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15 Dignity security and independence in old age

Introduction

15.1 Older people make up the largest single group of patients using the NHS. People over 65 account for two-thirds of hospital patients and 40% of all emergency admissions. Too often they are treated in inappropriate acute hospital settings because there is nowhere else. Older people also worry about the prospect of deteriorating health, and can be anxious that they may not receive the care they need, sometimes simply because of their age. They are also distressed when service providers fail to respect their dignity and privacy - a problem which can occur at home or in a nursing home, as well as on the hospital ward. There can be particular problems for those from black and minority ethnic communities in accessing the services which meet their needs and wishes.

15.2 This is the generation that has supported the NHS all their lives. This Plan sets out a major package of investment, to improve services and standards of care for older people. By 2004 the Government is making available annually an additional £1.4 billion for new investment in health and social services for older people.

15.3 We know from listening to older people that they want health and social services that will put them, and their needs and wishes, at the centre of service delivery:

  • assuring standards of care
  • extending access to services
  • promoting independence in old age
  • ensuring fairness in funding.

15.4 This NHS Plan sets out an ambitious programme to begin to make this a reality for older people and their carers.

Assuring standards

15.5 The new National Care Standards Commission will drive up standards across domiciliary and residential care. It will start its work in 2002. Now we intend to raise the standards of care for older people across the piece - health and social care. Later this year we will publish a new national service framework (NSF) which for the first time will set out clear standards for the services that older people use, including those for stroke, falls and mental health problems. Implementation of the standards will start from 2001.

15.6 The NSF will ensure that ageism is not tolerated in the NHS, with the elimination of any arbitrary policies based on age alone. Major concerns have been expressed about ageism in the NHS, and specifically with respect to resuscitation policies. All NHS organisations will be required to establish and implement local resuscitation policies based on the guidelines published by the British Medical Association, Royal College of Nursing and Resuscitation Council (UK) and to include compliance with these policies in their clinical audit programme. The Commission for Health Improvement will assess progress within its clinical governance reviews.

15.7 Health services in partnership with social services and other agencies will need to recognise the specific needs of older people in caring for them:

  • demonstrating proper respect for the autonomy, dignity and privacy of older people
  • treating the person, not just the most acute symptoms, by taking account of the full needs of older people, including the importance of good nutrition, maintaining tissue viability and enabling the older person to remain as active as possible while in hospital
  • making high quality palliative and supportive care available to those older people who need it
  • ensuring good clinical practice which recognises the complexities of caring for older people, for example, by promoting the good practice recommendations contained in the most recent report of the National Confidential Enquiry into Peri-Operative Deaths.

Extending access to services

15.8 By 2001 the NHS will: pilot an NHS retirement health check, a free health check on retirement, to review any current treatment and to identify any further potential health problems. We will work with professional bodies to determine the most appropriate package of measures to include. And breast screening will be extended to cover all women aged 65 to 70 years as soon as possible (see paragraph 14.5).

15.9 Local services will streamline their local assessment processes, recognising the complexity of what some older people require. By April 2002, we will introduce a single assessment process for health and social care, with protocols to be agreed locally between health and social services. Initially this will be introduced for those older people who are most vulnerable, for example, those who live alone or those who are recently bereaved or those recently discharged from hospital or entering residential or nursing care.

15.10 During 2002, each of these older people, and where appropriate their carers, will be involved in agreeing a personal care plan, which they will hold. The personal care plan will document their current package of health and social care, their care co-ordinator, monitoring arrangements, and a list of key contacts for rapid response at home and in emergencies.

15.11 There is an important role for clinical leadership in this area, and we will explore the potential for nurse consultants and for specialist nurses for older people.

15.12 We will also be establishing an entirely new service to benefit older people in particular. Care Direct will provide faster access to care, advice and support. This new service will provide information and advice about health, social care, housing, pensions and benefits by telephone, drop-in centres, on-line and through outreach services.

Promoting independence

15.13 In future, the NHS and local social services should support older people to make a faster recovery from illness, encouraging independence rather than institutional care, and providing reliable, high quality on-going support at home.

15.14 The Plan provides an extra £900 million by 2003/04 for investment in intermediate care and related services to promote independence and improved quality of care for older people. This, along with the additional £150 million made available this year, will:

  • promote independence through active recovery and rehabilitation services with an extra 5,000 intermediate care beds and a further 1,700 supported intermediate care places, together benefiting around 150,000 more older people each year 
  • prevent unnecessary admission to hospital with extra rapid response teams and other forms of admission prevention benefiting around 70,000 more people each year
  • enable 50,000 more people to live independently at home through additional home care and other support. In addition, 50% more people will benefit from community equipment services (assistive technology) ranging from simple care equipment and adaptations, like grab rails and pressure relief mattresses, to more sophisticated equipment such as fall alarms and remote sensor devices
  • extend carers respite services benefiting a further 75,000 carers and those they care for.

15.15 This will not only improve the care of older people and contribute to the elimination of 'bed blocking'. It will also enable the NHS to operate more efficiently by helping to release acute hospital beds. This should enable extra patients to be treated each year, contributing towards the targets on waiting.

Fairness in funding

15.16 Through this investment in intermediate care, older people will be able to maintain their health and independence much more effectively, and remain in their own homes wherever possible. However, for some people, residential or nursing care is the right option. When this is necessary, we must ensure that the funding of long-term care is fair and promotes rather than obstructs good partnership working across health and social services.

15.17 This is not the case at present. The present system of funding is confusing, complicated and anomalous. People who need nursing care in nursing homes may have to pay for it whereas it is free in every other setting. Many people fear having to sell their own homes to pay for their care. Rather than promoting independence, the present rules often reinforce an older person's dependency.

15.18 In 1997 the Government established a Royal Commission on Long-Term Care, under the chairmanship of Sir Stewart Sutherland to examine these issues and to make proposals for reform. The Government is extremely grateful to Sir Stewart and the Commission members. Many of the Commission's recommendations - such as the establishment of a National Care Standards Commission - have already been actioned. Now we are able to respond to the Commission's proposals on the funding of long term care. A full response to the Royal Commission is being published separately. We will action the following proposals:

  • from April 2001: for the first three months from admission to residential and nursing home care, the value of a person's home will be disregarded from the means testing rules. This will give people a breathing space in which to consider their position and allow the possibility of a return home. This will benefit around 30,000 people each year. The capital limits used when assessing someone's ability to contribute to the costs of their care will be restored to the 1996 value and will be kept under review. These changes will benefit around 20,000 people in residential care homes and nursing homes. We will, for the first time, issue statutory guidance to councils to reduce the current unacceptable variations in charges for home care. This could benefit many of the 500,000 people who receive home care each year.
  • from October 2001: subject to a decision by Parliament, nursing care provided in nursing homes will be fully funded by the NHS. People should not be asked to contribute towards the costs of their nursing care. We will introduce legislation this year to make these necessary changes. This will remove a major anomaly in the system of funding long-term care and give the NHS a far stronger incentive to ensure effective rehabilitation for people facing the prospect of long-term care. This change will benefit around 35,000 people at any time, and could save up to £5,000 for a year's stay in a nursing home.
  • from April 2002: payment of the Residential Allowance will cease for new care home residents and the resources will be transferred to local authorities. At present these resources can encourage councils to place older people in residential care and to select independent sector homes. The individual does not benefit from the money as the local authority usually recoups it. In future this money will be available to promote independence and active rehabilitation for older people.

We will provide extra help and financial support to those who entered residential care before April 1993 by ensuring that local councils become responsible for their assessment, care management and financial support. This change will benefit around 65,000 people. In doing this we will ensure that people cannot be moved against their wishes unless there are compelling reasons to do so. Meanwhile we will change the regulations to allow councils to help older people who entered care before the 1993 community care changes and who face eviction from their care home because they cannot pay the fees. A new grant to local authorities to expand loan schemes should help ensure no old person will be forced to sell their homes against their will when they go into long term care. The new system will be fairer and clearer. The Government is committed to consult on regulation of long-term care insurance once a Treasury led committee has reported on how the financial services industry can reassure its customers about the quality and reliability of the products available for financing long-term care. The committee's report will be published shortly as part of this consultation exercise, which will consider whether the impact of regulation would be beneficial and proportionate. 15.19 This response to the recommendations of the Royal Commission on Long Term Care means that by 2004 a further £360 million will be invested to help people meet the costs of their residential and nursing home care.

15.20 In proposing all these changes we have considered carefully all the recommendations of the Royal Commission on Long Term Care. The key proposals are accepted, including that nursing care should be free in all settings and that a National Care Standards Commission should be established. The majority report of the Commission also felt that all personal care in nursing and residential care homes should be free although it acknowledged that accommodation costs should still be means tested. By contrast, a minority note fundamentally disagreed with the idea that taxpayers resources should be used to make personal care free. In fact, personal care has never been free. It has been means tested by social services since 1948 although three quarters of people in nursing and residential care currently receive help with some or all their personal care costs. Actioning the proposal would absorb huge and increasing sums of money without using any of it to increase the range and quality of care available to older people. For that reason it is not supported by the Government. Our proposals will involve spending as much money as the majority report recommended but in ways that will bring greater benefits in terms of health and independence for all older people both now and in the future.

Conclusion

15.21 The Government is making £1.4 billion available in 2004 for new investment in better health and social care services for older people. In order to lead this programme of change and reform we will appoint a National Director for Services for Older People this autumn.

15.22 We will improve standards across the range of services that older people use. Wherever older people are cared for, we will expect that both they and their carers will be treated in a way which respects their dignity, privacy and autonomy. This is not an addition to care provision, it is an integral part of good care.

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