EMI Residential/Nursing Care for Bristol - Update

Commissioning Specialist EMI Residential/Nursing Care for the Bristol area

For years the successful operation of the NHS has been dependent on the Independent Sector. This has been more implicit than explicit, and has for the most part been subject to the intermediary link of the Local Authority Social Services.

Older people make up the majority occupiers of NHS acute beds, and many of them stay for longer than is deemed optimal either for the individual in question or for the acute service. "Bed blockers" is the current inelegant generic term applied to such unfortunates, who find themselves in an unenviably disempowered situation.

Analyses of the factors contributing to this situation tend to focus either on parts of the equation only rather than whole systems, or to examine static capacity/occupancy rather than throughput/relationships between services or group characteristics of "bed blockers".

Nationally NHS acute bed numbers have decreased and the Independent Sector has enjoyed a period of rapid growth followed by a sharp decline in the last three years. In the same period in the South West Region there has been a net loss of 7000 Care Home beds, with a particular reduction in specialist EMI Care Homes. Many factors have contributed to this decline including the recent implementation of the new Care Standards Act, and the basic fact that operators are finding it is increasingly difficult to make a profit in this field, whilst at the same time being subject to a whole raft of new legislation and raised standards.

One of the more overlooked factors in the equation has been the Commissioning relationship between the Statutory and Independent Sectors. For the most part this has developed in recent years as a "spot purchasing" link rather than a long term contract. This has left the Independent Sector carrying all the risks, including voids. During a time of net growth, such a system can flourish, with competition driving down prices. In the present situation of Independent Sector Providers getting out of the market, some risk sharing would seem to be an essential way of starting to treat the Independent Sector as a true partner in continuing care, rather than an evil to be kept at arms length and exploited if possible. There are well tested examples already in existence of such models, involving both long term contracts and Health contribution to the overall funding package.

What is becoming increasingly evident is that it is older people with complex care needs, usually dominated by dementia with secondary behavioural problems who are the most difficult to place onwards from hospital. It is equally clear that hospital is one of the most inappropriate environs in which to correctly estimate their long term care needs, often contributing adversely to their residual abilities. Perversely, older people with mental health problems have almost universally been excluded from Intermediate Care schemes where they might otherwise demonstrate that even people with dementia may have some rehabilitable potential.

In a political environment where it is acknowledged that most people would wish to receive care in their own homes rather than in the modern equivalent of the old workhouse, it is nevertheless apparent to the clinicians but overlooked by many planners that Care homes will remain an essential component of care for people with severe dementia with behavioural problems. Other frail older people may well avail themselves of and rejoice in the new concept "Very Sheltered" homes. By and large, these will not cope with people who persistently wander, put themselves at risk, rebuff personal care and so forth. They will continue to require places in the very care homes which are selectively being driven out of business.

It is extremely difficult to find a reference base for the number of specialist EMI places required for any given area. One such source is an agreed statement by the Royal Colleges of Physicians and of Psychiatrists in 1999, indicating numbers of acute and long term beds required for a standard population. Using this as a proxy, and taking the figure of 3 long term hospital beds per 1000 people over 65 and then replacing specialist EMI Nursing Home beds with health "top-up" payments for long term beds, then Bristol with a population over 65 of approximately 60,000, should have 180 beds. In fact it has 30 at Humphrey Repton House, 30 at Somerset Lodge and 24 at Treetops. Of these approximately 20 are used by non Bristol residents, bringing the total down to just 64 places. In addition there are 20 Bristol residents in long stay places at Blackberry Hill, making a total of 84 places almost 100 short of the target.

Bristol Social Services did produce a Vision for the Future document which incorporates a number of far sighted ideas. It falls short on both systematic quantification of need and a detailed implementation programme. Whilst its proposals on developing 600 Units of Very Sheltered Housing as an alternative to traditional Residential Care are innovative, its strategy for replacement of its in-house stock of EMI Residential Care Homes which do not meet the forthcoming Care Standards Act requirements is still at an early stage of development, and has not been analysed in the context of the total bed provision for EMI Continuing Care.

It is particularly in the category of Dementia with behavioural problems so-called "EMI" that the gulf between need and provision is so wide. This is the precise patient group least likely to be able to avail of new opportunities in Very Sheltered Housing schemes. Wandering, aggression and resistive behaviours resist the twin approach of "Smart" houses and intensive Home Care input, requiring 24 hour skilled care and a specialist approach with an emphasis on intuitive problem solving.

When such patients are currently admitted to acute medical beds, they are likely to experience multiple moves from ward to ward within the hospital, having a change of both nursing and medical staff each time, making the concept of continuity of care impossible, and obscuring the original reason they may have come in, as well as directly contributing to the likelihood of their deteriorating. The separation of Geriatric Medicine from Psychogeriatric medicine on different sites and in different Trusts creates a further distorting barrier.

Unfortunately it has not been deemed to be the responsibility of any one Statutory body to come up with a solution to this problem made more complex by the phenomenon of "cross boundary" flows (patients tend to be placed in homes near to involved relatives rather than to where they lived, and so "tidy" planning of sufficient places in Care Homes to meet the needs of local residents may easily be blown apart by an influx from an adjacent, but different Local Authority area, lacking in provision).

The dual stigma of being old and having mental health problems has also combined to relegate the task of finding a solution to this problem to the "less potent" committees or individuals. The profile and importance of the issue has been rising in recent months with the growing realization of the size of the problem, as successive EMI Nursing Homes close and these patients "back up" not only in Psychogeriatric wards but also in Acute Medical and Surgical wards, having a visible impact on waiting lists and thus acquiring a "political" status.

Nevertheless, most of the debate about what to do about the crisis has been characterized by a degree of hand wringing and shuffling about the margins rather than radical planning. Some of the current problems appear to be accepted as inevitable and unshiftable. This state of learned helplessness would seem to require an upbeat demonstration of "can-do" problem solving, and is unlikely to make headway unless representatives from the Independent Sector with a track record of delivering in this field are included in the debate.

An approach stressing Partnership between Statutory Sectors and Educational bodies (to address the workforce training needs) with the Independent Sector, in a Joint Commissioning framework, with risk and cost sharing involving long term rolling contracts, would seem to be the best way forward.

A strategy for commissioning an enduring partnership with the Independent Sector must be forthcoming. There is an urgent requirement to commission an additional 100 Specialist EMI Nursing Home beds with Health contribution to their funding for Bristol residents. This could make a singular contribution to the Current bed blocking crisis. Likely costs for such additions would be £550 per week per place, with "ordinary" Nursing contributions of £110 per week, "Specialist Health " top up of £150 per week, leaving a residual £290 per week Social Care cost, offset by personal contributions of at least £120 per week (state pension and attendance allowance at the higher rate). Thus the cost to any one sector is not exorbitant, and for Social Services could be offset by a reduction in ordinary Care Home placement (i.e. increase the proportion of EMI placements but keep the total number constant).

These views were written a year ago and have recently been largely endorsed by a review commissioned by the four unitary authorities that used to comprise Avon, and delivered by the Nuffield Research Institute. We await a response to the suggestions contained in that review and a further study commissioned from Price Waterhouse which has also made recommendations that care home placements should attract significantly more funding.