As with all public services, from the early 1980s there was an increasing emphasis on economy and efficiency within a context of public expenditure restraint. Two major targets for the health service were

1. the reduction of long-term care beds and
2. the reduction in waiting lists for acute operative care.

Both of these have had a dramatic impact on the health/social care divide. Turning to the first, during the 1980s and early 1990s, the moving of older and chronically ill patients on from hospital was assisted by the open-ended social security budget which provided board and lodging payments for residential and nursing home care in the ‘independent sector’.

 

What is most conspicuous is the rise in the number of nursing homes and the changing balance between residential and nursing home care:

In 1985 the ratio of residential home places to nursing home places was 7:1, by 1990 it was 3:1 and by 1994 it was 1.5:1.

This has been accompanied by a significant decrease in long term geriatric and psycho-geriatric hospital beds. This implies that private homes have been catering for increasingly infirm residents, particularly those with dementia, who were previously cared for in hospital. And the role of residential care, as opposed to nursing home care, has become less clear.

Increasingly, hospitals have focused their efforts on acute medical care and have been retreating from the provision of long-term care. The locus of long-term care is no longer in state funded hospitals but in nursing homes, access to which is subject to means testing. Only 8 per cent of the additional places created through the expansion of private nursing homes are paid for by Health Authorities or Health Boards, according to the 1999 Royal Commission on Long Term Care

At the same time, significant changes have been taking place in acute medical practice. New medical technologies, the introduction of minimal access surgery and developments in pharmacology, have all combined to reduce the length of stays in hospital. This has generated more acute medical work outside hospital settings, which has affected the role of community health workers. District nurses, for example, have become more involved in the provision of post-operative care and less involved in the provision of routine home-based nursing care, and their work is evaluated in terms of ‘tasks’ rather than ‘care’.

This change has been accompanied by the transformation of the social services’, home help service into a home care service. Consequently care at home, such as help with getting up and going to bed, or with bathing, is less likely to be available free of charge from the health service and more likely to be available only from means-tested social services.

All this indicates that much of what used to be defined as health care has been redefined as social care. More specifically, as General Wistow has argued, it is nursing that has become the disputed territory between the two. He suggested that, given the retreat of the health service for paying for long-term nursing care, the financial pressure on local authorities to direct people into nursing homes rather than provide home care, and the increasing size of nursing homes, community care was in danger of simply becoming the provision of institutional care in the community. As he put it, people would be moved ‘along the acute sector conveyor belt to the community care warehouse’

By the end of the 1990s the question of how long-term-care should be funded had become a prominent policy issue.

It was one particular case, described below, that put the funding of long-term care firmly on the policy agenda. This was when, in 1994, the Health Service Commissioner for England decided to uphold a complaint against the NHS for failing to pay for long-term care. Following this, the Commissioner was ‘inundated with enquiries’ from people in a similar situation.

At its 1994 annual meeting, the Association of Directors of Social Services cited evidence of terminally ill people being transferred to nursing homes days before their death, and it called on the government to clarify the responsibilities of health and social services for the long-term care of older people.

In 1994 the Health Service Commissioner for England investigated a complaint from the wife of a 55 year-old Leeds man with severe brain damage who had been discharged to a private nursing home when he no longer needed acute hospital care.

Her complaint was that she was required to pay for his continuing care when this should have been provided free of charge by the local health authority. The Commissioner found that no one disputed that her husband needed full-time nursing care. The NHS Management Executive, however, argued that, despite a duty under the National Health Service Act 1977 to meet all reasonable requirements whenever a doctor judged care to be necessary on clinical grounds, health authorities also had an overriding duty to determine priorities within the financial resources available.

The Commissioner noted that this implied that an individual patient might never receive treatment, judged that the service had failed, and decided that the complaint was upheld.

In 1995, the Department of Health issued guidelines on NHS responsibilities for meeting continuing health care needs. The guidance did not constitute a directive, however, so local agreements remained the main determinants of practice.

A year later, the government issued a policy statement on the funding of long-term care. It proposed that individual insurance policies should be promoted, from which payments would be made and then offset against a state means test. This, the government argued, would protect against the erosion of housing equity and savings, and allow those who had been thrifty to pass their assets to their children.

The incoming Labour government set up a Royal Commission to explore funding options for long-term care which reported back in March 1999. It severely criticised the existing system of funding and rejected the existing distinction between health and social care as unfair and unhelpful. Why, for example, it argued, should someone suffering from cancer be treated free in hospital while someone with Alzheimer’s disease has to pay for care in a care home?

It proposed that people in long-term care incur three kinds of costs:

• living costs ( food, clothing, heating amenities and so on)
• housing costs ( the equivalent of rent, mortgage payments and council tax)
• personal care costs (the additional cost of being looked after arising from frailty or disability)

Definition of personal care
Personal care would cover all direct care related to:

• personal toilet (washing, bathing, skin care, personal presentation, dressing and undressing..)
• eating and drinking (as opposed to obtaining and preparing food and drink)
• managing urinary and bowel functions (including maintaining continence and managing incontinence)
• managing problems associated with immobility
• management of prescribed treatment (e.g. administration and monitoring medication)
• behaviour management and ensuring personal safety (for example, for those with cognitive impairment - minimising stress and risk).

Personal care also includes the associated teaching, enabling, psychological support from a knowledgeable and skilled professional, and assistance with cognitive functions (e.g. reminding for those with dementia) that are needed either to enable a person to do these things for himself/herself or to enable a relative to do them for him/her.

 

Despite support from a number of pressure groups, the government for England and Wales rejected the proposals of the Royal Commission. Rather, it decided that the boundaries between nursing care and social care should be more clearly demarcated, with the former being provided free of charge and the latter being subjected to means testing.

It proposed that people who were currently paying for their own care in a nursing home, or having it paid by local authorities or through preserved entitlements to social security funding, would in future have the nursing element of their care paid for by the NHS. This revised system for paying or care began to be implemented in October 2001, through the Health and Social Care Act 2001.

The new Act defined ‘nursing care’ as the contribution of a registered nurse to the provision, planning and supervision of care in a nursing home setting. Personal care, such as help with washing or eating, was not included in this definition. Existing residents would have to be assessed by a registered nurse to determine whether they needed nursing care and if so, at what level.

Future prospective residents would be jointly assessed by health and social services to determine the respective contribution of each. The government proposed that budgets would be centrally located to, and managed by, health authorities and primary care trusts to pay for nursing care in nursing homes. In effect, nurses were to become the gatekeepers of free nursing care.

The Scottish Executive, however, in response to public opinion and political lobbying, decided to implement the proposals of the Commission. The Scottish response to the Royal Commission proposals suggests that there are choices to be made in how long-term care is financed.

Further reading
Care ruling “could cost NHS dear"
D. Brindle in The Guardian, 3rd February 1994

Response to Provide Long-Term Care
Scottish Executive, 2000

Royal Commission on Long Term Care: With Respect to Old Age Long Term Care – rights and responsibilities: a report
The Stationary Office CM4192-I

Failure to Provide Long-Term NHS Care for a Brain-Damaged Patient: Report of the Health Service Commissioner
WK Reid, HMSO 1994

Community care at the crossroads
G Wistow in Health and Social Care in the Community, Vol 3, No 4 pp227-240

Content last updated: 29/06/2006