The 2002 Healthcare Conference

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The 2002 Healthcare Conference
abcd

• 29 September-1 October 2002
• Scarman House, The University of Warwick,
  Coventry

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Long Term Care - Where is the new Government
Regime leading us?

• Richard M Thomas FCII
• Managing Director, RED ARC Assured Ltd

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Credentials

• 1990-1998 Managing Director, Hambro Assured
  Care plc - Specialist Long Term Care distribution
  company
• Chairman of the ABIs Long Term Care
  sub-committee for 3 years
• Gave evidence on LTC to
• Health Select Committee
• Royal Commission
• 1998 to present Managing Director, RED ARC
  Assured Ltd - Independent Care Advisory Service

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Agenda

• Context
• Where is the Government going?
• Legislation, Reform and Guidance
• Importance of Assessment
• Single Assessment Process
• Registered Nursing Care Contribution
• Intermediate Care and Rehabilitation
• Early Intervention and Prevention
• Equipment and Assistive Devices
• Early Signs and Premature Conclusions
• Discussion and Questions

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Context

• We will focus on England
• Devolution has allowed each country to develop
  its own policies
• Scotland
• all care in nursing homes is free
• no distinction between nursing and personal care
• Wales
• flat 100 allowance towards the cost of nursing
  care in nursing homes
• N Ireland
• still to decide
• Legislation and reform envisage major change
• timeframes typically run from 2001-2006
• it will be some time before we can make
  judgements about outcomes

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Where is the Government going?

• Big changes in commissioning and delivery of care
• NHS and Social Services more closely aligned
• multi-disciplinary teams
• pooling of budgets
• More appropriate use of available resources
• Single Assessment Process (SAP)
• care pathways
• Intermediate Care
• avoidance of bed blocking
• More prescriptive standards and audits
• More user choice

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Quality and Consistence in Assessment

• National Service Framework for Older People, 2001
• basis on which care decisions are reached
• Single Assessment Process (SAP)
• person centred
• professionals working together
• rounded picture of care needs
• taking account of user preferences
• standardised
• through an agreed evidence base
• sharing information across disciplines
• builds and supports good practice
• produces standardised assessment information
• outcome centred
• appropriate and effective care plan
• promoting healthy independence and quality of
  life

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Single Assessment Process - April 2002

• Nature of the problem?
• NHS
• GP/PCT
• Social Services
• Condition measured against set headings eg
• clinical background
• mental health
• personal care and wellbeing
• environment and resources
• Focus on specific issues using relevant
  specialist resources
• eg geriatric depression
• Complex, multiple needs assessed

Contact Assessment
Overview Assessment
In-depth Assessment
Comprehensive Old-age Assessment
NB No determination of Registered Nursing Care
Contribution can be made until SAP is completed.
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Single Assessment and Care Pathways
Assessment Completed
Care at home or in a residential home
Rehabilitation
CARE PLAN
NHS Continuing Care
Intermediate Care
Care in a Nursing Home
Referral to designated NHS Nurse. Checks all
options have been considered.
Evaluation of care needs in CARE PLAN
Allocation to RNCC Banding
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Registered Nursing Care Contribution

• Low Band - Minimal Nursing Requirement
  35 pw
• - Care needs can be met in other settings
• Medium Band - Multiple care needs 70 pw
• - Daily access to nursing
• - Physical/mental state STABLE AND
• PREDICTABLE
• High Band - Complex needs 110 pw
• - Frequent nursing interventions over
• 24 hours
• - Physical/mental state UNSTABLE AND
• UNPREDICTABLE

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Intermediate Care

• NHS and Social Services MUST
• provide high quality pre-admission and
  rehabilitation care to older people to help them
  live as independently as possible by reducing
  preventable hospitalisation and ensuring
  year-on-year reductions in delays in moving
  people over 75 on from hospital.
• NHS Plan
• Guidelines
• Care to last no more than 6 weeks
• pneumonia 1-2 weeks
• hip fracture 2-3 weeks
• stroke 6 weeks

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Intermediate Care Models

• Models include 2003/4 Targets
• Rapid Resource
• 24 hour access to AE, GPs NHS Direct 70,000
• Hospital at Home people pa
• intensive support at home beyond that
• normally provided in primary care
• Residential Rehabilitation 5,000 new
• to regain function and confidence to return
  beds
• home
• Supported Discharge
• home care and equipment to support earlier
• return home 1,700 places
• Day Rehabilitation
• short term therapeutic support in a Day Centre

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Intermediate Care - Residential Rehabilitation

• Multi-disciplinary team
• Occupational Therapy
• Physiotherapy
• Social Workers
• 138 admissions, mostly over 75 with mobility
  problems
• 88 returned home
• 7 still under treatment
• 4 hospitalised
• 1 nursing or residential home
• Follow-up on those returned home
• 76 still at home after 3 months
• 54 still at home after 6 months
• Source Broom Hayes, Rotherham Health Authority
  2001-2002

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Early Intervention and Prevention

• We believe the Governments aims to be
  principled, but it remains to be seen whether the
  money is spread too thinly across these key
  areas. In particular, more funding is needed to
  provide preventative support for older people
  early on, rather than waiting until they need
  intensive community or nursing care.
• Source Help The Aged
• (Response to the Secretary of States
• proposals for older peoples services)
• July 2002

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Early Intervention Can Work

• Home adaptations transform lives
• reduce the need for hospital and residential care
• Minor adaptations
• 62 of survey felt safer
• 77 felt that their health had improved
• Major adaptations
• before prisoners, degraded, afraid
• after independent, confident
• Psychological aspects as important as
  physiological
• Source Joseph Rowntree Foundation 2001

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Equipment and Assistive Devices

• Secretary of States announcement 23rd July 2002
  included
• Faster assessment by end 2004
• Social Services contact within 48 hours
• assessment within 1 month
• equipment in place within 1 week
• Removal of all charges for equipment from April
  2003 (subject to legislation)
• 500,000 extra pieces of equipment
• hand rails, ramps, hoists etc
• Extension of direct payments to older people
• choice of receiving a service OR cash payments
• Carers grants doubled to 185m by 2006

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Early Signs and Premature Conclusions

• Views from the coal face
• Nursing home co-ordinator
• Nursing home group
• Charities
• Premature conclusions
• A personal view
• As at February 2002
• Low 35 - 19
• Medium 70 - 58
• High 110 - 22
• Source HANSARD

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An NHS View

• Bedding in OK after initial disorganisation
• Each Authority establishing its own models for
  elder-care and intermediate care
• within framework and guidance
• highly dependent on existing resources
• Most determinations falling into middle RNCC band
• Workload issues
• reassessments at 3 and 12 months
• April 2003 DSS case load
• GPs and Consultants need to buy in to changes
• SSDs defensive
• especially on budgetary issues
• Source RED ARC Interviews, August 2002

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A Nursing Home View

• Free nursing care allowances inadequate
• most assessments fall into 70 band
• average difference between nursing home and
  residential home costs 113
• Payments made to care homes
• direct payments would offer more choice
• Bureaucracy
• costly use of scare NHS nursing resources
• single rate preferable (as in Wales)
• variations in Local Authority interpretation
• Ill-prepared
• start date 1.10.2001
• 20 assessments outstanding 1.1.2002
• Source RED ARC Interviews, August 2002
• DSS Rates 2001/2002

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A Charity View

• Government should meet full cost of Long Term
  Care
• no distinction between nursing and personal care
• Allocation to bandings largely reflect pre
  1.10.2001 self-payers
• placed themselves in care
• disposition will change over time
• fewer in the lowest banding
• Complaints about big increases in Nursing Home
  Fees
• some homes not passing on the savings
• shrinking supply of beds
• reducing 5 to 6 per annum
• Source Age concern England

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Conclusions

• The approach in England is well-thought through,
  comprehensive and joined up
• There is growing acceptance of the need to
  intervene earlier and apply the right level of
  care
• There is an intent to give users more choice
• Methodologies for standards monitoring,
  consistency of application and audit are in place
• BUT

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Conclusions (2)

• Its early days
• DoH review only just starting
• results not expected until early 2003
• There must be concerns about
• availability of trained resources to implement
  the changes
• ability to manage a large multi-disciplinary,
  multi-agency programme
• SOUND POLICIES
• SIGNIFICANT ADDITIONAL FUNDING
• DELIVERY ?

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Discussion and Questions

• Some issues for Insurers
• Will free nursing care improve LTCI sales?
• care homes passing on the savings
• general trends in nursing home costs
• anticipating actual costs
• Other opportunities. Where are they?
• product development
• affordable options
• early intervention and prevention
• controlling access to the customer
• Observations and questions