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A view from 30,000 feet
 Clive Bowman
 Divisional Medical Director, Bupa




Bupa   Private and Confidential   Date if required   1
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
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
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
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)
BCS Divisional Census 2009 – Diagnosis
                         UK    Aus        NZ   Spain
No 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%
The EU SHELTER study 2011 (unpublished: Prof Iain Carpenter)
                               England          Total sample
                                  500         Percent       n=4,156
Age, years (mean±SD)          84.5±9.5 yrs   83.4±9.4 yrs
Female gender                    72.0%         73.0%         3,035
Physical ability*
    Assistance required          26%           41.5%         1,723
    Dependent                    71%           39.8%         1,653

Cognitive function†                                          1,563
   Mild/Moderate impairment      35.7%         37.6%         1,265
   Severe impairment             28.8%         30.4%

Depression‡                      32%           32.0%         1,331
Behavioral symptoms              32%           27.5%         1,142
Falls                             7%           18.6%           774
Pressure ulcers                  10.7%         10.4%           432
Pain                             38%           36.0%         1,496
Urinary incontinence             72.0%         73.5%         3,054
Bowel incontinence               68.8%         55.2%         2,290
A bluffers guide to changing care home activity



                                                  Health

                                                  Dementia
 Activity




                                                  Housing

                           Time
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        10
Bupa Care Services     Dec      10                 10         24       9        10
                       Totals   195        1       178        172      75       80
Consequences of the increasing churn shorter stays




 increased admissions,
 occupancy down and intensity up
 Enhanced commissioning required
Care home outcomes today




                                  Convalescence


                                  Fluctuating illness

Function
                                  Respite


                                  Chronic disease
              Palliative
                care

                           Time
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
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
The “Dilnot” review findings only address part of the problem
We 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
Can a risk based approach to regulation of care home provision
work?

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
United Kingdom
                                Bupa UK Membership
Bupa 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 Zealand
Bupa International:
                                                                Bupa Care Services3,693
                                                                residents in 48 homes     Guardian Healthcare
Offices in Brighton, England;
Copenhagen, Denmark;                                                                      2,809 residents
Miami, US; Dubai, UAE;                           Saudi Arabia
Cairo, Egypt; and Hong
Kong                                             Bupa Arabia

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Clive Bowman: The future for residential care provision

  • 1. A view from 30,000 feet Clive Bowman Divisional Medical Director, Bupa Bupa Private and Confidential Date if required 1
  • 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. 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. 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. 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. BCS Divisional Census 2009 – Diagnosis UK Aus NZ Spain No 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. The EU SHELTER study 2011 (unpublished: Prof Iain Carpenter) England Total sample 500 Percent n=4,156 Age, years (mean±SD) 84.5±9.5 yrs 83.4±9.4 yrs Female gender 72.0% 73.0% 3,035 Physical ability* Assistance required 26% 41.5% 1,723 Dependent 71% 39.8% 1,653 Cognitive function† 1,563 Mild/Moderate impairment 35.7% 37.6% 1,265 Severe impairment 28.8% 30.4% Depression‡ 32% 32.0% 1,331 Behavioral symptoms 32% 27.5% 1,142 Falls 7% 18.6% 774 Pressure ulcers 10.7% 10.4% 432 Pain 38% 36.0% 1,496 Urinary incontinence 72.0% 73.5% 3,054 Bowel incontinence 68.8% 55.2% 2,290
  • 8. A bluffers guide to changing care home activity Health Dementia Activity Housing Time
  • 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 10 Bupa Care Services Dec 10 10 24 9 10 Totals 195 1 178 172 75 80
  • 10. Consequences of the increasing churn shorter stays increased admissions, occupancy down and intensity up Enhanced commissioning required
  • 11. Care home outcomes today Convalescence Fluctuating illness Function Respite Chronic disease Palliative care Time
  • 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. 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. The “Dilnot” review findings only address part of the problem We 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. Can a risk based approach to regulation of care home provision work? 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. United Kingdom Bupa UK Membership Bupa 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 Zealand Bupa International: Bupa Care Services3,693 residents in 48 homes Guardian Healthcare Offices in Brighton, England; Copenhagen, Denmark; 2,809 residents Miami, US; Dubai, UAE; Saudi Arabia Cairo, Egypt; and Hong Kong Bupa Arabia

Editor's Notes

  1. Care Homes are sadly still seen as a societal failure. Care Homes only generate bad news and at the end of the day it’s just a matter of warehousing older people
  2. This is where it gets a bit more difficult! In Australia and NZ there is a mandatory geriatric assessment prior to care home admission, which almost certainly accounts for the variation in diagnosis of Dementia and in particular Heart disease. Parkinson’s disease and diabetes are more consistent across the division. In these conditions, symptoms and treatment, we believe, lead to a greater consistency in diagnosis and documentation - incidentally the 5% prevalence in care of PD is consistent with other studies. Note that stroke is much lower in Spain, we are not clear whether this is related to Mediterranean diet
  3. In this simple slide I outline possible evolution of Care Home activity , The fall in use of care homes as a housing substitute has been offset by the growth in dementia cases. That is now ending and future demands for dementia care are likely to need new provision. Concurrently the use of care home beds for intermediate and various short admission stays is rising. Though the number of beds may be modest, the intensity of activity is contributing to the rapid increase in admission rates (10% per annum in the UK) and perhaps the falling occupancy with increasing “churn” intervals.
  4. From one country in 1947 to eight domestic operations, as well as a representative office in China and serving customers in over 190 countries via Bupa International, Amedex and IHI.