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NHS and Community Care Act 1990 and discharges from hospital to private residential and nursing homes

University of Wales College of Medicine, Cardiff CF4 4XN St Martin's Hospital, Bath BA2 5RP Correspondence to: Dr Lewis.

The NHS and Community Care Act 1990 requires social services departments to assess elderly inpatients who may need help after discharge from hospital and to use a care management process to arrange their care.¹ One of the main aims of the act was to reverse the "perverse incentive" for people to be cared for in private residential and nursing homes. The act tried to achieve this aim by ensuring that money that was originally available through social security to people in private homes who received income support was transferred to social services departments; social services could use the money to maintain people in their own homes.

Concern was expressed that the new assessment and care management might delay patients' discharge from hospital,² and such delays have been reported.³ It was also thought that a surge in the number of patients discharged to private institutions might occur before the act came into force as consultants tried to avoid becoming entangled in the new administrative procedures.

This study compared the proportions of patients discharged to private residential and nursing homes or elsewhere form a department of geriatric medicine before and after the implementation of the NHS and community care act in April 1993 and the lengths of time patients had spent in hospital before their discharge.

Patients discharged from hospital to private residential or nursing homes and
length of stay in hospital before discharge, according to period and year of
discharge
----------------------------------------------------------------------------------------------------------------
                                        1 April to           1 April to           Difference
                                    30 September 1992    30 September 1993  (95% confidence interval)
----------------------------------------------------------------------------------------------------------------
No (%) of patients discharged from
  hospital:
  Total                                   737                 738
  To private residential or nursing
  home                                     56 (8)              70 (9)          1.2% (3.7% to -2.0%)
Mean length of stay in hospital
  before discharge (days):
  To private residential or nursing
   home                                     55.3               59.8            4.5 days (20.0 days to - 11 days)
To other locations                          26.6               27.4            0.8 days (4.3 days to - 2.7 days)

Patients, methods, and results

Data were extracted from the computerised records on discharge for all patients (n=2234) discharged from the department of geriatric medicine at St Martin's Hospital, Bath, between 1 April 1992 and 30 September 1993. The average age of the patients (85 years) was similar to that of patients discharged from other departments of geriatric medicine in the Wessex region. We made comparisons between patients discharged between 1 April and 30 September 1993 - the first six months after implementation of the act - and the equivalent period in 1992, thus avoiding any systematic bias due to seasonal factors.

The table gives the numbers and percentages of patients discharged to private residential and nursing homes according to the period examined and the corresponding lengths of time spent in hospital before discharge. Between 1 April 1992 and 30 September 1993, 197 (8.8%) of the 2234 of the patients were discharged to a private residential or nursing home; in March 1993, the month before the act came into force, 17 (12.9%) of 132 patients were similarly discharged.

Comment

This is the first study of the effect of the NHS and Community Care Act 1990 on the number of elderly people being discharged to private residential and nursing homes and on their length of stay in hospital before discharge. The rate of discharge to these homes was not substantially affected by the implementation of the act; this suggests that disabled elderly people are not being given the option of receiving their care at home after their discharge from hospital. The differences in the length of stay in hospital for patients before and after the act came into force were well within the margins of variation expected by chance, with no evidence that discharge was being delayed.

More attempts were made to get patients admitted to private residential and nursing homes in the month before the act came into force than during the period of the study as a whole. The effect on total numbers was small, but the rise in the number of attempts might account for the shorter lengths of stay in hospital for patients discharged in March 1993. Overall, in its first six months the act seems to have had little impact on the patients in the department that we studied. We do not yet know whether this act, which may bring about innovative methods of home support,⁴ will allow more people than in the past to be managed at home

1. NHS and Community Care Act 1990. London: HMSO, 1990
2. Welsh Affairs Committee. Community care: the elderly. Fourth report. London: HMSO, 1992.
3. Age Concern. No time to lose. London: Age Concern, 1993.
4. Challis D, Darton R, Johnson L, Stone M, Traske K. An evaluation of an alternative to long-stay hospital care for frail elderly patients. I. The model of care. Age Ageing 1991;20:236-44. [Abstract/Free Full Text]

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Effect of NHS and Community Care Act Problem with interpretation

C Cooper, P Crome, P Lewis, N Vetter, R Dunn, C H McAlpine, J Rein, J P Milnes, I Smith, P M Easton, and J B Oliphant
BMJ 1994 309: 605. [Extract] [Full Text]

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