Appendix 1
Project Title:
Evaluation of the early discharge project of the ‘ASSIST’ team at
Mansfield District Council
By
Nottingham Business School, Nottingham Trent University
Mr Peter Murphy and Dr Donald Harradine
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Project Title:
Evaluation of the early discharge project of the ‘ASSIST’ team at Mansfield District
Council
By
Nottingham Business School, Nottingham Trent University
Mr Peter Murphy and Dr Donald Harradine
Project Objectives
To provide an independent appraisal of the business case for the continuation of the
ASSIST early discharge scheme in Mansfield.
1. Introduction and Background.
Nottinghamshire CC, Mansfield and Ashfield CCG, Newark and Sherwood CCG and
Mansfield District Council have collectively commissioned NBS to provide an
independent appraisal of the business case for the continuation of the ‘ASSIST’ early
discharge collaborative project in Mansfield. ASSIST is the acronym for the
Advocacy, Sustainment, Supporting Independence and Safeguarding Team at
Mansfield District Council. The ASSIST team are engaged in providing a variety of
services and other activities both for the council and other stakeholders but for the
purpose of this report we will refer to the early discharge project as the ASSIST
project. (A full range and definitions of ASSIST services provided by Mansfield DC
under the Care Act 2014 as classified under the ‘Universal Offer of Housing
Services’ was provided as part of the background documentation for this report).
Mansfield is the largest urban area in Nottinghamshire, outside Nottingham City with
a population of approximately 105,000 and is one of the most deprived local
authority areas in England and Wales. The health of people in Mansfield is worse
than the English average, and the life expectancy for both men and women is lower
than the English average. Those aged 65+ represent the second largest age group
(17.7% of the population) and in the recent estimates indicate 59% of the 65+ in
Mansfield had a limiting long-term illness. This level is the highest in the County and
far higher than the regional and national average.
The discharge pilot project is a scheme established to support the early discharge
and immediate residential care of patients from the Kings Mill Hospital in Mansfield
and receives clients from health, housing and social care partners in central
Nottinghamshire as well as occasional ad-hoc referrals. Although initially focussed
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on Mansfield DC administrative area it also co-operates with and co-ordinated some
of the equivalent services in the administrative area of Ashfield DC. The immediate
catchment area of Kings Mill Hospital includes the administrative area of Mansfield
DC and Ashfield DC. The pilot project was formally established in October 2014 and
the team is based within the Housing and Environment Directorate at Mansfield
District Council under the Head of Housing Hayley Barsby.
The ASSIST team has been working directly with Sherwood Forest Hospitals
National Health Service Foundation Trust (SFHNHST), the Adult Social Care and
Health team at Nottinghamshire CC, and the Mansfield and Ashfield and Newark and
Sherwood NHS Clinical Commissioning teams, well as wider stakeholders and
collaborators from the public, private and third sectors in the Mansfield and Ashfield
administrative areas.
The aims, intended activities and funding for the project as anticipated by the two
CCGs, is contained in Appendix A attached to this report, but in summary it aims to:



Prevent avoidable homelessness,
Support tenants to remain adequately housed,
Reduce or prevent avoidable or elongated admissions to Hospital or
residential care
Expedite discharges from the Kings Mill Hospital (both Emergency
Department (ED) and ward discharges), and from residential care and in
Mansfield.
This report is evaluating the early discharge aspect of the project. It does this
through the early identification and assessment of patients potentially needing
housing services who have presented for treatment at Kings Mill Hospital through
either ED or through elective care on a specialist or generalist ward.
On establishing a future potential need for a housing service, the full range of
housing services and advice that the housing authority can provide, are expedited to
facilitate early discharge and the freeing up of bed spaces at the hospital. This
ensures unnecessary stays within Kings Mill Hospital for patients are reduced and
ward capacity is increased for patients waiting to be treated.
Housing services includes, but is not limited to, re-housing of clients in more
appropriate accommodation, or major or minor adaptations to the patients’ current
accommodation (or proposed accommodation), or advice guidance on benefits and
other services.
2. The specification for the service evaluation.
The commissioners of the project require a formal evaluation of the pilot scheme to
record and demonstrate activity and outcomes, and to assess actual and potential
savings. An opinion is also sought as to whether development and/or continuation of
the scheme is considered to be replicable, scalable or portable to other locations.
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A team comprising Mr Peter Murphy and Dr Donald Harradine from Nottingham
Business School has carried out the evaluation, (their CVs are attached at Appendix
C).
The evaluation has been conducted as a cost benefit analysis that essentially
assesses the financial returns on investment. It is possible to provide either an
appraisal based upon a financial model essentially calculating the financial returns
on investment, or one based upon a calculation of the social returns on investment,
although the latter is more resource intensive.
Although we accept that an assessment based of the social returns on investment
for a scheme like ‘ASSIST’ would have been considered more appropriate by some,
this report is based upon a financial calculation of costs and benefits (with some
acknowledged assumptions about impacts). It is however accompanied by
comments on some of the wider long term ‘social’ impacts that should be
considered. It would not have been possible, given the inherent time, information and
resource constraints, to complete a coherent and realistic assessment of the full
social returns on investment although the commissioners might want to consider this
in the future. We return to this issue as part of our conclusions and
recommendations.
3. The methodology and methods adopted for the evaluation.
This section identifies the methods used for the study to identify the potential
financial consequences of the Mansfield DC hospital discharge scheme that has
been operational at the King’s Mill site of the SFHNHSFT. The research strategy had
four distinct phases.
a) Firstly there was the initial fact finding phase which involved examining the
parameters of the scheme. This involved interviews and meetings with senior
staff at Mansfield DC.
b) The second stage of the project was the determining the mechanics of the
system so that an appropriate appraisal could be identified and designed. The
methods involved in this stage was the shadowing of the Homeless
Prevention Officer, whilst undertaking her duties at the King’s Mill site. This
illuminated the issues and the methodologies she used to achieve solutions
for patients who needed housing assistance and who fell within the
parameters of the scheme. This exercise was undertaken for a day. During
the course of this visit contact was made with various stakeholders and
opportunities were taken for interviews to take place.
c) During the third phase further interviews and focus groups were undertaken
with staff involved in the project from Mansfield DC. In total 16 members of
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staff from Mansfield DC and 12 from KMHNFST took part in the study. The
names of these individuals are available, however, for ethical reasons, they
are not included. The focus groups and interviews were designed to explore
the practicalities of the scheme and the perceived benefits in qualitative
terms. Although the qualitative benefits are not the focus of the study it was
necessary to verify this aspect and corroborate the case studies produced by
Mansfield DC staff to ensure validity of the interventions made.
The study participants included:
 managers from the two main stakeholder organisations;
 those involved in delivering the scheme;
 health and social care professionals; and
 finance staff from both organisations.
d) The final phase of the research involved the examination of records of
interventions made. This examination was undertaken by staff from Mansfield
DC and the research team. Judgements were made based upon evidence of
the effectiveness of interventions as to the potential benefits to the discharge
process. All interventions were examined from the start of the scheme until
mid-May (the conclusion of the study), however, the two most representative
and appropriate months (March and April, 2015) were scrutinised in detail.
These months were those where, it was determined from data gathered in the
earlier phases of the research, the scheme was working effectively and was
after the initial set-up period of the scheme. These particular months were
also those which had the most detailed and reliable data. From these data
sets the savings in terms of in-patient days was determined and these were
used to determine the savings from the scheme as set-out in Appendix B.
The financial calculations were based upon the current CCG charge rates for excess
bed days on a HRG basis. This mean charge per day is £222, which, after the
addition of the appropriate market forces factor of 3.14%, provides a total of £229
per day. This information was confirmed by senior staff from the finance function at
SFHNHSFT before being adopted.
The costs of the Scheme to Mansfield DC have been provided and ratified by
members of the Council’s finance function. The evaluators, the finance specialists
and housing specialists from the authority, were of the view that, in terms of the cost
of housing stock, there is no marginal cost as the scheme, in terms of the use of
housing stock, is a prioritisation issue and therefore no additional cost.
Owing to the relatively short length of time that the scheme has been in operation it
is difficult to identify valid short, medium or long trends in terms of activity (Appendix
B: Tables 1 & 2), however, there does appear to be an increasing rather than
decreasing or stable level of activity. This assumption is supported by the activity
level of SFHNHSFT’s and associated issues of length of stay in certain specialties,
particularly in the context of the elderly. The service currently has no specific base
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within the hospital and there has been relatively little work to raise the level of
awareness of the service that could be provided. Similarly little has been done at the
weekends with regard the discharge scheme, although, changes in practices at the
hospital may mean that this will also increase the level of activity. As these issues
are addressed it is likely that activity levels will increase. The analysis has therefore
assumed that there will be growth in interventions but we consider our assumed
activity levels are at the ‘conservative’ end of the scale so as not to overstate
potential savings (Appendix B).
All savings and costs have been calculated on the most prudent options, therefore,
all savings are believed, by the investigators to be conservative for example a cap
was put on the most extreme and complex cases of 30 and in extreme cases of 60
days. There are likely to be further savings at SFHNHSFT owing to staff time being
saved by the activities of this intervention, however, these have not been quantified
during this study.
4. Project Appraisal
The key findings from the evaluation are as follows:
a) There was clear evidence from observation and interviews that the scheme
benefits the efficiency of hospital discharge and reduces the burden on
hospital and social services staff. The availability of the service, the staffs’
understanding of housing issues and the ability to action and expedite
solutions clearly assists in the discharge process.
b) From the limited scope of the current scheme current savings in terms of bed
days amount to approximately £664,000, rising potentially to a realistic
potential number of interventions of 60 per month resulting in approximate
savings of £1,328,000. The costs of providing this service produces net
savings related to the gross figures identified above of £379,800 and
£1,024,700 respectively Appendix B: Table 3).
c) The costs of providing the service are relatively fixed therefore there is a high
level of gearing in terms of net savings if there is a potential increase in
activity. These costs may achieve a step at some point in time, however, there
is not sufficient data to determine at what level of activity this will occur.
d) Many of the interventions are relatively low in terms of marginal cost, but
significant in the ability to enable a hospital discharge. At this stage the longterm mix of cases is not able to be determined. This is vital to any investment
decision; however, the margins are such the main findings from this study are
not undermined.
e) The research identified that the time taken to rehouse clients from outside of
the Mansfield District was consistently in excess of the time taken within the
District.
5. Comments on the projects expansion or ‘portability’ to other areas.
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It was quickly apparent to the evaluators that there were a number of factors that
were critical to the potential success of the discharge scheme, that were available in
Mansfield but are not universally available in all housing authority areas. There are
also a number of service configurations, patterns of deployment, inter-organisational
and inter-personal relationships that have been critical to successful delivery of the
pilot project that also may not be universally available.
In order to assess whether the service is scalable replicable, and/or portable, and
therefore whether the commissioners (or other NHS commissioners) would be willing
and able to invest in either expanding the Mansfield initiative and/or replicating it
elsewhere it is necessary to
a) Identify the critical success features that make the current pilot project a
success,
b) Identify the critical success factors that may be missing but could potentially
be developed.
c) Identify the critical success factors that are not available and cannot
realistically be developed.
We consider the project benefits significantly from the following list of tangible and
intangible features, which have been critical to the success of the pilot project. The
tangible and non-tangible features will be subject to change over time.




The housing services at Mansfield DC have a large and critical asset base in
terms of the number and variety of housing units that it has direct control over,
and the speed with which it can facilitate rehousing or dwelling adaptation.
Mansfield DC did not form an Arms-Length Management Organisation
(ALMO) nor outsource its dwelling stock. It has experienced relatively low
demand under right to buy. These features are not unique but are now
relatively rare among housing authorities particularly district councils.
Mansfield DC has also retained a directly controlled, Direct Labour
Organisation (DLO) with a full range of appropriate building skills and
experience to maintain and adapt dwellings. This again is not unique but is
now also rare among housing authorities particularly district councils. These
two features (retention of a large variable dwelling stock and a DLO) can and
do occasionally coincide.
The level of voids and turnover of tenancies within the current housing service
allows capacity and services to be flexible, responsive and where appropriate
bespoke to the individual tenant. Mansfield DC administrative area has a
single large town at its centre with a full range of services and is relatively
compact with relatively low travel costs, and potentially rapid response
capability.
Kings Mill Hospital is strategically located (relative to both Mansfield and
Ashfield District Councils administrative area and to Mansfield and Ashfield
CCG’s administrative area) and its catchment area, while not coterminous,
facilitates collaboration.
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The relationship and integrated working with private landlords, and those nonprofit and charitable services supporting vulnerable groups.
The citizen centred culture of the primary provider organisation (Mansfield
DC) and the sophisticated professional appreciation of the potential
contribution of housing and related services to meeting wider social and
economic objectives as well and particularly public health objectives.
The human resources available to in terms of qualified experienced housing
professionals and professionals experienced in supporting vulnerable groups
such as the homeless, vulnerable elderly, alcohol and drug dependent, and
those in need of mental health services.
Dwelling availability and land supply for new dwellings means the private
housebuilding industry is unlikely to compete vigorously for this part of the
market.
One interview expressed the view that this as a ‘perfect storm’ of circumstances,
which has enabled the pilot project to work synergistically with the circumstances of
both the host population; the various service provider’s communities of interests and
the resources, skills and experience available to the collaborating partners. This
multivariate synchronicity clearly arises from a combination of the features identified.
These features taken together, will unfortunately be relatively rare.
The exact determination as to which combination of factors are necessary; which
individual factors are necessary but not sufficient; and which individual factors (if not
currently available) can realistically be developed, is a matter that needs further
investigation, but there is little doubt that they have all contributed to the positive
outputs and outcomes being achieved by the pilot project.
It appears from our, admittedly limited, investigation and analysis for example, that
an extension of the scheme in its developing form is likely (with appropriate
adaptation) to be potentially feasible in Ashfield but less likely to be feasible in
Rushcliffe, Broxtowe, Gedling or Newark and Sherwood. To take an out of county
example, Chesterfield Royal Hospital, Derbyshire Adult Social Care and Bolsover,
Chesterfield and North East Derbyshire housing authorities may be an area where it
might conceivably be replicated, but probably not in Amber Valley, South
Derbyshire, Erewash, High Peak or Derbyshire Dales.
6. Conclusions and recommendations
The evidence from the evaluation suggests that there is a clear service and financial
justification for the continuation and extension of the scheme. The facilitate this the
following recommendations should be considered:
a) Development of a methodology for identifying the actual impact on discharges
so that a ‘real time’ record is achieved for validating the scheme. There is a
need for continued monitoring of the progress of the pilot scheme and a date
fixed for its completion
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b) A negotiation process requires to be established to transfer funds to enable
the scheme to continue.
c) In order to consider the continuation of the service for a two or three year
period a full business case should be prepared by the pilot’s partners from the
two local authorities and the NHS.
d) In order to consider the extension of the scheme to cover the Ashfield District
Council area a further business case should be prepared, which includes the
active involvement of that Authority.
e) The partners may wish to consider, as they may find it useful for the long-term
investment decisions and prioritisation of funds, an evaluation of a full year of
operation, either on the basis of the financial return on investment or the
social return on the investment.
f) The scheme needs to be fully embedded and developed into the partner
healthcare institution so that the service is understood and sign-posted
appropriately.
g) If supported the continuation of the service should be fully integrated into the
business/service planning system of Mansfield District Council,
Nottinghamshire County Council and NHS partners.
Acknowledgements
The authors would like to place on record their thanks to all who have given their
time for this review and particularly Michelle Turton, Christine Fisher and Kathleen
Moore from the Housing & Environmental Directorate who greatly assisted the
review by providing information, background briefing, organising interviews etc. They
also responded efficiently and effectively to any and all requests for documents or
information required to complete our investigation.
7. Appendices
Appendix A: Formal aims and objectives of the study
Appendix B: I Financial Assessment
Appendix C: Evaluation team CVs
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Appendix A: Formal aims and objectives of the study
To appraise and evaluate the outcomes and progress of the Hospital
Discharge Scheme by:

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

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
Assessing a wide range of ASSIST service interventions
Assess actual and potential savings by a cost benefit analysis
Assess wider and long term ‘social’ impacts
Identify the effectiveness of the scheme by evaluating critical success
factors and features
Examine the feasibility of replication in other areas
Provide evidence to inform a business case for continuation of the scheme
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Appendix B: Financial Assessment
Table 1
Total of interventions per month recorded (September 2014 to April 2015)
Months 2014/2015
April
March
February
January
December
November
October
September
Total
Analysis of
interventions
Mean number of
interventions per
month
Identified relevant
mean number of
interventions per
month for January to
April
Trend analysis
Interventions
51
38
47
35
30
31
30
16
278
35
42
Based on the limited data it is
not prudent to identify a trend,
however, based on the current
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Average number of
interventions for April
and May resulting in
savings
resources and working methods
there is an increasing trend
identified of approximately 4
interventions per month,
however, this is not statistically
valid.
31
NB: the actual number of
savings with interventions
appears to have little correlation
with the total number of
interventions, however, it is
likely that the number of
interventions with savings will
rise with activity. Those
interventions with savings are
likely to be between 60% to 70%
of the total base upon current
trends.
Average saving in
terms of hospital days
per intervention for
April and March
8 days
Table 2
Analysis of March and April activity in terms of hospital days saved
Month
March
April
Total
ASSIST and
Tenant
general
support
interventions
including
adaptations
and HF
applications
113
32
166
279
32
Lifelines
and keysafes
72
43
115
Respite
60
60
Total
277
209
486
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Table 3
Estimated Savings and associated costs from the scheme
based on potential achievable levels of activity per month with an estimated
60% of interventions producing savings in terms of inpatient days.
Monthly
interventions
31
resulting in
(Average
saved infor April
patient days and May
2015)
Estimated inpatient days
2.9
saved per
year (000’s)
Total
annualised
664.1
saving to
NHS
(£000’s)
Annual cost
of Scheme to
284.3
MDC
(£000’s)
Net
annualised
379.8
savings of
scheme
(£000’s)
Return on
annual
134%
investment
35
40
45
50
55
60
3.4
3.8
4.3
4.8
5.3
5.8
778.6
870.2
984.7
1,099.2
1213.7
1328.2
286.7
290.3
293.9
296.3
299.9
303.5
491.9
579.9
690.8
802.9
913.8
1024.7
172%
200%
235%
271%
305%
338%
Appendix C: Evaluation Team
Peter Murphy (Principal Investigator) BA, MA, FETC, FHEA, MRTPI, CIMPSA, RSA.
Pete Murphy is the Director of the International Centre for Public Services
Management and Director of the Public Management and Governance Research
Group at Nottingham Business School within Nottingham Trent University. He is also
Joint Editor of the International Journal of Emergency Services and a member of the
advisory board of the Centre for Public Scrutiny. He has previously been on the
boards of a number of NHS Trusts.
Prior to joining the Business School in 2009 he was a Senior Civil Servant in
Whitehall for nine years, most recently, as Director of Local Government Practise in
the Office of The Deputy Prime Minister (2002-2005) and Director of Local
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Government (East Midlands) at the Department of Communities and Local
Government (2005-2009). Between 1977 and 2000 he was employed in local
authorities most recently as the Chief Executive of Melton BC in Leicestershire.
Donald Harradine, FMAAT, ACMA, CGMA, MBA, PG Cert (SSRM) PhD.
Dr Don Harradine is Director of the Health and Social Care Finance Research Unit at
Nottingham Business School, a principal lecturer; and Research Coordinator for the
Division of Accounting and Finance. He has fourteen years’ experience of working in
the finance discipline within public service organisations: local government and
health at a strategic level.
As well as being published in academic journals he has been involved in various
reviews of initiatives: the LinkAge Plus project; Service Line Reporting and budgeting
in the NHS; an examination of strategic financial leadership in the public services;
and a study of international financing methods for healthcare. He is a member of the
editorial board of the I Journal of Finance and Management in Public Services.
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