Home from home: residents' opinions of nursing homes and long-stay wards

Age and Ageing,  March, 1998  by Paul F.D. Higgs,  Lea D. MacDonald,   MacDonald John S.,  Michael C. Ward

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Introduction

The idea of `home' has become a central issue in discussions about community care policies for older people. The notion encapsulates many positive elements such as independence, security, choice and privacy. This contrasts with the notion of `institution', where many of these elements appear to be difficult to find or are non-existent. However, the meaning of `home' is more complicated than much writing about community care would indicate [1].

The complex nature of the debate is illustrated by those who point out the varied social processes going on in residential homes [2] and those who note that even the domestic household has the potential to be an institution [3]. This issue becomes more complicated in many highly dependent older people, for whom `home' has become equated with the home-like setting of a nursing home [4]. This reorientation of the location of `home' is justified on the grounds that it recreates many of the features of the resident's own home and therefore provides an acceptable alternative to institutional care [5].

By contrast, community care policy does not seem able to embrace the legacy of National Health Service (NHS) long-stay wards. These hospital-based health care resources are seen as embodying most if not all the negative features of the `institution' [6, 7].

Background

In the UK, the provision of institutional care to highly dependent older people has changed dramatically in the 1980s and 1990s [4, 8-10]. The relaxing by the Government of rules affecting the funding of places in privately owned nursing homes in 1984 led to a marked increase in the numbers of homes and beds. Similarly, the reform of the NHS in 1991 created circumstances in which the number of hospital beds available for the long-stay care rapidly contracted. The consequence of these two processes became apparent with the introduction of a third piece of Government policy--community care--in 1993.

Before the NHS and Community Care Act of 1990, local authorities had a limited statutory responsibility to ensure the provision of services for people in their locality, with the result that there was widespread variation in what services were provided and to whom. The Act, in contrast, gave them explicit responsibilities for the assessment and arrangement of appropriate services based on the identification of need. Unfortunately, the effect of these changes was to point policy in different directions at the same time. The desire to allow people the choice to live at home where possible was sometimes in contradiction with other objectives such as controlling financial resources. The assessment procedure that was supposed to lead to needs being identified and appropriate services provided has often become a rationing device [11].

While there is debate about the effect of these changes on users and providers [12], there has been implicit acceptance that the move away from the institution has been a positive one. The policy of community care has had a long gestation, becoming formalized in the desire to close the large Victorian-era asylums in the 1960s [13]. Representations of `institutionalization' in such films as `One Flew Over the Cuckoo's Nest' provided popular support for the arguments of Townsend [14] and Goffman [15]. Some empirical research has also supported the contention that institutional--and particularly hospital-based--long-stay facilities are inimical to the independence and self-worth of patients [6]. The processes whereby such institutionalization occurs are thought to be located in the position of the patients and the interactions that occur between them and the staff. The asymmetry of power and the effects of block living are said to produce a compliant and unassertive population.

This common-sense conclusion, along with the legacy of a previous era of punitive poorhouses, has left important questions about the nature of institutional living largely unresearched. Instead, we have an implicit ranking of options that owes as much to social principles (such as individual autonomy) as it does to practical considerations. In his review of chronic illness, Bury makes the point that sociologists have put too much emphasis on the nature of the difficulties and disadvantages that accompany such conditions rather than studying the responses and positive actions of those affected [16]. Perhaps the same issue applies to highly physically dependent older people.

The most striking feature of most elderly people in institutional care is their extremely high levels of physical dependency [8]: most routine activities of daily living are beyond their capacities. Often the only task that they are able to undertake independently is eating [10]. While levels of physical dependency are slightly lower in nursing homes than in long-stay wards [9], many residents are dependent on others for self-care.

In an earlier report [17] we argued that these constraints acted as the real basis for long-stay NHS patients' assessments of satisfaction with their care. Given that residents of nursing homes may comprise a very similar group of elderly patients, we would anticipate similar assessments.