Clive Bowman: The future for residential care provision

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Clive Bowman, Medical Director, Bupa Care Homes, gives a history of care homes in England and looks at the challenges facing residential care provision in the future.

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Clive Bowman: The future for residential care provision

  1. 1. A view from 30,000 feet Clive Bowman Divisional Medical Director, BupaBupa Private and Confidential Date if required 1
  2. 2. The simple medical approach• Presentation / diagnosis• Treatment (first - do no harm, secondly - treatment delayed is treatment denied) ◦ Cure or ◦ Alleviation of symptoms and prevention of complications• Effectively and efficiently• Prevention through risk and lifestyle management• Informed by access and choice etc• Controlled by incentive and regulation
  3. 3. Care homes • A sad remnant of the Poor Law in the UK and often seen as failure of policy • Unloved: only bad news comes from care homes and the cost… • A simple business revolving around occupancy/fees/costs
  4. 4. Some things don’t change Parliamentary Acts in 1531 and 1536 developed the first comprehensive English system of poor relief forming the positive elements of poor relief that would continue for centuries:• governmental criteria about who is legitimately in need• governmental obligation to search out those in need• government registration of need; definition of what government should do for the needy• construction and administration of a system of contributions for the poor. These laws also continued and expanded the previous system of punishments for those who were able to work. Fast forward to Supreme Court July 7 2011 - Stroke victim Elaine McDonald lost an appeal to the Supreme Court for a night-time carer. Judges, with one exception, said she had no right to demand a helper and that social workers were within the law when they withdrew the carer to save £22,000 a year
  5. 5. Diagnosis: What is it that care homes do?• Provide a (largely inappropriate) housing solution• Provide a refuge or sanctuary for the cognitively impaired, physically disabled and dying• Provide cost effective solutions for parts of NHS care What part of these activities are social care? (as opposed to housing or health)
  6. 6. BCS Divisional Census 2009 – Diagnosis UK Aus NZ SpainNo Medical Diagnosis 6% 2% 1% 4%Arthritis 18% 24% 18% 16%Cancer 7% 11% 10% 6%Cerebral Palsy 0% 0% 0% 0%Dementia 44% 53% 50% 46%Depression 11% 23% 16% 18%Diabetes and Endocrine 14% 18% 20% 20%Epilepsy 6% 4% 4% 2%Fractures 12% 14% 13% 20%Heart disease 21% 38% 47% 28%Huntingdons disease 0% 1% 0% 0%Learning difficulties 2% 1% 1% 1%Lung/chest disease 8% 12% 17% 12%Manic Depression 1% 2% 1% 3%Missing limbs 1% 1% 2% 1%Motor Neurone disease 0% 0% 0% 0%Multiple Sclerosis 1% 0% 1% 0%Neurological trauma 2% 3% 3% 2%Osteoporosis 9% 19% 16% 17%Parkinsons disease 5% 6% 5% 5%Schizophrenia 2% 4% 3% 2%Stroke 20% 18% 23% 9%Other Diagnosis 28% 63% 45% 60%
  7. 7. The EU SHELTER study 2011 (unpublished: Prof Iain Carpenter) England Total sample 500 Percent n=4,156Age, years (mean±SD) 84.5±9.5 yrs 83.4±9.4 yrsFemale gender 72.0% 73.0% 3,035Physical ability* Assistance required 26% 41.5% 1,723 Dependent 71% 39.8% 1,653Cognitive function† 1,563 Mild/Moderate impairment 35.7% 37.6% 1,265 Severe impairment 28.8% 30.4%Depression‡ 32% 32.0% 1,331Behavioral symptoms 32% 27.5% 1,142Falls 7% 18.6% 774Pressure ulcers 10.7% 10.4% 432Pain 38% 36.0% 1,496Urinary incontinence 72.0% 73.5% 3,054Bowel incontinence 68.8% 55.2% 2,290
  8. 8. A bluffers guide to changing care home activity Health Dementia Activity Housing Time
  9. 9. Activity impact of intermediate care Month Int care Int Int care LTC LTC LTC Admiss death disch admiss deaths disch 150 bed care home Jan 17 1 19 8 6 3 5x30 bed units Feb 20 21 19 2 1 1unit PCT Mar 21 13 7 8 7 commissioned April 15 13 16 2 9 ~15 Int care beds May 17 12 15 8 5 Activity whole home J 14 16 17 5 10 701 adm/disch/deaths of which 374 Int care July 25 15 13 4 7 327 LTC Aug 15 16 14 6 5 Sept 12 13 10 8 7 Oct 8 14 12 11 6 Nov 21 16 17 6 10Bupa Care Services Dec 10 10 24 9 10 Totals 195 1 178 172 75 80
  10. 10. Consequences of the increasing churn shorter stays increased admissions, occupancy down and intensity up Enhanced commissioning required
  11. 11. Care home outcomes today Convalescence Fluctuating illnessFunction Respite Chronic disease Palliative care Time
  12. 12. The characteristics of “social” (LTC) care home residents • Tired and old • Cognitively impaired • Unlikely to be independent in movement • Likely to be incontinent • Likely (circa 70%) to be reliant on state funding (poor) • Running out of choices and control • In the last phase of the life course
  13. 13. Diagnosis: Care homes face a crisis• Costs up, income down• Activity up, occupancy down• Importance to health and social care poorly recognised• Still a fragmented industry: much provision unlikely to be fit for an aspirational future (where will new capacity come from for the ‘poor and needy’?)• Wide variation of NHS care and support• Wide variation of statutory behaviour and support, quality concerns, cost and responsibility shunting• Poor professional development and recognition
  14. 14. The “Dilnot” review findings only address part of the problemWe need……. • Funding to address intensity of services and cost inflation • Clarity on health and social care responsibilities (equality for the aged!) • Improved commissioning and sustainable investment by providers • Intelligent regulation • A rethink on personalisation
  15. 15. Can a risk based approach to regulation of care home provisionwork?Probably not!But with better intelligence and incentives:• Co-production of care with defined shared responsibility and accountability on a foundation of licensed standards• Continual quality improvement and ceaseless quest for sustainable efficiency implying a proper R&D programme and clear policy leadership for care homes• Transparent funding to deliver no more no less than this …we could have confidence
  16. 16. United Kingdom Bupa UK MembershipBupa 2011 Bupa Health Assurance Bupa Wellness Insurance Spain UK Care Services 18,700 businesses Sanitas people in over 300 homes Provision India businesses Sanitas Hospitals Healthcare at Home * Max Bupa Sanitas * Cromwell Hospital Care Homes Residencial Bupa Commissioning Integrated 3800 people in health services 38 homes, China US Representative Office Beijing * Health Dialog Hong Kong Bupa Hong Kong Thailand Australia Bupa Thailand Bupa Australia/ *MBF New ZealandBupa International: Bupa Care Services3,693 residents in 48 homes Guardian HealthcareOffices in Brighton, England;Copenhagen, Denmark; 2,809 residentsMiami, US; Dubai, UAE; Saudi ArabiaCairo, Egypt; and HongKong Bupa Arabia

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