Breaking down the Berlin Walls

8 Jun 00
Tony Blair breezed back into Downing Street this week after completing his paternity leave with a vow to sort out the care of the elderly.

09 June 2000

This declaration of intent could signal a fundamental reorganisation of health and social services in next month's National Plan for the NHS.

Blair's first official engagement was to chair a health summit of ministers from Westminster and the three devolved assemblies, which discussed plans to reduce bed blocking by elderly patients, including bringing social services under greater NHS control.

Bed blocking occurs when patients cannot be discharged because there are insufficient resources to look after them in the community – a problem caused by an artificial split between health and social care, health managers argue.

Elderly care has jumped to the top of the health agenda because bed blocking is seen as one of the chief causes of long waiting lists. The Department of Health's National Beds Inquiry found that over-65s occupy two-thirds of hospital beds, while over-75s account for half the unprecedented growth in emergency admissions over the last decade. Discharge of one in eight elderly patients is delayed unnecessarily and one in five does not need to be in hospital at all.

Ideas for tackling bed blocking include the creation of a new grade of nurse to care for the elderly, and using spare beds in private hospitals, while Health Secretary Alan Milburn has announced that new cottage hospitals will be built to accommodate elderly patients.

These suggestions would take some pressure off acute beds but would not get to the root of the problem, according to the NHS Confederation. In England, Scotland and Wales, health and social services are split, making it difficult to co-ordinate discharge. The system also confuses patients, who receive free NHS care but are means-tested for many social services.

Some progress has been made in breaking down these 'Berlin Walls', notably by pooling budgets, but the confederation, which represents health authorities and trusts, says more radical action is needed.

Janice Miles, policy manager with the confederation, says the division between health and social services presents a 'real challenge', particularly in the care of the elderly. In its submission to the National Plan, it proposes narrowing the gap by creating a unified funding stream for elderly care.

'We are suggesting a single allocation that would go to primary care trusts (PCTs) to commission the whole package of care for elderly people,' she says. 'One of the biggest barriers at the moment is that there is a resource allocation formula for health and a different formula for local government, so there is a fundamental mismatch.'

The system would be similar to the one that operates in Northern Ireland, where health and social services have been fully integrated since 1973. In January last year, the Commons health committee praised the strategy, where the four health and social services boards buy services from NHS trusts and independent providers.

But while services to patients appear to be seamless, there is some debate in the province over whether the boards have been able to develop coherent policies that cover both areas.

However, this week the prime minister described the Northern Ireland experience as 'invaluable' and Milburn has hinted on several occasions that he favours more formal links between health and social services.

This will alarm the Local Government Association, which is naturally suspicious, to say the least, of the trend towards diminishing local authorities' spheres of influence. The LGA dismissed the confederation's proposal as a 'disaster'.

Its chair, Sir Jeremy Beecham, says: 'The idea that the NHS could run both its own services and those for elderly and physically disabled people is completely unproven and would be a mistake both in practical and philosophical terms. It would remove a vast amount of services from democratic control into an organisation that is at present facing its own areas of failure.

'What is needed is not organisational change but better working between the NHS and social services departments for the good of elderly people.'

Miles says fears that the move would create a democratic deficit could be addressed by including local people on PCT boards. 'Something similar to Best Value could be introduced into the PCT commissioning process to ensure they critically review what they are doing and consult their local populations,' she adds.

Pauline Ford of the Royal College of Nursing says PCTs would be in an ideal position to pilot one of its proposals – a new nursing grade specialising in the care of the elderly. These nurses could work across health and social care boundaries.

'The post would be flexible so the nurse would be in and out of the hospital, nursing homes and patients' own homes,' she adds.

A spokesman for Age Concern England agrees, saying: 'We would be happier to see something like this than using the spare bed capacity in the private sector for rehabilitation, for which the sector simply isn't geared up.'

The government is being bombarded with ideas to improve the care of the elderly and its decision will be crucial. The length of waiting lists and thus its credibility on health depends heavily on it.


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