Timetable and Budget
|
Description |
Deadline/Limit |
|---|---|
|
Deadline for Stage 1 Applications |
11 July 2023, 1 PM |
|
Notification of outcome of Stage 1 Application |
October 2023 |
|
Project Start |
December 2023 / January 2024 |
|
Project Duration |
20 – 24 months |
|
Budget |
£200,000-£250,000 |
Due to the urgency of this research call, applications will be assessed through a fast-track single stage Committee assessment process, based on information provided in the outline stage 1 application form. Successful applicants will be invited to respond to Committee feedback in an expanded form and will directly proceed to contracting and project start-up.
Introduction
The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for an evaluation of the £1.6 billion funding that the Department for Health and Social Care is making available to support hospital discharge in 2023-24 and 2024-25. This includes the £600m Discharge Fund (2023-24) and the further £1 billion committed for 2024-25.
This research project will fund an evaluation of the funding to understand the impact of the funding on system-level and, where possible, patient-level outcomes.
Applicants are invited to submit plans and costs for the research.
Background
Urgent and emergency services have been through the most testing time in NHS history with a perfect storm of pressures impacting the whole health and care system but causing the most visible problems at the front door.
Problems discharging patients to the most appropriate settings with the right levels of care and support, alongside the demands of flu and COVID peaking together, has seen hospital occupancy reach record levels. This means patient ‘flow’ through hospitals has been slower.
Delayed discharge is a significant and complex challenge for the health and social care system. Delays in discharge have knock-on effects for the rest of the system, meaning that patients have to spend longer in A&E and wait longer for ambulances.
There is also some evidence that delays or prolonged stays in hospital may negatively impact health outcomes; for example, the 2014 National Audit of Intermediate Care found that ‘undue waiting in hospital is highly damaging for older people’.1
Reducing delayed discharge and improving hospital flow is a priority for the recovery of urgent and emergency care services and for the adult social care system.
The Government has therefore committed £1.6 billion in 2023-24 and 2024-25 to help ensure people are able to leave hospital on time with the right care and support, freeing up NHS beds for those who need them. This was first announced in the Autumn Statement 2022 (5.61 - Central government adult social care and discharge funding increase), and consists of the £600m Discharge Fund (2023-24) and the further £1 billion committed for 2024-25.
For more information on 2023-24 Discharge Fund, please see the grant determination.
To support the partnership working that is needed to reduce delayed discharge, the funding will be shared equally between local authorities (LAs) and integrated care boards (ICBs). This will increase the ‘Better Care Fund’ (BCF), which encourages integration by requiring integrated care systems and local authorities to enter into pooled budget arrangements, to a record £10 billion by 2024-25.
Research priorities
The research questions we are seeking to answer are:
- What is the impact of additional funding for hospital discharge in 2023-24 and 2024-25?
- What is the impact of particular interventions to support hospital discharge that were funded in 2023-24 and 2024-25?
If feasible within the budget and timescales outlined, we would also be interested in the evaluation exploring the following question:
- What is the value for money of additional discharge funding in 2023-24 and 2024-25? We hope that it will be possible to make an assessment of value for money: however, we are aware that limitations in the data available and challenges associated with identifying impact may make this challenging. We would expect any approach to value for money assessment to be developed iteratively based on findings from research questions (1) and (2).
We expect these questions to focus primarily on system-level discharge outcomes and metrics due to the availability of relevant data; however, we also welcome proposals that include analysis of patient-level outcomes where this is possible. The evaluator should also consider unintended consequences when considering impact.
Design and methodology
We are not prescriptive with regards to methodology and invite applicants to propose suitable approaches to answer the research questions set out above. However, we encourage applicants to consider approaches taken in similar evaluations previously. For example, work package 3 from the 2018 evaluation of the Better Care Fund used various panel data methods, including fixed effects and synthetic control to understand the impact of BCF funding on relevant outcome variables.
The Department is also conducting an internal evaluation of the 2022-23 Adult Social Care Winter Discharge Fund, and we expect to work closely with the evaluator to share learning and insights from this approach when finalising the evaluation design for 2023-24 and 2024-25 funding. The approach we are taking builds on the 2018 evaluation of the Better Care Fund, and will use similar panel data methods to consider impact on the metrics set out in the section below.
We expect these questions to focus primarily on system-level discharge outcomes and metrics due to the availability of relevant data; however, we also welcome proposals that include analysis of patient-level outcomes where this is possible. The evaluator should, where possible, also consider unintended consequences when considering impact.
Data sources and outcome metrics
Given the lack of available data on patient-level outcomes, we expect the evaluation to primarily focus on attributing and estimating the impact of the additional funding – and, where possible, particular interventions - on system-level outcomes. The evaluator will be expected to work with the Department to agree relevant outcome metrics, including consideration of findings from the evaluation of the 2022-23 Adult Social Care Winter Discharge Fund when these are available. These should reflect both the ‘stock’ and ‘flow’ of patients in hospital - for example:
|
Metric |
Source |
|---|---|
|
“Discharge Ready Date” / time between discharge ready date and actual date of discharge |
As part of the delivery plan for recovering urgent and emergency care services, NHSE are committed to developing a new metric that measures the time between a patient no longer meeting the Criteria to Reside (their “Discharge Ready Date”) and their actual date of discharge, to be published for all systems ahead of winter 2023. As this is a new metric, there may be a lead-in time before it is available or suitable for complex analysis; however, we would expect the evaluation to consider how best this new metric could be incorporated. More information is available in the NHS publication discharge ready date submission and adult social care discharge fund |
|
Number of people ‘not meeting criteria to reside’ (and who have not been discharged) |
|
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Hospital admissions |
|
|
Number of discharges |
|
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Length of hospitalisation |
Unpublished data, which the Department would aim to share with the evaluator upon contract signature |
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A&E Attendances within 4 hours from arrival to admission, transfer or discharge |
|
|
Bed Availability and Occupancy |
Other relevant metrics may also be considered, but these may be less appropriate or feasible to incorporate due to scope or data quality – please see Annex 1 for examples. We recognise that the time to access data may impact timings and therefore, we are open to proposals from applicants on the most appropriate set of metrics that can be accessed and analysed within the timescales laid out in this specification. Applicants are asked to take into account time to access data within their planned approaches.
While we are interested in understanding the impact on patient-level outcomes where possible, we believe that the potential for meaningful analysis of these is limited given the data currently available. Proposals that include suggested methodology for incorporated patient-level outcomes are welcome.
Information on the LA reporting requirements associated with the 2023-24 Discharge Fund is available in the grant determination; information on reporting requirements for ICBs are set out in the Better Care Fund planning requirements 2023-25 (in the section “additional discharge funding”). The Department would aim to share activity and spend data for the Discharge Fund (when available) following contract signature.
For research question (2), which focuses on the impact of particular interventions, we would expect the approach to involve analysis of activity data from monitoring returns that the Department would share with the evaluator. This could also include classification or typology analysis (supported by qualitative research where appropriate / necessary) to group interventions before taking statistical approaches to identifying the impact of types or groups of intervention. We appreciate that typology analysis can be quite time intensive and therefore, may not be feasible within the timescales. Findings from the DHSC internal evaluation of 2022-23 funding may provide some relevant evidence on types of intervention; the evaluator will have access to these.
Technical requirements / Expertise required
Required
- Expertise in impact evaluation, and particularly econometric approaches to identifying impact in panel data (e.g. difference-in-differences, synthetic control)
Desirable:
- Knowledge of and familiarity with health and social care policy
- Experience and expertise working with relevant health and social care data sets
Outputs
Throughout the project, the team would be expected to have regular meetings with DHSC to discuss emerging findings. This is crucial to inform future policy related to hospital discharge and adult social care.
The team would be expected to share interim findings from the evaluation, in the form of a policy briefing note, with DHSC by summer 2024. The precise timeline will be finalised upon contract award; however, this milestone is required to ensure that early findings can feed into ongoing policy development and funding decisions.
Full findings from the evaluation of 2023-24 funding are expected by early 2025. This should take the form of a report suitable for non-technical policy audiences, accompanied by a technical note to provide full insight into the methods and approaches used.
Findings from the evaluation of 2024-25 funding are expected by summer 2025; the format is the same as for the findings for 2023-24.
Final reporting and project conclusion is expected by winter 2025. This should include a full report, written to a publishable standard and suitable for non-technical / policy audiences (e.g. with a clear executive summary and conclusions / key findings), covering findings across the 2023-24 and 2024-25 funding and any further relevant context.
We would expect presentations of findings to technical and non-technical audiences at each of these reporting stages.
Additional briefing notes or updates may be requested by the Department.
The Department would expect to work closely with the evaluator throughout the evaluation, both to share insights from previous evaluation activity and to ensure that officials have a detailed understanding of the methodology and findings of this evaluation so that the policy impact can be maximised. This may include the sharing of any modelling or data processing, including relevant datasets, spreadsheets and code, for the purposes of furthering understanding and allowing additional analyses if required in future.
Budget and duration
The Department of Health expects the research to be delivered within a cost of £200-£250k
The research will be conducted over a period of 20-24 months
Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning panel members will assess applications against.
Management arrangements
A research advisory group including, but not limited to, representatives of DHSC, other stakeholders and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:
- Provide regular feedback on progress
- Produce timely reports to the advisory group
- Produce a final report for sign off
Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.
New Guidance on Inequities and Inequalities data collection within NIHR PRP Research:
Inequities and inequalities in the provision, access to and experience of health and care services is a high priority area within the Department of Health and Social Care and the NIHR and is present in the majority of funded projects. We will now assess all NIHR research proposals in relation to health and care inequalities. NIHR asks researchers to explore issues of inequality and inequity in the research being proposed.
Our goal is also to facilitate more widespread and consistent reporting of data on health and care inequalities relating to the primary outcomes of NIHR funded research. Applicants should, if feasible, collect or analyse data related to health and/or care inequalities, we request that this stated in the proposal. This is a new request from the NIHR PRP and we will be continuing to monitor queries and make any necessary clarifications, as needed.
We understand that research projects may employ different methodologies, and focus on different populations. We ask that you please clearly identify in the research plan section of the application whether your application has a health and care inequalities component. If the project uses quantitative methods, please include detail of the core set of data that will be collected or analysed. Submission of the data collection will be a condition of final reporting that will need to be submitted to NIHR PRP when the grant has finished. If a health and/or care inequalities component is not included, please explain clearly why this does not fit within your research.
Specifically for this project, it may be useful to consider whether any particular groups are particularly impacted by discharge delays, and whether interventions have any differential impact for different groups. This may include consideration of local / regional variation, deprivation or characteristics covered by the Equality Act.
A recording of the Health Inequalities in NIHR PRP Research Q&A Event which was held on 19 September 2022 is available online, this may be useful to refer to as it provides additional information.
Further details about this new request can be found in Annex 2.
References and key documents
- NHS Benchmarking Network (2014). National Audit of Intermediate Care Summary Report: National Audit of Intermediate Care Summary Report (accessed 21.04.23)
Annex 1
Additional discharge metrics which may merit consideration when identifying suitable outcome metrics:
|
Metric |
Source |
|---|---|
|
Number of care packages purchased for care homes, domiciliary care and intermediate care |
To be collected via a monitoring return in 2023-24; the Department would aim to share with the evaluator upon contract signature |
|
Number of people discharged to their usual place of residence |
Measures from the Adult Social Care Outcomes Framework - NHS Digital) |
|
Number of ‘bed days lost’ to delayed discharge by trust |
|
|
Proportion (%) of the bed base occupied by patients who do not meet the criteria to reside, by trust |
Statistics » Urgent and Emergency Care Daily Situation Reports 2022-23 ) |
It will also be necessary, where feasible within budget and timescales, to consider broader data sources when identifying suitable outcome metrics and / or control variables; this is likely to include demographic data at local area level (including population density, age and deprivation of population and proportion of population with disabilities), social care occupancy and capacity data and other data relating to hospital activity and urgent and emergency care.
Annex 2: Further Detail on the New Guidance on Health Inequalities data collection within NIHR PRP Research:
Health Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects. We are now assessing all NIHR research proposals in relation to health inequalities. We are asking applicants to identify in their application whether or not there is a health inequalities component or theme and how this research hopes to impact health inequalities. We are also asking researchers to collect relevant data related to health inequalities, if appropriate for the research. Collecting specific information about health inequalities in research submitted to the programme will allow for categorisation of health inequalities research, curation of data to aid future health inequalities research and enable policymakers to better understand the implications of health inequalities within their policy areas. This is a new request from the NIHR PRP and we will be continuing to monitor queries and adapt the process as needed. If you have any feedback on this new request, please contact us at prp@nihr.ac.uk.
Our goal is to facilitate more widespread and consistent reporting of health inequality breakdown data relating to the primary outcomes of NIHR funded research. We would ideally like researchers to focus on the following equity-relevant variables: age, sex, gender, disability, region*, 5 ONS Ethnic groups**, and the 5 IMD quintile groups. These variables are considered an ideal, but we understand that these are subject to change depending on the sample population and specific research question.
For qualitative research projects, this can be purely baseline characteristics of the participants, for example, the number of participants in each ethnic group.
For quantitative research projects, if there are multiple outcomes/effects with your stakeholders, select a small number of main outcomes as appropriate to report equity breakdowns. We will not be prescriptive about the number of the outcomes, as it will depend on the number of study design types and the nature of the project aims. We are asking for one way cross tabulations of each primary outcome by these equity-relevant variables, if appropriate for your research, together with the number of observations in each cell. If more detailed cross tabulations are appropriate for your proposed research, please include these as well. This request applies to both primary data collection studies and secondary analysis of routine data, and to causal inference studies as well as descriptive studies; however, if this is not possible due to data limitations then please explain. Due to sample size and other data limitations there may be difficult scientific and/or data security*** judgement calls to make about which breakdowns to report and whether to merge categories to increase counts in particular cells; we ask you to make these judgments yourself, bearing in mind our data curation aim of enabling future evidence synthesis work in pooling results from different studies. We also ask that researchers report breakdowns for the unadjusted as well as adjusted outcomes/effects, as appropriate.
We understand that research projects may employ different methodologies, and focus on different populations. Please explain how the variables and data collection methods chosen are appropriate to the methodologies used.
We ask that you please clearly identify in the research plan section of the application whether your application has a health inequalities component or not and detail the core set of health inequality breakdown data that will be collected, if applicable. Submission of the data collection will be a condition of the final report for all research with relevant methodologies regardless of whether the research has a health inequalities component that will need to be submitted to NIHR PRP when the grant has finished. This should only take a few sentences within the research plan section.
* Table below uses the nine regions in England, further regions can be used if using the UK as the study population. Please report region breakdown for large samples in nationally representative descriptive studies. There is no need to report this for small sample studies, for sub-national studies, or for quasi-experimental studies where it would require time-consuming re-estimation.
** White, Mixed/ Multiple ethnic groups, Asian/ Asian British, Black/ African/ Caribbean/ Black British, Other ethnic group. If the sample size is small then it is fine to report only some of the requested equity breakdowns and to merge some of the sub-groups as appropriate.
*** For guidance on how to handle data security concerns in reporting of sensitive data please see ONS guidance.
Example data table for submission at the end of the funded research project
(N.B. If there is more than one main outcome then you will require more tables and if you adjust your outcome then you will need two tables for the adjusted outcome and unadjusted outcome. For other methodologies, variable vs number of observations may be more appropriate to record participant data). This table is for an example only. It does not contain sub variables and does not illustrate any preference for certain variables, as these will be dependent on the proposed research.