so, what’s next? prof. clive bowman school of health sciences city university london...
TRANSCRIPT
So, What’s Next?
Prof. Clive Bowman School of Health Sciences
City University London
Care England ConferenceNovember 2015
• We don’t need care homes• We can’t do without care homes• New forms of housing are the answer• Technology is the answer
• Care Homes– Financing and fees– Regulatory pressure– Staffing costs– Occupancy weak
• NHS– Funding Black hole– Regulatory pressure– Primary care crisis– Hospital beds full
• Understand frailty, death and dying• Understand purpose(s) of Care Homes for Older
People• Regulation, Policy leadership, Purchasing,
Governance and Quality Improvement• Realise through Digital Transformation +
Trajectories to death
• 20% Sudden death • 20% Cancer• 20% Chronic illness
• 40% Progressive Dwindling
Formative Care: defining the purpose and clinical practice of care for the frailClive Bowman and Julienne MeyerJ R Soc Med, March 2014; vol. 107, 3: pp. 95-98
Lynn J, Adamson DM. Living Well at the End of Life, Adapting Health Care to Serious Chronic Illness in Old Age, Santa Monica, CA: Rand Health, 2003.
By minimizing the number of years people suffer from chronic illness, we enable older people to live more successful, productive lives that benefit themselves and society.
James Fries: Compression of mortality
As more people age healthily - as preventable illness is prevented and long term conditions are better managed more people become “eligible” or at risk of dwindling conditions and associated frailty for which we have no coherent policy or narrative and relatively little evidence
Squaring off morbidity the politicians straw
Squaring up to progressive dwindling
Care Home purpose now
• Housing solution• NHS LTC replacement• Dementia care• Intermediate/Indeterminate care• End of Life Care
And why dwindlers dawdle• NHS
– Prevention– Diagnosis– Treatment– Rehabilitation– Palliative Care– Prevention of hosp.
admissions
• Social Care– Care and support needs– Eligibility– Safeguarding– Commissioning– Personal budgets– End of Life Care
There is no common construct for progressive dwindlers, those on a glide path but who are not actively dying
Care Home purpose(s) revisited
• Lifestyle / economic – “choice”• Specialist care Dementia today – others to
follow • Skilled Nursing Facilities sub-acute care, re-
ablement and end of life care (rebrand)• Formative care, the best possible quality of life
for people whose lives have been reframed by frailty and disability (progressive dwindlers) –(re purpose)
Policy fails and feckless solutions
• NSF older people assessment….• Stamping out bad practice through regulation• Medicines usage• Infection control• End of life care• ?Dilnot
The rise of the SNFs ?• Unsustainable hospitals• Sub-acute care• Re-ablement• No capital resource
Will require sophistication• Proper contracts• Integration
Oxford Circus London a lesson in sophistication through re-engineering
12
Oxford Circus re-engineered in 2009 on the model on the Shibuya crossing Tokyo
From a highly regulated a place for everything and a place for everything
to a place where you have to take responsibility but have greater freedom
Policy and Care Homes
• DH Health (more than 4x no of care home beds for every NHS bed)
• DH Social Care (80% adult social care budget)• CQC• NICE
Executive agencyMedicines and Healthcare products Regulatory AgencyPublic Health England
Executive non-departmental public bodyCare Quality CommissionHealth Education EnglandHealth Research AuthorityHealth and Social Care Information CentreHuman Fertilisation and Embryology AuthorityHuman Tissue AuthorityMonitorNHS Blood and TransplantNHS Business Services AuthorityNHS EnglandNHS Litigation AuthorityNHS Trust Development AuthorityNational Institute for Health and Care Excellence
Advisory non-departmental public bodyAdministration of Radioactive Substances Advisory CommitteeAdvisory Committee on Clinical Excellence AwardsBritish Pharmacopoeia CommissionCommission on Human MedicinesCommittee on Mutagenicity of Chemicals in Food, Consumer Products and the EnvironmentIndependent Reconfiguration PanelNHS Pay Review BodyReview Body on Doctors' and Dentists' Remuneration
OtherAccelerated Access ReviewMorecambe Bay InvestigationNational Information Board
The Department of Health works with 26 agencies and public bodies
Quality/Compliance surveillance
• Provider internal systems• Regulatory surveillance• Commissioner assurance
Do we really need three lots of folk doing essentially the same thing ?
What we need• Standardised operational processes and care
practices + Digital transformation• Assessment • Regulatory monitoring• Medicines management and surveillance• Experience and outcomes monitoring
• An policy executive agency (departmental or not)– a mix of
• Public Health Observatory• Office Budget Responsibility/Monitor• People planning
MDS: The HubBowman C. IIHA - University of BristolReviews in Clinical Gerontology 1998 8 275-277
MDS-RAI
Individual Care Planning
RUGScommissioning RAPS
GeratologicalCont. health careOutcomes (QI’s)
PACE R&D
Governance
Assessment & reviewNurse SpecialistGP/Ger Med.
• 256 patients in 55 homes
• Av 7.2 medicines/ resident
• 70% residents have medication errors
• 39 % prescribing errors
• 37% dispensing errors
• 22% administration errors
• No one person is responsible
http://www.birmingham.ac.uk/Documents/college-mds/haps/projects/cfhep/psrp/finalreports/PS025CHUMS-FinalReportwithappendices.pdf
CHUMs Report 2009
Antipsychotics in long-term residential care and the National Dementia Strategy
Cohort C n = 7000 baseline and at 48m n= 9000
Professor Ala Szczepura Dr Deidre Wild Dr Amir J Khan Dr David Owen Dr Tom Palmer Tariq Muhammad Dr Michael D Clark Professor Clive Bowman2015 In review
howRwe report showing locations where patient experience is above and below average.
Benson T, Bowman C. HRQoL and Patient Experience in Care Homes: A Study in Three Countries. Medicine 2.0, London, 2013R-Outcomes.com
howRU report showing locations where health status is above and below average.
Benson T, Bowman C. HRQoL and Patient Experience in Care Homes: A Study in Three Countries. Medicine 2.0, London, 2013
CDC United States Flu Activity Google Flu Trends estimate
Big data vs traditional data gathering
Why doesn’t being kept warm protect the frail from dying in cold climates?
Source Google
In Conclusion• There is a need now and for the foreseeable future for Care
Home beds• Same old Same old won’t do• Policy and Provision needs to be clearer in purpose and value • Regulation won’t do this• Big data provides both operational efficiency and intelligence
in other jurisdictions and could here
• We need a consistent executive body not an array of task and finish groups
And finally…
Could the NHS reduce hospital beds by ~10% pa for 3 years and buy double the number of Care Home Beds closed as Skilled Nursing Facilities?
Thank you…… questions?