The Department of Health has confirmed that it is considering the option of using spare capacity in private nursing homes in order to free-up acute NHS capacity and solve the problem of so-called "blocked beds" - for which, read "beds occupied by elderly people". The major response to this news to date has reflected on the apparent ideological u-turn that the government has performed in accepting the role of the private sector.
This is nonsense. There has long been acceptance of the independent sector as major providers of long-term care; the only difference is a shift towards seeing this as care which might be purchased in bulk by the NHS, rather than (as is often the case at present) by local authority social services departments.
It is important that the proposal to use nursing home beds is scrutinised in detail, and issues explored which go way beyond those of ideological dogma. Does it really offer a solution, or would it merely offer a short-term answer while storing up further problems in the long run?
The appeal of the idea lies in its simplicity. The argument goes that there is a problem in the NHS because of all of these old people. Most of them don't actually need the facilities of an acute hospital, but they are not well enough to go home. If they can be moved, temporarily, to a nursing home environment, then they can get the care they need and can continue their recovery at their own pace.
So far, so good. But it's not that simple. The issue with care of older people is not merely a technical one of insufficient beds. In recent years, there has been increasing emphasis on the need to recognise that older patients frequently need longer to recover from trauma or surgery. The blocked beds phenomenon is primarily the result of two factors: first the emphasis on efficiency (and hence of rapid hospital throughput, and shorter lengths of stay), and second it reflects the often disputed responsibilities between health and social services authorities, and consequent delayed discharges.
The proposal could further muddy these already murky waters by introducing a new group of patients who will remain the responsibility of the NHS (in financial and care terms), even though they are being cared for in a private nursing home, alongside other elderly people (whose medical and social condition will often be indistinguishable from this first group) but who are either being funded by social services, or who are paying for their own care (and typically, a combination of these two).
In other words, this solution would merely intensify the difficulties and anomalies which surround paying for long-term care which a royal commission reported on more than 14 months ago, and to which the government has still not fully responded (albeit that a white paper is expected this summer).
There are other concerns about the capacity of the nursing home sector to deliver. At present there is very little short-term use of nursing home care in the sense that is now being envisaged. The vast majority of such homes have neither the facilities, the staff or the skills to offer the type of rehabilitation which would be required. As David Hinchliffe (chair of the health select committee) has also cautioned, many such homes encourage dependence rather than independence. Indeed, the system has failed to provide any financial incentives for nursing homes to do anything other than maintain high occupancy levels.
Developing the role of the nursing home to provide sub-acute level care is not a new idea, and various models exist. However, these are characterised by a range of features including investment in appropriate staff, and the provision of facilities which enable the home to operate in a genuinely rehabilitative mode (such as self-contained flatlets which people can move into in preparation for more independence and a return home). These features cannot simply be bolted on to homes which happen to have spare beds. Moreover, it is a matter of some uncertainty whether, even if it were possible to develop this capacity, the approach could co-exist within homes where the major business remains that of long-term (that is, permanent) care.
In anticipation of the white paper on long-term care, it seems that speculation about likely developments continues unabated. This latest proposal for the use of nursing homes as an overflow valve for the acute sector comes hard on the heels of a story that the government is moving towards a position in which nursing care would be free - in part, but certainly not in whole, addressing the recommendations of the royal commission on long-term care.
It is hard to avoid the conclusion that leaks and rumours are being used to test response to ideas without going through the usual democratic processes of formal consultation on policy proposals.
It is undeniable that many elderly people currently occupying hospital beds need not be there. It is equally clear that for them to return to a level of acceptable independence and to go home can only happen with sufficient investment in rehabilitation and preventative support.
Indeed, this has been precisely the focus of activity which the Department of Health has been encouraging through a programme of grants to local authorities aimed at promoting independence. The short-term answer offered by this new overflow initiative not only ignores the valuable work which is already under way, but risks introducing a slick political solution which overlooks the very real practical impediments to changing the ethos and motivation of nursing home providers. More significantly, it is a solution which appears essentially to be born out of a perspective which views older people as a burden to the NHS, and a commodity to be shunted elsewhere.
Without considerable development, and real investment, this proposal is not an answer to how best to care for older people needing sub-acute care, but to the quite separate issue of how to deliver on the continuing spectre of the waiting list pledge.
• Melanie Henwood is an independent health and social care analyst.
