Long-term care facilities in London

Few aspects of Britain's welfare services have changed as much over recent decades as has residential and nursing-home care. Up to the late 1970s, there were many long-stay geriatric nursing homes and wards (and even hospitals) run by the National Health Service (NHS), and local authorities had built up a considerable number of their own residential care homes. But from the early 1980s, successive governments have promoted the involvement of independent (or private sector) proprietors, social housing providers, and voluntary organizations, and discouraged direct NHS and local authority provision. Under the community-care provisions of the 1990 National Health Service and Community Care Act, the new mixed economy of residential care has been consolidated. NHS, and therefore "free," long-term care provision has been curtailed, extending the range of disabilities and care needs that are provided for through means-tested social care. The results have confused and dismayed many older people with chronic impairments and their caregivers. How to pay for longterm care became a juridical and politically contentious issue. The new Labour administration of 1997 fully appreciated the complexities and sensitivity of the issue and appointed a Royal Commission on the Financing of Long Term Care (1997-1999) to appraise options and make recommendations. After thorough consultation and research, the majority report made the radical proposal that both the "nursing" and "social care" elements of residential care should be free at the point of delivery and financed through general taxation. A dissenting report, heavily influenced by alarmist (and dubious) projections of the likely increase in the prevalence of disability, took the view that the costs would be "insupportable" and should in large part be passed to the residents or users. The government's response was distinctly cool and evasive. It has accepted that nursing care should be free, and accepted the procedural recommendations designed to improve the technical qualities of care. These are being implemented through the Care Standards Act 2000 and the establishment in April 2002 of a more centralized system of quality regulation through a new independent body, the Commission for Social Care Inspection. Interestingly, the newly devolved Scottish Parliament has more fully implemented the royal commission's proposals; in Scotland, personal care in residential homes is free. Meanwhile, the government is giving high priority to its modernization plans for the NHS.1 These include the implementation of National Service Frameworks (NSF), one of which concerns older people's services.2 The NSFs are wide-ranging statements of principles, objectives, and good practice. They have been accompanied by a wide range of "intermediate care" initiatives, designed inter alia to develop support for frail older people in their own homes. These initiatives have affected all sectors of the statutory health and social care services for older people, and have meant that despite a high rate of closure of independent and voluntary homes, the issue has claimed relatively little attention and the government is not responding urgently or with additional funds to maintain the existing level of provision. This chapter takes stock of the changes in residential and nursing-home care provision in London over the last two decades by examining the volume, nature, and locations of current provision and the characteristics of the residents.