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abcd The 2002 Healthcare Conference 29 September-1 October 2002 Scarman House, The University of abcd The 2002 Healthcare Conference 29 September-1 October 2002 Scarman House, The University of Warwick, Coventry

Long Term Care Where is the new Government Regime leading us? Richard M Thomas Long Term Care Where is the new Government Regime leading us? Richard M Thomas FCII Managing Director, RED ARC Assured Ltd

Credentials n 1990 -1998 : Managing Director, Hambro Assured Care plc - Specialist Long Credentials n 1990 -1998 : Managing Director, Hambro Assured Care plc - Specialist Long Term Care distribution company n Chairman of the ABI’s Long Term Care subcommittee for 3 years n Gave evidence on LTC to: n Health Select Committee n Royal Commission n 1998 to present : Managing Director, RED ARC Assured Ltd - Independent Care Advisory Service

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

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

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

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

Single Assessment Process - April 2002 Contact Assessment Overview Assessment In-depth Assessment Comprehensive Old-age Single Assessment Process - April 2002 Contact Assessment Overview Assessment In-depth Assessment Comprehensive Old-age Assessment 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 NB: No determination of Registered Nursing Care Contribution can be made until SAP is completed.

Single Assessment and Care Pathways Assessment Completed Care at home or in a residential Single Assessment and Care Pathways Assessment Completed Care at home or in a residential home Rehabilitation NHS Continuing Care CARE PLAN Intermediate 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

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

Intermediate Care n NHS and Social Services MUST “provide high quality pre-admission and rehabilitation Intermediate Care n 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 n Guidelines n Care to last no more than 6 weeks n pneumonia n hip fracture n stroke 1 -2 weeks 2 -3 weeks 6 weeks

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

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

Early Intervention and Prevention n “We believe the Government’s aims to be principled, but Early Intervention and Prevention n “We believe the Government’s 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 State’s proposals for older people’s services) July 2002

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

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

Early Signs and Premature Conclusions n Views from the coal face n Nursing home Early Signs and Premature Conclusions n Views from the coal face n Nursing home co-ordinator n Nursing home group n Charities n Premature conclusions n A personal view n As at February 2002 Low Medium High £ 35 £ 70 £ 110 - 19% - 58% - 22% Source : HANSARD

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

A Nursing Home View n ‘Free nursing care’ allowances inadequate n most assessments fall A Nursing Home View n ‘Free nursing care’ allowances inadequate n most assessments fall into £ 70 band n average difference between nursing home and residential home costs £ 113* n Payments made to care homes n direct payments would offer more choice n Bureaucracy n costly use of scare NHS nursing resources n single rate preferable (as in Wales) n variations in Local Authority interpretation n Ill-prepared n start date 1. 10. 2001 n 20% assessments outstanding 1. 1. 2002 Source : RED ARC Interviews, August 2002 *DSS Rates 2001/2002

A Charity View n Government should meet full cost of Long Term Care n A Charity View n Government should meet full cost of Long Term Care n no distinction between nursing and personal care n Allocation to bandings largely reflect pre 1. 10. 2001 ‘self -payers’ n placed themselves in care n disposition will change over time n fewer in the lowest banding n Complaints about big increases in Nursing Home Fees n some homes not passing on the ‘savings’ n shrinking supply of beds n reducing 5 to 6% per annum Source : Age concern England

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

Conclusions (2) n It’s early days n Do. H review only just starting n Conclusions (2) n It’s early days n Do. H review only just starting n results not expected until early 2003 n There must be concerns about n availability of trained resources to implement the changes n ability to manage a large multi-disciplinary, multi-agency programme SOUND POLICIES … SIGNIFICANT ADDITIONAL FUNDING … … DELIVERY ?

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