Community care for elderly people

Will improve only when there are national standards and explicit funding

For an elderly person discharged from hospital in Britain, gaining access to continuing health care is like queuing for a car parking place in a multistorey car park on a Saturday afternoon. A “one in, one out policy” operates; you can never be sure how long you will have to wait; when you do get a place it is usually furthest away from where you want to be; and, if you miscalculate your length of stay against the amount paid, you will incur a hefty fine.

This picture will sound familiar to most community practitioners, but earlier this year the Clinical Standards Advisory Group gave further credence to professional concerns and made explicit the deficiencies in the community care of older people.1Its report, Community Health Care for Elderly People, used the care of people discharged from hospital after treatment for fractured femur as a tracer condition for identifying the range, level, and quality of community health services for older people. It reinforces deficiencies in the community care of older people identified by others.2^–4Despite the existence of a joint policy statement on discharging elderly people from the Royal College of Nursing, the British Geriatrics Society, and the Association of Directors of Social Services,4 the report again finds poor coordination of discharge plans, lack of interagency collaboration, lack of attention to the rehabilitation needs of older people, and inequities in provision.

The advisory group found unacceptable variations in service provision according to where people live and the kind of accommodation they occupy. Such inequity has been identified before,5but again the report confirms that decisions about care are based on “who pays” rather than the needs of the individual. As a result there are important gaps in care. Primary health care teams have felt the impact of shorter lengths of stay in secondary care (the Clinical Standards Advisory Group found an average length of stay of 7.8-10.2 days). While most older people welcome a short hospital stay, many experience unacceptable care deficiencies on discharge because of limited health and social care budgets. The rhetoric of “the money following the patient” has long been exposed as hollow as older people with increasingly acute needs are cared for in community settings without a corresponding increase in resources. Indeed, many community facilities (such as community hospitals) are placed under increasing threat of closure as health authority budgets fail to meet acute care demands.

The report declares that no health district was capable of making a satisfactory distinction between health and social care needs. This finding comes as no surprise: people's needs cannot be so neatly compartmentalised. For example, access to regular meals (defined as social care and therefore means tested) has an obvious impact on an individual's overall health status and quality of life. It is disappointing that the government's response, published within the report, simply repeats calls for greater collaboration between health and social care services rather than recognising the need for their integration. The divide between health and social care needs has enabled health care consistently to evade its responsibility for the continuing care of older people.6

The Clinical Standards Advisory group calls for national standards for care, national eligibility criteria, local rehabilitation services, and a separation in payments between “health” costs and “bed and board.”While organisations such as the Royal College of Nursing have made similar requests,5these have largely gone unnoticed. Undoubtedly, there is considerable fear of implementing such proposals because of the perceived costs to the health service. It seems to be easier to continue with local bickering about who should pay for care rather than take the risk of implementing a national standards framework and costing mechanism. Such resistance may be based on the wrong assumption that an increasingly aged population will result in increased costs to the state.

If almost all that this report says has been said before, why should we welcome it? Firstly, the report is timely because of the work of the Royal Commission into the funding of long term care. Secondly, the report has been largely welcomed by the government, and a government level action plan is included in the report. Although the recent white papers in the NHS7 and the “Better services for vulnerable people” initiative all discuss many of the issues raised by this report, the rhetoric of rights and responsibilities continues to prevail at a government level, in the absence of specific action. What is needed is specific action—for the problems are not about to disappear easily. As a society we have several choices about how to express our commitment to the development of services for older people. The only ethical choice is one that treats them as citizens of equal value by appropriately and effectively meeting their health and social care needs.