Published: 01/12/2005 Volume 115 No. 5984 Page 19

Eligibility criteria for NHS-funded nursing home care is causing unfair discrepancies.

And It is time to iron out the anomalies NHS long-stay care has changed radically. In the process, detailed criteria have been established to determine who is eligible to receive NHS-funded nursing home or domiciliary care.

These criteria embody some questionable definitions of healthcare.

Consider the outcome of NHS continuing care assessments for three (fictional but credible) nursing home residents. All suffered from dementia, have experienced stroke, and were unable to walk, or stand unaided. They all had some difficulty swallowing, were doubly incontinent, and had fits.

Mrs A's condition fluctuated so her care and treatment needed regular adjustments. This meant that she was judged to be entitled to free NHS care.

With Mr B and Mrs C, their primary need was judged to be for social care, not healthcare, on the grounds that their condition was one of stable and predictable decline, and so were deemed ineligible for NHS funding.

As a result of these decisions, Mrs A's nursing home costs were met in full by the NHS. The other two had small amounts of savings so had to meet weekly charges of nearly£500.

Families in this position, and the organisations that support them, argue that small distinctions in nursing needs are not a reasonable basis for decisions with such large financial consequences.

They question how these distinctions would have applied to the woman whose Appeal Court case significantly influenced the construction of NHS guidance. There is particular bitterness when a resident ceases to be eligible because of increasing frailty.

Meanwhile, finance directors note the increasing numbers of successful applications and ask where the money is going to be found to pay for them.

The Department of Health has responded to criticism by looking to establish national guidelines and improve assessment-training to reduce a 'post-code lottery' element.

While welcome, this is effectively tinkering with an outdated model. What is needed are rules that robustly define the limits of NHS responsibility in a world where much long-stay care has moved out of hospitals.

There are three principles with the potential to affordably transform eligibility criteria.

. Eligibility assessments should be based on the extent of individual morbidity, not on questions of whether an individual's condition is stable.

. The personal care of people who need nursing care is an NHS responsibility, and should be provided free at the point of use, whatever the setting.

. No-one is entitled to have the accommodation cost element of longstay care provided free by the NHS (this is the most contentious of the three).

What would be the impact on the three fictional residents described earlier if these principles were adopted?

Mrs A would have to pay for the accommodation element of her care.

The other two would receive additional funding from the NHS to cover the costs of personal care as well as registered nursing care. If all were self-funding, all would pay the same charges.

For the NHS, with every nursing home resident treated in the same way, the reason for continuing care assessments would largely disappear.

Overall, the result would be a more equitable, less bureaucratic, and potentially affordable system - a considerable improvement on the current situation.

The author, who is writing anonymously, has chaired a number of NHS continuing care restitution appeal panels, both as a primary care trust non-executive director and as an independent chair.