The Balance of Care approach: supporting integrated care planning
Dr Paul Forte
Balance of Care provides a ‘whole system’ approach strategic planning and commissioning of long-term care services across a complete local health and social care economy. The largest group of people with the most complex long-term care needs is older people, and the approach is ideally suited to supporting the discussion and planning requirements involved.
Finding the capacity locally for developing a strategic vision for service development is too often swamped by the effort of managing day to day operations and crises. The absence of strategic planning can contribute directly to continuing operational problems and difficulties in co-operation and joint working between different agencies – it’s not really an optional extra.
Strategic planning is not an easy task to undertake with such a large number of interested parties (statutory, private and voluntary sectors; client and carer groups) to accommodate and with data and information about needs and service uptake often poor and difficult to share across organisations. It’s why strategic plans are usually statements of good intent which everyone can sign up to but which no-one can easily translate into quantifiable objectives and operational action plans
Clearly, there are differences in the specific problems encountered in different localities, but the fundamental issue of tackling the balance of care between different services, agencies, population needs, and available resources, is not unique to any single locality. There are, therefore, benefits to be gained both from the experience of other places, and in adopting a whole systems approach to addressing local planning issues.
The Balance of Care approach is one such methodology with a focus on strategic planning for long-term care. It comprises local planning workshops involving all interested parties – not a novel idea in itself – but, as an integral part of this process, there is a spreadsheet model which, with local data and expertise, enables real-time exploration and quantification of different policy implications with everyone present. This is a crucial extra dimension to the workshop process as it enables people not only to start quantifying the resource consequences of their plans, but to undertake rapid and immediate “what-if?” testing of different assumptions and sensitivities as they are being formulated and discussed.
The Balance of Care approach itself has a long pedigree; with the original concept going back to the 1970s (1). Since then its modelling component has been through several transformations and embedded within a workshop package (Forte and Bowen (2).
The Balance of Care approach in action
In the east of England the model was used to model and explore issues with local stakeholders around care options for older people with dementia. The model structure illustrated for the case of older people with dementia in figure 1 is straightforward. It defines and describes population needs (demand) on the left, linking these via care options to requirements for services on the right (supply). ‘Need’ can be defined in terms of physical and mental characteristics of individuals and also the extent to which these demands might be modified by informal support from family and friends. In the dementia example three dependency categories were used based on the person’s mini-mental state examination score (which is a relevant marker for the use of particular dementia drug therapies). Health and care professionals then described care options for people in each of these categories but which also enabling account to be taken of other health characteristics and the availability of informal support (figure 2). For any given level of dependency there may be a variety of ways of providing long-term care each with their own implications for the type and quantity of services, for the agencies which might provide it and the costs involved. The model enables all of these issues to be explored.
Figure 1: Structure of the Balance of Care model
| Mild | Not frail | Frail | ||
| Carer | No carer | Carer | No carer | |
| Community psychiatric nurse | 1 hr pa | 1 hr pa | 1 hr pa | 1 hr pa |
| Community support wkr (psych) | – | – | – | – |
| Health Care Supt wkr (PCT prov) | – | – | – | – |
| Home care supt (soc ser) | – | – | – | – |
| Table 5 | ||||
| Moderate | Not frail | Frail | ||
| Carer | No carer | Carer | No carer | |
| Community psychiatric nurse | 1 visit pcm | 1 visit pcm | 1 visit pcm | 1 visit pcm |
| Community support wkr (psych) | 2 visit pcm | 4 visit pcm | 2 visit pcm | 4 visit pcm |
| Health Care Supt wkr (PCT prov) | – | – | 2 hrs pcm | 4 hrs pcm |
| Home care supt (soc ser) | – | – | 1 hr pw | 6 hrs pw |
| Table 6 | ||||
| Severe | Not frail | Frail | ||
| Carer | No carer | Carer | No carer | |
| Community psychiatric nurse | 1 visit pcm | 1 visit pcm | 1 visit pcm | 1 visit pcm |
| Community support wkr (psych) | 3 visit pcm | 6 visit pcm | 4 visit pcm | 8 visit pcm |
| Health Care Supt wkr (PCT prov) | – | – | – | – |
| Home care supt (soc ser) | 2 hr pw | 5 hrs pw | 3 hr pw | 6 hrs pw |
Figure 2: Examples of care options (partial illustration)
Results from one of the scenarios illustrate the potential resource implications arising from population estimates of people in the different dependency categories, and care options specified by local stakeholders (figure 3). An interesting point here is that while there would be cost implications of moving towards the ideal of improved community-based services as a way of avoiding or delaying long-term care home placement, there is the potential to offset at least some of the new investment required by a reduction in the existing costs of long-term care placement.
| Staff Type | WTE | Annual Cost |
| Community psychiatric nurse | 181 | £4.7 million |
| Community support worker (psych) | 400 | £6.0 million |
| Health Care Supt worker (Comm prov) | 82 | £1.2 million |
| Home care support (Adult services) | 238 | £5.0 million |
| Total community staff | 901 | £16.9 million |
| Current Care Homes places (inc respite) | £67.8 million |
Figure 3: Potential cost and volume consequences of a Balance of Care modelling scenario
Balance of Care is a decision support model; it does not produce ‘a right answer’ or take away any of the responsibility for local decision-makers to set the agenda, engage in deliberation with each other, and be responsible for taking any decisions. However, it makes an excellent starting point for the development and quantification of strategies and, where a robust organisational framework is already in place, can highlight areas for development and strengthen the commitment to a shared approach.
- Gibbs R J, 1978, The use of a strategic planning model for health and personal social services. J Operational Research Soc 29: 875-83.
- Forte P and Bowen T, 1997, Improving the balance of elderly care services. In: Cropper S and Forte P, (eds), Enhancing Health Services Management pp 71-85 (Milton Keynes, Open University Press).
A free copy of the Balance of Care Approach model can be downloaded from www.balanceofcare.com or contact Paul Forte