Select Committee on Health Appendices to the Minutes of Evidence


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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