RPP 18 1 Kristin Denniston An economic analysis of Best Value for discharging patients into community care: a pilot study of social worker time costs

Research Policy and Planning: The journal of the Social Services Research Group – Vol 18 (1) 2000

An economic analysis of Best Value for discharging patients into community care: a pilot study of social worker time costs

Kristin Denniston, Research Fellow in Welfare Economics, School of Social Sciences, Cardiff University; Andrew Pithouse, Director of Social Work Studies, Cardiff University; Professor Michael Bloor, School of Social Sciences, Cardiff University

Abstract

This paper describes the results of a small pilot study, funded by the Wales Office of Research and Development, to assess the feasibility of using economic analysis to evaluate different models of joint working in community care. We used a concurrent time diary method to estimate the unit cost of social worker time in the assessment and care planning process in hospital settings, GP attachment and area team based teams. The results suggested that there are potentially significant variations in work patterns across these settings that may have substantial impacts on the costs, quality and effectiveness of an assessment. Although the findings indicated that hospital social workers may have slightly lower assessment costs and spend more time in direct face-to-face contact with clients and families during the assessment process, GP attached social workers actually spend more time liaising with other professionals, especially those in community and primary care. We also examined the usefulness of the concurrent diary method and concluded that although this approach may have higher opportunity costs of social worker time and a lower response rate than a retrospective diary method, the gains in accuracy and information may justify its use in a larger study.

Introduction

The 1990 NHS and Community Care Act enacted the largest changes in the financing, organisation and delivery of community care services since the creation of the welfare state (Wistow et. al., 1996). The reforms sought better value for money in the delivery of community care by shifting the responsibility for the provision of community care to local social services departments and making the proper assessment of need and care management the basis for high quality community care. Local governments have tried to meet the requirements of the 1990 legislation with differing methods of service reorganisation and varying levels of success. An economic analysis of these programs may provide a particularly useful means for assessing the service and cost effectiveness of the different reorganisations in order to determine which models deliver ‘best value.’

A major component of most economic analyses is a determination of the true program costs (see Buckingham and Ludbrook, 1989; Bebbington, 1993; Webb et al., 1998). The costs to local authorities of the 1990 legislation are largely unknown. It added new assessment and case management costs to some social services departments and created additional burdens on social worker time that have changed their work patterns. Some social workers argue that a potential hidden cost of complying with the legislation was an increase in paperwork and a reduction in time spent in face-to-face contact with clients which may have influenced the quality of intervention.

After the 1990 NHS and Community Care Act took effect in 1993, the local authority discussed in this paper relocated several social workers from the hospital environment into community-based area teams and GP surgeries. The objective was to improve the quality of community care delivery by increasing accessibility and providing greater continuity of contact within the local community. Policymakers hoped that locating social workers in the community would improve the quality of the care package, reduce the likelihood of its breakdown and prevent future hospital admissions.

The authority wanted several questions about the new working arrangements answered. First, what were the actual economic costs of complying with the 1990 legislation, especially in terms of performing assessments and developing care plans for patients being discharged from hospital? Second, how has relocating social workers from hospital into the community affected both the costs and quality of assessments and care plans? Third, should the local authority continue to divert social work resources from hospital to community locations, particularly GP surgeries?

This paper describes a small pilot study to assess how economic methods can be applied to evaluate the different models of joint working between health and social services in the discharge of patients from hospital into community care. In the study we applied various economic costing methods to evaluate a unique natural experiment in which we could directly compare the costs, quality and effectiveness across different joint working arrangements on a demographically similar population of patients. Time constraints and ethical considerations prevented us from both interviewing clients about outcomes and estimating the subsidies from health to social workers based in hospitals and GP surgeries. However, we were able to address, in some fashion, the first and second policy questions posed by the local authority. We estimated the largest component of a needs assessment and care planning – the unit costs of social worker time. To do this we used a diary that recorded time spent on individual cases from the beginning of an assessment to the establishment of a care package. We also identified some interesting variations in social work practice in the different settings which appear to affect cost and possibly quality of outcome. In future work, we hope to address the third question of allocative efficiency with a large-scale cost-effectiveness study that more precisely compares the marginal costs and benefits of each joint working arrangement.

The pilot study had several objectives. First and foremost was to estimate the unit cost of social worker time spent in a needs assessment for a typical hospital discharge. A second was to determine how social work practice and consequently unit costs varied under the different methods of joint working and with client and social worker characteristics. A third was to evaluate the usefulness of the time diary format for identifying work patterns and variations in unit costs. A fourth was to disseminate our findings to a wide social care audience in order to generate some debate on methods and to communicate the availability of the full report to interested parties.

Background

Several studies have used time diary-like instruments to value the cost of social worker time in different community care experiments (Challis and Davies, 1986; Challis et al., 1989; Challis et al., 1990). Since the implementation of the 1990 NHS and Community Care Act, there have been two large studies using them to estimate the unit costs of a community care assessment. Petch et al. (1996) sampled cases from 65 practitioners in four Scottish local authorities. They asked practitioners to record the frequency (not the duration) of various contacts, such as telephone calls, letters, and face-to-face contacts with clients, professionals, carers and family members during an assessment. The authors then retrospectively estimated the average length of time spent on each type of contact by interviewing a sub-sample of practitioners. They found that challenging behaviour, immediate risks to mental or physical health, a carer needing support, living alone or in specialist care, and the presence of learning disabilities all increased costs. Hospital-based teams also had higher assessment costs than community-based social workers due to greater frequency of contacts with other professionals, but this may be a result of more specialised medical assessments taking place in the hospital-based teams. In this study, time costs for elderly patients varied from £36 to £915. The advantage of this method is that it comprehensively records potential time costs for all agencies and parties involved in the assessment in order to derive a true social cost. The main disadvantage is that it understates the time costs for complex cases resulting in a spurious positive correlation between lower assessment costs and worse health and morale outcomes.

Average time costs of social work involvement feature prominently in studies by Netten (1997) and by Levin and Webb (1997). Levin and Webb surveyed some 300 community care social workers in a London borough, a metropolitan district, and a county council. The study asked social workers retrospectively about the number and types of professionals contacted and the total amount of time spent on their last assessment until the care package was put in place. They focused exclusively on the cost of the social work input into an assessment, and estimated an average time cost for social workers of £111. They also found that costs were higher for hospital-based social workers, those with lower caseloads, and for assessments resulting in a nursing or residential care placement. Their method is useful with a large sample because recording is relatively easy for the social worker. However, the retrospective nature of the study probably led to an underestimate of the time costs.

In our study, we used a concurrent diary method to obtain an estimate of social worker time costs involved in community care needs assessments and care planning for patients being discharged from the medical, surgical, and trauma wards of two major general hospitals in a South Wales city. The main advantage of our method is that it is less likely to underestimate the time costs. It also permits a more detailed examination than previous studies of both working patterns and consequent cost variations that may be due to the work environment. Hospital-based social workers are more likely to react to pressure from medical personnel to discharge patients early while their peers in community settings may take more time to establish a care plan and consult more community professionals in the process. Thus, this study examines in detail the impact of different joint working arrangements between health and social services on social work practice, social worker time costs and the potential impact of practice on quality of care. We also examine the implication of patient characteristics, such as the reason for referral, on social worker time costs.

As indicated below, our study involved a small sample so it is difficult to draw definitive conclusions. Nonetheless we found some interesting variations in work patterns across the different organisational environments that affect the costs and quality of assessment and care planning. Social workers attached to GP practices spent a higher percentage of time with other professionals during an assessment and had more contacts with primary care and community professionals which may have improved the quality of the final package. Hospital-based social workers appear to have had more face-to-face contact time with clients and families and to have received referrals from ward staff more quickly than GP-attached colleagues. Although these results were suggestive and statistically significant at either the 5% or 10% level with a simple t-test, they were not statistically significant if we controlled for clustering of the standard errors at the social worker level.

Context

In the local authority studied, there exists a unique opportunity to study the impact of three joint-working arrangements on the costs and quality of care for a similar population of patients discharged from hospital into community care. Elderly and/or physically disabled patients may be referred to a hospital-based social work team, a social worker attached to a GP practice, or a social work area team. If the client’s surgery has a GP-attached social worker, then the case will go to that person. If the patient had previous contact with a particular social work team, then the client will be referred there. Clients without GP-attached social workers at their surgery or previous contact with social services are referred directly to a hospital-based social work team. Thus, there exists a subset of new case referrals that is demographically similar across all the social work teams.

Placing social workers in a hospital or community setting may have implications for the cost-effectiveness and quality of care for elderly persons being discharged from hospital. The GP-attached social workers, who are loosely managed by the area team managers, are potentially more accessible to clients, their families, and the primary care team. They are uniquely situated to receive referrals from community and primary care professionals allowing them to take early action to prevent or delay future hospital admissions. Social workers in community-based area teams may provide some of these advantages but not to the same extent as GP-attached peers. (see Cumella et al., 1996). This greater accessibility may result in more preventative needs assessment and delayed breakdown of care packages.

The possible benefits of a community setting may be offset by potentially higher operational costs of maintaining social workers there, as well as those associated with reduced contact with acute care hospital-based professionals and delayed hospital discharge. An economic evaluation must consider the full range of these hidden costs and benefits when determining which models of joint working provide best value. The time diaries used in our pilot study provided some clues about the impact of joint working arrangements on some of these cost and efficiency measures.

Methodology

To develop an hourly unit cost of social worker time, we used a diary which asked social workers to record the time spent on various activities as they assessed need and developed a care plan for a particular case. Twenty social workers agreed to collaborate in the study: eight based in medical social work teams in two large city hospitals; eight in four community based teams and four attached to GP practices. To generate a random sample of referrals and outcomes, we requested that each of the participants keep a diary for the next three referrals they received. We asked them to keep diaries on referrals from hospital wards with high referral rates in order to generate a sample of cases with similar health characteristics. We did not sample referrals from specialty wards such as neurology and cardiology. Thus, the unit cost estimated from the pilot study reflects a lower level of case complexity than might be expected more generally. Referrals did not necessarily lead to assessment and care planning, but of 58 diaries returned, 31 described a needs assessment that resulted in a care plan.

To develop an hourly unit cost of social worker time, we followed the costing methodology described in Netten (1997). The hourly wage, incorporating all of the hidden on-costs and overheads associated with employing the social worker, approximates the long-run marginal opportunity cost of a social worker, or the economic value of a social worker in his/her next best alternative use. The objective of the costing methodology is to allocate all resources associated with the provision of social worker time in an assessment to measurable outputs, such as time spent on activities that benefit clients. In this case, we could use the cost per hour of social worker time spent on face-to-face contact with clients or the cost per hour spent on client-related activities. Since the cost of the former was likely to understate the amount of input to a case, we calculated both measures and focused on the cost per hour of client-related time.

Table 1 describes how we derived the hourly unit cost of social worker time. First, we calculated the annual salary costs by adding salary on-costs (employer’s super-annuation and National Insurance contribution), revenue overheads (administration, maintenance, consumables, etc.) and capital overheads (building and land costs) to the annual salary. This generated a total annual cost that included the hidden overheads of employing a social worker1. Next, we calculated an hourly cost of social worker time based on a 37-hour working week, 20 days annual leave, 10 statutory leave days and 10 sickness days. The resulting £18 per social worker hour compares favourably with the national hourly average of £17 estimated by Netten and Dennett (1998).

Table 1: Developing a unit cost of social worker time 1

Cost component Social worker
Salary 20,313
Salary oncosts 2 3,636
Revenue overheads 3,592
Capital overheads 1,755
Annual cost 29,296
Hourly cost £19
Hourly cost of face-to-face contact £68
Client-related hourly cost £23

1 Follows costing methodology of Netten (1997).

2 Includes the employer’s contribution to national insurance weighted by the gender composition of the local workforce.

To calculate the cost of face-to-face contact time, we could either use the figures from a National Institute of Social Work study (see Levin and Webb, 1997) of community care social workers or the figures obtained from the time diaries. The Levin and Webb study suggested that social workers spend 20.87 per cent of their time in face-to-face contact with clients. Using this figure the cost of such contact time is £68 per hour. If we use the comparative alternative of 20.3 per cent derived from the time diaries, this figure becomes £89 per hour.

To calculate the hourly cost of client-related time, we used the Tibbitt and Martin (1992) estimate that 77 per cent of a social worker’s time is spent on client-related activities. Other studies have found this estimate to be fairly robust despite variation in location and social worker type (Von Abendorff et al., 1994; 1995). On this basis the calculated cost of client-related time is £23 for social workers. This was the hourly unit cost we used in our study to derive the cost of social worker time spent performing an assessment and developing a care plan. Ideally, we would have liked to attach the unit cost to a final output, such as the probability of a care package breakdown2. However, in view of time constraints we instead estimated the unit cost in relation to intermediate output of time spent on client-related activities, which should be positively correlated with better client outcomes.

Results

Of the 58 diaries returned, 31 listed a date when a care plan had been established. Twenty five of these involved an assessment and planning of either a residential, nursing or domiciliary care package. Two diaries established some form of package for the client despite their needs being too low. In one case, the client died after their care package had been put in place, and another deteriorated to long-term hospital care after the assessment and formation of a care plan.

Frequency of time spent on assessment and care planning

There is a considerable variation in the time required to do an assessment and set up a care package – from 155 minutes (2.6 hours) for an elderly man admitted with flu who required meals on wheels and attendance at a memory clinic to 1168 minutes (19.5 hours) for a suspected case of elderly abuse ( approximately twice as long as the second-most time consuming assessment). The mean length of time (excluding the elderly abuse case) to assess and organise a care package was 309 minutes (5.2 hours), just 10 minutes more than Levin and Webb’s (1997) estimate. Our results still suggest that the retrospective format of the latter study may have underestimated time costs, as their sample included complex assessments, such as those for disabled individuals and people with specialist medical problems. Multiplying 5.2 hours by £23 per hour generates an estimated unit cost of performing a community care assessment and developing a care plan of £123, slightly more than Netten’s (1997) estimate of £111. The median length of time required for assessing and setting up a care package was 288 minutes (4.8 hours).

Our time estimate was considerably lower than that of the local authority of 18.75 hours, obtained through retrospective interviews with social workers. The most likely reason is that we did not sample referrals for complex hospital discharges requiring specialised medical care or referrals for disabled individuals. Our estimate reflects the time costs of more typical hospital discharges, such as elderly persons with memory or mobility problems as well as those recovering from fractures, strokes and respiratory ailments. Also, retrospective estimates by any department of the time taken to do an assessment may sometimes be ‘generous’ in order to protect budget and staff.

The average proportion of time spent on each activity during assessment and care planning.

Although social workers claim that the quantity of paperwork has increased since the introduction of the 1990 NHS and Community Care Act, contact with clients and families still takes up the bulk of their time (29.6%) during an assessment. Paperwork and contacting other professionals also consume considerable amounts of time (23.6% and 23.3% respectively of total time spent), during the process. Assuming a rate of three minutes per mile travelled, social workers spend 10.5% of their total time travelling to case conferences or meetings with the clients or family. Little time is spent consulting with a supervisor or screening the referral.

Although the sample size of completed assessments is small, the results do suggest that there may be differences in the work practices of social workers operating in different joint working contexts. These may have an impact on the effectiveness of an assessment, but because of time constraints, we were unable to correlate them with the quality and outcomes of an assessment.

Hospital-based social workers had more time in direct face-to-face contact with patients and families than GP-attached social workers. This is not surprising due to the proximity of the hospital team. However, the total time spent on the phone and in direct face-to-face contact with clients did not differ across teams.

Table 2: Comparison of work practices among the different methods of joint working (excludes 1168 minute outlier for GP-attached social worker), completed assessments

GP attached Hospbased Area
Sample size 11 10 9
Average total time spent 298 289 345
Average total time spent (excludes travel time) 268 257 311
Average face-to-face contact in meetings with client or family (%) 20.9 22.1 17.6
Phone time spent with client or family (%) 10.1 6.2 11.7
Average time spent in total with client or family (%) 31.0 28.3 29.4
Time spent on paperwork (%) 20.6 27.3 22.0
Average time spent with other professionals (%) 26.3 17.6 27.1
Average time spent on travel (%) 10.3 11.0 10.4
Average time spent with PSSO (%) 2.6 1.1 2.6
Average time spent with Senior Practitioner and other social work colleagues (%) 2.1 2.5 3.8
Average time spent on other background activities, such as thinking time (%) 5.6 10.6 4.9
Average time spent on screening (%) 1.6 1.8 0.3
Average working days between referral and allocation to the social worker 1 2.1 0.3 0.14
Average working days between date of allocation and beginning of the assessment phase 1 1.1 1.2 3.9
Average time from the beginning of the assessment to the start date of the care plan1 (figures do not exclude weekends) 13.7 20.5 12.9

1 Excludes one diary from the hospital team which was an assessment that discovered problems after hospital discharge during the monitoring phase

Hospital-based social workers also spent a lower proportion of their time in contact with other professionals than either their GP-attached or area-based colleagues. This appeared to be related to greater contact by GP-attached social workers with community-based staff. This group reported an average of 1.45 contacts with community-based professionals compared to 0.8 from hospital-based social workers.

Hospital social workers also spent a greater proportion of their time on paperwork than their GP-attached peers. Follow-up interviews with those attached to GPs suggested a high degree of autonomy which allowed them to selectively complete the forms. As a result they carried higher caseloads – an average of 60.4, compared with 57.5 for those based in hospital. The impact of this on the quality and effectiveness of an assessment is unclear, but most social workers felt that paperwork generally detracted from the quality of an assessment.

The diaries indicated that attaching social workers to GP practices delayed the beginning of an assessment. It took 2.1 days on average for GP-attached social workers to receive a referral from the hospital compared to just 0.3 days for those based in hospital. However, GP-attached social workers took the same amount of time as their hospital-based colleagues to begin assessing once the referral was allocated and the average time from referral to care plan start date was actually lower for GP-attached than hospital-based social workers. These preliminary results suggest that the autonomous position of GP attached social workers may delay patient discharge slightly, but the community setting does not delay the assessment and care planning process once it has begun.

The results for area-based and GP-attached social workers were remarkably similar. The only significant difference was that social workers in the area teams spent slightly less time in face-to-face contact with clients and their families and received the referral in less time than GP-attached associates. Since area-based social workers were primarily assessing or re-assessing clients previously known to them, they may have felt that phone calls were efficient substitutes for such meetings.

Table 3 presents the estimated assessment costs for various client characteristics and characteristics of the final care package. In spite of the small sample size, the results tentatively suggest that hip and leg fractures, younger age, female gender and establishing a large domiciliary care package increase the cost of assessment and care planning. The high costs for hip fractures seem surprising because social workers considered these to be fairly common and routine. However, there were often hidden medical problems that caused the fall and fracture, so the resulting domiciliary care packages were often intensive but short-term.

Table 3: The impact of client characteristics on social worker costs of assessment and care planning

Primary medical complication: Sample size Av. Cost
Broken hip or femur 8 £138
Stroke 5 £125
Respiratory infection 4 £88
Terminal illness 2 £114
Confusion 2 £107
Non-specific illness 3 £94
Other 6 £125
Age 65 to 75 25 £138
Age greater than 75 5 £114
Female 21 £128
Male 9 £96
Lives alone 12 £120 /td>
Does not live alone 11 £112
Large domiciliary care package 12 £128
Moderate domiciliary care package 5 £111
Small domiciliary care package 5 £97
Residential care 2 £154
Nursing care 2 £99
Had previous SS care package 9 £129
No previous care package 20 £113
SW felt complicating aspects 9 £105
Straight-forward – no complications 13 £122
Medical ward 10 £110
Surgical ward 4 £102
Trauma ward 8 £126
Other ward 8 £130

Implications for Policy and Practice

The small sample size meant that most of the results were indicative rather than definitive. The higher percentage of time that GP-attached social workers spent liaising with other professionals was statistically significant at the 5% level with a simple two-sided t-test and no cluster effects. This suggests that attachment to a GP setting increases the number of contacts a social worker has with primary care and community professionals, which may improve the quality of the care package and reduce the likelihood of breakdown.

The differences in work practices across the different methods of joint working may have substantial impacts on the cost and quality of an assessment and are worthy of further study. A larger sample of community care assessments and care plans is necessary to control for other influences on costs, such as social worker characteristics that may be correlated with the work environment. A larger sample would also allow researchers to perform a cost function analysis to determine the most significant factors affecting costs in the different environments. Ultimately, any economic analysis will need to link costs with client outcomes to determine ‘best value.’ Challis and Davies (1986) describe how they linked the cost of the care package under case management to an index measure of patient well-being, or morale. In this study, we linked the hourly cost of social worker time to an intermediate measure of output, such as client-related time. Given a longer timescale, a larger study could link costs to final outputs, such as patient health or psychological well-being and the probability of having a care package break down.

The concurrent diary method is also a potentially useful tool for evaluating costs in the field of community care. Although some social workers filled in the forms retrospectively, the concurrent diary method has less of a bias towards underestimation than a retrospective approach. The trade-off, however, is a smaller sample of completed diaries and more opportunity costs of social worker time spent recording information for cases that never end in a care plan. Nonetheless, learning about time spent on referrals that never reach a care plan is useful in its own right in revealing information about social work outputs often hidden from higher levels of management.

Limitations of the Methodology

The unit cost measured in this study is of social worker time involved in the assessment and establishment of a care plan. To calculate the true societal costs of assessment and care planning, it is necessary to cost the resources used by all agencies involved, including those in the independent sector. Most social workers listed the number of contacts with other professionals, but they often understated the time spent on these and did not list the other professionals attending a case conference. Thus, we were unable to calculate the total unit cost to society of the assessment and care planning process.

At the end of the study we interviewed social workers to assess the usefulness of the method for estimating unit costs and tracking the activities associated with particular cases. Although workers were asked to fill in the diaries concurrently as they worked on a case, 62% percent admitted in the follow-up interviews that they had completed them retrospectively. Furthermore, the response rate was low with workers returning only 35% percent of the diaries requested. One reason for this was an inherent problem with the approach in this area – only half of the referrals sampled resulted in an assessment and formulation of a care plan. Many clients died in hospital or simply wanted counselling and advice. Other factors, such as an impending reorganisation of the social services department and increased job insecurity made social workers reluctant to fill in forms that could potentially be used to evaluate their performance. Social workers also believed that learning how to complete another form was quite time consuming though actually filling in the diaries every day was not. The concurrent diary method undoubtedly yielded useful information about assessment activities and the time costs of other social work activities associated with community care referrals. However, the fact that many staff completed the diaries retrospectively suggests that a retrospective approach may ultimately be the pragmatic choice in any larger study, unless ways can be found to generate better compliance with the concurrent model.

Finally, our estimate of the unit cost reflected the time of year when the study took place. The diaries were kept between late November 1998 and the end of January 1999 and the sample therefore contains higher proportions of referrals for flu and respiratory ailments than the annual case-mix of referrals. Also, increased demands for hospital beds and higher levels of sick/holiday leave among social workers may have influenced work practices during that time of year, especially the time taken to complete an assessment.

Concluding comments

This article described the results of a small pilot study to measure the unit costs of assessment and care planning, identify sources of cost variations, and investigate the impact on outcomes for a future large-scale economic comparison of various methods for discharging patients from hospital into community care. The findings permit some tentative conclusions that we hope will aid future studies of joint working arrangements in the delivery of community care.

First, we concluded that the use of a concurrent time diary method to monitor costs and identify cost variations is potentially useful in a large-scale study but not necessarily pragmatic given the higher opportunity costs of staff time in recording cases that never lead to a care plan. However, the method is probably most useful in studies of workload across social work teams, as in James (1997), because it captures information about the substantial hidden costs of social worker time spent processing cases that never appear on the case monitoring system. If practitioners wish to implement the approach, making the form part of the job requirement may improve the response rate, although it may equally distort results if workers see it as a method for evaluating their work effort and efficiency. Doing the research through an external organisation and guaranteeing confidentiality may improve the response rate. Second, our research yielded some interesting results about how changes in organisational setting may affect work practices, costs and quality of outcome. For example, hospital-based social workers appear to spend a larger percentage of time in face-to-face contact with clients and families because of their proximity to patients than community based social workers who conduct more of their follow-up interviews over the phone. Although the total amount of time spent with patients and their families was similar across social workers in all settings, greater face-to-face to contact with clients may improve the quality of the initial assessment and reduce the probability of having the care package breakdown. Social workers in GP surgeries had more contacts with Notes community care professionals than their hospital-based colleagues workers when developing the initial care plan, but they experienced a one or two day delay in receiving some hospital referrals. This supports the perception of hospital consultants that social workers based in the community are less responsive to the need for quick and efficient hospital discharges. Although the results from the pilot point to some hidden costs of removing social workers from the hospital into the community, the potential preventive benefits of GP-attachment may outweigh these and a larger economic study is necessary to draw robust conclusions.

Finally, the results from the pilot emphasise the need for further research into the effectiveness and cost effectiveness of the various joint working arrangements spawned by the 1990 NHS and Community Care Act. A variety of anthropological and sociological approaches can usefully illuminate the inefficiencies and changes in care quality resulting from the various organisational arrangements. If it is possible to find a population of similar individuals over which comparisons can be made, then the addition of an economic analysis can provide a structural framework for making decisions about optimal program design and resource allocation (see Denniston et al., 1999, for a more detailed description about applying economic analysis to social care programs.)

Future research should investigate in more detail the links between organisational arrangements, work practices, costs and quality of outcome. Various practice differences that may be due to the physical proximity of social work teams to patients, hospital staff and primary care professionals are likely to influence the cost and effectiveness of the assessment and case monitoring processes. For example, the finding that community based social workers tend to contact clients and families over the phone rather than face-to-face may affect the probability of care package breakdown. This, and other differences in work practice brought about by the contrasting organisational arrangements, may affect the quality of interaction with clients and the degree of empowerment achieved (Stevenson and Parsloe, 1993). Furthermore, our pilot study focused on assessment, but future research could compare the quality of case monitoring by social workers in primary care and hospital settings where quality is measured as the probability of a care package breaking down, changes in client morale, or other appropriate scale. Nonetheless, effectiveness and quality of outcome is only half the story. Studies of the full social costs, including subsidies from health to social services, need to be linked to outcomes before policymakers can make sound allocation decisions – hence the need for continued attempts to add an economic perspective to studies of social care programs.

1 Where possible we used local authority costs. Since the employer’s National Insurance contribution varies according to whether the employee pays superannuation and is a married female or not, we calculated a weighted average based on the percentage of female social workers. Unfortunately, we were unable to obtain accurate capital and revenue overhead costs for the hospital-based teams as the Trust insisted on ethics committee approval before the information could be released, which couldn’t be obtained within the timescale. Obtaining this information for GP-attached social workers required the permissions of all of the relevant surgeries which was also outwith our timescales. Fortunately, the social services department collects most of the necessary information for the area teams, although it was impossible to derive an accurate local cost component for the capital and revenue overheads without the NHS information. We therefore used national estimates with a non-London adjustment for these cost components. Following Netten and Dennett (1997), we assumed that revenue overheads were approximately 15% of a social worker’s overall salary including on-costs. We also obtained a capital component by multiplying the capital estimate of £1773 from Netten and Dennett (1998) with the non-London multiplier.

2 An essential component in a study of ‘best value’ is measuring the effectiveness of a program. The effectiveness of a social care program is the impact of the program on intermediate outputs and/orfinal outputs. Interinediate outputs are changes in process outcomes or quality standards that produce final outputs. Final outputs are the changes in client well-being, such as improvements in morale or health outcomes brought about by changes in the intermediate outputs, such as speedier discharge or greater face-to-face contact with clients.

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