The NHS and Community Care Act 1990

Abstract

Aims and Method

The Community Care Act came into effect in April 1993. In order to see what impact this would have on the discharge profile of dementia inpatients, prospective studies of inpatient discharges from a dementia assessment ward before the Act, and five and 41 months after the Act were conducted.

Results

The proportion of patients discharged to their own homes and to residential/nursing homecare remained unaffected by the Act. Duration of hospital stay increased after the Act in 1993 and 1996 (P=O.02) largely due to delays in placement into care homes. Placement delay was increased both in 1993 and 1996, but by 1996 the difference was no longer statistically significant. Duration of hospital stay was unaffected by the Act for those patients discharged to their own homes.

Clinical Implications

The new care management process by social services was found to be associated with delayed discharges for people with dementia requiring residential/nursing home placements, thus causing pressures on beds and hig her in-patient costs.

The implementation of the National Health Service (NHS) and Community Care Act 1990 on 1 April 1993 made local authority social services departments responsible for organising and funding support and care in the community to “enable people affected by aging or disability to live as independently as possible”. It required social services departments to use a care management process to arrange care in the community by assessing elderly in-patients for possible help after discharge from the hospital.

Concerns have been reported as to the success of the reforms (Tonks, 1993; Impallomeni & Starr, 1994; Dean, 1995) due to the lack of funding, bed closures (both NHS and local authority) and an ever increasing elderly population. Mixed results have been reported on the discharge profile of elderly patients from hospital. While Lewis et al (1994) and Smith et al (1994) reported no difference before and after the Act, a change for the better (Ajayi et al, 1995) and a change for the worse (McAlpine & Read, 1994; Newnham et al, 1995) after the Act, have also been reported. The Act was reported to have had little effect in reducing the institutionalisation of old people (Impallomeni & Starr, 1995).

The aim of this study was to compare the effects of the reforms on the discharge of dementia in-patients from hospital before and after the Community Care Act by comparing: (a) the proportion of patients discharged to residential/nursing home care; (b) mean duration of hospital stay; and (c) placement delay in residential/nursing homes following referral for care management.

The study

All admissions to the dementia assessment ward at the Forston Clinic in Dorchester during a three-month period in the years 1992, 1993 and 1996 (1 September to 30 November to avoid any seasonal bias) were followed up prospectively. Patients admitted for respite and those who were transferred or died during the admission were excluded from the study. The data collected were name, age, gender, dates of admission and discharge, placement on discharge and date of referral to social services for care management. Analysis of data was carried out with SPSS (version 6.1, 1994), using descriptive statistics and non-parametric tests (Mann-Whitney U and χ² tests). Examination of variables suggested non-parametric tests were most appropriate.

Findings

The mean ages (years) for the three groups were 79.6 (95% CI 76-82) in 1992, 79.7 (95% CI 77-81) in 1993 and 81.3 (95% CI 78-84) in 1996. There was no significant difference in age or gender in the three groups. Table 1 shows the numbers and proportion of patients discharged to residential/nursing home care and to other locations (home, sheltered/warden controlled accommodation) before and after the Act. The median length of stay in hospital for those discharged to nursing/residential homes was prolonged by 33 days in 1993 and by 19 days in 1996 as compared with 1992, prior to the Act. The differences were statistically significant (Table 1). The median length of stay for those discharged to their own homes was unaffected (not significant). The median placement delay from date of referral to social services, to discharge from hospital, for those patients placed in residential/nursing home care was increased by 25 days in 1993 (statistically significant) and 22 days in 1996 (not significant) as compared with the period prior to the Act in 1992.

Table 1 Patients discharged to private residential and nursing home care, length of stay in hospital and placement delays before and after implementing the Community Care Act, according to period and year of discharge

	1 Sept-30 Nov 1992	1 Sept-30 Nov 1993	Significance	1 Sept-30 Nov 1996	Significance
Number of patients discharged from hospital
To residential or nursing homes (%)	15 (41)	13 (32)	χ2=0.7	13 (45)	χ2=0.1
To other locations (%)	22 (59)	28 (68)	P=0.4	16 (55)	P=0.7
Total	37	41		29
Median length of stay in hospital in days before discharge
To residential or nursing homes (interquartile range)	30 (16-45)	63 (39-73)	Z=2.3	49 (37-71)	Z=2.3
			P=0.02		P=0.02
To other locations (interquartile range)	20 (14-28)	18 (13-26)	Z=0.6	21 (13-30)	Z=0.4
			P=0.6		P=0.7
Median placement delay from time of referral to discharge from hospital in days (interquartile range)	14 (7-18)	39 (13-55)	Z=2.3	36 (15-44)	Z=1.7
			P=0.02		P=0.09

Comment

This study compares the discharge of dementia patients from hospital five months before the Community Care Act, five months and 41 months after the Act. Although the numbers are small, Forston Clinic is the only dementia assessment unit for West Dorset and the discharges were studied prospectively.

Three years after the Act, the number of admissions/discharges had reduced. Increased length of stay was seen in those people discharged to residential/nursing home care, which was accounted for by increased placement delay. Likely reasons for reduced numbers of admissions is not clear from the data available. It may have been due to reduced availability of beds following from increased bed occupancy caused by increased length of stay. Likely reasons for delays in placement could be that the process of assessment by social services is time consuming, or that there were shortages of available resources. Residential/nursing home beds may have been taken by people directly placed in care following community assessments, there may have been lack of funds available to social service departments for supporting patients in care homes, objections by relatives in a small proportion or simply due to insufficient placement number for the population. Challis & Henwood (1994) expressed concern over the lack of equity in the distribution of public resources thus having the potential to lead to differential service provision. This is a plausible explanation for mixed results reported in different studies from different areas.

In conclusion, this prospective study showed delays in discharges of dementia in-patients to residential/nursing homes following the Community Care Act. Lack of resources and assessment delays may have played a part. Likely implications of delayed discharges would be unnecessary pressure on beds and rise in cost of in-patient care.