APPENDIX 4
Memorandum by The Medical Director, BUPA
Care Services (DD 7)
BUPA Care Services is the largest independent
provider of nursing and residential care beds in the United Kingdom.
Nationally it has a broad range of contracts with Health Authorities
and Social Services Departments. Information and evidence here
reflects that experience in its Care Services division, principally
relating to Care Homes.
1. Models of Care: Successful intermediate,
rehabilitative and other services should be part of a seamless
journey of care for patients irrespective of provider. The diversity
of clinical problems referred to "generic" intermediate,
rehabilitative care and other services ranging from post-surgical,
post-medical or indeed psychiatric care make an unwieldy case
mix. Intermediate care schemes integrated into and facilitating
existing primary, secondary care and social services provisions
could usefully become a long-term component of a specialty clinical
service (the specialty model) or part of the management network
for common disease areas that are issues for hospitals and the
community (the disease model). An example of the specialty model
could be services incorporated into orthopaedic provisions and
the disease model such as rehabilitation from stroke and other
degenerative neurological diseases. Services orientated to be
"community buffers" capable of averting hospital admission
or general "step down beds" need particularly strong
clinical leadership to ensure that vulnerable people do not become
divorced from specialist skills and services diagnosis, treatment
and care.
2. Commissioning: Our provision of new services
has generally been of short-term contracts addressing winter pressures
with limited audit rather than strategically planned sustainable
initiatives that develop capacity. New funding streams have not
been converted into the development of partnership working as
envisaged so far. Modernisation of health services, particularly
"shifting the balance" seems to have introduced further,
probably transitional difficulties in commissioning. Difficulties
in configuration, negotiation and authorisation of the substantive
contracts capable of yielding the improvements in public services
desired are apparent.
3. Clinical Governance: The clinical governance
of schemes that have been made to facilitate discharge is a matter
of concern. Patients entering intermediate care commonly have
been discharged from hospital specialist care but are often not
under the care of their regular General Practitioner. Where special
medical officers have been appointed to supervise intermediate
care co-ordination with emerging systems of governance in secondary
care or for that matter those in primary care are poor. This partly
explains why case mix and outcomes of intermediate care are not
critically reviewed. An inclusive form of governance we believe
needs to be a core part of these initiatives, particularly in
the light of the experience and recommendations from the "Bristol
inquiry". These may be achieved by adopting the specialist
or disease orientated approach to commissioning (see 1).
4. Service Competency: We have observed reluctance
of hospital teams to allow discharge of some patients to intermediate
care illustrated by this vignette, in one contract provision we
noted that upper limb fractures outnumbered hip fractures by 2
to 1. We were led to believe that clinicians were reluctant to
see hip fractures being referred to the intermediate care services
through lack of confidence and control over the continuing nature
of rehabilitative care. In consequence upper limb fractures that
merely required heightened personal care whilst in a state of
incapacity (immobilised limbs) were deemed safe for transfer,
in reality these patients could have equally just been in ordinary
residential care.
5. The needs of the Dying: Presently, hospices
are unable to consistently meet the needs of terminally ill people.
In our care homes, many people are admitted for terminal care
but we understand that there are still large numbers of people
who die in the hospital, largely due to the lack of appropriate
provisions for their needs. Consideration should be given to the
inclusion of terminal care within intermediate care. This could
have significant potential to ease pressure on acute hospital
beds and provide a better environment for the dying. It would
also have the potential to build on the experience of the hospice
movement in the community nurses using Care Homes for support
at the end of life.
21 January 2002
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