Preface Editorial Commentary Glossary... 21

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4 CONTENTS Preface... 4 Editorial... 5 Commentary Glossary Schemata 1 Services for elderly people Schema 1.1 Private nursing home Schema 1.2 Private residential care home Schema 1.3 NHS nursing home Schema 1.4 Local authority home Schema 1.5 Local authority day care Schema 1.6 Hospital services Schema 1.7 Meals on wheels Services for people with mental health problems Schema 2.1 Local authority home Schema 2.2 Local authority day care Schema 2.3 Hospital services Services for people with learning difficulties Schema 3.1 Local authority home Schema 3.2 Local authority social education centre Schema 3.3 Hospital services Generic services Schema 4.1 Speech therapist Schema 4.2 Psychologist Schema 4.3 Art and music therapist Schema 4.4 Drama therapist Schema 4.5 Occupational therapist Schema 4.6 Physiotherapist Schema 4.7 Chiropodist Schema 4.8 Community psychiatric nurse Schema 4.9 Health visitor Schema 4.10 District nurse grade G Schema 4.11 District nurse grade D Schema 4.12 Auxiliary nurse grade B Schema 4.13 General practitioner Schema 4.14 Social worker Schema 4.15 Home care Inflation indices References Author index Service index

5 PREFACE The Department of Health (DH) is commissioning a number of exercises to throw light on the unit costs of services. As part of this, a working group has been established, primarily drawn from members of the Personal Social Services Research Unit (PSSRU) and the Centre for Health Economics (CHE). This volume is based on an earlier report by the authors to this working group. Ann Netten is a Research Fellow at the PSSRU, and Steve Smart was at the DH. Our thanks are due to the other members of the working group: Martin Knapp (chair), Andrew Bebbington, Jeni Beecham, Kirsteen Smith, Raphael Wittenberg and Ken Wright, and in particular to Jeni Beecham and Raphael Wittenberg for much advice and patience. Research assistance was provided by Anita Whitley. Bleddyn Davies and Charlotte Salter have provided valuable advice and comments. Many people from the following organisations provided useful feedback and information on a previous draft of this report: the Audit Commission, Berkshire Social Services Department, Bexley Housing and Social Services Department, Birmingham Social Services Department, Bradford Social Services Department, the Chartered Society of Physiotherapy, Croydon Community Trust, Hampshire Social Services Department, Homewood NHS Trust, the Institute of Public Finance, Kent Social Services Department, Lewisham Social Services Department, the National Asssociation of Health Authorities and Trusts, and the Society of Chiropody. Within these organisations, we are particularly grateful to Peter Graham, Deborah Smith, and David Ward. Our thanks are also due to Cam Donaldson (Health Economics Research Unit, Aberdeen) and Neil Garrod (University of Wales, Bangor) for their valuable comments. Nick Brawn and Jane Dennett at the PSSRU helped in the production of this report. 4

6 EDITORIAL There is a growing demand for information about the costs of community care. More specifically, there is both a need for and a lack of accurate information on the unit costs of services. Although there has been research which has included a costing element and research that can inform the costing process, there is a need to establish an agreed set of guidelines on what exactly constitutes, say, the cost of providing an hour's counselling by a social worker, or the cost of a GP consultation. It is anticipated that this report will be the first in a series bringing together the most up-to-date information about national unit costs of services. The intention is to produce a reference volume providing readers with sufficient detail for them to amend or adapt the unit costs presented to suit their own particular purposes. Each report will contain a set of cost `schemata' containing specific information about the cost of each service covered; a commentary detailing the basis for the estimates; price indices; a reference list of key studies; a glossary and indexes. As the first in the series, this editorial describes the basic principles behind the cost estimates and the schemata. It identifies issues of concern and briefly outlines the programme of work which will feed into future publications. Principles and practice in estimating unit costs Throughout this volume the economic concept of opportunity cost is used to define what should be measured and how. The rationale behind this approach has been discussed in detail elsewhere (see Netten and Beecham, 1993), but it is important to be clear about the implications for the estimates produced here. Ideally, the opportunity cost of a service represents the value of alternative uses of the resources tied up in the production of that service. The opportunity cost of a unit of service represents the value tied up in producing an additional or marginal unit in the long term. Thus, in estimating the cost of a session of day care, it is relevant to include capital costs as, at the margin, a new establishment may need to be constructed to accommodate an expanding service or sold when a service is contracting. Limitations on data mean that the costs actually estimated frequently fall far short of the ideal. For example, it is important to note that, based as they are on available data, the costs necessarily represent long-run average costs assuming the current level of capacity. This is appropriate for many purposes, but does not allow for changes in scale. Thus it would not be appropriate to use the unit costs presented in the schemata to estimate the resource implications of a major development of one or more services. Moreover, local authority-provided services incur a number of types of overhead: for example, direct management, departmental support and central services from other local authority departments. There are similar types of overhead expenses associated with providing health services. At present it is not easy to distinguish exactly what is included in available data or the consistency with which different authorities recharge for different types of overhead. In principle, however, the only overheads that should be included here are those associated with the provision of the service. These may be direct (such as supplies and services or line management) or indirect (such as personnel and training). Costs associated with the local authority function (such as the expenses associated with administering social services committees) or with purchasing (such as inspection and regulation) are excluded from the unit costs of providing services. This is in line with guidelines for auditors currently being drawn up by the Audit Commission. Detailed definitions will be clarified in future issues as these guidelines are developed. Another area causing problems of principle and definition is the pricing of capital inputs. These are of particular importance as capital frequently represents a high proportion of unit costs, and estimates are highly sensitive to different assumptions. While opportunity costing specifies that it is the value of the resources tied up in capital that should be priced, how that valuation is made depends upon the circumstances in which the cost is to be used. The assumption was made throughout that services were expanding and that the appropriate value was that of `new build'. Alternative approaches - such as 5

7 retraction models - can be used when, for example, long-term hospital care is known to be a contracting service. It was not possible to include such assumptions here, although ongoing studies are using retraction models and it may be possible to incorporate discussions in future issues. In producing nationally applicable up-to-date information, it was anticipated that for the most part the costs would be used for planning or providing estimates of current costs. Thus the unit costs estimated will refer to the current financial year. Necessarily, therefore, inflators have been used for a number of estimates. Where they are necessary, the inflator used for each element has been identified. Why schemata? While an objective in assembling unit cost information was to initiate an agreed approach and standard of costing which could prove of value to local and health authorities, the way in which a costing is estimated depends fundamentally on the purpose of the costing exercise (see Netten and Beecham, 1993). Clearly, if the costing approach is to be of value to different users it will be for a number of purposes. Even within the Department of Health a variety of potential uses for estimated unit costs of services have been identified: costing the effect of demographic changes or new policies on public expenditure; option appraisal such as the cost-effectiveness of different modes of care; and examining the technical efficiency of services over time. To facilitate both this and the identification of important gaps in our knowledge, it was judged important to provide `building blocks' of cost information in order to provide an approach to costing services which was as flexible and valid as possible. In doing this it was necessary to identify the key elements in constructing unit costs. The elements identified were: client group; type of service; providing agency; resource type (for example, capital, labour and overheads); activities (for example, time use, tasks and commodities); and causes of variation (for example, regional issues, population scatter and dependency of clients). Moreover, in converting the prices of inputs to service unit costs, the appropriate levels of aggregation need to be made clear: what exactly are the costing units? The schemata demonstrate the way in which we resolved the problems presented by the need to consolidate and identify this level of detail. First, two main types of service were identified - peripatetic and facility-based - each of which had different implications for the costing process (Allen and Beecham, 1993). For each service a schema was devised. In the top half of the schema the main elements of the cost are identified. For facility-based services these are capital, revenue expenditure, providing-agency overheads and other costs. The elements included in the capital and revenue overheads are specified although, at the nationally applicable level, it was never in fact possible to establish the value of each element. For peripatetic services these elements are the salary or wage of the employee concerned, salary on-costs, providing agency revenue overheads, capital overheads and travel costs. The lower half of each schema contains the information necessary to convert these basic data into a unit cost. Thus, to estimate a daily or hourly cost, it is necessary to know how many days a facility is open each year, how many hours a peripatetic worker works and so on. For each available piece of information the primary data source, reference and value are identified. The reference section includes all of the literature drawn on in the process of establishing the most appropriate research results and information for establishing unit costs. Exactly what was used for what purpose is identified in the schemata, allowing readers to check whether the research methodology reflected any issues relevant to the purpose of an individual costing exercise. Each schema also identifies references that contain cost-related material about the service. Where further clarification is necessary, brief comments are included on the schema. Fuller discussion is included in a commentary which introduces the schemata and identifies the principal issues raised in establishing the current unit cost for each service. This is of particular importance because what information has been used, and in what way, is often not made clear in the literature, which makes it difficult to adapt the material for other applications. The intention here is to make the information in the schemata serve as many purposes as possible. 6

8 The schemata themselves are organised by client groups where appropriate, but the vast majority of peripatetic services are not specific to any one client group so these have been included in a final section (generic services). The schemata contain many gaps, reflecting a general paucity of information, particularly in relation to appropriate weightings to reflect dependency, regional variations, outcomes and quality of care. The unit costs presented provide the best available estimates at the present time and do provide a valuable basis from which to work. There is clearly a long way to go, however. In determining the best way forward, it is helpful to identify issues of concern in the current estimates. Issues of concern The information presented in the schemata necessarily draws on historical research and publicly available statistics. This may create difficulties because these reflect the costing needs of the social and health care world before changes such as the purchaser-provider divide introduced as a consequence of the NHS and Community Care Act, If the costs are to be of value in a world of flexible and innovative provision, it is more than ever vital to know what is being costed and why. Providing as much detail as possible and describing the rationale behind each service costing enables users to adapt the the information for different purposes and circumstances. While problems remain because of a lack of detail and because there is clearly a need to develop further sources of information (for example, with regard to capital costs), the most important questions are still what exactly has been costed and what unit is the most appropriate to cost. Addressing these questions is of importance if any attempt is to be made to use the figures or methods to compare different areas, modes of care, or changes in unit costs over time. It is vital to compare like with like and this can only be done if what each service provides is clearly defined. Whether this presents a problem depends primarily on the unit to be costed. For example, home care workers can and do provide both personal care and housework. As they are paid the same rate regardless of the task, the unit cost per hour will not vary unless clearly-defined additional payments are identified. The cost implications of different tasks undertaken will be reflected primarily through the number and distribution of service hours received directly by the client. The same is not true for all services, however. In particular, day care of elderly people covers an enormous range of provision. Some centres provide a variety of commodities such as personal care, physiotherapy, chiropody, group therapy and entertainment, in addition to the basic level of social contact and meals provided by most establishments. Indeed, the variety in types of provision has led to considerable debate in the process of defining the service (Tester, 1989; Brearley and Mandelstam, 1992). The range of service components featured by centres is unlikely to account for all of the variation in costs, but, in using cost information, planners, evaluators and policy makers need to know the average cost of different types of day care services. What information there is about the causes of variation in the costs of day care was based on data collected in the mid-1970s (Knapp and Missiakoulis, 1982). Although there was some evidence that the facilities and services offered by different centres did affect costs, it was not in a form that could be used in this context. Moreover, in contrasting different types of service delivery, it would also be useful to establish, for example, the marginal cost of physiotherapy at a day centre compared with the cost at a clinic or health centre. Such estimates would have to be made with care. For example, in estimating differential costs, allowance would need to be made for case mix. What is clear, however, is that as day care develops over time and differentially between areas, unit cost per place is likely to be less and less appropriate as a means of comparison, or even of planning for services. There is a need for an agreed method of defining what exactly is being provided by the day centres in question. Such problems are likely to increase rather than decrease in importance as services continue to diversify. For example, day activities for people with learning disabilities can no longer be assumed to be provided in a single establishment. Using core and satellite models of care will have important implications for the unit costs of such activities. Moreover, the increasing importance of resource centres providing day, domiciliary and residential services means that each service will need separate and careful costing. There are also problems in using the cost information presented in the schemata for all peripatetic professional staff. These arise because there is often little or no information about the relationship 7

9 between the time spent with a client and time spent on other client-related and non-client-related activities. A valuable study of community nurses was conducted by the Office of Population, Censuses and Surveys in 1980 (Dunnell and Dobbs, 1982), but there have since been radical changes in the organisation of the community health service and grading of staff. Physiotherapists are unusual in the level of information about workload management (Williams, 1991; Stock and Seccombe, 1992). They introduce an alternative approach to the unit to be costed: the episode of care. The cost of this will depend upon the condition to be treated (such as lower back pain), but where information is available on the incidence of such conditions in a given population it provides a more appropriate way to cost service requirements. The problems presented by lack of information are at their most acute when estimating the cost of social work. This is of particular importance because of the pervasiveness of social workers' involvement in the community care of all client groups. Research conducted in the USA suggests that there is considerable variety in the proportion of social work time spent with clients. This may reflect differences in practice, caseload demands, type of service offered or simply differences in methodologies and definitions (Fein and Staff, 1991). Moreover, there are limited data on the variations in patterns of working associated with different client groups. Although there is some information about this from a Scottish study (Tibbitt and Martin, 1991), patterns of working are likely to be different south of the border. Furthermore, the costing of overheads for social work is based on one small-scale study of child care in Suffolk (Knapp et al., 1984). In addition to these problems there is the question whether direct client contact is a useful indicator of the resource implications of social work involvement. While counselling and assessment involve much direct contact, many tasks such as coordinating and planning services may depend more on the number of services involved with the client than with the amount of time the social worker spends in direct contact. Thus we must deal with the question of how we should measure social work involvement before we can discuss how we should cost it more accurately. The issue of what is being costed is highlighted by the introduction of care management. Other professionals, such as occupational therapists, may well take over or continue performing care management tasks. Just as in the costing of residential care it is desirable to reflect the average spread of dependency in the unit cost on a national level so, in costing care management, it will be desirable to reflect the professions and grades of the people who become involved at each stage of the care management process. The numerous gaps and problems with the information presented in the schemata are detailed for each service in the commentary, and so are not repeated here. The broad issue which needs to be addressed is how the current data can best be developed to reflect the changing requirements of those who need to use nationally applicable unit costs. The way forward The purpose in assembling the information about unit costs was to provide a `state of the art', comprehensive and flexible source of unit cost information for the use by central and local government, health authorities and those involved in research. The need for this type of information will grow rather than diminish and, while local costs should reflect local circumstances, consistency in approach can only be of value. Clearly there are many gaps in the current level of knowledge and the aim for future reports will be to draw on currently planned research and other sources to enhance and expand the services to be costed. Early priorities will be: to develop schemata for services for children and families; to develop approaches to the estimation of the costs of day services; to develop approaches to professional time use drawing on the literature and ongoing research; and to improve capital estimates. 8

10 It will not be possible to produce ideal costings overnight. The intention is to seek to improve estimates over time, drawing on material as it becomes available. In this process, users of this and subsequent reports have a valuable role to play. The aim is to provide a focus for the development and exchange of cost information. In this exercise the more that readers feed back criticisms and additional information, the more valuable this type of publication is likely to be. Please send all suggestions, comments and criticisms to:... Ann Netten, Personal Social Services Research Unit, University of Kent at Canterbury, Canterbury, Kent, CT2 7NF. 9

11 Bibliography Allen, C. and Beecham, J.K. (1993) Costing services: ideals and reality, in Netten, A. and Beecham, J.K. (eds) (1993) Costing Community Care: Theory and Practice, Ashgate, Aldershot. Brearley, P. and Mandelstam, M. (1992) A Review of Literature on Day Care Services for Adults, Department of Health/Social Services Inspectorate, HMSO, London. Dunnell, K. and Dobbs, J. (1982) Nurses Working in the Community, OPCS Social Survey Division, HMSO, London. Fein, E. and Staff, I. (1991) Measuring the use of time, Administration in Social Work, 15, 4, Knapp, M.R.J. and Missiakoulis, S. (1982) Inter-sectoral cost comparisons: day care for the elderly, Journal of Social Policy, 11, 3, Knapp, M.R.J., Bryson, D. and Lewis, J. (1984) The comprehensive costing of child care: the Suffolk cohort study, PSSRU Discussion Paper 355, University of Kent at Canterbury. Netten, A. and Beecham, J.K. (eds) (1993) Costing Community Care: Theory and Practice, Ashgate. Stock, J. and Seccombe, I. (1992) Understanding Physiotherapy Staffing Levels, Report for the Association of Chartered Physiotherapists in Management by the Institute of Manpower Studies, University of Sussex. Tester, S. (1989) Caring by Day: A Study of Day Care Services for Older People, Policy Study in Ageing no 8, Centre for Policy on Ageing, Dorset. Tibbitt, J. and Martin, P. (1991) Where the Time Goes, Central Research Unit Paper, Scottish Office, Edinburgh. Williams, J. (1991) Calculating Staffing Levels in Physiotherapy Services, Pampas Publishing, Rotherham. 10

12 COMMENTARY The unit costs presented in the schemata have been estimated from various sources. They are rarely ideal but reflect the current level of information in the field, so figures quoted are subject to a margin of error depending on the assumptions made. This commentary details these assumtions and particular problem areas. Definitions of terminology used both here and in the schemata can be found in the glossary (page 21). The reference numbers on the costing schemata and in the text refer to the reference list on pages At the bottom of each costing schema references are given to other literature that is relevant to that particular service. The cost estimates are national averages with regional multipliers detailed where available. All services costed are quoted at 1992/93 prices. Most of the peripatetic services costed are based on 1992/93 pay scales. Unit costs for the other services, mainly facility based, have had to be inflated to 1992/93 prices. Where costs have been revalued, the inflator used is detailed. Inflation indices can be found on page 55. The elements included in the unit cost for each service are detailed in the schemata. The resulting unit costs have been rounded to the nearest 10p, and are as comprehensive as possible. However, in a number of cases reliable estimates of certain elements of cost are not available (for example the local authority (LA) residential and day care figures do not include social services departments (SSDs) overheads). Care needs to be taken when using these costs to ensure that: (i) all the elements included are relevant to the job in hand; and (ii) account is taken of missing elements if they are considered to be important. It is also important to be aware that capital costs form a high proportion of many unit costs, and the assumptions that need to be made about the opportunity cost of capital vary, depending on the circumstances of the exercise. Users of the information presented here need to consider carefully whether the `new-build costs' assumed throughout are appropriate to their purposes. FACILITY-BASED SERVICES For most of the facility-based services the capital costs have been spread over the life of the facility by converting them into annual equivalent costs, assuming a building life of 60 years and a discount rate of 6 per cent (as recommended by HM Treasury). Hospital inpatient services For hospital inpatient services the capital estimate is 15 per cent of revenue costs. This is based on some costings for the Care in the Community Demonstration Programme, undertaken by the Personal Social Services Research Unit (ref 58). This method is not entirely satisfactory as it was based on work conducted in the mid to late 1980s and it is probable that, given the recent trends in construction prices, the percentage relationship between revenue and capital costs has altered. An attempt was made to build up a capital cost estimate using information provided by the National Health Service Estates Directorate (ref 63). This enabled a cost per bed (including buildings, essential complementary accommodation, on-costs, equipment and land) to be calculated. However, this cost per bed was not used in the schemata as it did not reflect the average capital cost per bed. No estimate was available for a share of central capital (for example, offices, car parks, kitchens and boiler rooms). Estimating the capital cost of hospital services should prove easier in future given the introduction of capital charges to the NHS in April In effect, the capital charge should represent the economic cost of capital. At the very least the compilation of the asset registers necessary for the implementation of the capital charging system will provide a useful source of data when estimating capital costs. Publicly available individual NHS Trust business plans should prove a useful source of provider-level capital charge information. 11

13 The appropriate capital estimate to employ will depend on the use to which the unit cost is to be put. For example, when costing a bed in an institution which is scheduled to close, the market value of the occupied land might be the appropriate capital cost estimate to use. The revenue figures for hospital services are taken from a memorandum placed before the Health Committee (ref 51). These national estimates are based on Department of Health (DH) FR12 figures for 1989/90. FR12s are district-based specialty returns and provide an estimate of hospital expenditure for each specialty. However, they only cover direct treatment expenditure and do not include expenditure on general services such as laundry, cleaning and administration. The figures quoted in the memorandum have been grossed to total expenditure on the basis of pre-1987/78 data on overhead costs by hospital type. A major problem with the FR12 figures is that they are specialty-based. Consequently, it is impossible to differentiate between different types of hospital setting. For example, the revenue figure for beds for people with mental health problems includes both long-stay beds and short-stay acute beds. Ideally these figures should be adjusted to reflect a particular hospital type (for example, short-stay, long-stay, district general and community residential unit) but the necessary data are not available. The situation should improve in the near future as the DH is now collecting provider-based financial information, although even this will have its problems as a provider may well encompass more than one type of hospital. Local authority services The revenue figures for local authority day care for the three client groups costed are based on Chartered Institute of Public Finance and Accountancy (CIPFA) 1990/91 actuals. CIPFA figures for the gross cost per place filled excluding capital charges are assumed to approximate the revenue cost of day care. These figures are not ideal: they suffer from a lack of consistency in definition across local authorities and there is some concern as to whether all relevant revenue overheads are included. However, they do provide the best available national estimates. Local authority expenditure figures collected by the Department of the Environment (DoE) are considered to be more reliable (see ref 66, chapter 6) than CIPFA figures, but these are not publicly available in a usable format. The CIPFA all-england figure is used as the best estimate of a national average cost. The all-england figure is based on all responding local authorities. Ideally, those figures which look suspiciously high or low should be omitted from this estimate. However, the information necessary to do this (to split the gross cost per place filled excluding capital charges into a numerator and a denominator) is not available. The cost per place per day is calculated by assuming a 250 day year (ref 54). For both local authority residential and day care services for the three client groups costed there is a possibility of a mismatch between capital and revenue cost estimates. The capital figure in each case is either a cost per bed or a cost per place assuming 100 per cent occupancy, whereas the revenue figure is a cost per resident/client with occupancy rate unknown. If the occupancy rate for the revenue estimate is known, the capital estimate should be adjusted accordingly. PERIPATETIC SERVICES The methodology for calculating unit costs for the peripatetic services has principally been taken from either Beecham (ref 54) or Netten (ref 61). Where possible a unit cost per visit as well as a unit cost per hour are presented. In the case of physiotherapy, it has also been possible to cost an illustrative `episode of care' which may be the appropriate unit to cost in many circumstances. However, for most of the services costed, the necessary information (for example, length and number of visits) was not available to be able to do this. The majority of the peripatetic services presented are classed as generic. Client group-based costings would require the average salary for workers dealing with that client, the typical length of visit and appropriate client to non-client contact ratio. These should reflect average case mix and the spread of 12

14 visit type (for example, assessment, treatment and follow-up). Unfortunately, information at this level of detail is not currently available for any client group. The salaries quoted are either weighted averages of all whole time equivalent (WTE) staff in post or, as is the case for community nurses and social workers, the mean of the relevant salary scale. Where weighted average salaries have been calculated, this has been done using 1992/93 pay scales and the latest available information on numbers of staff in post (this is either September 1990 or March 1991). The uplifts (percentage additions) for salary on-costs are based on the latest applicable employers national insurance and superannuation contributions. All NHS and personal social services (PSS) staff costed are contracted out in terms of national insurance contributions. Although detailed information is not yet available, two types of revenue overhead have been distinguished: direct and indirect. These both refer to the costs of providing the service. Direct costs include day to day expenses such as supplies and services, immediate line management, telephone, heating and stationery. Indirect overheads include managing agency costs such as personnel, specialist support teams and financial management. Costs associated with the purchasing function, such as inspection and regulation, are assumed to be excluded. For most of the services, no specific allowance for sickness leave has been made. In the cases of physiotherapy and chiropody, information was available and included in the estimates of unit costs. Where information is available, the difference between the costs of a domiciliary visit and a clinic or office visit has been distinguished. It should be noted, however, that the costs have reflected time use and no allowance has been made for the capital implications. Community health services For NHS professionals and community nurses, revenue and capital overhead uplifts are taken from Netten (ref 61). The revenue uplift (16.5 per cent) is based on the proportion by which general services net of direct credits increased salary costs for community health services nationally. This figure is based on 1989/90 data. Depending on the particular situation, it may be appropriate to recalculate this figure for the latest available year and/or base it on local data. For the purposes of this exercise, travel costs are not included in overheads but estimated separately. The capital uplift (8 per cent excepting district nurses) is based on the percentage increase in health services expenditure accounted for by capital in This estimate is not really satisfactory but is the best available at present. The new capital charging system referred to above should produce more accurate data from which to make estimates. District nurses and nursing auxiliaries are only given a capital uplift of 3 per cent as Dunnel and Dobbs (ref 4) found that over 60 per cent of district nurses and auxiliaries worked from home so there was no capital element other than that associated with revenue overheads. The following grades of community nurses are costed: grade G plus psychiatric lead (equivalent to a community psychiatric nurse); grade G (equivalent to a health visitor, mental handicap nurse or an old category district nurse SRN); grade D (equivalent to an old category district nurse SEN); and grade B (equivalent to an old category nursing auxiliary). No additional allowances have been included to allow for evening and weekend working. One Community NHS Trust has estimated that this costs an additional per cent, depending on skill mix. 13

15 Travel costs per visit for NHS staff are also taken from Netten (ref 61) uprated to 1992/93 prices using the fares and other travel costs element of the retail price index. These are based on the expected average annual level of claims divided by the number of contacts per district nurse to give an average cost per visit (1989/90). This figure has been used for all NHS staff. A number of observers have suggested that this estimate appears low but have been unable to produce another substantiated figure. Travel costs are highly dependent on the type of area (rural/urban), and wherever possible it is suggested a more appropriate figure is used for planning and estimates. The client contact multipliers included for community nurses are based on Dunnel and Dobbs (ref 4, p.33, table 6.5). These allow a cost per hour spent with a client to be calculated. Assuming that each visit lasted an hour, the cost per visit for community nurses would be the cost per hour spent with a client plus the travel cost per visit. The regional (London) multipliers detailed for NHS professionals are based on work undertaken by Akehurst et al. (ref 42). These authors estimated that skilled labour costs were 22 per cent and unskilled 17 per cent higher in London than in England as a whole. The skilled labour multiplier is applicable for all NHS professionals excepting grade B (auxiliary) nurses where the unskilled multiplier is applicable. These multipliers should be applied to all elements of cost excluding travel. The NHS professionals costed are assumed to be community based. If hospital based NHS professionals are being costed then overhead and capital cost uplifts relevant to hospitals should be used. Personal social services The regional (London) multipliers for PSS workers are taken from work undertaken, on the higher unit costs of PSS services in London, by Bebbington and Kelly (ref 43). Both multipliers are based on staff cost differentials. The following brief descriptions of each individual costing schema are presented in client group order. 1. ELDERLY PEOPLE 1.1. Private nursing home (page 24) The method of estimating the unit cost of a private nursing home is taken from Kavanagh et al. (ref 56). The direct unit cost of private nursing homes is assumed be the fee. Where a market is fairly competitive, such as the market for private nursing homes, it is reasonable to assume that the fee will approximate the social cost of the service. The average fee for 1991/2 is taken from the latest Laing and Buisson market survey (ref 60). The figure quoted is the average fee in England for a single room multiplied by the percentage of single rooms, plus the average fee in England for a shared room multiplied by the percentage of shared rooms. This figure is then uprated to 1992/93 prices using the hospital and community health services (HCHS) pay and prices inflator. Added to this direct cost are two sources of indirect cost. First, 5 per cent is added to the unit cost to reflect costs borne by other agencies, primarily DHAs and FHSAs. The figure of 5 per cent is taken from Knapp et al. (ref 58) and is based on costings of some of the Care in the Community projects. Second, the Department of Social Security (DSS) personal allowance for 1991/2 is added as a proxy measure of personal consumption Private residential care (page 25) The unit cost for private residential care homes has been calculated in exactly the same manner as for private nursing homes. Once again the Laing and Buisson survey provides an estimate of fees. The personal social services (PSS) inflator is used to inflate the average fee to 1992/93 prices NHS nursing home (page 26) The unit costs for NHS nursing homes are taken from Donaldson and Bond's (ref 45) cost effectiveness study of three experimental NHS nursing homes. Two of these homes were located in the north of England and one in the south. The study includes all NHS costs, including hospital costs for NHS 14

16 nursing home residents. A breakdown of the various elements of cost was not available. Capital has been included, discounted at the 5 per cent rate recommended by HM Treasury at that time; this has since been changed to 6 per cent. The unit costs presented in the costing schema have been uprated to 1992/93 prices (from 1986/7) using the HCHS pay and prices inflator. The 1992/93 DSS personal allowance applicable to long-stay hospital patients has been added to this cost as a proxy for personal consumption. No information is available about costs to other agencies Local authority residential care (page 27) The capital cost for a local authority home for elderly people has been taken from Beecham (ref 54). This figure originates from the building cost information service and is based on the actual cost of schemes. The figure quoted is inclusive of land values and professional fees but exclusive of VAT. This has been uprated to 1992/93 prices (from 1989/90) using the DoE output price index for new public works. The estimate of gross revenue cost for a local authority home for elderly was taken from Kavanagh et al. (ref 56). The original source was a memorandum laid before the House of Commons Health Committee (ref 51) which in turn was based on 1988/9 DoE RO3 returns (these cover gross costs) and 1988/9 DH activity statistics. This has been uprated to 1992/93 prices from 1988/9 using the PSS inflator. The revenue estimate is an amalgam of residential care for elderly people and for younger physically handicapped (YPH) people. However, due to the lack of a better estimate, and the fact that residential care for elderly people by far outweighs residential care for younger physically handicapped people, it is assumed to approximate the revenue cost of a local authority residential home for elderly people. Another problem with the estimate is that it does not include a share of local authority SSDs' general overheads. As with private residential and nursing homes, 5 per cent is added to the above costs to reflect expenditure by other agencies. The DSS personal allowance figure (1992/93), for people in a local authority part III home, is used as a proxy for personal consumption. During 1992/93 the DSS personal allowance figure for this group was less than for people in private residential homes or private nursing homes. The costing schema also presents a multiplier for use when costing services for people with high dependency. This is based on Darton and Knapp (ref 8) who found that high dependency clients in local authority elderly peoples homes added 25 per cent to the revenue costs Local authority day care (page 28) As with local authority residential homes, the capital cost for a local authority day centre is taken from Beecham (ref 54), and originates from the building cost information service. In fact, the figure here refers to the capital cost of a day centre for people with learning difficulties or mental health problems. However, given the lack of any better information, this figure is used as an estimate of the capital cost of a local authority day centre for elderly people. The cost is uprated to 1992/93 (from 1989/90) prices using the DoE output price index for new public works. Following Netten (ref 61), the revenue cost estimate is taken from CIPFA (1990/91) actuals. The CIPFA estimates are comparable with the average costs of day care found by Davies et al. (ref 36) in their study of service receipt by elderly people in ten local authorities and on this basis have been assumed to include transport costs. Costs were inflated to 1992/93 prices using the PSS inflator. CIPFA give a separate estimate for Inner and Outer London, English Counties and Metropolitan Districts. Multipliers, based on the CIPFA estimates, to use when converting the all-england revenue estimate to an English Counties, Metropolitan District or Outer London estimates are included in the costing schema. A multiplier for Inner London is not included as the figure quoted is lower than for all other categories, which does not seem reasonable. It should be noted that the all-england figure includes the Inner London Boroughs that responded as it was impossible to separate them out. This underlines 15

17 the need for extreme care when using these figures Hospital services (page 29) The unit cost of hospital services is based on a memorandum to the Health Committee (ref 51). This gives the average revenue cost for geriatrics based on DH FR12 figures. Capital is accounted for by adding 15 per cent to the revenue cost (ref 58). Costs were inflated to 1992/93 prices using the HCHS pay and prices inflator. If a more comprehensive unit cost is required, then 4.2 per cent can be added to the revenue cost to reflect expenditure by agencies other than the NHS. This is made up of local authority SSD costs (such as hospital social workers), voluntary expenditure and the DSS personal allowance (again used as a proxy for personal consumption). The basis for this is work undertaken by the PSSRU during the Care in the Community demonstration programme (ref 58). However, it should be noted that these additions to the costs to other agencies are only applicable to long-stay elderly patients, whereas the NHS revenue average reflects the revenue costs of all types of patient classed as geriatric Meals on wheels (page 30) The estimated unit cost for meals on wheels was taken from Netten (ref 61) and uprated to 1992/93 prices using the PSS inflator. This in turn was based upon the key indicators for PSS produced by the Department of Health with 20 per cent added to the average figures for London and the rest of England to allow for revenue and capital overheads. 2. PEOPLE WITH MENTAL HEALTH PROBLEMS There are no up-to-date surveys of private residential care homes for client groups other than elderly people. However, Darton et al. (ref 20) in a survey conducted in 1986/7 estimated that the costs (not fees) of a residential home for people with a mental health problem were 12.5 per cent higher than those for a residential care home for elderly people Local authority residential care (page 32) The unit cost of local authority provided residential care for people with a mental health problem has been calculated in the same way as the unit cost of local authority provided residential care for elderly people. Again the capital cost estimate is taken from Beecham (ref 54) and the revenue cost estimate is taken from a memorandum laid before the House of Commons Health Committee (ref 51). The same inflators were used to inflate these costs to 1992/93 levels as were used in costing local authority residential care for elderly people. The DSS personal allowance payable is used as a proxy for personal consumption. 5 per cent is added to the combined capital and revenue costs to reflect costs borne by other agencies (ref 58) Local authority day centres (page 33) The capital estimate is the same as for local authority day centres for elderly people. Likewise, the source for the revenue estimate is CIPFA (1990/91) Actuals. The schema details multipliers, based on CIPFA, to convert the all-england revenue figure into a figure applicable for Outer London (Inner London is omitted for the reason given in 1.5), English Counties and Metropolitan Districts Hospital services (page 34) The NHS unit cost of hospital services for people with a mental health problem are calculated in exactly the same way as hospital services for elderly people. No estimate is available for the costs to other agencies. The DSS personal allowance payable can again be used as a proxy for personal consumption for long-stay patients. 16

18 3. PEOPLE WITH LEARNING DIFFICULTIES There are no up-to-date surveys of private residential care homes for client groups other than elderly people. However, Darton et al. (ref 20), in a survey conducted in 1986/7, estimated that the costs (not fees) of a residential home for people with learning difficulties were per cent greater than those of a residential care home for elderly people Local authority residential care for people with learning difficulties (page 36) The unit cost of local authority provided residential care for people with learning difficulties has been calculated in the same way as the unit cost of local authority provided residential care for elderly people. Again the capital cost estimate is taken from Beecham (ref 54) and the revenue cost estimate is taken from a memorandum laid before the Health Committee (ref 51). The same inflators were used to inflate these costs to 1992/93 levels as were used in costing local authority residential care for elderly people. The DSS personal allowance payable is used as a proxy for personal consumption. 5 per cent is added, to the combined capital and revenue costs, to reflect costs borne by other agencies (ref 58) Local authority social education centres (page 37) The capital estimate is the same as for local authority day centres for elderly people. Similarly, the source for the revenue estimate is CIPFA (1990/91) actuals. The all-england revenue figure is of a comparable magnitude, once the different years are taken into account, to those estimated by Wright and Tolley (ref 26) for adult training centres for people with learning difficulties. As the services provided by these centres diversify, there is likely to be a considerable increase in the range of costs of social education centres, and particular caution should be exercised when using these average figures. The costing schema details multipliers, based on CIPFA, to convert the all-england revenue figure into a figure applicable for London, English Counties and Metropolitan Districts Hospital services (page 38) The NHS unit cost of hospital services for people with learning difficulties are calculated in exactly the same way as hospital services for elderly people. As with elderly people, the DSS 1992/93 personal allowance figure can be included as a proxy for personal consumption for long stay patients. The estimates of other costs (plus 1.5 per cent to the NHS revenue cost for education and social work) are taken from Wright and Haycox (ref 11). Although their study was conducted in 1981/2 and included only one hospital, this is the best estimate available. The costing schema also includes multipliers to apply to the NHS revenue costs when costing high or low dependency clients. These are also taken from the work of Wright and relate to the same hospital (ref 25). 4. GENERIC SERVICES 4.1. Speech therapist (page 40) A weighted average salary for a speech therapist was calculated using 1992/93 pay scales and numbers (WTEs) of people in each grade at 31 March 1991 (these were the latest available figures). A total of 11.2 per cent was added to this figure to account for employer's national insurance (7.2 per cent) and superannuation (4 per cent) contribution. Following Netten (ref 61), 16.5 per cent is added to the cost to reflect revenue overheads and 8 per cent added to the total revenue cost to reflect capital expenditure. The travel cost per visit is also taken from Netten. The number of hours per year has been calculated by assuming a 36 hour working week (DH guidelines for drama and art and music therapists) and a 45 week working year (5 weeks leave and 10 days 17

19 statutory holiday). There is no information available on client contact time, hence it has not proved possible to provide a per visit unit cost estimate Psychologist (page 41) As with speech therapists, a weighted average salary has been calculated using 1992/93 pay scales and the numbers of staff in post at 31 March per cent is added for employer's national insurance (7.7 per cent) and superannuation (4 per cent) contributions. Revenue (16.5 per cent) and capital (8 per cent) overheads are added as for speech therapists. The travel figure is again the one taken from Netten (ref 61). The same assumptions for working time are made as for speech therapists Art and music therapist (page 42) The same methodology is used as for speech therapists and psychologists. The weighted average salary is based on 1992/93 pay scales and numbers in post by grade as at September An addition of 11.2 per cent is made for employer's national insurance and superannuation contributions per cent is added for revenue overheads and 8 per cent for capital. The number of hours in the working year is based on a 36 hour week and a 45 week year Drama therapist (page 43) Drama therapists are employed on the same grades as art and music therapists. The weighted average salary is smaller as there were no people employed in the most senior grades as at September Indeed there were only 11 WTE drama therapists in England at this time Occupational therapist (page 44) A weighted average salary for occupational therapists was calculated in the same way as for other NHS professionals. There is no national pay scale for occupational therapists employed by local authorities although some authorities relate their pay to social worker grades. An addition of 11.2 per cent was made for employer's national insurance and superannuation contributions per cent has been added for revenue overheads and an addition of 8 per cent is made for capital costs. Additional costs associated with the purchase and supply of aids have not been allowed for here. Netten's (ref 61) estimated average community health service travel cost has been used. In the absence of detailed workload information, an average visit has been assumed to last 40 minutes and the ratio of direct client contact time to total time is assumed to be the same as for health visitors. This gives an average of 19 visits a week (855 visits per year). Using these assumptions the average length of a visit, a cost per visit as well as a cost per hour figure is quoted Physiotherapist (page 45) Physiotherapists who work in the community are for the most part employed on senior 1 grade. Williams (ref 50) presents detailed information about levels of sickness, training and client contact time. This has been adapted to the format of the schema and translates (once sickness leave and holidays have been taken into account) into an allowance of 76 per cent additional time required to establish a given period of face to face contact time with a client. The balance of activities will vary according to the type of contact and the caseload and case mix of individual workers, so assumptions about typical visits using a simple multiplier may often be inappropriate. Another approach is to consider the costing unit to be an `episode of care'. This gets closer to the ideal of costing outcomes. If the information were available, an `average' episode for a client group might be estimated reflecting the number and type of treatment slots required for the balance of conditions treated for that group. Although this is not yet possible, information from Williams has been used to demonstrate the cost of an example episode Chiropodist (page 46) The weighted average salary is based on 1992/93 pay scales and figures for WTE staff in post in 18

20 September Information, courtesy of the Society of Chiropody, was available on the expected level of sickness leave during a year, time spent on training and meetings, and the average of treatments per week. The cost per visit is based on an average number of 40 domiciliary visits per week and 75 clinic visits. These figures allow for failure to keep appointments Community psychiatric nurse (page 47) Community psychiatric nurses (CPNs) are employed on nursing grade G. The average salary figure is based on the mean of grade G plus the psychiatric lead payment. An addition of 11.2 per cent is made to account for employer's national insurance (7.2 per cent) and superannuation contributions (4 per cent). The working week is 37.5 hours and the number of weeks per working year is assumed to be 45 (5 weeks annual holiday plus 10 days statutory holiday). The client contact multiplier is taken from Dunnel and Dobbs (ref 4). This is based on the ratio of time spent with a patient as opposed to time spent travelling and on non-clinical activities. A cost per hour and a cost per hour spent with a client (the cost per hour multiplied by the client contact multiplier) are presented in the schema Health visitor (page 48) Health visitors are also employed on grade G. The unit costs provided are calculated using the same methodology as for CPNs District nurse grade G (page 49) The unit costs presented are calculated using the same methodology as for CPNs. The capital uplift is 3 per cent, rather than 8 per cent, to reflect the proportion of district nurses who work from home and do not generate direct capital cost overheads (ref 4) District nurse grade D (page 50) The unit costs presented are calculated using the same methodology as for a grade G nurse. The salary on-costs uplift is 10 per cent rather than 11.2 per cent (4 per cent superannuation and 6 per cent national insurance) Auxiliary nurse grade B (page 51) The unit costs presented are calculated using the same methodology as for a grade G nurse. The salary on-costs uplift is 10 per cent rather than 11.2 per cent (4 per cent superannuation and 6 per cent national insurance) General practitioner (page 52) The methodology for costing a surgery appointment or a domiciliary visit is taken from Beecham (ref 54). The combined net remuneration and practice expenses for 1992/93 was targeted at 60,010 by the Review Body Report on Doctors and Dentists Remuneration (ref 64). Following the methodology used by Knapp et al. (ref 33), per cent has been added to reflect the costs of ancillary staff, premises, improvements to premises, drugs and dispensing. The working time multiplier has been taken from Beecham (ref 54) and the surgery and domiciliary multipliers have been taken from Butler and Calnan (ref 18). Beecham notes that half the time costed for a domiciliary visit is spent travelling. Hence a visit to a group home should have half of the domiciliary unit allocated between all clients seen for the travel element and the other half allocated to each client seen for the GP's time Social worker (page 53) Social workers are employed on a scale on a spinal column from point 22 ( 12,438) to point 34 ( 18,231) (source: National Association of Local Government Officers (NALGO)). The average of the 13 scale points was assumed to be the average social work salary. It should be noted that this does not reflect the proportions of social workers employed at each grade per cent was added to the average salary to represent employer's national insurance (7.2 per cent) and superannuation (6 per cent) contributions

21 per cent (ref 10) was added for management and administration overheads and 9.76 per cent (ref 33) for capital and office running costs such as heating and electricity. An hourly cost was calculated by assuming a 37 hour week and a 45 week year. Based on information gathered in a Scottish study of the allocation of social work time (ref 49), which found that 77 per cent of a social worker's time is spent on client-related activities, a cost per hour spent on client-related activities is also presented. This is not the same as the community nurse cost per hour spent with a client. There the multiplier represented actual time spent with a client rather than time spent on clientrelated activities. It is not possible to estimate a cost per visit as there is no information available on the number of visits, their typical length or the ratio of time spent with a client as opposed to time not spent with a client. Moreover, no information about travel costs for social workers is readily available. The regional multiplier included is based on recent work undertaken by Bebbington and Kelly (ref 65) who found that during 1990/91 staff costs for social workers were 17 per cent higher in London than the national average Home care workers (page 54) Home care workers are employed by local authorities as manual workers on grade 5. The hourly wage rate, as at 1 September 1992, for a grade 5 manual worker was provided by the National Union of Public Employees (NUPE) per cent was added to this figure to represent employer's national insurance (6.1 per cent) and superannuation (5 per cent) contributions. The results of the study reported by Davies et al. (ref 36) were used to add a percentage (16 per cent) to the hourly salary cost to account for revenue overheads. There are no capital implications in employing a home care worker other than those associated with supervisory and administrative staff already covered in the 16 per cent figure. The travel cost per visit is taken from Netten (ref 61) uprated to 1992/93 prices using the fares and other travel costs element of the retail price index. Davies et al. (ref 36) found that making allowance for leave and time spent on activities other than care increased the hourly cost by 22 per cent. This has been used in estimating a cost per hour spent on clientrelated activities. The multiplier to use when estimating London costs has been taken from Bebbington and Kelly (ref 65), who found that during 1990/91 staff costs for home care workers were 19 per cent more in London than the national average. 20

22 GLOSSARY Agency o/hs. Overhead costs borne by managing agency. Central capital. Elements of capital cost which are not directly affected by new build (for example, hospital car parks, kitchens and boiler rooms when wards are built) but for which there are longterm implications when additions are made to existing institutions. Client/non-client contact. The relationship between the time spent with a client and time spent on other client-related and non-client-related activities. For example, if the ratio of client to non-client activities is 1:1.5 each hour with a client requires 2.5 paid hours. Commodities. The results of activities such as personal care and housework. The production of or enablement of the production of commodities is an important objective of most community care services. Direct overheads. Day to day expenses such as supplies and services, immediate line management, telephone, heating and stationery. Durables. Items such as furniture and fittings. Indirect overheads. Ongoing managing agency costs such as personnel, specialist support teams and financial management. Long-term. The period during which short-term fixed costs such as capital can be varied. Marginal cost. The cost of an additional unit of a service. Multiplier. The figure by which a cost should be multiplied to reflect a cost raising factor such as administrative activities. On-costs. Essential associated costs such as employer's national insurance contributions on salaries. Opportunity cost. The value of the alternative use of the assets tied up in the production of the service. Price base. The year to which cost information refers. Retraction models. Methods of determining the opportunity cost of contracting services. Schema. Framework and contents of cost synopsis for each service. Short-term. The period during which durable assets cannot be immediately added to or removed from the existing stock of resources. Uplifts. Percentage additions to reflect an element of the cost. 21

23 22

24 SERVICES FOR ELDERLY PEOPLE 23

25 SCHEMA 1.1 Service Sector NURSING HOME PRIVATE Commodities/tasks Client group ELDERLY PEOPLE COSTS Primary source Ref Value A: Fees Laing & Buisson Market Survey per resident week B: `Other' services per resident week (DHA/FHSA) C: Personal allowance DSS per resident week Price base of costs 1992/93 Unit costs available per resident week (includes A to C). Commentary: page 14 Other useful references: 19, 20, 24, 56 24

26 SCHEMA 1.2 Service Sector RESIDENTIAL CARE PRIVATE Commodities/tasks Client group ELDERLY PEOPLE COSTS Primary source Ref Value A: Fees Laing & Buisson Market Survey per resident week B: `Other' services per resident week (DHA/FHSA) C: Personal allowance DSS per resident week Price base of costs 1992/93 Unit costs available 238 per resident week (includes A to C). Commentary: page 14 Other useful references: 19, 20, 56, 66 25

27 SCHEMA 1.3 Service Sector NHS NURSING HOME NHS Commodities/tasks Client group ELDERLY PEOPLE COSTS Primary source Ref Value Capital costs 45 Area A ; area B , area C , per resident week A: Buildings B: Land C: On-costs D: Equipment Revenue costs E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs I: Other costs DSS: Personal allowance per resident week UNIT ESTIMATION Use of facility by client Occupancy Regional variation Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available Area A ; area B 484; area C (includes A to G plus I) per resident week. Commentary: page 14 Other useful references: 26

28 SCHEMA 1.4 Service Sector RESIDENTIAL CARE LOCAL AUTHORITY Commodities/tasks Client group ELDERLY PEOPLE COSTS Primary source Ref Value Capital costs Building cost information service per resident week 4.53 durables per resident week A: Buildings B: Land C: On-costs D: Equipment Revenue costs DoE RO3 plus DH activity statistics per resident week E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs I: Other costs DSS: Personal allowance Personal expenditure: per resident week UNIT ESTIMATION 58 Services provided by other agencies: 7.45 DHA, 7.45 FHSA per resident week Use of facility by client weeks per year Occupancy Regional variation Dependency/condition x (E to G) for high dependency Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to G plus I) per resident week. Commentary: page 15 Other useful references: 13, 14, 33, 43, 56, 66 27

29 SCHEMA 1.5 Service Sector DAY CARE LOCAL AUTHORITY Commodities/tasks Client group ELDERLY PEOPLE COSTS Primary source Ref Value Capital costs Building cost information service p for durables per place per day A: Buildings B: Land C: On-costs D: Equipment Revenue costs CIPFA Actuals per client per day E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs I: Other costs UNIT ESTIMATION Use of facility by client 250 days per year Occupancy Regional variation CIPFA Actuals Outer London 1.32 x (E to G) Eng. Counties 0.91 x (E to G) Met. Districts 1.20 x (E to G) Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available 23 (includes A to G) per client per day. Commentary: page 15 Other useful references: 13, 14, 33, 43, 61 28

30 SCHEMA 1.6 Service Sector HOSPITAL SERVICES NHS Commodities/tasks Client group ELDERLY PEOPLE COSTS Primary source Ref Value Capital costs per inpatient day A: Buildings B: Land C: On-costs D: Central capital E: Equipment Revenue costs per inpatient day F: Salary costs G: Supplies and services H: Other revenue o/hs I: Agency o/hs J: Other costs DSS: Personal allowance 1.55 per inpatient day UNIT ESTIMATION 58 Services provided by other agencies: 1.94 per inpatient day Use of facility by client days per year Occupancy Regional variation Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to H) per inpatient day. Commentary: page 16 Other useful references: 29

31 SCHEMA 1.7 Service Sector Commodities/tasks Client group MEALS ON WHEELS LOCAL AUTHORITY MEALS/NUTRITION ELDERLY PEOPLE COSTS Primary source Ref Value A: Meal DH Key Indicators 61 Non-London 1.87 per meal London 3.13 per meal B: Overheads: direct 61 Non-London 0.37 per meal London 0.63 per meal C: Overheads: indirect D: Capital overheads E: Travel costs Price base of costs 1992/93 Unit costs available 2.20 per meal (non-london); 3.70 per meal (London). Commentary: page 16 Other useful references: 33, 43 30

32 SERVICES FOR PEOPLE WITH MENTAL HEALTH PROBLEMS 31

33 SCHEMA 2.1 Service Sector RESIDENTIAL CARE LOCAL AUTHORITY Commodities/tasks Client group PEOPLE WITH MENTAL HEALTH PROBLEMS COSTS Primary source Ref Value Capital costs Building cost information service per bed per week - LA Hostel 4.53 durables per bed per week A: Buildings B: Land C: On-costs D: Equipment Revenue costs E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs Memoranda laid before House of Commons Select Committee per resident week I: Other costs DSS Personal allowance per resident week UNIT ESTIMATION 58 Services provided by other agencies: per resident week Use of facility by client weeks per year Occupancy Regional variation Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to G plus I) per resident week. Commentary: page 16 Other useful references: 22, 33, 43, 55, 56, 59 32

34 SCHEMA 2.2 Service Sector DAY CARE LOCAL AUTHORITY Commodities/tasks Client group PEOPLE WITH MENTAL HEALTH PROBLEMS COSTS Primary source Ref Value Capital costs Building cost information service plus 45p durables per place per day A: Buildings B: Land C: On-costs D: Equipment Revenue costs CIPFA Actuals per client per day E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs I: Other costs UNIT ESTIMATION Use of facility by client 250 days per year Occupancy Regional variation CIPFA Actuals Outer London 1.34 x (E to G) Eng. counties 0.89 x (E to G) Met. districts 1.18 x (E to G) Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to G) per client per day. Commentary: page 16 Other useful references: 22, 33, 43, 56, 59 33

35 SCHEMA 2.3 Service Sector HOSPITAL SERVICES NHS Commodities/tasks Client group PEOPLE WITH MENTAL HEALTH PROBLEMS COSTS Primary source Ref Value Capital costs per inpatient day A: Buildings B: Land C: On-costs D: Central capital E: Equipment Revenue costs per inpatient day F: Salary costs G: Supplies and services H: Other revenue o/hs I: Agency o/hs J: Other costs DSS: Personal allowance 1.55 per inpatient day UNIT ESTIMATION Use of facility by client days per year Occupancy Regional variation Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to H) per inpatient day. Commentary: page 16 Other useful references: 6, 22, 33, 50, 55, 56, 59, 63 34

36 SERVICES FOR PEOPLE WITH LEARNING DIFFICULTIES 35

37 SCHEMA 3.1 Service Sector RESIDENTIAL CARE LOCAL AUTHORITY Commodities/tasks Client group PEOPLE WITH LEARNING DIFFICULTIES COSTS Primary source Ref Value Capital costs Building cost information service per bed per week - LA Hostel 4.53 durables per bed per week A: Buildings B: Land C: On-costs D: Equipment Revenue costs per resident week E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs I: Other costs DSS: Personal allowance per resident week UNIT ESTIMATION 58 Services provided by other agencies: per resident week Use of facility by client weeks per year Occupancy Regional variation Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to G plus I) per resident week. Commentary: page 17 Other useful references: 3, 21, 33, 40, 43 36

38 SCHEMA 3.2 Service Sector SOCIAL EDUCATION CENTRE LOCAL AUTHORITY Commodities/tasks Client group PEOPLE WITH LEARNING DIFFICULTIES COSTS Primary source Ref Value Capital costs A: Buildings B: Land C: On-costs D: Equipment Building cost information service plus 45p durables per place per day Revenue costs CIPFA Actuals per client per day E: Salary costs F: Supplies and services G: Other revenue o/hs H: Agency o/hs I: Other costs UNIT ESTIMATION Use of facility by client 250 days a year Occupancy Regional variation CIPFA Actuals London 1.11 x (E to G) English counties 1 x (E to G) Met districts 0.96 x (E to G) Dependency/condition Quality of care Market structure Price base of costs 1992/93 Unit costs available (includes A to G) per place per day. Commentary: page 17 Other useful references: 33, 40, 43 37

39 SCHEMA 3.3 Service Sector HOSPITAL SERVICES NHS Commodities/tasks Client group PEOPLE WITH LEARNING DIFFICULTIES COSTS Primary source Ref Value Capital costs per inpatient day A: Buildings B: Land C: On-costs D: Central capital E: Equipment Revenue costs per inpatient day F: Salary costs G: Supplies and services H: Other revenue o/hs I: Agency o/hs J: Other costs DSS Personal allowance 1.55 per inpatient day UNIT ESTIMATION 11 Services provided by other agencies: 1.27 per inpatient day Use of facility by client patient days per year Occupancy Regional variation Dependency/condition 25 Low depend x (F to H) High depend x (F to H) Quality of care Market structure Price base of costs 1992/93 Unit costs available 97 (includes A to H) per inpatient day. Commentary: page 17 Other useful references: 1, 3, 12, 17, 21, 33, 40, 50, 63 38

40 GENERIC SERVICES 39

41 SCHEMA 4.1 Service Sector Commodities/tasks Client group SPEECH THERAPIST NHS COMMUNICATION GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 16,051 per year B: Salary on-costs 1,798 per year C: Overheads: direct Regional health authorities 61 2,945 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,664 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave Client/non client contact Domiciliary v. office/clinic visit DH: Health authority personnel division 1620 hours per year (45 week year, 36 hours per week) Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour (includes A to F). Travel 0.89 per visit. Commentary: page 17 Other useful references: 40

42 SCHEMA 4.2 Service Sector Commodities/tasks Client group PSYCHOLOGIST NHS MENTAL HEALTH GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 24,939 per year B: Salary on-costs 2,918 per year C: Overheads: direct Regional health authorities 61 4,596 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 2,596 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave Client/non client contact Domiciliary v. office/clinic visit DH: Health authority personnel division 1620 hours per year (45 week year, 36 hours per week) Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour (includes A to F). Travel 0.89 per visit. Commentary: page 18 Other useful references: 54 41

43 SCHEMA 4.3 Service Sector Commodities/tasks Client group ART AND MUSIC THERAPIST NHS MENTAL HEALTH GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 16,097 per year B: Salary on-costs 1,803 per year C: Overheads: direct Regional health authorities 61 2,954 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,668 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave Client/non client contact Domiciliary v. office/clinic visit DH: Health authority personnel division 1620 hours per year (45 week year, 36 hours per week) Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour (includes A to F). Travel 0.89 per visit. Commentary: page 18 Other useful references: 42

44 SCHEMA 4.4 Service Sector Commodities/tasks Client group DRAMA THERAPIST NHS MENTAL HEALTH GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 15,240 per year B: Salary on-costs 1,707 per year C: Overheads: direct Regional health authorities 61 2,796 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,619 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave Client/non client contact Domiciliary v. office/clinic visit DH: Health authority personnel division 1620 hours per year (45 week year, 36 hours per week) Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour (includes A to F). Travel 0.89 per visit. Commentary: page 18 Other useful references: 43

45 SCHEMA 4.5 Service Sector Commodities/tasks Client group OCCUPATIONAL THERAPIST NHS PHYSICAL AND BEHAVIOURAL FUNCTIONAL ABILITY GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 16,220 per year B: Salary on-costs 1,817 per year C: Overheads: direct Regional health authorities 61 2,976 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,681 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division 1620 hours per year (45 week year, 36 hours per week) Client/non client contact mins per visit. Ratio of client contact to non-client contact 1:1.9 Domiciliary v. office/clinic visit Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per visit (includes A to G). 14 per hour (includes A to F). Commentary: page 18 Other useful references: 44

46 SCHEMA 4.6 Service Sector Commodities/tasks Client group PHYSIOTHERAPIST NHS PHYSICAL FUNCTIONAL ABILITY GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 16,948 per year B: Salary on-costs 1,899 per year C: Overheads: direct Regional health authorities 61 3,110 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,757 per year F: Travel per visit UNIT ESTIMATION Working time DH: Health authority personnel division hours per year (45 week year, 36 hours per week) Sickness leave hours per year Client/non client contact 50 Ratio of client to non-client contact 1:1.76 Domiciliary v. office/clinic visit 50 Outpatient visit 20mins Domiciliary visit 47mins Regional variations 42 London 1.22 x (A to E) Commodity/task 50 Elderly/short rehabilitation episode 52 hours Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per domiciliary visit (includes A to G) per hour (includes A to F) per clinic visit. Example episode: Commentary: page 18 Other useful references: 62 45

47 SCHEMA 4.7 Service Sector Commodities/tasks Client group CHIROPODIST NHS FOOT HEALTH/MOBILITY GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 16,316 per year B: Salary on-costs 1,827 per year C: Overheads: direct Regional health authorities 61 2,994 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,691 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave Client/non client contact Domiciliary v. office/clinic visit DH: Health authority personnel division 1620 hours per year (45 week year, 36 hours per week) 72 hours per year 2 weeks training and meetings per year Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per domiciliary visit (includes A to G) per clinic visit (includes A to F). Commentary: page 19 Other useful references: 46

48 SCHEMA 4.8 Service Sector Commodities/tasks Client group COMMUNITY PSYCHIATRIC NURSE, GRADE G NHS MENTAL HEALTH CARE GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 17,878 per year B: Salary on-costs per year C: Overheads: direct Regional health authorities 61 3,280 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,853 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division hours per year (45 week year, 37.5 hours per week) Client/non client contact 4 Ratio of client to non-client contact 1:1.8 Domiciliary v. office/clinic visit Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour, per hour spent with a client (includes A to E). Travel 0.89 per visit. Commentary: page 19 Other useful references: 7, 33, 59 47

49 SCHEMA 4.9 Service Sector Commodities/tasks Client group HEALTH VISITOR NHS HEALTH CARE GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 17,468 per year B: Salary on-costs 1,956 per year C: Overheads: direct Regional health authorities 61 3,205 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England 61 1,810 per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division hours per year (45 week year, 37.5 hours per week) Client/non client contact 4 Ratio of client to non-client contact 1:1.9 Domiciliary v. office/clinic visit Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour, 42 per hour spent with a client (includes A to F). Travel 0.89 per visit. Commentary: page 19 Other useful references: 33 48

50 SCHEMA 4.10 Service Sector Commodities/tasks Client group DISTRICT NURSE GRADE G NHS HEALTH CARE GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 17,468 per year B: Salary on-costs 1,956 per year C: Overheads: direct Regional health authorities 61 3,205 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division hours per year (45 week year, 37.5 hours per week) Client/non client contact 4 Ratio of client to non-client contact 1:1.1 Domiciliary v. office/clinic visit Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour; 29 per hour spent with a client (includes A to E). Travel 0.89 per visit. Commentary: page 19 Other useful references: 14, 33, 66 49

51 SCHEMA 4.11 Service Sector Commodities/tasks Client group DISTRICT NURSE, GRADE D NHS HEALTH CARE GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 11,594 per year B: Salary on-costs 1,333 per year C: Overheads: direct Regional health authorities 61 2,133 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division hours per year (45 week year, 37.5 hours per week) Client/non client contact 4 Ratio of client to non-client contact 1:1 Domiciliary v. office/clinic visit Regional variations 42 London 1.22 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available 9.20 per hour; per hour spent with a client (includes A to E). Travel 0.89 per visit. Commentary: page 19 Other useful references: 14, 33, 66 50

52 SCHEMA 4.12 Service Sector Commodities/tasks Client group AUXILIARY NURSE, GRADE B NHS HEALTH CARE GENERIC COSTS Primary source Ref Value A: Wages/salary DH: Health authority personnel division 8,860 per year B: Salary on-costs 886 per year C: Overheads: direct Regional health authorities 61 1,608 per year D: Overheads: indirect E: Capital overheads Health and PSS statistics for England per year F: Travel per visit UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division hours per year (45 week year, 37.5 hours per week) Client/non client contact 4 Ratio of client to non-client contact 1:0.6 Domiciliary v. office/clinic visit Regional variations 42 London 1.17 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available 6.90 per hour; per hour spent with a client (includes A to E). Travel 0.89 per visit. Commentary: page 19 Other useful references: 14, 33, 66 51

53 SCHEMA 4.13 Service Sector Commodities/tasks Client group GENERAL PRACTITIONER FHSA PRIMARY HEALTH CARE GENERIC COSTS Primary source Ref Value A: Net renumeration Review Body Report on Doctors and Dentists Renumeration (22nd Report) B: Practice expenses Review Body Report on Doctors and Dentists Renumeration (22nd Report) C: Ancillary staff, premises, improvements, drugs and dispensing 54 40,010 per year 54 20,000 per year 33 26,662 per year UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division 110,700 minutes per year (45 week year, 41 hours per week) Domiciliary v. surgery appointment Regional variations Commodity/task Dependency/condition Outcomes Surgery visit 9.3 mins Domiciliary visit 27.1 mins Price base of costs 1992/93 Unit costs available 0.78 per minute (includes A to C) per surgery visit, per domiciliary visit. Commentary: page 19 Other useful references: 46 52

54 SCHEMA 4.14 Service Sector SOCIAL WORK LOCAL AUTHORITY Commodities/tasks Client group GENERIC COSTS Primary source Ref Value A: Wages/salary 1992/93 salary scales provided by NALGO 15,202 per year B: Salary on-costs 2,007 per year C: Overheads: direct 10 2,581 per year D: Overheads: indirect E: Capital overheads 33 1,932 per year F: Travel UNIT ESTIMATION Working time Sickness leave DH: Health authority personnel division 1665 hours per year (45 week year, 37 hours per week) Client/non client contact 49 Ratio of client-related to nonclient-related work 1:0.43 Domiciliary v. office/clinic visit Regional variations 65 London 1.17 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available per hour; per hour spent on client-related activities (includes A to E). Commentary: page 19 Other useful references: 14, 21, 27, 28, 43, 61, 66 53

55 SCHEMA 4.15 Service Sector Commodities/tasks Client group HOME CARE LOCAL AUTHORITY PERSONAL CARE, HOUSEWORK, MONITORING GENERIC COSTS Primary source Ref Value A: Wages/salary 1992/93 LA salary scales provided by NUPE per hour B: Salary on-costs 0.45 per hour C: Overheads: direct LA accounts per hour D: Overheads: indirect E: Capital overheads F: Travel per visit UNIT ESTIMATION Working time Client/non client contact 61 Ratio of client to non-client contact 1:0.22 Regional variations 65 London 1.19 x (A to E) Commodity/task Dependency/condition Outcomes Price base of costs 1992/93 Unit costs available 5.20 per hour; 6.40 per hour spent on client-related activities (includes A to D). Travel 0.39 per visit. Commentary: page 20 Other useful references: 36, 43 54

56 INFLATION INDICES Year HCHS Pay and Prices Index PSS Pay and Prices Index DoE Public Works Output and Price Index / / / / / / / / / / / / / / /93 p Figures refer to calendar year, e.g. 1980/81 = 1980 p Predicted 55

57 REFERENCES 1 Felce, D., Mansell, J. & Kushlick, A. (1980) Evaluation of alternative residential facilities for the severely mentally handicapped in Wessex: revenue costs, Adv. Behav. Res. Ther., 3, Jones, R., Goldberg, D. & Hughes, B. (1980) A comparison of two different services treating schizophrenia: a cost-benefit approach, Psychological Medicine, 10, Felce, D. (1981) The capital costs of alternative residential facilities for mentally handicapped people, British Journal of Psychiatry, 139, Dunnell, K. & Dobbs, J. (1982) Nurses Working in the Community, OPCS, HMSO. 5 Knapp, M. & Missiakoulis, S. (1982) Intersectoral cost comparisons: day care for the elderly, Journal of Social Policy, 11, 3, McKechnie, A., Rae, D. & May J. (1982) A comparison of in-patient costs of treatment and care in a Scottish psychiatric hospital, British Journal of Psychiatry, 140, Mangen, S., Paykel, E., Griffith, J., Burchell, A. & Mancini, P. (1983) Cost-effectiveness of community psychiatric nurse or out-patient psychiatrist care of neurotic patients, Psychological Medicine, 13, Darton, R. & Knapp, M. (1984) The cost of residential care for the elderly: the effects of dependency, design and social environment, Ageing & Society, 4, Hildick-Smith, M. (1984) Geriatric day hospitals - changing emphasis in costs,... Age & Ageing, 13, Knapp, M., Bryson, D. & Lewis, J. (1984) The comprehensive costing of child care: the Suffolk cohort study, Discussion Paper 355, Personal Social Services Research Unit, University of Kent at Canterbury. 11 Wright, K. & Haycox, A. (1984) Public sector costs of caring for mentally handicapped persons in a large hospital, Discussion Paper 1, Centre for Health Economics, University of York. 12 Wright, K. & Haycox, A. (1985) Costs of alternative forms of NHS care for mentally handicapped persons, Discussion Paper 7, Centre for Health Economics, University of York. 13 Bebbington, A., Charnley, H., Davies, B., Ferlie, E., Hughes, M. & Twigg, J. (1986) The domiciliary care project: meeting the needs of the elderly (interim report), Discussion Paper 456, Personal Social Services Research Unit, University of Kent at Canterbury. 56

58 14 Challis, D. & Davies, B. (1986) Case Management in Community Care, Gower. 15 Davies, B. & Challis, D. (1986) Matching Resources to Needs in Community Care, Gower. 16 Donaldson, C., Wright, K. & Maynard, A. (1986) Determining value for money in day hospital care for the elderly, Age & Ageing, 15, Felce, K. (1986) Accommodating adults with severe and profound mental handicaps: comparative revenue cost, Mental Handicap, 14, September. 18 Butler, J.R. & Calnan, N. (1987) Too Many Patients? A study of the economy of time and standards in general practice, Gower. 19 Darton, R., Jefferson, F., Sutcliffe, E. & Wright, K. (1987) PSSRU/CHE survey of residential and nursing homes: tables of charges, Discussion Paper 549, Personal Social Services Research Unit, University of Kent at Canterbury. 20 Darton, R., Jefferson, F., Sutcliffe, E. & Wright K. (1987) PSSRU/CHE survey of residential and nursing homes, Discussion Paper 563, Personal Social Services Research Unit, University of Kent at Canterbury. 21 Davies, L. (1987) Quality, Costs and an Ordinary Life, Kings Fund: No Knapp, M., Beecham, J. & Renshaw, J. (1987) The cost-effectiveness of psychiatric reprovision services, Discussion Paper 533/3, Personal Social Services Research Unit, University of Kent at Canterbury. 23 Netten, A. (1987) Costing hospital beds and day care for the elderly, Discussion Paper 543, Personal Social Services Research Unit, University of Kent at Canterbury. 24 Stanniland, P. (1987) Nursing Home Care: a report on private nursing homes, 25 Wright, K. (1987) Cost-effectiveness in Community Care, Discussion Paper 33, Centre for Health Economics, University of York. 26 Wright, K. & Tolley K. (1987) Costs of Day Services for Adults with a Mental Handicap,... Annex B, SSI Inspection of Day Services for People with a Mental Handicap. 27 Davies, P., Dyson, P., Lynch, G. & Miller, C. (1988) Workloads and resources, Social Work Today, 6 October. 28 Davies, P., Dyson, P., Lynch, G. & Miller, C. (1988) Bottom up, top down planning, Community Care, 13 October. 57

59 29 Maynard, A. (1988) Economic resources and ageing, in Wells & Freer, The Ageing Population, Stockton. 30 Shiell, A. (1988) Appendix 1: The costs of schemes established under the central initiative, in A. Leonard, Out of Hospital. 31 Challis, D., Chesterman, J., Traske, K. & von Abendorff, R. (1989) Assessment and case management: some cost implications, Social Work and Social Sciences Review, 1, 3, Donaldson, C. & Gregson, G. (1989) Prolonging life at home: what is the cost? Community Medicine, 11, Knapp, M., Beecham, J. & Allen, C. (1989) The methodology for costing community and hospital services used by clients of the care in the community demonstration programme, Discussion Paper 647, Personal Social Services Research Unit, University of Kent at Canterbury. 34 Allen, C. & Kitchen, S. (1990) The costs of electrotherapy, Physiotherapy, 76, Challis, D., Chessum, R., Chesterman, J., Luckett, R. & Traske K. (1990) Case management in social and health care, Discussion Paper 755, Personal Social Services Research Unit, University of Kent at Canterbury. 36 Davies, B., Bebbington, A., Charnley, H. & colleagues (1990) Resources, Needs and Outcomes in Community Based Care, Avebury. 37 Gerard, K. (1990) Economic evaluation of respite care for children with mental handicaps: a preliminary analysis of problems, Mental Handicap, 18 December. 38 Knapp, M. & Beecham, J. (1990) Costing mental health services, Psychological Medicine, 20, Knapp, M. & Beecham, J. (1990) Reprovision: clients, costs and care, Discussion Paper 715, Personal Social Services Research Unit, University of Kent at Canterbury. 40 Korman, N. & Glennerster (1990) The cost of reprovision, Chapter 10, Hospital Closure. 41 Melzer, D. (1990) An evaluation of a respite care unit for elderly people with dementia: framework and some results, Health Trends, 2, Akehurst, R., Hutton, J. & Dixon, R. (1991) Review of higher costs of health care provision in inner London and a consideration of implications for competitiveness: final report, York Health Economics Consortium, University of York. 43 Bebbington, A. & Kelly, A. (1991) Unit costs of personal social services in inner London: stage one report, Discussion Paper 757/2, Personal Social Services Research Unit. 58

60 44 Beecham, J., Knapp, M. & Fenyo, A. (1991) Costs, needs & outcomes: community care for people with long-term mental health problems, Discussion Paper 730/2, Personal Social Services Research Unit, University of Kent at Canterbury. 45 Donaldson, C. & Bond, J. (1991) Cost of continuing-care facilities in the evaluation of experimental NHS nursing homes, Age & Ageing, 20, Hughes, D. (1991) Costing consultations in general practice: towards a standardized model, Family Practice, 8, 4, Donaldson, C. & Farrar, S. (1991) Needs assessment: developing an economic approach, Discussion Paper 12/91, Health Economics Research Unit, University of Aberdeen. 48 Knapp, M. (1991) Cost, Administration in Social Work, Tibbet, J. & Martin, P. (1991) The Allocation of `Administration and Casework' Between Client Groups in Scottish Departments of Social Work, Scottish Office CRU Papers. 50 Williams, J. (1991) Calculating Staffing Levels in Physiotherapy Services, Pampas, Rotherham. 51 Department of Health (1991) Public Expenditure on Health Matters Memorandum laid before the Health and Social Services Committee session , HMSO, HC Bartlett, W. & Le Grand, J. (1992) The impact of NHS reforms on hospital costs, Studies in Decentralisation and Quasi-Markets, No Bebbington, A. & Kelly, A. (1992) Unit costs of personal social services in inner London: stage two report, Discussion Paper 776/2, Personal Social Services Research Unit, University of Kent at Canterbury. 54 Beecham, J. (1992) Costing services: an update, Discussion Paper 844 (DRAFT), Personal Social Services Research Unit, University of Kent at Canterbury. 55 Garrod, N. & Vick, S. (1992) Costing care for the mentally ill: causes and outcomes, Research Paper No. 92.6, School of Accounting, Banking and Economics, University of Wales, Bangor. 56 Kavanagh, S., Schneider, J., Knapp, M., Beecham, J. & Netten, A. (1992) Elderly people with cognitive impairment: costing possible changes in the balance of care, Discussion Paper 817/2, Personal Social Services Research Unit, University of Kent at Canterbury. 57 Knapp, M., Beecham J. & Gordon K. (1992) Predicting the community costs of closing psychiatric hospitals: national extrapolations, Discussion Paper 801, Personal Social Services Research Unit, University of Kent at Canterbury. 58 Knapp, M., Cambridge, P., Thomason, C., Beecham, J., Allen, C. & Darton, R. (1992) Care in the Community: challenge and demonstration, Ashgate. 59

61 59 Knapp, M. & Kavanagh, S. (1992) Health economics relevant to developments in community psychiatry, Current Opinion in Psychiatry, 5, Laing & Buisson (1992) Care of Elderly People: market survey 1991/92, 61 Netten, A. (1992) Some cost implications of caring for people: interim report, Discussion Paper 809/3, Personal Social Services Research Unit, University of Kent at Canterbury. 62 Stock, J. & Seccombe, I. (1992) Understanding Physiotherapy Staffing Levels, IMS Report No. 226, Institute of Manpower Studies. 63 NHS Estates Concise 4 Database: version 9.3, 64 Review Body on Doctors' and Dentists' Remuneration (1992) Twenty-second Report, HMSO Cm Bebbington, A. & Kelly, A. (1993) Area differentials in the cost of PSS staff, and their relevance to Standard Spending Assessments Discussion Paper 898/3, Personal Social Services Research Unit, University of Kent at Canterbury. 66 Netten, A. & Beecham, J. (1993) Costing Community Care: theory and practice, Ashgate. 60

62 AUTHOR INDEX These numbers refer to the entry on pages 57-60, and not to page numbers. Akehurst, R., 42 Allen, C., 33, 34, 58 Bartlett, W., 52 Bebbington, A., 13, 36, 43, 53, 65 Beecham, J., 22, 33, 38, 39, 44, 54, 56, 57 58, 66 Bond, J., 45 Bryson, D., 10 Buisson, 60 Burchell, A., 7 Butler, J.R., 18 Calnan, N., 18 Cambridge, P., 58 Challis, D., 14, 15, 31, 35 Charnley, H., 13, 36 Chessum, R., 35 Chesterman, J., 31, 35 Darton, R., 8, 19, 20, 58 Davies, B., 14, 15, 36 Davies, L., 21 Davies, P., 27 Dixon, R., 42 Dobbs, J., 4 Donaldson, C., 16, 32, 45, 47 Dunnell, K., 4 Dyson, P., 27, 28 Farrar, S., 47 Felce, D., 1, 3 Felce, K., 17 Fenyo, A., 44 Ferlie, E., 13 Garrod, N., 55 Gerard, K., 37 Glennerster, 40 Goldberg, D., 2 Gordon K., 57 Gregson, G., 32 Griffith, J., 7 Haycox, A., 11, 12 Hildick-Smith, M., 9 Hughes, B., 2 Hughes, D., 46 Hughes, M., 13 Hutton, J., 42 Jefferson, F., 19, 20 Jones, R., 2 Kavanagh, S., 56, 59 Kelly, A., 43, 53, 65 Kitchen, S., 34 Knapp, M., 5, 8, 10, 22, 33, 38, 39, 44, 48, 56, 57, 58, 59 Korman, N., 40 Kushlick, A., 1 Laing, 60 Le Grand, J., 52 Lewis, J., 10 Luckett, R., 35 Lynch, G., 27, 28 Mancini, P., 7 Mangen, S., 7 Mansell, J., 1 Martin, P., 49 May J., 6 Maynard, A., 16, 29 McKechnie, A., 6 Melzer, D., 41 Miller, C., 27, 28 Missiakoulis, S., 5 Netten, A., 23, 56, 61, 66 Paykel, E., 7 Rae, D., 6 Renshaw, J., 22 Schneider, J., 56 Seccombe, I., 62 Shiell, A., 30 Stanniland, P., 24 Stock, J., 62 Sutcliffe, E., 19, 20 Thomason, C., 58 Tibbet, J., 49 Tolley K., 26 Traske K., 31, 35 Twigg, J., 13 Vick, S., 55 von Abendorff, R., 31 Williams, J., 50 Wright, K., 11, 12, 16, 19, 20, 25, 26 61

63 SERVICE INDEX The numbers in bold refer to the schemata. Art and music therapist, 18, 4.3, 42 Auxiliary nurse, 19, 4.12, 51 Chiropodist, 19, 4.7, 46 Community psychiatric nurse, 19, 4.8, 47 Day care, 5, 7, 11, 12, 15 elderly people, 1.5, 28 people with mental health problems, 2.2, 33 District nurse, 13, 14, 19, 4.10, 49, 4.11, 50 Drama therapist, 18, 4.4, 43 General practitioner, 5, 19, 20, 4.13, 52 Generic services, 17, 4, Health visitor, 13, 18, 19, 4.9, 48 Home care, 20, 4.15, 54 Hospital services, 6, 11, 12, 16, 17 elderly people, 1.6, 29 people with learning difficulties, 3.3, 38 people with mental health problems, 2.3, 34 Local authority day care, 15, 16, 1.5, 28, 2.2, 33 residential care, 15, 16, 17, 1.4, 27, 2.2, 32, 3.1, 36 social education centre, 17, 3.2, 37 Meals on wheels, 16, 1.7, 30 NHS nursing home, 14 elderly people, 1.3, 26 Occupational therapist, 8, 18, 4.5, 44 Physiotherapist, 7, 8, 12, 13, 18, 4.6, 45 Private nursing home, 14, 1.1, 24 residential care, 14, 1.2, 25 Psychologist, 18, 4.2, 41 Residential care elderly people, 1.4, 27 people with learning difficulties, 3.1, 36 people with mental health problems, 2.2, 33 Social worker, 5, 8, 13, 16, 19, 20, 4.14, 53 Speech therapist, 17, 18, 4.1, 40 62

64

65