APPENDIX 6
Memorandum by BUPA (EA6)
1. EXECUTIVE
SUMMARY
1.1 BUPA is a provident association. This
means that any surplus from fees is reinvested in better schemes
and services for the benefit of all BUPA's customers. It has 55
years experience in "the prevention and relief of sickness"
and "the promotion of health".
1.2 BUPA is the largest single provider
of care home places in the UK and is committed to providing the
best possible care to people resident in its 17,000 care home
beds in the UK.
1.3 BUPA does not tolerate abuse in any
of its care homes. However, it acknowledges that even with monitoring
and support that is over and above regulation and statutory protection,
distressing incidents occur. Thankfully, they are rare.
1.4 BUPA has policies, training programmes
and procedures in place that endeavour to ensure a positive and
open care culture that prevents neglect and abuse from occurring.
These include an active approach to whistleblowing.
1.5 On the rare occasion that an incident
does occur, BUPA investigates the incident rigorously, then informs
and actively collaborates with statutory agencies. BUPA does everything
in its power to learn from experience and wherever possible takes
action to prevent similar incidents from happening again.
1.6 Staff in BUPA care homes are provided
with extensive training opportunities to enable them to provide
quality care for people who may be considerably distressed because
of their health status.
1.7 BUPA takes its duty of care to vulnerable,
elderly people extremely seriously. BUPA endeavours to create
an environment that strikes a balance between providing an appropriate
level of care and supervision and giving residents the freedom
and quality of life they deserve.
1.8 BUPA is concerned at the apparent broadening
of the term abuse to encompass acts that until now have been viewed
as errors of judgement, insensitivity to personal needs and preferences—largely
due to ignorance. However distressing, these incidents arise out
of a lack of training and awareness rather than an intention to
abuse or neglect vulnerable people.
1.9 Statutory authorities and the media
focus attention on events in care homes yet little attention is
given to the inadequate commissioning of services. This contributes
to poor patterns of care currently deemed abusive. Whilst care
in homes is subject to considerable observation by staff and visitors,
and statutory regulation, these safeguards are much diminished
in people's own homes where much care is provided by individuals
in isolation.
2. ABOUT BUPA
2.1 BUPA is a provident association. This
means that any profit is reinvested in better schemes and services
for the benefit of all BUPA's customers. It has 55 years experience
in "the prevention and relief of sickness" and "the
promotion of health".
2.2 BUPA was established in 1947 and is
a broad-based health and care organisation with a growing international
presence. With long standing interests in Hong Kong, Spain and
Malta, BUPA's rapid expansion in recent years means it is now
also involved in businesses based in Thailand, Saudi Arabia, Ireland,
Singapore and Australia. It has more than 7 million customers
in 180 countries and approximately 40,000 employees. Its main
interests are health insurance, hospitals, care services, health
assessments, workplace health and childcare services. It also
provides recruitment services for healthcare professionals and
has a network of nurseries for the children of working parents.
3. ABOUT BUPA
CARE HOMES
3.1 BUPA Care Services cares for approximately
16,000 residents in 245 residential and nursing homes across the
UK. Approximately 70% of BUPA's residents receive some funding
from the state for their care.
3.2 In 2002, BUPA Care Services committed
to spend £3 million on training over the next three years.
It ran 12,000 certified courses on subjects such as health and
safety, fire training and food hygiene. It also put 1,600 people
through a mixture of NVQ levels two, three and four and provided
work placements for NHS nurse trainees as part of their course.
It is the one of the largest companies to be awarded Investor
In People status, which it gained for the second time in September
2003.
4. PREVALENCE
OF ABUSE
IN CARE
HOMES
4.1 Confirmed cases of abuse with intent
are rare within BUPA's care homes. Like all care home providers,
BUPA is subject to formal regulation and inspections. In addition
to this, BUPA operates a robust system that investigates and monitors
all complaints and issues that are brought to its attention and
monitors this through its management system. However, despite
the regulation, monitoring and a strong whistleblowing policy,
abuse can occur. The problem is that the term abuse appears to
have expanded: there is now a lack of clarity about when insensitive
care, or complex needs that are inadequately recognised through
service commissioning or ignorance, give the term legitimacy.
4.2 Abuse is not tolerated but an analysis
of the cause of the abuse is seldom undertaken and, in most cases,
action is taken against the immediate perpetrator. The true cause
may lie in an environment that tolerated abuse. There is inadequate
research to understand the cause of real abuse and a tendency
to micro manage the consequences rather than develop environments
where the risk of abuse is minimised.
4.3 Understanding abuse has always been
methodologically difficult and is likely to continue to be so.
The literature on abuse and neglect spans a remarkable range from
sexual assault and theft to "stagnant activity levels"
and lack of privacy. The definition of Elder Abuse by the charity
Action on Elder Abuse is:
"A single or repeated act or lack
of appropriate action, occurring within any relationship where
there is an expectation of trust, which causes harm or distress
to an older person".
4.4 BUPA considers this definition to be
too wide as it devalues the importance of the term abuse as a
marker of utterly unacceptable behaviour.
5. CAUSES OF
ABUSE
5.1 BUPA reflects that standards and patterns
of care have evolved from before the Poor Law to the present time
and that expectations and patterns of need change, as does societal
acceptance of risk and safety.
5.2 At present commissioning and funding
streams for long stay care require contractual arrangements involving
multiple agencies. BUPA observes that these are predicated more
on "quantity and cost of care" required at the time
of need rather than the quality of care required for the individuals
optimum care experience throughout their remaining life course.
A recent report from the Rowntree Foundation suggested that local
authorities are paying care homes approximately £80 per person
per week less than is required to care for their residents. Additional
increases in the National Minimum Wage and NI contributions are
squeezing the sector.
5.3 BUPA suggests that inadequate and relatively
(compared with service provision) unaccountable commissioning
processes may be a significant factor. Other external factors
could also play an important role. They may include:
— a deficiency of beds leading to a
tolerance of care homes that are not "fit for purpose";
— a market economy that may result
in care homes accepting residents when the homes are ill equipped
to provide appropriate care for those residents. BUPA believes
this situation arises when care homes on the brink of bankruptcy
due to low levels of local authority funding are forced to take
all residents offered to them; and
— a litigious and overprotective climate
that may result in a preoccupation with residents' safety that
leads to an increased, and possibly inappropriate, use of restraints
and the practice of confinement.
5.4 Continued press attention is focused
on elderly care home residents being over medicated with sedative
agents. The recurring allegation is that care homes tranquilise
residents to keep them manageable. BUPA strongly disputes this
allegation. All medication is prescribed by the residents' own
GPs. Doctors decide what drugs care home residents should take
and decide on the dose. BUPA's care home staff are responsible
for administering the medication to residents. They may seek medical
review of residents' symptoms and behaviour but it is a medical
decision to prescribe sedation. Care home regulators do not have
jurisdiction over the prescribing habits of attending doctors,
though it is acknowledged there may be discussion between care
staff that will be influential. Research is required to understand
the severity and extent of this issue and to inform policies that
provide a lasting remedy.
5.5 Although research is limited, residents
vulnerable to sexual abuse are often characterised by severe intellectual
impairment and physical frailty, while those with challenging
behaviour can lead to staff retaliating abusively.
6. WHAT CAN
BE DONE
ABOUT IT?
6.1 BUPA considers that in its care homes,
clear lines of managerial accountability and trained and valued
staff, allied to a stable, supportive management, all minimise
the risk of abuse.
6.2 Within care homes, immediate appropriate
action is necessary when concerns regarding care are raised irrespective
of whether abuse has been specifically alleged. Under the present
definitions of abuse and systems for the protection of vulnerable
adults, the statutory response is best described as all or nothing
and usually in response to a single event or sequence of events
perpetrated by an individual or group of individuals. The protection
of vulnerable older adults would be enabled if abuse and neglect
were viewed as one extreme of elder mistreatment with insensitive,
disparaging and dehumanising care (known as "malign care")
at the other.
6.3 Between the extremes of abuse and malign
care is maltreatment. This is usefully considered as deliberate
acts of harsh care that may be absorbed into the culture of a
care home and condoned. BUPA believes that more investment into
preventing malign care and maltreatment would provide a more enduring
protection as these circumstances almost certainly allow the emergence
of abuse. To help prevent incidents of abuse and maltreatment,
acts of malign care must not be tolerated or dismissed as not
worthy of comment.
7. RECOMMENDATIONS
7.1 The burden of regulation is already
adequate to safeguard vulnerable people in care homes. BUPA believes
that existing NCSC regulations coupled with strong internal whistleblowing
and complaints procedures are sufficient to ensure the highest
possible quality of care. There should be no new regulations.
BUPA does have concerns that providing care in peoples' own homes,
unregulated sheltered accommodation units and assisted living
arrangements may require new protective measures.
7.2 BUPA believes that the better the training
the greater the reduction in incidence of abuse. Adequate training
is made difficult by local authorities who pay care homes for
care with no specific consideration for the support and development
of the infrastructure of training. Local authority fees need to
be set at fair rates that make the sector viable and allow services
to be improved through investment in, for example, staff training.
7.3 Care homes should incorporate into their
internal policies staff training on the "Identification of
Abuse and the Protection of Vulnerable Adults" and the designation
of members of the care team as resident advocates.
7.4 The more often friends and relatives
visit, the less likely it is that issues will arise, particularly
if friends and relatives are encouraged to raise any concerns
they have. Integrating care homes within the community, ensuring
they are viewed as an important local asset and that they have
an open and welcoming culture to encourage relatives to visit
would serve to foster positive care outcomes. BUPA already makes
a point of trying to incorporate all its care homes into the local
community.
7.5 The development of a Protection of Vulnerable
Adults list, similar to that utilised in child protection would
identify individuals deemed unfit to work with vulnerable adults
in any setting.
November 2003
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