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Chapter 2: Change and recent trends
Services are not static, and there have been many changes over the last 20 or 30 years. Community care policy has long been to maintain those who wish to do so in their own homes, or in homely settings in the community, wherever possible. In support of that, the NHS has worked with local authorities to increase services to people in their own homes and has reduced long-stay hospital provision for older people.
Thus there has been a shift in provision away from
- NHS long-term care towards care homes and complex packages of care delivered at home
- nursing home care to care at home.
Our first report noted that
"From the NHS perspective, with advances in medical treatment, the Health sector has been moving towards shorter periods of treatment and shorter lengths of stay in hospital. With a more intensive use of beds and more rapid turnover, more people are being treated in hospital, but for shorter periods of time. There has also been a reduction in the number of continuing care beds and a move to care in the community.
Local authority models of community care have also been changing, with a move away from care in care homes to more support for people in the community to help them live as independent a life as possible in their own homes for as long as possible. There are some concerns, however, that these changes in the pattern of care have developed unevenly and have resulted in a gap in provision for some people between NHS hospital care and care at home or in a care home. There is a need for new models of care to be developed to recognise this, with more intermediate rehabilitation taking place to maximise the independence of the older people involved".
To illustrate this:
- the number of NHS Scotland geriatric long-stay beds and patients increased over the 1980s, but showed a marked decline over the 1990s - indeed the number fell by more than 50% between 1990 and 2000.
- by contrast, nursing home places increased substantially during the 1980s and during the period 1990 and 1995, increased more gradually until 1998 before falling back slightly subsequently.
- provision of special needs housing for older people increased dramatically in the years to 1998, and has remained relatively constant subsequently.
- provision of very sheltered housing, while only accounting for a minority of all special needs housing for older people, is continuing to increase, but there were only 2,872 such dwellings in 2004.
Services will continue to change in the future, partly through population and technological changes and partly through the impact of national policies as they develop following, for example, the Kerr Report Building a Health Service Fit for the Future.
Drivers for Change
There are many drivers for change, and these were set out in a paper prepared as part of the work leading to Building a Health Service Fit for the Future which can be accessed at www.show.scot.nhs.uk/sehd/nationalframework
This Report noted, and described in some detail, the following drivers for change:
- Demography - Scotland's ageing population, the increasing numbers of older people expected in the next 10 and 20 years
- The rise in the number of older people living alone, which has been particularly rapid in the last ten years. Across Scotland as a whole, people living alone accounted for 29% of households in 1991, but 34% in 2004. More than a third of people in Scotland now live on their own (Registrar General's household estimates for 2004 (August 2005)). Between 1991 and 2001 the numbers of people aged 85 and over who lived alone increased from 30,000 to 44,000, mainly reflecting a rise in numbers in the age group but also a rise in the proportion living alone ( ISD Scotland, 2003).
- The increased incidence and burden of chronic illness
- Rising patient expectations
- Workforce pressures, including
- an ageing workforce
- fewer people coming into the labour market
- more working part time, and
- the European Working Time Directive, which stipulates a 48 hour maximum average working week.
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