MEDICINE AND PUBLIC ISSUES
Geriatric Care in the United Kingdom: An American Perspective ANNE R. SOMERS, Princeton, New Jersey
Geriatric care is a complex and challenging aspect of health care. The United Kingdom, with 1 3 . 6 % of its population over 65 years of age, compared to 1 0 . 1 % in the United States, has given special attention to this field. Characteristics of the British system include financing through the National Health Service, existence of a specialty of geriatrics, absence of "nursing homes," emphasis on home care, and avoidance of "heroics" for the terminally ill. While British life expectancy at birth is longer than that for Americans, the opposite is now true for those over 65. The British have made efforts to maximize efficiency in a high-demand, comparatively low-resource context. But there are limits to which professional dedication and patient manipulation can be pushed. Some new policy directions— primarily aimed at prevention and other methods of reducing demand, other than reimposing financial barriers— may have to be explored.
GERIATRIC CARE is probably the most complex, neglected,
and challenging aspect of health care facing the developed countries during the last quarter of the twentieth century. In all these countries, both the number and proportion of elderly persons continue to rise steadily. In the United Kingdom, where the retirement age for women is 60 and for men is 65, pensioners constituted nearly 17% of the population by 1973 (1,*), and 13.6% of the population was 65 and older (Table 1). Although few, if any, other countries have reached this extreme (the United States ratio for 1973 was 10.1%), and the proportions continue to vary considerably, the ratios are now rising throughout the developed world. Particularly dramatic is the rise in numbers and proportion of those older than 75 and even 85 years of age. Only in case of a major war, depression, or some totally unforeseen catastrophe is this trend likely to be reversed. Every advance in the treatment of cancer, heart disease, * Official statistics are sometimes confined to England and Wales, sometimes to Great Britain (England, Wales, and Scotland), and sometimes applied to the United Kingdom (Great Britain and Northern Ireland). Wherever available, data used in this article are for United Kingdom. However, slight differences do not affect the broad trends and issues discussed here. • From the Departments of Community Medicine and Family Practice, College of Medicine and Dentistry of New Jersey—Rutgers Medical School, Piscataway, New Jersey.
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stroke, diabetes, and arthritis, and in the salvage and rehabilitation of victims of trauma will increase the need for geriatric care. Every month added to the life expectancy of those persons 65 and over means a higher proportion of those in the most dependent age groups—the 75 and over and 85 and over groups. At the same time, the sharply reduced birthrates mean fewer employed workers to support elderly persons. To compound the problem, relatively few physicians, health planners, and even public health authorities are professionally engaged in, or committed to, long-term care of elderly persons. In most countries, pressure groups working for health-care legislation and appropriations are overwhelmingly oriented to acute care. Nevertheless, the inexorable pincer movement of growing proportions of elderly persons, pressing on limited health-care resources, is forcing all nations, regardless of political philosophy, to face up to this problem. My report on geriatric care in the United Kingdom—an aging society trying valiantly to cope with the medical, ethical, political, and economic implications—is based on four visits during the past 2 decades, the most recent in August 1975. I suggest a number of trends and issues that will become increasingly relevant to the United States' experience as our population continues to age and as limits on our national resources become more apparent ( 2 ) . Major Characteristics In 1973, the crude birthrate in the United Kingdom was 13.9 per 1000 population (Table 1 ) . The average life expectancy at birth was 69.0 years for men and 75.2 for women. The average life expectancy at age 65 was 12.2 years for men and 16.1 for women. There were 7.6 million persons 65 and older. Those older than 75 numbered 2.7 million and accounted for 4.8% of the population, and those older than 85 numbered 0.5 million and 0.9% of the population. Projections for 1981 anticipate that retired persons will constitute 17.4% of the total population, while those over 75 will constitute 5.5% ( 3 ) . In 1973, there were 27.9 elderly per 100 persons of working age, compared with only 14.5 in 1931. The projection for 1981 is 28.3 elderly per 100 persons of working age. The differences between the United Kingdom and the United States in health care for elderly persons are more Annals of Internal Medicine 84:466-476, 1976
striking than in any other aspect of health care. These differences are discussed below. FINANCING
The existence of the National Health Service (NHS), which provides complete and nearly free (at the time of delivery) health and medical care to all ages, for all conditions, and with no limits on duration, means that there are no special problems of financing care for elderly persons as opposed to the general population, or long-term care as opposed to acute care. The main source of finance is the central government, which, directly or indirectly through grants to local authorities, in 1974 provided about 8 1 % of total health and social services costs ( 4 ) . The balance came from local authority rates (local property taxes), 7.25%; NHS contributions (payroll taxes), 6.50%; payments by users, 4.75%; other, 0.50%. In 1975, the central government's share is expected to rise by another 10 percentage points. The consolidated NHS budget is thus clearly dominant, providing a more powerful instrument for controlling both overall costs and the allocation of resources within the system than is available in most democratic countries, including the United States. In practice, it is often alleged that acute hospital services receive a disproportionate share of national health resources, both manpower and financial. The hospitals do receive the major share of the health and social services dollar, approximately half in 1973 and 1974 ( 5 ) . But there are no built-in statutory biases in this direction. Rather, on the contrary, Dr. John Brotherston, Chief Medical Officer of the Scottish Home and Health Department and one of the leading spokesmen for the United Kingdom in health matters, has said: Nothing will really flow smoothly in the Health Service until we reach an adequate stage of provision in our society for the elderly. This means many things apart from hospital beds. . . . A major phenomenon of the elderly vis-a-vis the Health Service is underdemand not overdemand [6]. Funds are now in seriously short supply for the Health Service as a whole (see below), but there is a continuing effort to protect and even enlarge somewhat the proportion of resources devoted to geriatric care. When increasing financial stringencies dictated a general cutback in projected capital expenditures for 1974/1975, there was no reduction in the allocation for geriatric services ( 7 ) . GENERAL PRACTICE
Britain's more than 25 000 general practitioners (GPs) constitute a much higher ratio of GPs to all practicing physicians than in the United States. The percentages for 1973 were 45 and 18, respectively ( 8 ) . (If one adds United States' specialists in internal medicine to those in general practice, the percentage rises to 33.) The heavy emphasis on primary care (9) and the persistence of a strong, officially encouraged GP service within the reorganized NHS permit greater continuity than is usual with specialty services, more attention to social and community factors, and generally provide an important
Table 1. Elderly Population: Numbers, Proportions, Life Expectancy, and Death Rates, 1973*
United Kingdom
United States
Total population, millions 56.0 210.4 Birthrate, crude (per 1000 population) 13.9 14.9 Deathrate, crude (per 1000 population) 12.0 9.4 Deathrate by age and sexj (per 1000 population in specified group) 65-74 53.8 (M) 27.8 (F) 48.2 (M J) 25.3 (FJ) 75-84 119.8 (M) 78.2(F) 101.2 (MJ) 65.8 (Ft) 85+ 248.0 (M) 197.3 (F) 196.0 (Mt) 162.0 (Ft) Life expectancy at birth, years§ Male 69.0|| 67.5 Female 75.2|| 75.1 Life expectancy at 65, years§ Male 12.2|| 13.1 16.1|| 17.0 Female Population 65+ Total number, millions 7.6 21.3 % of total 13.6 10.1 Population 75+ Total number, millions 2.7 8.1 % of total 4.8 3.8 Population 85+ Total number, millions 0.5 1.6 % of total 0.9 0.8 * Sources: United Kingdom: Central Statistical Office, Annual Abstract of Statistics 1974, Her Majesty's Stationary Office (HMSO), pp. 13, 30, 45; Central Statistical Office, Social Trends, no. 5, 1974, HMSO pp. 75, 90; Department of Health and Social Security, Health and Personal Social Services Statistics for England (with summary tables for Great Britain), 1974, HMSO, pp. 11, 15. United States: Department of Commerce, Bureau of Census, Statistical Abstract 1974, p. 5; Bureau of Census, Population Estimates and Projections, ser. P-25, no. 519, April 1974, Table 1, p. 12; U.S. Department of Health, Education and Welfare, National Center for Health Statistics, Vital Statistics of U.S., Life Tables 1973, vol. 11-sect. 5; National Center for Health Statistics, Monthly Vital Statistics Report, 10 February 1974, vol. 23, no. 11, suppl. 2, p. 7; Monthly Vital Statistics Report, 30 May 1975, vol. 23, no. 13, p. 1. t In 1972. t Excludes non residents of the U.S. Based on 50% sample of deaths. M = male; F = female. § 1971-1973. || England and Wales.
base for the supportive type of care so frequently needed by elderly persons. Moreover, GPs receive small supplements for each elderly person on their patient lists, an amount that may not fully compensate for the extra care needed but at least helps to reduce any lack of incentive. The GPs who care for residents of old peoples' homes (residential homes) also receive a title of Visiting Health Officer and an additional supplement. GERIATRICS AS A MEDICAL SPECIALTY
According to the Royal College of Physicians, geriatrics is "the branch of general medicine concerned with the clinical, preventive, remedial, and social aspects of health and disease in the elderly" (10). However, an increasing number of able and aggressive English and Scottish phySomers • Geriatric Care in the United Kingdom
Downloaded from https://annals.org by Tulane University user on 01/12/2019
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persons requiring medical attention is provided in geriatric beds in general hospitals. There were in 1973 some 70 000 geriatric beds in Great Britain, 14% of all hospital beds (15). Projected capital expenditures for 1974/1975 are estimated at nearly £ 2 6 million, out of a total of £ 2 1 2 million (16). Official guidelines call for 10 such beds per 1000 persons in the population over 65 (17). Typically, they are provided in departments of 100 to 300 in district general hospitals. The quality of care in the geriatric wards is frequently criticized by health authorities (18), while the public complains that it is extremely difficult—in some areas nearly impossible—to gain admission. The occupancy rate for 1973 was 9 3 % (19), with a reported waiting'list of 9000. However, with a 1974 average length of stay of only 99 days (down slightly from 102 in 1973) (20), it is clear that these beds have not been permitted to become "warehouses" for the long-term storage of ailing and homeless elderly persons. Part of the pressure for more institutional services has been relieved by the development of "geriatric day hospitals'' a new concept in hospital outpatient care that emerged in the late 1950s and has grown rapidly in recent years (21). The day hospital, usually operated by a general hospital, provides facilities for physiotherapy and occupational therapy, medical examination, nursing treatment, dentistry, chiropody, and other health-related activities. Patients spend 4 to 8 hours a day in the center, including lunch and afternoon tea and are usually brought by special transport. Inpatients also come over from their wards. In 1959, there were only 10 day hospitals in the United Kingdom; by 1971, there were 111. Between 1964 and 1974, the number of new geriatric "day patients" rose from 4800 to more than 28 000 (22). There were nearly 1 million "attendances" (patient visits), 147 per 1000 persons in the population over 65. The majority of patients using day hospitals suffer from stroke, arthritis, or "chronic brain syndrome" (23). The principal reasons for attendance are physical maintenance, rehabilitation, and relief of relatives. Although the evidence as to cost effectiveness of the day hospital is not conclusive, most studies indicate reduced inpatient admissions, shorter inpatient length of stay, lower per diem costs, or improved quality of care, or all of the above (24). Day hospitals are distinguished from "day centers," which are run by local authorities or voluntary agencies and provide social facilities, a meal, and possibly a bath and chiropody, but none of the remedial services found in the day hospital. Residential accommodations for elderly persons, as well as the physically handicapped and mentally disordered, have been required of local government authorities since the National Assistance Act of 1948, and they are colloquially identified as "Part 3 " homes, named after the relevant section of the law. Official norms call for 25 places per 1000 elderly persons by 1983 (25). They can be provided by the local authority directly or through delegation to voluntary organizations. The present "old people's homes" evolved out of the traditional public
sicians have succeeded in establishing geriatrics as a separate specialty, officially recognized as one in which hospital consultant appointments are made and, to an increasing extent, recognized as a specialty in medical education (11). The British Geriatric Society (originally called Medical Society for Care of the Elderly) was founded in 1948. By 1974, there were almost 300 geriatric specialists in the United Kingdom. Each geriatrician serves an average of 250 000 elderly people, deals with more than 100 GPs, and admits to hospital about 700 patients annually (12). He is directly responsible for about two fifths of the hospital beds occupied by elderly persons but less than one fifth of those admitted to hospital. There is an important distinction between elderly patients in general, and geriatric patients. The latter are confined to those who have a combination of physical, mental, and social problems and who require long-term care. Hence the need for special training and special interest on the part of the geriatric specialist as opposed to general surgeons, general physicians, or even specialists in internal medicine. So important are the mental problems that a subspecialty of psychogeriatrics has recently emerged—the only division of psychiatry with expanding chronic bed occupancy. Some 25 psychogeriatricians are now employed in British hospitals (13). As of 1972, 246 hospital-geriatric consultant (specialist) posts were filled, plus about 100 registrars (intermediate hospital physicians) and 300 senior-house officers (junior physicians) (14). Many positions in all three categories were unfilled, and the great majority of registrars and senior house officers were foreign-born, a source of distress to those seeking to strengthen the specialty. It is not possible to make a precise comparison with American medicine in this respect. The American Geriatric Society has about 8000 members, the majority of whom are internists. According to Dr. Ewald Busse, President, there are about 200 physicians giving full-time clinical practice to care of elderly persons*. While this is a growing field in the United States, the relatively stronger position of British geriatrics is probably a major factor in both the qualitative and quantitative development of long-term care for the elderly in Britain. INSTITUTIONAL CARE
Nursing homes, in the American sense of the term, are virtually nonexistentf. Institutional care for elderly persons requiring special medical, nursing, or rehabilitation services, or all three, is provided in hospital geriatric beds or through geriatric "day hospitals." Residential facilities for those not requiring such services are provided by local government authorities or voluntary agencies. Proprietary or commercial interests are not involved. Nonacute care for stroke patients and other elderlv * Telephone communication, 15 January 1976. t The term "nursing home" is applied in Britain, to a group of independent (non-NHS), small hospitals (185 in mid-1975) that specialize in nonemergency surgery. With the projected phasing-out of the remaining NHS pay beds (Department of Health and Social Security [DHSS] consultative paper, 11 August 1975), this group is planning to expand, partly with American and other foreigh capital, a development that has aroused great controversy. 468
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assistance or welfare homes. Some 10% to 12% of the local authority homes are still of the traditional variety—too large, outmoded, and impersonal. The newer type aim for an occupancy of 30 to 60 and a "homelike" atmosphere with numerous physical and social amenities. All meals are eaten communally. At the end of 1974, 108 000 persons 65 and over were in such homes, nearly 90% in local authority units (26). The reported average cost was £ 3 0 a week (about $65). One such home, operated by the Hammersmith Borough Council in London and visited by me in August 1975, operated at an average cost of £ 5 0 per resident per week*. Residents pay the full cost or as much as they can afford, subject to payment of a minimum weekly charge and the retention of a small amount of weekly pocket money. The sum of these two figures is equal to the basic social security retirement pension, plus a supplementary benefit if necessary. "Sheltered homes", operated by local authority housing divisions, permit a greater degree of independence. Residents^ frequently have private-bed sitting rooms, bring some of their own furniture and belongings, prepare their own breakfast, and are watched over by a "warden." Apparently there are no national norms for this category, but the Scottish Development Department suggests 25 per 1000 elderly persons t. Among the voluntary organizations, Age Concern has played an important leadership role not only in publicizing the need for nonhospital residential facilities but in establishing and operating model units. The Abbeyfield Society, a smaller group, provides places for some 4000 elderly persons in homes of 7 to 12 each, at an average cost of
Geriatric Care in the United Kingdom: An American Perspective ANNE R. SOMERS, Princeton, New Jersey
Geriatric care is a complex and challenging aspect of health care. The United Kingdom, with 1 3 . 6 % of its population over 65 years of age, compared to 1 0 . 1 % in the United States, has given special attention to this field. Characteristics of the British system include financing through the National Health Service, existence of a specialty of geriatrics, absence of "nursing homes," emphasis on home care, and avoidance of "heroics" for the terminally ill. While British life expectancy at birth is longer than that for Americans, the opposite is now true for those over 65. The British have made efforts to maximize efficiency in a high-demand, comparatively low-resource context. But there are limits to which professional dedication and patient manipulation can be pushed. Some new policy directions— primarily aimed at prevention and other methods of reducing demand, other than reimposing financial barriers— may have to be explored.
GERIATRIC CARE is probably the most complex, neglected,
and challenging aspect of health care facing the developed countries during the last quarter of the twentieth century. In all these countries, both the number and proportion of elderly persons continue to rise steadily. In the United Kingdom, where the retirement age for women is 60 and for men is 65, pensioners constituted nearly 17% of the population by 1973 (1,*), and 13.6% of the population was 65 and older (Table 1). Although few, if any, other countries have reached this extreme (the United States ratio for 1973 was 10.1%), and the proportions continue to vary considerably, the ratios are now rising throughout the developed world. Particularly dramatic is the rise in numbers and proportion of those older than 75 and even 85 years of age. Only in case of a major war, depression, or some totally unforeseen catastrophe is this trend likely to be reversed. Every advance in the treatment of cancer, heart disease, * Official statistics are sometimes confined to England and Wales, sometimes to Great Britain (England, Wales, and Scotland), and sometimes applied to the United Kingdom (Great Britain and Northern Ireland). Wherever available, data used in this article are for United Kingdom. However, slight differences do not affect the broad trends and issues discussed here. • From the Departments of Community Medicine and Family Practice, College of Medicine and Dentistry of New Jersey—Rutgers Medical School, Piscataway, New Jersey.
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stroke, diabetes, and arthritis, and in the salvage and rehabilitation of victims of trauma will increase the need for geriatric care. Every month added to the life expectancy of those persons 65 and over means a higher proportion of those in the most dependent age groups—the 75 and over and 85 and over groups. At the same time, the sharply reduced birthrates mean fewer employed workers to support elderly persons. To compound the problem, relatively few physicians, health planners, and even public health authorities are professionally engaged in, or committed to, long-term care of elderly persons. In most countries, pressure groups working for health-care legislation and appropriations are overwhelmingly oriented to acute care. Nevertheless, the inexorable pincer movement of growing proportions of elderly persons, pressing on limited health-care resources, is forcing all nations, regardless of political philosophy, to face up to this problem. My report on geriatric care in the United Kingdom—an aging society trying valiantly to cope with the medical, ethical, political, and economic implications—is based on four visits during the past 2 decades, the most recent in August 1975. I suggest a number of trends and issues that will become increasingly relevant to the United States' experience as our population continues to age and as limits on our national resources become more apparent ( 2 ) . Major Characteristics In 1973, the crude birthrate in the United Kingdom was 13.9 per 1000 population (Table 1 ) . The average life expectancy at birth was 69.0 years for men and 75.2 for women. The average life expectancy at age 65 was 12.2 years for men and 16.1 for women. There were 7.6 million persons 65 and older. Those older than 75 numbered 2.7 million and accounted for 4.8% of the population, and those older than 85 numbered 0.5 million and 0.9% of the population. Projections for 1981 anticipate that retired persons will constitute 17.4% of the total population, while those over 75 will constitute 5.5% ( 3 ) . In 1973, there were 27.9 elderly per 100 persons of working age, compared with only 14.5 in 1931. The projection for 1981 is 28.3 elderly per 100 persons of working age. The differences between the United Kingdom and the United States in health care for elderly persons are more Annals of Internal Medicine 84:466-476, 1976
striking than in any other aspect of health care. These differences are discussed below. FINANCING
The existence of the National Health Service (NHS), which provides complete and nearly free (at the time of delivery) health and medical care to all ages, for all conditions, and with no limits on duration, means that there are no special problems of financing care for elderly persons as opposed to the general population, or long-term care as opposed to acute care. The main source of finance is the central government, which, directly or indirectly through grants to local authorities, in 1974 provided about 8 1 % of total health and social services costs ( 4 ) . The balance came from local authority rates (local property taxes), 7.25%; NHS contributions (payroll taxes), 6.50%; payments by users, 4.75%; other, 0.50%. In 1975, the central government's share is expected to rise by another 10 percentage points. The consolidated NHS budget is thus clearly dominant, providing a more powerful instrument for controlling both overall costs and the allocation of resources within the system than is available in most democratic countries, including the United States. In practice, it is often alleged that acute hospital services receive a disproportionate share of national health resources, both manpower and financial. The hospitals do receive the major share of the health and social services dollar, approximately half in 1973 and 1974 ( 5 ) . But there are no built-in statutory biases in this direction. Rather, on the contrary, Dr. John Brotherston, Chief Medical Officer of the Scottish Home and Health Department and one of the leading spokesmen for the United Kingdom in health matters, has said: Nothing will really flow smoothly in the Health Service until we reach an adequate stage of provision in our society for the elderly. This means many things apart from hospital beds. . . . A major phenomenon of the elderly vis-a-vis the Health Service is underdemand not overdemand [6]. Funds are now in seriously short supply for the Health Service as a whole (see below), but there is a continuing effort to protect and even enlarge somewhat the proportion of resources devoted to geriatric care. When increasing financial stringencies dictated a general cutback in projected capital expenditures for 1974/1975, there was no reduction in the allocation for geriatric services ( 7 ) . GENERAL PRACTICE
Britain's more than 25 000 general practitioners (GPs) constitute a much higher ratio of GPs to all practicing physicians than in the United States. The percentages for 1973 were 45 and 18, respectively ( 8 ) . (If one adds United States' specialists in internal medicine to those in general practice, the percentage rises to 33.) The heavy emphasis on primary care (9) and the persistence of a strong, officially encouraged GP service within the reorganized NHS permit greater continuity than is usual with specialty services, more attention to social and community factors, and generally provide an important
Table 1. Elderly Population: Numbers, Proportions, Life Expectancy, and Death Rates, 1973*
United Kingdom
United States
Total population, millions 56.0 210.4 Birthrate, crude (per 1000 population) 13.9 14.9 Deathrate, crude (per 1000 population) 12.0 9.4 Deathrate by age and sexj (per 1000 population in specified group) 65-74 53.8 (M) 27.8 (F) 48.2 (M J) 25.3 (FJ) 75-84 119.8 (M) 78.2(F) 101.2 (MJ) 65.8 (Ft) 85+ 248.0 (M) 197.3 (F) 196.0 (Mt) 162.0 (Ft) Life expectancy at birth, years§ Male 69.0|| 67.5 Female 75.2|| 75.1 Life expectancy at 65, years§ Male 12.2|| 13.1 16.1|| 17.0 Female Population 65+ Total number, millions 7.6 21.3 % of total 13.6 10.1 Population 75+ Total number, millions 2.7 8.1 % of total 4.8 3.8 Population 85+ Total number, millions 0.5 1.6 % of total 0.9 0.8 * Sources: United Kingdom: Central Statistical Office, Annual Abstract of Statistics 1974, Her Majesty's Stationary Office (HMSO), pp. 13, 30, 45; Central Statistical Office, Social Trends, no. 5, 1974, HMSO pp. 75, 90; Department of Health and Social Security, Health and Personal Social Services Statistics for England (with summary tables for Great Britain), 1974, HMSO, pp. 11, 15. United States: Department of Commerce, Bureau of Census, Statistical Abstract 1974, p. 5; Bureau of Census, Population Estimates and Projections, ser. P-25, no. 519, April 1974, Table 1, p. 12; U.S. Department of Health, Education and Welfare, National Center for Health Statistics, Vital Statistics of U.S., Life Tables 1973, vol. 11-sect. 5; National Center for Health Statistics, Monthly Vital Statistics Report, 10 February 1974, vol. 23, no. 11, suppl. 2, p. 7; Monthly Vital Statistics Report, 30 May 1975, vol. 23, no. 13, p. 1. t In 1972. t Excludes non residents of the U.S. Based on 50% sample of deaths. M = male; F = female. § 1971-1973. || England and Wales.
base for the supportive type of care so frequently needed by elderly persons. Moreover, GPs receive small supplements for each elderly person on their patient lists, an amount that may not fully compensate for the extra care needed but at least helps to reduce any lack of incentive. The GPs who care for residents of old peoples' homes (residential homes) also receive a title of Visiting Health Officer and an additional supplement. GERIATRICS AS A MEDICAL SPECIALTY
According to the Royal College of Physicians, geriatrics is "the branch of general medicine concerned with the clinical, preventive, remedial, and social aspects of health and disease in the elderly" (10). However, an increasing number of able and aggressive English and Scottish phySomers • Geriatric Care in the United Kingdom
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persons requiring medical attention is provided in geriatric beds in general hospitals. There were in 1973 some 70 000 geriatric beds in Great Britain, 14% of all hospital beds (15). Projected capital expenditures for 1974/1975 are estimated at nearly £ 2 6 million, out of a total of £ 2 1 2 million (16). Official guidelines call for 10 such beds per 1000 persons in the population over 65 (17). Typically, they are provided in departments of 100 to 300 in district general hospitals. The quality of care in the geriatric wards is frequently criticized by health authorities (18), while the public complains that it is extremely difficult—in some areas nearly impossible—to gain admission. The occupancy rate for 1973 was 9 3 % (19), with a reported waiting'list of 9000. However, with a 1974 average length of stay of only 99 days (down slightly from 102 in 1973) (20), it is clear that these beds have not been permitted to become "warehouses" for the long-term storage of ailing and homeless elderly persons. Part of the pressure for more institutional services has been relieved by the development of "geriatric day hospitals'' a new concept in hospital outpatient care that emerged in the late 1950s and has grown rapidly in recent years (21). The day hospital, usually operated by a general hospital, provides facilities for physiotherapy and occupational therapy, medical examination, nursing treatment, dentistry, chiropody, and other health-related activities. Patients spend 4 to 8 hours a day in the center, including lunch and afternoon tea and are usually brought by special transport. Inpatients also come over from their wards. In 1959, there were only 10 day hospitals in the United Kingdom; by 1971, there were 111. Between 1964 and 1974, the number of new geriatric "day patients" rose from 4800 to more than 28 000 (22). There were nearly 1 million "attendances" (patient visits), 147 per 1000 persons in the population over 65. The majority of patients using day hospitals suffer from stroke, arthritis, or "chronic brain syndrome" (23). The principal reasons for attendance are physical maintenance, rehabilitation, and relief of relatives. Although the evidence as to cost effectiveness of the day hospital is not conclusive, most studies indicate reduced inpatient admissions, shorter inpatient length of stay, lower per diem costs, or improved quality of care, or all of the above (24). Day hospitals are distinguished from "day centers," which are run by local authorities or voluntary agencies and provide social facilities, a meal, and possibly a bath and chiropody, but none of the remedial services found in the day hospital. Residential accommodations for elderly persons, as well as the physically handicapped and mentally disordered, have been required of local government authorities since the National Assistance Act of 1948, and they are colloquially identified as "Part 3 " homes, named after the relevant section of the law. Official norms call for 25 places per 1000 elderly persons by 1983 (25). They can be provided by the local authority directly or through delegation to voluntary organizations. The present "old people's homes" evolved out of the traditional public
sicians have succeeded in establishing geriatrics as a separate specialty, officially recognized as one in which hospital consultant appointments are made and, to an increasing extent, recognized as a specialty in medical education (11). The British Geriatric Society (originally called Medical Society for Care of the Elderly) was founded in 1948. By 1974, there were almost 300 geriatric specialists in the United Kingdom. Each geriatrician serves an average of 250 000 elderly people, deals with more than 100 GPs, and admits to hospital about 700 patients annually (12). He is directly responsible for about two fifths of the hospital beds occupied by elderly persons but less than one fifth of those admitted to hospital. There is an important distinction between elderly patients in general, and geriatric patients. The latter are confined to those who have a combination of physical, mental, and social problems and who require long-term care. Hence the need for special training and special interest on the part of the geriatric specialist as opposed to general surgeons, general physicians, or even specialists in internal medicine. So important are the mental problems that a subspecialty of psychogeriatrics has recently emerged—the only division of psychiatry with expanding chronic bed occupancy. Some 25 psychogeriatricians are now employed in British hospitals (13). As of 1972, 246 hospital-geriatric consultant (specialist) posts were filled, plus about 100 registrars (intermediate hospital physicians) and 300 senior-house officers (junior physicians) (14). Many positions in all three categories were unfilled, and the great majority of registrars and senior house officers were foreign-born, a source of distress to those seeking to strengthen the specialty. It is not possible to make a precise comparison with American medicine in this respect. The American Geriatric Society has about 8000 members, the majority of whom are internists. According to Dr. Ewald Busse, President, there are about 200 physicians giving full-time clinical practice to care of elderly persons*. While this is a growing field in the United States, the relatively stronger position of British geriatrics is probably a major factor in both the qualitative and quantitative development of long-term care for the elderly in Britain. INSTITUTIONAL CARE
Nursing homes, in the American sense of the term, are virtually nonexistentf. Institutional care for elderly persons requiring special medical, nursing, or rehabilitation services, or all three, is provided in hospital geriatric beds or through geriatric "day hospitals." Residential facilities for those not requiring such services are provided by local government authorities or voluntary agencies. Proprietary or commercial interests are not involved. Nonacute care for stroke patients and other elderlv * Telephone communication, 15 January 1976. t The term "nursing home" is applied in Britain, to a group of independent (non-NHS), small hospitals (185 in mid-1975) that specialize in nonemergency surgery. With the projected phasing-out of the remaining NHS pay beds (Department of Health and Social Security [DHSS] consultative paper, 11 August 1975), this group is planning to expand, partly with American and other foreigh capital, a development that has aroused great controversy. 468
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assistance or welfare homes. Some 10% to 12% of the local authority homes are still of the traditional variety—too large, outmoded, and impersonal. The newer type aim for an occupancy of 30 to 60 and a "homelike" atmosphere with numerous physical and social amenities. All meals are eaten communally. At the end of 1974, 108 000 persons 65 and over were in such homes, nearly 90% in local authority units (26). The reported average cost was £ 3 0 a week (about $65). One such home, operated by the Hammersmith Borough Council in London and visited by me in August 1975, operated at an average cost of £ 5 0 per resident per week*. Residents pay the full cost or as much as they can afford, subject to payment of a minimum weekly charge and the retention of a small amount of weekly pocket money. The sum of these two figures is equal to the basic social security retirement pension, plus a supplementary benefit if necessary. "Sheltered homes", operated by local authority housing divisions, permit a greater degree of independence. Residents^ frequently have private-bed sitting rooms, bring some of their own furniture and belongings, prepare their own breakfast, and are watched over by a "warden." Apparently there are no national norms for this category, but the Scottish Development Department suggests 25 per 1000 elderly persons t. Among the voluntary organizations, Age Concern has played an important leadership role not only in publicizing the need for nonhospital residential facilities but in establishing and operating model units. The Abbeyfield Society, a smaller group, provides places for some 4000 elderly persons in homes of 7 to 12 each, at an average cost of
