Quality of institutional care and the elderly: policy issues and options.
Authors: P Day, R Klein
Journal: BMJ (1987)

The debate about standards of care provided in private nursing homes and rest homes has so far been conspicuously short of systematic evidence and specific proposals. Is the quality of care in the private sector inadequate and, if so, in what respects? Does the system of public regulation need to be tightened up and, if so, what changes are needed? These are the questions prompted by public concern. But before addressing them it is important to emphasise that the way in which they are usually presented risks falling into a trap. This is to assume that there is necessarily something special about the private sector of institutional care for the elderly: some form of original sin exclusive to the provision of care for profit. We shall argue that, on the contrary, most of the problems of regulation can be understood only if they are seen as stemming from the nature of institutional care for the elderly, whether publicly or privately provided. If there is concern about standards (as there should be) then it should be an across the board concern. If there is a case for discussing ways of improving the existing machinery for safeguard? ing standards (as there is) then again the policy options should be examined in the context of the public and private sectors of institutional care taken as a whole. Taking the latest available figures, for 1984, there were about 280 000 places for the elderly in England in a variety of institu? tions.12 Of these, approximately 53000 (19%) were in National Health Service geriatric hospitals and 28000 (10%) in nursing homes; 110000 places (39%) were in local authority residential homes and about 90 000 (32%) in private and voluntary rest homes. So in 1984 private provision, which we define to include voluntary homes, accounted for over two fifths of all institutional places for the elderly. Indeed throughout the 1980s private nursing and rest homes have been increasing their share of total institutional provision. While the number of geriatric beds has been falling slightly and local authority provision has barely increased the number of private nursing home beds went up by 35*6% between 1982 and 1984. The number of private residential home beds rose by 42*2% over the same period. The growth of the private sector in part reflected changes in the supplementary benefits system, although it had started well before the introduction of new rules in 1983 and has since slowed down. As a result of the change in the supplementary benefits rules social security payments now support about two fifths of all the residents in the private sector.3 In total, supplementary benefits payments to people in private sector homes rose from ?105 million in 1983 to an estimated ?500 million in 1986. In this article we explore the wider concerns in the particular case of nursing homes, which account for roughly a quarter of institutional places. In doing so we draw on interviews and documentary material generated by a research project that is examining the way in which health authorities carry out their statutory responsibilities for registering and inspecting nursing homes.4 We do not attempt to look at the regulation of private residential homes by local authorities although this has given more cause for anxiety, some of which has rubbed off on to nursing homes. Although each of the sectors of institutional care?public and private, nursing and residential?undoubtedly has its own special characteristics and problems, our main interest hereis with issues common to all of them.