The role of local authority homes in the care of the dependent elderly

The radical 1948 legislation, which established a comprehensive health and welfare system for the elderly, asserted that it was the duty of the State to provide appropriate facilities for not only the sick, but for all old people "in need of care and attention". The intention was that the welfare services (retermed social services in 1968) would develop small group homes to accommodate the fit elderly who were in need of care primarily as a result of social disadvantage. However, Townsend's penetrating study. The Last Refuge (1962), destroyed any illusion that these were State analogues of guest houses, and since 1970 occasional publications arising from surveys of Local Authority homes have consistently reported high levels of physical, mental and behavioural disabilities among the residents. Assessing this literature, and following discussions with social services staff, two fundamental, unanswered questions about the role of Local Authority homes in the care of the dependent elderly could be delineated- 1. Was the level of behaviour disabilities increasing in the homes? 2. What made an old person suitable for this type of care? Following a detailed review of the literature five hypotheses to be tested in the project were generated from these questions. Hypothesis One: If Local Authority homes are modifying their role because of increases in the number of elderly, then there will be an increase in the mean levels of disabilities managed in the homes and/or an increase in the number of dependent or demented residents. Hypothesis Two: The prediction of mortality may be a useful method of determining suitability for care. Hypothesis Three: Residents who are considered unsuitable for the home by the staff will have behaviour disabilities of a different nature or severity from those of other residents. Hypothesis Four: A standardised behaviour rating scale with designated cut-off values, accurately reflects the staff's opinion of suitability for the home. Hypothesis Five: The admission of old people to Local Authority homes may shorten their life and/or increase their dependency. The project was carried out prospectively between 1978 and 1980 upon the population (about 400 residents) living in the eleven Local Authority homes for the elderly within Gartnavel Royal Hospital's catchment area. Investigations consisted of a behavioural assessment of each resident by the senior members of staff in the home, using the Shortened Stockton Geriatric Rating Scale (SSGRS) and a psychometric assessment of each resident by a psychiatrist using the Crichton Orientation Test and the Modified Kew Test. The psychometric instrument was a novel combination of tests and therefore had to be validated as a method of identifying cases of dementia. The results of the study, summarised in Chapter 11, rejected hypotheses one, two and five, and supported hypotheses three and four. The interpretation of these findings was that Local Authority homes for the elderly contain large numbers of highly dependent residents within a population characterised by its wide range and nature of disabilities However they do not have the capacity or resources to admit severely dependent old people indefinitely, and having determined to employ a more defensive selection posture, repercussions occur in the hospital services and in the community. Local Authority homes can cope with most types of disability and do accept that their role involves the care of the dependent elderly. However old people with severe physical disabilities which are intimate, and unpleasant and time-consuming to nurse are not suitable for this form of care. The identification of these traits is one method of developing exclusion criteria, although the agreement between a standardised behaviour rating scale (SSGRS) and staff opinion of suitability for care is high enough to warrant its application in this task. Recommendations were divided into two categories. Firstly short term, relatively inexpensive measures that increase liaison between the health and social services, improve the health care input into the homes and develop better assessment procedures. More important however is the need to provide a long-term solution to the growing problem of highly dependent old people whose disabilities are beyond the scope of the Local Authority homes, and the shared care 16 arrangements that have evolved between hospital day and- domiciliary services and relatives or friends in the community. The justification for health service continuing care units sited in the community to be served has been established. The failure to develop this type of accommodation can only aggravate the plight of all those involved with this section of the population, and through the abrogation of State responsibility, may ultimately recreate a pre-1948 climate for the dependent elderly in our society