11 March 1994

Dear Colleague

CONTINUING CARE OF THE FRAIL ELDERLY

Summary

1. This Circular clarifies Government policy on continuing care of the frail elderly outlined at a meeting with COSLA on 25 January 1994.

Background Objectives

2. We opened the meeting by setting out the present policy position as reflected in the White Paper "Caring for People" and more particularly in the circular "Community Care: Joint Purchasing, Resource Transfer and Contracting: Arrangements for Inter-Agency Working" (NHS Circular MEL(1992)55 of 15 September 1992) copied to social work and housing authorities.

3. The Government’s policy of community care is designed to enable vulnerable people who require professional care to live in their own homes and communities as far as possible. If we are to achieve this desirable policy objective, we need to move away from institutional to community-based care. This shift in the pattern of care has two aspects.

4. First, patients who require continuing specialist medical and nursing supervision will continue to be the responsibility of the NHS. The NHS will arrange for all aspects of their care and will meet the full cost of it. The provision of care may be undertaken by an NHS Trust, a Directly Managed Unit, a Voluntary Body or a Private Sector Company. So far as possible the settings should not be institutional and should be integrated into the community as far as practicable.

5. Second, patients who do not need continuing specialist medical and nursing care will normally have their needs met within the community by either the local authority or a voluntary or private sector body. This will mean the gradual transfer to local authorities of responsibility for people who do not need the level of care provided by the NHS although Health Boards will retain responsibility for meeting any health needs of the client which cannot be met by the General Practitioner and other members of the primary care team.

Effect on Frail Elderly

6. These principles apply equally to the frail elderly as to other client groups. However, in practice the shift in the balance of care from institutional to community-based care for the

frail elderly is likely to be achieved gradually through changes in the pattern of admission to hospital rather than by discharging patients. Our expectation is that relatively few frail elderly people currently accommodated in NHS long-stay facilities will be discharged from institutions to community placements.

7. The NHS will continue to be responsible for providing assessment and rehabilitation facilities for the frail elderly. It will also continue to require long-stay facilities for frail elderly people with complex medical needs or with patterns of behaviour which would be very difficult to manage in a community-based setting. The volume of long-stay NHS provision for the frail elderly is likely to decline gradually to a relatively low level.

Future Arrangements

8. In planning the pattern of health care provision, the NHS will in future plan outwards from primary care. The intention is to provide as large a volume and as wide a range of services in a primary care setting or in a community hospital as is cost effective. This applies to all services and to all client groups, but is clearly of particular relevance to the care of the frail elderly. We also look to the NHS and to local authorities (both regions and districts) to work closely together in planning the pattern of services and in delivering services to individual clients. Previous circulars have emphasised the need for changes in the pattern of provision to be agreed locally between the agencies concerned and to be implemented jointly. In particular they have emphasised that there should be no unilateral withdrawals from services or working arrangements. It is clear that joint working is increasing and developing and we welcome that. Within these local negotiations there needs to be discussion about the level of resource transfer. The resource transfer arrangements set out in Circular NHS MEL(1992)55 are an essential component in the community care process, including for the frail elderly client group. (These arrangements are highlighted in the Housing and Community Care Circular SWSG7/94.)

9. The scale and pace of change and the extent to which it is being achieved in different parts of the country will be a matter in which the Management Executive must take a close interest in relation to the NHS. But, as we made clear at the meeting, the Management Executive has not set targets for individual Health Boards for the expected level of reduction in continuing care beds within a specified period. Shifting the balance of care is a matter for local discussion and agreement with the emphasis on joint working and joint assessment of needs.

10. We welcomed the opportunity of the meeting to clarify the policy on continuing care of the frail elderly and we hope that that discussion and this letter will be helpful. We are giving this letter a wider circulation among trusts and voluntary organisations.

Yours sincerely

W MOYES N G CAMPBELL