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Long-term Nursing Care – a Historical Perspective

By Dr Geoffrey Phillips

Prior to the early 1980’s, virtually all-dependent elderly patients were either managed at home by their family, or else cared for on the long-stay wards of large geriatric or psychiatric hospitals. The nursing care was often excellent but the usually Victorian hospitals provided very poor facilities, with lack of privacy for patients and the buildings were expensive to maintain. At that time, almost 40% of the then NHS bed base subserved a long-stay role and, of course, being part of the NHS was completely free. A relatively small number of nursing homes, often run by charitable organisations, provided alternative facilities but even these were, at least in part, funded by Health Authorities. By contrast, a tiny number of privately run nursing homes existed and were almost always exclusively patronised by the wealthy.

Local Council Authorities provided residential homes, under Part III of the 1948 Act – so called Part III homes. The residents were usually well in so much as their medical and nursing needs were essentially incidental and ancillary to their need for accommodation. Such patients were mostly rational, mobile, continent and needed little, if any, help with dressing or bathing. These facilities were not free and were means tested.

Sheltered accommodation with Warden supervision was available for those more independent individuals who chose that type of accommodation, rather than remain at home. Such accommodation was often provided by both local Council Authorities and charitable organisations and was again not free.

The mid 1980’s saw financial pressures within the health service, which led to the closure, over the next decade of virtually all the NHS long-stay facilities. Fairly generous central Government funding encouraged entrepreneurs to open private nursing homes on a profit-making basis, to take up the slack. The new facilities were far superior and NHS beds were closed in large numbers, with minimal protest. Most Health Authorities retained a small number of long-stay facilities to cope with the relatively small number of patients whose needs were too complex to be devolved to the private sector. These beds were provided free in contrast to the nursing home funding, which was means tested.

By the early 1990’s, nursing home funding had been devolved from central Government to Local Authorities and many Health Authorities had allowed their small stock of long-stay beds to reduce by attrition. Health Authorities still retained the responsibility to provide long-term NHS care for those who required it for health needs but increasingly, they called it continuing care and chose to fund it in a handful of nursing homes, rather than provide the facilities themselves.

Increasingly, Heath Authorities and their successors progressively tightened the criteria for continuing care funding, to such a point where few are eligible and even fewer are successful in their application.

As a consequence, over the last twenty years or so, long-term NHS nursing care for the chronically sick has largely disappeared, having been replaced by means tested care in private nursing homes. The various Health Authorities provide few, if any beds themselves and fund only a little as they operate confusing and diverse criteria for eligibility.

© Dr Geoffrey Phillips
Consultant Geriatrician FRCP
January 2006

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