INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 7: 71-73 (1992)

EDITORIAL

Nursing Homes: The End of a Great British Tradition?

The tradition is compromise, making do or making the best of things and acceptance that there is virtue and pride to be taken in austerity. Its embodiment has been the inheritance of mental hospital wards and workhouse accommodation that spawned Old Age Psychiatry and Geriatric Medicine, and the Part I11 Homes which Local Authorities offered to the elderly in need of care but not so ill, disabled or disturbed that medical and nursing supervision are mandatory. Part 111 Homes were themselves replacements for Public Assistance Institutions which were visited and exposed as entirely unsuit- able to their purpose by Peter Townsend (1962). His remarkably effective study and crusade for better care made great play of the observations that where small, good quality rest homes were available the residents appeared livelier, happier, better fed, better dressed, less disturbed and less incontinent. In contrast conditions and behaviour in large insti- tutions were awful. Through the 1960s and 1970s Local Authorities made every effort to be rid of their workhouses and repIaced them with purpose- built or converted accommodation sited within centres of population and usually offering 20-40 beds (Wilkin et al., 1985). The level of provision was variable and usually fell below the guideline of 25 beds for every 1000 aged over 65 years. It was clear that simply providing better accommo- dation did not change the characteristics of resi- dents: the population previously displaced to the workhouse retained many of their behavioural defi- cits and this was compounded by the need to embrace more very old people, most of whom require care because of dementia (Wilkin et al., 1978).

Admission to Part 111 reflected failure of care at home and has always been rationed, the demand for places exceeding the availability. Thus places have been allocated, usually after much debate and lobbying, by fairly senior officers of the Social

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Services Department, sometimes after consulting medical opinion and often guided by the views of the matron (officer-in-charge) of the receiving Home.

Specialist medical and psychiatric services for the elderly have included a ration of ‘long stay’ accom- modation within their spectrum of activities. This allowed for direct placements of patients from home or placement via acute or rehabilitation wards of the hospital or from Part I11 Homes when it had become clear that the needs of the patients had progressed beyond what could be safely and reasonably provided there or in the private house- holds of the family. Despite the considerable over- lap in behavioural characteristics of patients in long stay wards and Part 111 homes, there was no doubt- ing the concentration of the most disabled, most disturbed in the hospital sector (Wilkin and Jolley, 1978).

The phenomenon of the ‘overlap’ has excited attention. Townsend himself suggested that the compromise that was Part I11 should be dismantled and that able residents should be offered flats where they would be ‘self-caring’ but supervised by pro- tective wardens, whilst the disabled or ill should be the responsibility of Health Authorities and removed to hospital.

Outside of this world of ‘statutory’ care, an alter- native system of rest homes and nursing homes was becoming available within the ‘independent’ - voluntary and private sector. The distribution of such facilities was not uniform, being largely con- fined to well heeled Districts and heavily concen- trated in the South Coast seaside retirement belt (Larder et al., 1986). For most professionals work- ing with the elderly in other parts of this country it was an unknown world, though something like it formed the basis of provision for the elderly in North America, Europe and Australasia. Avail- ability of places within the independent sector was

72 EDITORIAL

not, is not, rationed other than by its pricing and its cost to the individual purse. Admission requires no professional intervention or judgment but reflects the choice or determination of family. The best interests of the individual who is to be placed in care may be submerged in the consideration of others who are much more able to make their case than the enfeebled, perhaps demented, perhaps depressed old person. In the same way, consider- ation of the sensitivities of other residents is much more likely to hold sway in deciding whether Ethel can be accepted or indeed allowed to stay on. Displacement to another place may be deemed in- appropriate in the interests of others. The scenario is a puzzling cocktail of apparent freedom of choice, laced through with abasement to the needs and views of everyone else.

Freed from the shackles of the personal impecu- nity of this nation’s elderly, the independent (private) care sector has burgeoned like Topsy, suc- coured by special DSS payments to those who deem themselves (or are so deemed by others with or without qualifications) in need of residential or nursing home care (Audit Commission, 1986). This has seemed a good thing in some ways. There is no doubt that many people who would have bene- fited from residential care in the nineteen fifties, sixties, seventies, and early eighties were forced to accept the discomforts and hazards of care at home because neither they, nor their Local Authority nor their Health Authority, could afford to do the right thing by them (Opit, 1977).

There have been anxieties that the amount of money available through DSS has not been suffi- cient to allow Homes to cater adequately for the needs of more disabled residents. These anxieties and suspicion that some unscrupulous owners give very poor value for money remain. More troubling still is that this Topsy continues to grow and is set to starve Part I11 and the long stay hospital sectors out of existence. An astonishing paragraph in the new ‘Community Care’ legislation (Dept. of Health, 1989) requires that Local Authorities con- tinue to make payments from their own sources for residents in directly managed (Part 111) Residen- tial Homes, but may use DSS derived monies to sponsor residents in the independent sector. Part I11 is choked at its roots. Health Authorities are falling over themselves, and frequently ignoring the limitations placed on them by Law, to be rid of their responsibilities for long term care of the very disabled by ‘making arrangements’ with the inde- pendent nursing home sector where patients pay

for their care on a means tested basis (Age Concern, 1990). Some of us feel that it is wrong to strip specialist services of their direct involvement in long stay care (Millard et al., 1989). We are accused of seeking to retain power through beds (a dreadful sin, known to be endemic amongst doctors). It is pointed out that patients and relatives much prefer to be cared for in nursing homes. The evidence for this derives from the Newcastle analysis of the experimental NHS nursing homes (Bond et al., 1989). These had the benefit of new, purpose built accommodation in contrast with the hospital wards which formed the ‘control’ and the experimental design did not include a comparison of good quality nursing homes with good quality community hospi- tals, the difference between these being the con- tinued involvement of the full consultant led team in the community hospital. Care in NHS nursing homes is free to patients. There has been no great growth of NHS nursing homes with the assurance of high quality staffing assumed in the experiment. What has followed on has been private sector devel- opment. This is not free to patients, but is ‘free’ to Health Authorities - simply because patients are not in a hospital - because they are not under the care of a consultant.

Specialist teams are deskilled and debased by this manoeuvre. Patients are disenfranchised. The inde- pendent sector can only grow. Within it a system of categorisation and grading requires that resi- dents of differing characteristics be housed in dif- ferent homes, licensed for: ordinary elderly frail, EMI, nursing home for the elderly dependent, nurs- ing home for EMI. Individual Homes make sure that the demands made upon their care staff do not rise too high by controlling the characteristics of patientslresidents at admission and demanding that people move on if their characteristics change (usually toward more dependency/more distur- bance). They are likely to be supported in this by inspection teams. The sector as a whole becomes unnecessarily large so that more demanding patients are ‘diluted’ by extra fairly able co- residents. Square pegs may be moved on repea- tedly. It is the very antipathy of everything good in the community care philosophy. People are not encouraged or enabled to stay at home and find no Home can give an assurance that this is a final safe haven.

A recent survey through the membership of the Section of Old Age Psychiatry of the Royal College of Psychiatrists details loss of hospital beds of all sorts, loss of Part I11 beds almost everywhere and

EDITORIAL 73

irregular growth of the private residential and nurs- ing home sector (including registered EM1 homes) in many places. Some Districts have little or no private accommodation and their residents have to move elsewhere, this is a feature of several inner London Districts (Benbow and Jolley, 1991).

Is it inevitable that this country will have lost its heritage of discipline and austerity which had begun to provide the backbone of a workable com- munity service (Jolley, D., and Arie, T., 1991)? Per- haps. Yet, maybe the softwood of the soft option that has grown so fast so recently will wither in the exposure to rationing that will come with the enactment of Community Care legislation. Maybe someone will think to modify the perverse financial arrangements that have forced it on: we might then hope for a healthier use of the nation’s money in good quality community hospitals, day hospitals and Part I11 Homes of modest capacity but giving shelter and strength to vigorous, flexible, respon- sible and responsive community services (Jolley, S., and Jolley, D., 1991).

DAVID JOLLEY Withington Hospital, Munchester, UK

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