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EDITORIALS: Brendan McCormack Community care for elderly people BMJ 1998; 317: 552-553 [Full text]

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Conformity or diversity?

Tim Blackman   (1 September 1998)

Primary care arrangements for elderly people in residential and nursing homes

Shane Kavanagh   (23 September 1998)

Conformity or diversity? 1 September 1998
Tim Blackman, Director, Oxford Dementia Centre Oxford Brookes University Send response to journal: Re: Conformity or diversity?	There is an interesting tension between Brendan McCormack's call for a national standards framework and costing mechanism for community care and Richard Alderslade's advocacy of public health services that are, 'technically expert, but rooted in functioning democracies at both central and local levels' (1). Whilst it is just to provide localities with a block of funding that reflects the needs of one locality relative to another, local electorates should be able to influence its distribition and possibly supplement it with locally raised income. Giving local government the power to decide about how to allocate a block of resources between different services is a means of enlivening local democracy. Such local political decision-making should be informed by technical expertise but ultimately the decisions are political and, ideally, sensitive to local conditions. The recent White Paper on local government addresses how to improve this sensitivity, but for a local government system that has lost much of its power to unelected bodies (2). Local decision-making means that whilst some localities might have more nursing home places or home helps per head, others might have more council houses with central heating or sports centres. In the interests of social justice we might want a national framework for the distribution of public funding for social policy. However, to prescribe how allocations are spent in the way that Brendan McCormack and many others are advocating will erode local democracy and stifle local experimentation in combining resources to achieve better overall outcomes. 'Better' in this context may not be what is technically better, but what is preferred. Local government is deprived of the responsibility which would enhance its role in our democracy - the planning and delivery of health services. A step in this direction would be to return the public health function to local councils. There it could inform the imaginative deployment and combination of resources across the range of local public services from housing and recreation to hospitals and district nurses. Local variation in provision is something to be valued as a reflection of local democracy rather than a problem. The fundamental debate should be about the overall volume of national wealth we devote to services that are democratically allocated. (1) Alderslade, R. Community care for elderly people: will improve only when there are national standards and explicit funding. BMJ 1998; 317: 552-553. McCormack, B. The Public Health Act of 1848: The act's qualities of imagination and determination are still needed today. BMJ 1998; 317: 549-550. (2) Department of the Environment, Transport and the Regions. Modern Local Government in Touch with the People. 30 July 1998.
Primary care arrangements for elderly people in residential and nursing homes 23 September 1998
Shane Kavanagh, Research Fellow Personal Social Services Research Unit at University of Kent Send response to journal: Re: Primary care arrangements for elderly people in residential and nursing homes	Shane Kavanagh, Martin Knapp Personal Social Services Research Unit, University of Kent at Canterbury, Kent CT2 7NF Personal Social Services Research Unit, London School of Economics and Political Science, London WC2A 2AE EDITOR - McCormack highlights variations, inequities and problems in care for elderly people discharged following short stays in hospital. Declining NHS long-stay provision and shorter acute inpatient stays have increased pressure on community services, exacerbating perverse incentives between health and social care [1]. As long-term elderly care is redefined as 'social' care, general practitioners have become responsible for the healthcare of increasing numbers of - frailer - residential and nursing home residents. However, evidence on the effect is scarce [2]. We conducted preliminary research by examining residents' arrangements for general practitioner consultations. We approached two samples of independent sector homes: a 20 per cent random sample of Kent nursing homes; and 12 residential homes chosen from a study of social services organisation [3] in Kent (n=4), London (n=3) and Sheffield (n=5). Letters to home managers were followed by telephone interviews (December 1997 to February 1998). Few homes dealt with one general practitioner only. Typically 4 or 5 general practitioners looked after residents (see table). Regular clinics, held in half of the homes, usually weekly, were open only to patients of the particular general practitioner organising the clinic. For other residents, general practitioners visited only when requested by home staff. Arrangements varied: while one general practitioner did a weekly 'ward round' to 85 residents, most visits were to individual patients. Overall, the reported number of contacts with residents was high, albeit in the winter months. Payments under the general practitioner contract appear small relative to these levels of activity and provide a poor incentive for quality care. Some home staff reported difficulties getting general practitioners to visit residents, while many homes that did not have regular clinics wanted them. One nursing home with regular clinics and good reported liaison between staff and the general practitioner paid the general practitioner £3,000 quarterly, further blurring the health and social care boundary and professional accountability. Although our data come from uncorroborated telephone interviews with a small number of homes largely concentrated in south-east England, they are consistent with issues raised by McCormack [1]. Moreover, they suggest that the health/social care boundary is further complicated by the division of primary/secondary healthcare funding and responsibilities. The role of general practitioners and their professional responsibilities need to be clarified [4]. Primary care groups [5] have potential but as always the 'devil will be in the detail'. References 1 McCormack, B. Community care for elderly people (editorial). BMJ 1998; 317:657-660. 2 Kavanagh S, Knapp M. The impact on general practitioners of the changing balance of care for elderly people living in institutions. BMJ 1998; 317:322-7. 3 Wistow G, Knapp M, Hardy B, Forder J, Kendall J, Manning R. Markets for Social Care: Progress and Prospects. Buckingham: Open University Press, 1996. 4 Black D, Bowman, C. Community institutional care for frail elderly people: time to restructure professional responsibility (editorial). BMJ 1997;315:441-442. 5 Department of Health The New NHS Modern, Dependable, Cm3807. London: The Stationary Office, 1997. Table: Arrangements for general practitioner visits to residential and nursing home residents Random sample Sample of homes of Kent from social nursing services homes(a) organisation project(b) (n=27) (n=11) Registration % nursing home only 52 9 % residential home only 0 64 % dual registration 48 27 Number of residents per home Mean 34 32 Median 31 24 Range 12-67 14-85 1 GP responsible for all residents % yes 11 27 % Residents per GP mean 25 46 median 17 33 range 3-100 8-100 Regular clinics % none 52 46 % weekly 41 36 % monthly 4 18 % less frequently 4 0 % Residents consulting GP in past month mean 49 56 median 29 42 range 8-100 27-100 Consultation rate in past month (for people who consulted) Mean 2.6 1.9 Median 1.5 1.0 Range 1.0-8.9 1.0-4.6 No. of consultations per GP visit Mean 5.0 4.8 Median 1.0 1.9 Range 1.0-27.8 1.0-18.9 Notes (a) Six homes were ineligible (2 had closed and 4 did not provide elderly care), while 1 home refused to partipate, leaving a sample of 27. (b) One home refused to participate leaving a sample of 11.