The NHS and Community Care Act 1990: is it a success for elderly people?

BMJ 1995; 310 doi: (Published 18 February 1995) Cite this as: BMJ 1995;310:439
  1. Victoria Ajayi, research assistanta,
  2. Frank G Miskelly, consultanta,
  3. Ivan G Walton, consultanta
  1. a Department of Medicine for the Elderly, Charing Cross Hospital, London W6 8RP
  1. Correspondence to: Dr Miskelly.
  • Accepted 25 November 1994

The NHS and Community Care Act 1990 signified a controversial change in the government's health and social policy.1 Phase 3 of the act was implemented on 1 April 1993, transferring the responsibility for funding of patients in the voluntary sector and in private residential and nursing homes from the Department of Social Security to local authority social services departments. We studied the effects of this reform on hospital practice.

Methods and results

From 1 April 1992 to 31 March 1994 we observed all patients aged >65 in the general medical, geriatric, and orthopaedic wards of our hospital who had been inpatients for >28 days. We observed these 766 patients weekly until discharge and noted the date when the patients became “medically stable”—that is, no longer benefiting from acute hospital care or rehabilitation—where they were discharged to, and reasons for delay of discharge. We used χ2 test with Yates's correction to compare results before 1 April 1993 with those after 1 April.

We enrolled 362 patients into the study during 1 April 1992 to 31 March 1993 and 404 patients during 1 April 1993 to 31 March 1994. In this preliminary report we present an analysis of 100 randomly selected patients discharged before and 100 such patients discharged after 1 April 1993; 142 were aged 80-90, and 143 were women. The 100 patients before 1 April and those after 1 April accounted for 8875 (median 63) and 7131 (35) patient bed days respectively—a reduction of 19.7% after 1 April.

The number of patients discharged within 10 days of becoming medically stable increased after 1 April—from 30 to 52 (P<0.0001). The patients remained in hospital after being designated medically stable for 3958 bed days before 1 April compared with 2796 after, a reduction of 29.4%.

The number of patients discharged home increased from 44 before 1 April to 68 after (P=0.001); the number discharged to nursing homes decreased from 38 to 13 (P<0.0001). No change occurred in the number of patients discharged to other destinations. The reasons for final delay before discharge varied before and after 1 April (table).

Reasons for last delay before discharge among 100 patients before and 100 patients after 1 April 1993

View this table:


The transfer of funding under the NHS and Community Care Act provoked anxiety that discharging patients would become more difficult.1 Early reports seemed to confirm these suspicions.2 3 At our hospital the procedure for discharging patients needing social workers changed substantially after 1 April. The findings presented here are relevant to the Borough of Hammersmith and Fulham and may not be applicable nationally as other boroughs and counties have interpreted the legislation in different ways.

We tried to reduce the possibility of bias. Most hospital staff were unaware that we were monitoring the effect of the community care legislation as our study began 12 months before the legislation was implemented. Many end points were precise and not open to interpretation—for example, discharge date. When the end points were less precise, such as when a patient became medically stable, the decision to discharge was taken by ward staff and not by the investigators. VA collected the data throughout the study.

The reduction in the length of hospital stay, both overall and after the classification of medically stable, is consistent with the findings that after the legislation patients were more likely to be in hospital for rehabilitation than awaiting placement and fewer were having difficulty with discharge arrangements. Some factors, such as delays in aids and adaptations, showed no change between the 12 months before legislation and the 12 months after.

This study shows that the changes implemented on 1 April 1993 as a result of the new act enabled patients in the Borough of Hammersmith and Fulham to be discharged from hospital earlier and that they were more likely to be discharged home than elsewhere.

We thank all the hospital staff who cooperated with the study. VA was supported by a grant from Hammersmith and Fulham social services and Riverside District Health Authority.


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View Abstract