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.
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
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)
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
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
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
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.
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.