Mohammed T. Abou-Saleh

COMMUNITY CARE: THE BACKGROUND 673This shrinkage in the role of the NHS in continuing care andrehabilitation and the barrier to effective services created by theartificial distinction between health and social care 19 has beenwidely criticized 18,20,21 . There is growing consensus that things willonly get properly ‘‘joined up’’ when the funding rules for healthand social care are harmonized and the nettle of the cost of ourageing population is properly grasped by the politicians. TheRoyal Commission 23 set up by the government recommended thatall care (as opposed to board and lodging and general living) costsshould be publicly funded from general taxation, eliciting littleresponse as yet from a government still wedded to reducingtaxation and maintaining means testing. The earlier JosephRowntree Enquiry 22 reached similar conclusions on the carecosts but favoured a hypothecated, prospective, compulsoryhealth/social care insurance levied on payrolls as a way ofenabling each generation to fund its own care in old age. If thegovernment finally accepts one or other of these options, themillennium could usher in an exciting new phase in communitycare.REFERENCES1. Arie T, Isaacs AD. The development of psychiatric services for theelderly in Britain. In Isaacs AD, Post F, eds, Studies in GeriatricPsychiatry. Chichester: Wiley, 1978: 241–61.2. Department of Health. The New NHS: Modern and Dependable.London: HMSO, 1997.3. Department of Health. Partnership in Action. London: HMSO, 1998.4. Department of Health. Health Act, 1999. London: The StationeryOffice, 1999.5. House of Commons. Community Care: Carers. Social Services SelectCommittee Report. London: HMSO, 1990.6. Department of Health. Caring About Carers: a National Strategy forCarers. London: DOH, 1999.7. Rosenvinge HP, Dawson J, Guion J. Sitting service for the elderlyconfused. Health Trends 1986; 18: 47.8. Godber C. Kinloss Court: an experiment in sheltered housing andcollaboration. Social Work Service 1978; 15: 42–5.9. Lewis RJ. Flying Warden answers 80-year-old’s Monday call. ModGeriat 1979; 3: 26–33.10. Tinker A. An Evaluation of Very Sheltered Housing. London: HMSO,1989.11. Challis D, Chesterman J, Darton R, Trasker K. Case management inthe care of the aged: the provision in difficult care settings. In BournatG et al., eds, Community Care: a Reader. Milton Keynes: Macmillan/Open University, 1993.12. DHSS. Resource and Single Payment Amendment Regulations.Regulation 9, Supplementary Benefit Requirement. Circular 7/143,1980.13. Audit Commission. Making a Reality of Community Care. London:HMSO, 1986.14. Davies B, Challis D. Matching Resources to Needs in CommunityCare. Aldershot: Gower, 1986.15. Challis D, Darton R, Johnson L et al. Case Management and HealthCare of Older People: The Darlington Community Care Project.Aldershot: Arena, 1995.16. Griffiths R. Community Care: Agenda for Action. London: HMSO,1988.17. Secretaries of State for Health, Social Security, Wales and Scotland.Caring for People. Cm 849. London: HMSO, 1989.18. Calviou A, Hockley J, Schofield. An Evaluation of Marlow EPICS.South Buckinghamshire NHS Trust and Buckingham CountyCouncil Social Services, 1997.19. Department of Health. NHS Responsibilities for Meeting ContinuingHealth Care Needs. HSG(95)8, LAC(95)5. London: HMSO, 1995.20. House of Commons. NHS Responsibility for Meeting ContinuingHealth Care Needs. Health Select Committee, Session 1995–96, FirstReport, Volume 1.21. Audit Commission. The Coming of Age: Improving Care Services forOlder People. London: HMSO, 1997.22. Joseph Rowntree Foundation Enquiry. Meeting the Cost ofContinuing Care: Report and Recommendations. York: JosephRowntree Foundation, 1996.23. Royal Commission on Long Term Care. With Respect to Old Age:Long-term Care—Rights and Responsibilities. Cm 4192, 1,11/1,11/3.London: The Stationery Office, 1999.24. National Health Service and Community Care Act. London: HMSO,1990.Health Care of the Elderly: the Nottingham ModelTom ArieUniversity of Nottingham, UKThe Nottingham University Department of Health Care of theElderly was designed as a collaboration in which physicians,psychiatrists, gerontologists and other health workers are equalpartners. It is neither a department of psychiatry with geriatricianson its staff, nor vice versa: it is an integrated joint enterprise. Itwas the model for 20 years. Following the retirement of thefoundation professor, the university restructured the Departmentbut the service ethos continues, as does the joint teachingprogramme. Described here is the Joint Department as it was,and as it became well known, from 1977 to 1997.Diagrams may put things best. Figure 1 shows the structure,and makes the important point that although the department isunified, its services are differentiated. Physicians do medicalwork, psychiatrists psychiatry. There is cross-training, and aboveall constant formal and informal collaboration and support,both in the hospital and in assessing and keeping people going athome.The aim is to make easily available what patients need. Thus, apatient of the psychiatric service has as easy access to physiciansand their facilities as if he/she were their patient, and vice versa. Inthis way it is possible to offer responses that match the pattern ofmorbidity characteristic of the very old, namely that it is mixedand often unpredictably changeable. There are no demarcationdisputes, and there is no waiting list. Things were very differentwhen the department was established in 1977.INTEGRATIONThe services are based in two general teaching hospitals. InUniversity Hospital the professorial unit has a medical and apsychiatric ward side-by-side. There are close links with the rest ofthe health specialties and professions, both inside and outside thehospital. For instance, trainees rotate from general medicine,