitals and hospices. In their most recent CQC inspection,6 12 hospitals in the West Midlands received ‘Good’ ratings for end of life care. A further 6 were assessed as ‘requiring improvement’ and one was assessed as ‘inadequate’. All of the hospices in the West Midlands received a ‘good’ or ‘’outstanding’ rating in their most recent CQC inspection.

Recognising that the effect of population ageing can be overstated, we set out to ask what effect an older population will have on demand for health and care services. Here, we explain why typical approaches ‘overlook the fact that rising life expectancy makes … older people “younger”, healthier, and fitter than their peers in earlier cohorts’. This report is the first in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective, these three reports provide a useful and robust framework on which local commissioning organisations can base their strategic planning.

Waiting times in A&E have become the defining healthcare performance issue of our time, much like elective waiting times and hospital acquired infections have been in the past. Since 2004, the NHS in England has sought to ensure that patients spend no more than 4 hours in Accident and Emergency Departments. In recent years reported performance has deteriorated and, in the winter of 2017/18, almost one quarter of attendances at major A&E departments breached the target maximum duration. The decline in performance has been steady, sustained and almost ubiquitous. Attempts to restore performance levels have waxed and waned whilst the media’s interest in the target continues to grow. In 2018, NHS England announced plans to review all constitutional waiting times targets, reopening the intense debate about the value and impact of the 4-hour A&E target. Whilst there is no shortage of commentary on the subject, there have been few detailed analyses of the factors that are driving increases in A&E attendance durations and 4-hour breaches. In the absence of clear causal explanations, responsibility for ‘poor performance’ is often levelled at A&E departments, with implications of poor management and inefficiency. This report presents a detailed review of the demand-side, supply-side, practice and emergent factors that lead to 4-hour breaches with a particular focus on changes that have taken place since 2010. The report reviews both commonly cited causal factors and a range of more novel hypotheses. It sets out the causal theories underpinning each factor and seeks statistical evidence in support of them. Finally, the analysis scales the relative impact of each causal factor and aims to provide an explanation for the recent deterioration in A&E waiting times within the limits of national datasets. New insights emerge which have the potential to reshape the received wisdom about the performance of A&E departments, carrying important implications for healthcare policy and system leadership.

Recognising that the effect of population ageing can be overstated, we set out to ask what effect an older population will have on demand for health and care services. Here, we explain why typical approaches ‘overlook the fact that rising life expectancy makes … older people “younger”, healthier, and fitter than their peers in earlier cohorts’. This report is the first in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective, these three reports provide a useful and robust framework on which local commissioning organisations can base their strategic planning.

This rapid scan of the evidence base on demand management formed part of a broader analysis of the current challenges and opportunities to manage demand, specifically within the context of a primary-care led model. The aim of the review was to identify relevant research and practice-based evidence to inform an overall approach to demand management.

The Strategy Unit worked as a strategic partner of the NHS Future Fit Programme in Shropshire and Telford & Wrekin from its initiation and until it was able to move to public consultation. A key output was the comprehensive appraisal of acute hospital options, the recommendations from which were unanimously approved by a Joint Commissioning Committee of two CCGs with their partners.