Bupa Private and Confidential Date if required 1

A view from 30,000 feet

Clive Bowman Divisional Medical Director, Bupa

The simple medical approach

• Presentation / diagnosis

• Treatment (first - do no harm, secondly - treatment delayed is treatment denied)

◦ Cure

or

◦ Alleviation of symptoms and prevention of complications

• Effectively and efficiently

• Prevention through risk and lifestyle management

• Informed by access and choice etc

• Controlled by incentive and regulation

Care homes

• A sad remnant of the Poor Law in the UK and often seen as failure of policy

• Unloved: only bad news comes from care homes and the cost…

• A simple business revolving around occupancy/fees/costs

Some things don’t change

Parliamentary Acts in 1531 and 1536 developed the first comprehensive English system of poor relief forming the positive elements of poor relief that would continue for centuries:

• governmental criteria about who is legitimately in need

• governmental obligation to search out those in need

• government registration of need; definition of what government should do for the needy

• construction and administration of a system of contributions for the poor. These laws also continued and expanded the previous system of punishments for those who were able to work.

Fast forward to Supreme Court July 7 2011 - Stroke victim Elaine McDonald lost an appeal to the Supreme Court for a night-time carer. Judges, with one exception, said she had no right to demand a helper and that social workers were within the law when they withdrew the carer to save £22,000 a year

Diagnosis: What is it that care homes do?

• Provide a (largely inappropriate) housing solution

• Provide a refuge or sanctuary for the cognitively impaired, physically disabled and dying

• Provide cost effective solutions for parts of NHS care

What part of these activities are social care?

(as opposed to housing or health)

BCS Divisional Census 2009 – Diagnosis

UK Aus NZ SpainNo Medical Diagnosis 6% 2% 1% 4%Arthritis 18% 24% 18% 16%Cancer 7% 11% 10% 6%Cerebral Palsy 0% 0% 0% 0%Dementia 44% 53% 50% 46%Depression 11% 23% 16% 18%Diabetes and Endocrine 14% 18% 20% 20%Epilepsy 6% 4% 4% 2%Fractures 12% 14% 13% 20%Heart disease 21% 38% 47% 28%Huntingdons disease 0% 1% 0% 0%Learning difficulties 2% 1% 1% 1%Lung/chest disease 8% 12% 17% 12%Manic Depression 1% 2% 1% 3%Missing limbs 1% 1% 2% 1%Motor Neurone disease 0% 0% 0% 0%Multiple Sclerosis 1% 0% 1% 0%Neurological trauma 2% 3% 3% 2%Osteoporosis 9% 19% 16% 17%Parkinsons disease 5% 6% 5% 5%Schizophrenia 2% 4% 3% 2%Stroke 20% 18% 23% 9%Other Diagnosis 28% 63% 45% 60%

The EU SHELTER study 2011 (unpublished: Prof Iain Carpenter)

England Total sample

500 Percent n=4,156

Age, years (mean±SD) 84.5±9.5 yrs 83.4±9.4 yrs

Female gender 72.0% 73.0% 3,035

Physical ability* Assistance required Dependent

26%71%

41.5%

39.8%

1,7231,653

Cognitive function† Mild/Moderate impairment Severe impairment

35.7%28.8%

37.6%30.4%

1,563

1,265

Depression‡ 32% 32.0% 1,331

Behavioral symptoms 32% 27.5% 1,142

Falls 7% 18.6% 774

Pressure ulcers 10.7% 10.4% 432

Pain 38% 36.0% 1,496

Urinary incontinence 72.0% 73.5% 3,054

Bowel incontinence 68.8% 55.2% 2,290

A bluffers guide to changing care home activity

Health

Dementia

Housing

Time

Activity

Activity impact of intermediate care

Month Int careAdmiss

Intdeath

Int care disch

LTCadmiss

LTCdeaths

LTCdisch

Jan 17 1 19 8 6 3

Feb 20 21 19 2 1

Mar 21 13 7 8 7

April 15 13 16 2 9

May 17 12 15 8 5

June 14 16 17 5 10

July 25 15 13 4 7

Aug 15 16 14 6 5

Sept 12 13 10 8 7

Oct 8 14 12 11 6

Nov 21 16 17 6 10

Dec 10 10 24 9 10

Totals 195 1 178 172 75 80

Bupa Care Services

150 bed care home5x30 bed units1unit PCT commissioned~15 Int care beds

Activity whole home701 adm/disch/deathsof which 374 Int care327 LTC

Consequences of the increasing churn shorter stays

increased admissions, occupancy down and intensity upEnhanced commissioning required

Care home outcomes today

Convalescence

Function

Time

Palliative care

Respite

Fluctuating illness

Chronic disease

The characteristics of “social” (LTC) care home residents

• Tired and old

• Cognitively impaired

• Unlikely to be independent in movement

• Likely to be incontinent

• Likely (circa 70%) to be reliant on state funding (poor)

• Running out of choices and control

• In the last phase of the life course

Diagnosis: Care homes face a crisis

• Costs up, income down

• Activity up, occupancy down

• Importance to health and social care poorly recognised

• Still a fragmented industry: much provision unlikely to be fit for an aspirational future (where will new capacity come from for the ‘poor and needy’?)

• Wide variation of NHS care and support

• Wide variation of statutory behaviour and support, quality concerns, cost and responsibility shunting

• Poor professional development and recognition

The “Dilnot” review findings only address part of the problem We need…….

• Funding to address intensity of services and cost inflation

• Clarity on health and social care responsibilities (equality for the aged!)

• Improved commissioning and sustainable investment by providers

• Intelligent regulation

• A rethink on personalisation

Can a risk based approach to regulation of care home provision work?

Probably not!

But with better intelligence and incentives: • Co-production of care with defined shared responsibility

and accountability on a foundation of licensed standards• Continual quality improvement and ceaseless quest for

sustainable efficiency implying a proper R&D programme and clear policy leadership for care homes

• Transparent funding to deliver no more no less than this

…we could have confidence

Spain

Sanitas

Sanitas Hospitals

Sanitas Residencial

3800 people in 38 homes,

United Kingdom

Bupa UK Membership

Bupa Health Assurance

Bupa Wellness

UK Care Services 18,700 people in over 300 homes

Healthcare at Home

* Cromwell Hospital

Bupa Commissioning

China

Representative Office Beijing

Hong Kong

Bupa Hong Kong

Thailand

Bupa Thailand

Saudi Arabia

Bupa Arabia

Australia

Bupa Australia/ *MBF

Bupa Care Services3,693 residents in 48 homes

New Zealand

Guardian Healthcare

2,809 residents

US

* Health Dialog

Bupa International:

Offices in Brighton, England; Copenhagen, Denmark; Miami, US; Dubai, UAE; Cairo, Egypt; and Hong Kong

Insurance businesses

Provision businesses

Integrated health services

India

* Max Bupa

Care Homes

Bupa 2011