Community institutional care for frail elderly people

Time to structure professional responsibility

Responsibility for the medical management of elderly people in community institutional care (residential or nursing) remains poorly defined. It currently rests by default rather than by design on the heavily burdened shoulders of general practitioners. The number of patients in private or voluntary homes in Britain has risen from 18 200 in 1983 to 148 500 in 1994.1 The management of frail elderly people in nursing homes has also been regarded as beyond the scope of the general medical services contract and as a non-core activity.2

To add to this uncertainty, the role of geriatricians has undergone major changes. Increasing responsibilities for acute services have meant less time for continuing care and community care generally. These changes are partly due to the reduction of NHS long term beds, the withdrawal from acute admission duties by some medical specialities, and the lack of understanding and appreciation of geriatric care in the contracting process. The white paper Choice and Opportunity envisages, perhaps optimistically, new entrants into the community care market for health care.3 Generally, the lack of national benchmark standards has contributed to these difficulties. Some aspects of these issues have …