long-term care

Published: 12/12/2001, Volume II2, No. 5835 Page 24 25 26 27

The government's policy on long-term care is unclear and the debate too narrowly focused. Melanie Henwood calls for a radical rethink

The history of long-term care in Britain, as in most other countries, is one that has been punctuated by scandals, revelations of appalling practices and dehumanising regimes. The roots in the poor law and the workhouse have left an enduring legacy that has been hard to shake off, despite the fact that most residential provision is now in the independent sector and has broken the physical link with former institutions.

From Peter Townsend's 1962 indictment of residential care homes that failed to meet the 'physical, psychological and social needs of the elderly people living in them', through various formal inquiries, including the Wagner report on residential care and most recently the Royal Commission on Long-Term Care, recurrent themes can be identified.

1,2,3 At root there is a fundamental ambivalence towards long-term care. The existence of care homes disturbs us. Both as individuals and as a society, most people retain a sense of guilt and shame at 'putting away' older people and others needing care.

Townsend argued that alternative services should quickly take the place of residential provision.While the aspiration was laudable, it was never likely to be wholly practical.Moreover, the existence of poor quality care is not an argument per se against residential provision, but an argument for regulation and inspection, the establishment of national standards and improved staff training and development.

By the mid-1980s, there was a recognition that long-term residential facilities occupied a vital place within the spectrum of care, and the Wagner report marked a departure in shifting the focus on residential care from a service of last resort, to one of positive choice.

Two 'fundamental requirements' for the proper functioning of long-term care services were identified. The royal commission reiterated this, stating: 'People who move into a residential establishment should do so by positive choice, and living there should be a positive experience.'

The commission similarly emphasised the importance of independence and autonomy, and while accepting the important role of residential provision it advocated that a larger proportion of care could, and should, be provided in people's own homes or in other settings 'which allow a greater degree of independence than traditional residential or nursing care'.

Disappointingly, recent debate over long-term care has been dominated not by wide-ranging exploration of what alternative models might look like and how best to promote them, but by fairly narrow concerns over issues of home closures. The UK Home Care Association said in evidence to the health select committee inquiry into delayed discharges that the public debate on options for intermediate care had been 'hijacked by the care home providers'.

4The figure of 50,000 'lost beds' is widely quoted and misquoted. Denise Platt, chief inspector of social services and director of older people's services at the Department of Health, told the Commons health select committee in February this year that the net figure was 19,000 beds. Prime minister Tony Blair has referred to this figure under questioning from the Opposition.

The committee's own conclusion, in its report on delayed discharges published in July 2002, was that the first estimate 'arguably overstates the full losses that have occurred since it includes NHS provision that is different in kind from care home provision'.

'At the same time, however, the figure of 19,000 appears to us to be arguably an under-estimate of the losses that have taken place. If trends in the provision of all care home places (across local authority, private and voluntary providers) are considered, there has been a net loss of 34,200 places between 1997-2001.'

4Whatever the precise figures, there has undoubtedly been a considerable reduction in overall care home capacity and a pattern of transfer from nursing homes to residential care and dual registration. This is a reflection of the market response to financial pressures, particularly the reluctance of local authority purchasers to meet the fees of higher cost nursing places and the difficulties of securing and maintaining sufficient numbers of qualified nursing staff. The inevitable knock-on effects of reduced capacity and the associated bottlenecks in hospital throughput have concentrated ministerial minds.

The difficulties of meeting waiting-list targets and other key NHS pledges have seen a flurry of activity aimed at tackling delayed discharges. Attempts have included the NHS plan's focus on the development of intermediate care services to the£300m grant announced in October 2001 to enable councils to increase capacity, the establishment of the DoH's change agent team to devise local solutions to delayed discharges and, most recently, the proposals for reimbursement or cross-charging of social services for avoidable delays.

The opposition has complained that care home closures are the result of the government's failure to resource social care adequately and ensure adequate fee levels for care home provision. And for its part the government has, at times, defended itself by arguing that the trends are simply the result of mercenary care home owners cashing in on a buoyant property market. Such arguments are unhelpful and draw a veil over the reality that closures have resulted largely from a failure or inability to manage the market actively, either by central government direction or by local authority action. And the scope to do so has been seriously constrained by the long-standing under-resourcing of social care which has limited the development of realistic alternative facilities in the community, as well as constraining the pattern of investment in residential and nursing home provision.

In some localities there was undoubtedly an oversupply of care homes, mainly the result of the rapid growth of the sector in the late 1980s and 1990s, and some shake-out was inevitable. But it has been unplanned; good homes have closed as well as some of dubious or dreadful quality.

While it is axiomatic that people want to be cared for in their own homes wherever possible and a range of services are required for this, there is no direct engagement with the question of what type and volume of service should be pursued.We have long moved away from crude normative approaches to the planning of service provision - and for good reasons. But the resulting freedom to mix and match, the consequent postcode lottery of choice for individual service users and the continued vagueness about the overall direction that should be pursued continues to bedevil this territory.

The health select committee's report on delayed discharges called for 'dynamic alternatives to the options of residential care, nursing care or care at home'. These should include care villages, such as the model of Hartrigg Oaks, a continuing care retirement community near York established by the Joseph Rowntree Foundation (and visited by the committee). It provides a continuum of care from home support to full nursing care in a nursing home on the site. The committee also drew attention to the vital role of housing and the potential of telecare solutions in developing new models of care.

Above all, it argued, there needs to be shift away from offering 'more of the same'. The government agreed that there needs to be greater choice and that the objective was to 'broaden the spectrum of services available', but is vague about how that should be achieved.

On 23 July, health secretary Alan Milburn announced an intention to 'plan to increase the number of care home places supported by local councils' in order to achieve 'a modest increase in bed numbers'.He also noted that the building capacity resources had enabled social services to increase fee levels to care homes and that the additional resources being paid from April 2003 would 'allow local councils to pay higher fees still if that is what is needed to stabilise their local care home market'.

The virtual monopsony position of social services as purchaser has certainly given it the power to drive down, and hold down, prices. Indeed, it was an explicit objective of the community care reforms of the 1990s that local authorities should be able to use their purchasing weight in this way. The government's apparently belated recognition that the consequence has been to drive some providers out of the marketplace altogether points to a highly reactive response to social care development.

The strategy of throwing money at the problem is a solution of sorts. It provides an emergency means of stabilising the market overall, but is no basis on which to plan. The recurrent mantra used by ministers that the driving objective should be the provision of the 'right care, in the right place, at the right time' is a highly appealing aspiration. But it begs the question of how this is to be determined.

The level and type of residential provision required should not be determined merely by reference to the needs of the provider market.

The needs and wishes of service users, which should be paramount in this debate, have become highly marginalised.

Attention has increasingly been directed towards raising the standard of provision. The Care Standards Act 2000 was a major step forward in introducing a new regulatory framework and in signalling for the first time the establishment of clear national standards.What, then, should we make of Mr Milburn's U-turn in July this year on some of those standards before the ink was fully dry? The defensive tone of the announcement - 'but we always said that we would keep the new standards under review' - was apparent.

The revisions to the environmental standards (addressing the size of rooms and doorways, availability of single rooms, lift provision and assisted baths) were proposed as a further measure to control the exodus of care homes.Mr Milburn acknowledged that the standards were important, 'but they should not mean good local care homes having to close'. Clearly, no-one wants to see pointlessly bureaucratic rules and regulations imposed, but a dilution of the national standards so early in the process sends out some very worrying messages about whose interests are really being protected.

Care homes will be required to make it clear whether or not they meet the standards 'and let those who are choosing homes make an informed choice for themselves', Mr Milburn said.How real a 'choice' that will be for many people remains dubious.

The establishment of the Royal Commission on Long-term Care in December 1997 could have been a major opportunity to consider fundamental questions about the role of residential provision and the need to develop genuinely innovative alternatives.

Despite some valiant efforts to shine light in these dusty corners, the commission was largely constrained by its terms of reference, which focused specifically on the 'options for a sustainable system of funding of long-term care'.

The eventual response by the government to the commission's recommendations that people should contribute to the housing and living costs of care, but not to the costs of care that arose from frailty or disability, produced a settlement of a kind (and a radically different one in Scotland, where the recommendations were accepted in full).

But the compromise is such that it seems certain that further action will be required sooner or later.

Rather than accepting that all 'personal care' should be free of charge (which in the commission's view would have immediately resolved the continuing disputes over whether a given service was really health or social care), the government instead agreed that nursing care should be available free under the NHS, including to people in care homes.

Thus, long-term care continues to exist in parallel and hierarchical universes:

care organised and paid for in full by individuals who are self-funding;

means-tested provision for those supported by local authorities;

payment of the registered nursing care contribution for those in nursing homes;

NHS long-stay hospital provision.

continuing healthcare fully funded by the NHS.

The virtual withdrawal of the NHS from long-stay provision is well documented. That process began at the same time that independent care homes were burgeoning under the subsidy of the uncontrolled income support system (capping that budget was a central objective of the community care reforms introduced in 1993). The disappearance of NHS continuing care has happened by default, rather than by design.

Formally, DoH policy has emphasised that the NHS does have ongoing responsibilities and criteria for continuing health and social care provision should be agreed at local level to ensure there are no gaps in services.

5In practice, it is often hard to determine what distinguishes NHS responsibilities from those of local councils, and what would qualify for fully funded continuing care in one part of the country would fail in another. Such issues have returned to the agenda in the wake of the introduction of the NHS funding responsibilities for the registered nursing care contribution.

The top of the three-band approach in particular is defined in terms that are similar to those used to define continuing care, especially in relation to the evaluation of stability, predictability and risk.

6The anecdotal evidence that in some homes the benefit of the NHS payment for nursing care is being absorbed through higher fees, rather than passed on as a subsidy to the resident, points to the confusion and messiness of the continued separation of NHS and social services responsibilities.

To point to the withdrawal of the NHS from longterm care is not to argue for a mass return to longstay wards in hospitals. A hospital ward should never be a permanent address. Nonetheless, there is a debate to be had about whether the NHS should have a direct role. The experimental development of nurse-managed NHS nursing homes some two decades ago was short-lived. The evaluation of the three homes was positive in its conclusions and certainly the homes provided a more positive physical and social environment than traditional hospital care.

The demonstration projects reflected much that was accepted at the time to represent good practice in long-term residential provision, with an emphasis on domestic scale, community integration, individualised care and maximum autonomy and choice. If a case was to be made for resurrecting the model today, what would be the distinctive contribution? Arguments could be advanced for specialist facilities that provide intensive specialised rehabilitation and intermediate care.

In some areas, community hospitals provide a similar function. In others, these facilities are unknown or are used simply as a means of absorbing (and often merely warehousing) discharge pressures from the acute sector. But if the current emphasis on developing 'whole systems' solutions to care needs is to have meaning in long-term care, the focus should be on approaches that maximise the skills, knowledge and experience across health and social care and which fully integrate the independent sector as partners. Criticisms of 're-badging' of NHS services as intermediate care are an indication of what can occur without such partnership and provide few grounds for optimism in recommending a narrow NHS model for long-term care provision more broadly.

The NHS could have a new role in long-term care in funding the capital investment where additional capacity is required.The government's plans for a further 6,000 people to be supported in care homes by local authorities by 2006 raise significant questions about supply. Some of this additional capacity might be encouraged by the payment of higher fees, but homes that have been lost from the sector altogether cannot simply be resurrected.

Within the new planning framework for the NHS and the role of strategic health authorities in developing local delivery plans, it is possible that a wider responsibility may develop for actively commissioning and procuring new capacity in the public sector.

At the end of October, Hampshire county council announced plans to build 500 new nursing home beds in a scheme funded by the council, the DoH and Hampshire and Isle ofWight SHA (see box).

Long-term care continues to be an area that demands imaginative reform.We have come a long way over the last couple of decades, standards are improving and there is much wider acceptance of what good practice looks like. But there can be no room for complacency, and vigilance is required to ensure that progress continues.

The real debate which has still to take place must now address the appropriate role of separate institutional provision in a modern society.How far reliance on residential provision can be reduced is untested.

The experience of some other countries, notably in Scandinavia where intense round-the-clock home support appears to minimise reliance on residential care, would suggest there is scope for more radical approaches.

If we start from the needs and aspirations of the service users themselves, it is highly unlikely we would design the system we have inherited. In any discussion about future development, this should be the guiding principle; achieving it will require a new approach and champions who are prepared to lead, not merely follow.

Pillow talk: nursing home beds in Hampshire

A£60m initiative to provide Hampshire with an extra 500 nursing home beds for elderly people was passed by Hampshire county council's cabinet on 28 October.The council, Hampshire and Isle of Wight strategic health authority and the Department of Health will jointly fund the scheme.The council will meet estimated annual running costs of£13m.

The purpose-built homes will be established on 15 sites, yet to be decided, mostly on county council land attached to its residential homes, but some will be on NHS land.The first beds are expected to be ready for use by 2004. It is envisaged that primary care trusts and hospital trusts will be involved in staff recruitment and training.According to the council, Hampshire has lost 10 per cent of its nursing home beds in the last three years due to home closures.

Hampshire county council leader Ken Thornber said: 'There were compelling reasons for taking this groundbreaking approach, but foremost has been nursing home closures, which have meant it has been increasingly difficult to find nursing home beds for elderly people being discharged from hospital.'


1Townsend P. The last refuge. Routledge and Kegan Paul, 1962.

2Residential care: a positive choice. Report to the Independent Review of Residential Care, 1988.

3Royal Commission on Long-Term Care.With Respect to Old Age:

long-term care - rights and responsibilities, 1999.

4House of Commons health committee. Delayed Discharges: third report of session 2001-02, volume II, minutes of evidence and appendices, 2002.

5Secretary of state for health. HSC 2001/015 LAC (2001)18. Continuing Care:

NHS and local councils' responsibilities. Department of Health, 2001.

6Secretary of state for health. NHS-funded Nursing Care: practice guide and workbook. Department of Health, 2001.

Key points

The government policy on the future of long-term care is unclear.

The debate has been narrowly focused on home closures and users' interests have been marginalised.

The government's U-turn on care standards in July sent out worrying messages about whose interests are being protected.

The NHS may have a role in providing capital investment for new developments.

Experience in Scandinavia suggests more intense home support could lessen reliance on residential services.

Melanie Henwood is an independent health and social care analyst.