Mohammed T. Abou-Saleh

672 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYresources of the specialist team itself for further assessment,treatment, respite or crisis intervention. A great deal of the workof the elderly mental health service takes place in the patient’shome. Ours, for example (catering for an elderly population of60 000), has 20 CMHNs, all with large case-loads and betweenthem clocking up about 20 000 patient contacts a year. This iscomplemented by outreach from other members of the service(e.g. 8000 medical community contacts), two day hospitals anddeployment of staff to support day centres specializing in the careof the elderly patients with mental health problems. An originalbed complement of 250 (mainly long-stay) has reconfigured to 40continuing-care and 90 short-stay beds, 35 of the latter forfunctional illness. This has necessitated extensive outreach andsupport to residential and nursing homes but has released funds toredeploy into community developments, such as the establishment7 of a sitting service to offer home respite to carers fordemented patients. This has now diversified into other areas ofcommunity support for elderly people with mental healthproblems as a thriving provider in the new mixed economy ofcommunity care.SOCIAL CARE IN THE COMMUNITYProgress in community care in Britain has been hampered by thevery different way in which health and social services areorganized and financed and the frequent lack of co-terminosityin their local boundaries. The NHS is funded from taxation and ispredominantly free at the point of delivery. It has strong centraldirection and is coordinated locally by (unelected) district healthauthorities. Social and housing services are run by (elected) localauthorities, which receive block allocations from central governmentbut also have to raise much of their revenue through localtaxation and by means-tested charging of services to clients. Localauthorities were traditionally the main providers of domiciliaryand residential support for disabled people.The 1970s saw many initiatives in specialized supported housingfor older people 8–10 and in individualized and sometimes intensivedomiciliary services to support, in their own homes, frail elderlypeople who might otherwise have required residential care.Evaluation of these and subsequent projects usually showedthem to be valued by clients and generally cost-effective at lowand moderate levels of disability, but decreasingly so (and at timesvery expensive) for those with heavier dependency 10,11 . Becausethey generally rely on intermittent carer input or on the clientsummoning assistance, they tend to be less effective for patientswith advancing dementia than for those with a purely physicaldisability.Generalization of these initiatives in community care wasseriously hampered by the economic problems of the 1970s andearly 1980s. The incoming Thatcher government found thingsreaching crisis point but was unwilling to give the necessarysupport to local authorities to expand domiciliary based care.Instead, it changed the regulations governing social securitybenefits 12 to allow these to be used to pay fees in privateresidential and nursing homes, with no provision for needsassessment. This led to a huge expansion (from £10 million to over£1 billion a year during the 1980s) in this sector, but none indomiciliary provision, which was not eligible for this source offunding. This wasteful and retrograde trend was castigated by theAudit Commission 13 , which drew attention to the contrastingeffectiveness and popularity of the Kent Community Carescheme 14,15 . This had been using care management to assess theneeds of frail elderly people in the community and to put togetherpackages of domiciliary care, drawing on a range of neighbourhoodresources. This was enabling many people who wouldotherwise have needed residential care to remain in their ownhomes, despite a budget ceiling well below the cost of theresidential placement.To establish a transition to this model, the Audit Commissionproposed a ring-fencing of all public expenditure on communityand institutionally-based continuing care (including all residential,nursing home and NHS continuing care) to be administered by asingle district care agency on a care management basis. Theseproposals were endorsed by the government’s managementguru 16 , who also stressed the need to ring-fence the budgets forall continuing care and to ensure adequate transitional funding tosecure ample early investment in domiciliary-based options. Theresulting White Paper 17 unfortunately ignored these two crucialpoints. The result gave Social Services departments the responsibilityfor care management (including the purchase of long-termnursing home care) but without arrangements for any transfer offunds released within the NHS if it closed equivalent continuingcarebeds.Implementation of the Act since 1993 has therefore broughtabout a modified resurgence of community care for older peoplein Britain. Social services departments were encouraged to focuson the assessment and care management functions and tostimulate a mixed economy of domiciliary care providers, fromwhom they purchase packages tailored to the needs of clients. It isvery gratifying to see one’s patients getting individualized supportpackages, combining informal, social and healthcare elements andoften assembled at short notice in the event of a crisis. Aware ofthe growing pressure on acute hospital beds, some health andsocial services departments have also collaborated to developdomiciliary and intermediate care options to reduce the need forhospital admission and facilitate early discharge 18 . The advent ofPCGs should certainly stimulate that sort of approach. Unfortunately,because the means-testing rules make residential carecheaper for social services than the domiciliary equivalent foranyone with moderate care needs, the cost ceiling applied by mostdepartments to domiciliary packages for individual clients is along way below the level of residential home fees. This rules outsuch care for many people for whom it would otherwise havecontinued to be cost-effective, particularly those with dementia.POLITICAL AND ECONOMIC FACTORSLack of investment has been the main cause of our slow progresswith community care for older people in Britain. The politicianshave generally been seduced into thinking that it is a cheapoption, but at times of economic hardship domiciliary provisionhas always been the first target for cuts. In the 1980s spending oncare of the elderly increased greatly but in the wrong direction andit is taking a long time for the pendulum to swing back. Theseparate organization and funding of health and social care havecreated perverse incentives, which have been exploited to preservean inadequately funded NHS by narrowing its focus to the care ofacute illness. This constriction of the range of free NHS care hasled to artificial and increasingly absurd demarcations betweenhealth and social care, which undermines efficient and effectivepartnership and has thrown an increasing share of the cost ontopatients themselves. Failure to ring-fence the NHS continuingcare within the community care budget has allowed the closure of60 000 beds since 1990 (with savings redeployed to support otherNHS priorities), while social services have had to pick up the loadwith an increase in their nursing home purchasing from 100 000 to180 000 beds—a cost shift to social services and (through meanstesting) to patients and families of over £300 million a year. Notsurprisingly, this has encroached on investment in domiciliarycare, which only increased by 56% in the first 5 years ofimplementation of the community care legislation 18 .