NHS faces timebomb: An ombudsman's ruling has serious implications for the care of the elderly

JACK will be 90 years old next month and suffers from a lung disorder which leaves him short of breath. In November last year his wife Louise, 89, suffered a second stroke which paralysed her and left her partially sighted and very confused. A locum doctor was called to their remote cottage in Herefordshire, and decided that she was better at home than in hospital.

Their daughter, who is unemployed and lives in Bristol, paid for 48 hours of private nursing, but for almost a week Jack struggled to care for his wife alone.

Then another doctor called and said Louise should be admitted to hospital immediately. For three weeks Jack visited her every day, a 16-mile round trip by taxi, which he paid for from his pension. Then the hospital said Louise no longer needed medical care and should really be at home or in a nursing home. Jack and his daughter, who visits her parents most weekends, had no option. Louise came home.

Jack does everything for her: he washes and dresses her, lifts her in and out of bed, takes her to the lavatory, and is on call every night because she will wake at least two or three times. He does all the household chores. He cannot leave Louise alone. Private care - even for a respite period for Jack - is beyond the family's means. The health service cannot help further unless Louise gets worse, and social services can only provide a home help for two hours each week.

'It isn't that he can't cope but he does need something, some kind of support,' Jack's daughter says. 'It will just go on and on until my father collapses from exhaustion.'

The chronically sick and the 6.8 million people who care for them are not popular media fodder. But a ruling by the NHS Commissioner - the health service ombudsman - last week put them under the spotlight, and set ticking a 'financial timebomb' for the NHS. He ruled that the service had a duty to provide long-term nursing care for a profoundly brain-damaged man.

Leeds Health Authority and Leeds General Infirmary were found guilty of a 'failure in service' for discharging a man suffering major neurological damage, who was immobile and doubly incontinent, to a private nursing home, for which his wife had to find pounds 6,000 a year in top-up fees, even though the family was on income support.

The ombudsman, William Reid, took the unprecedented step of issuing a special report on the case because of 'the issues of general public interest it raises'. Philip Hunt, director of the National Association of Health Authorities and Trusts, said: 'If health authorities are to have a duty to provide or pay for continuing care, the potential costs, depending on numbers, are absolutely enormous.'

It was an extreme case but it has implications for hundreds of thousands of people, disabled by disease or age and in need of long-term nursing or continuing care rather than medical care. Although no precise figures are available, the number of long-term-care NHS beds has fallen dramatically since the early 1980s, when social security payments became available for private nursing homes. Many health authorities bailed out of the long-term-care business, discharging people into the private homes which sprang up everywhere.

Then in April last year, the NHS and Community Care Act 1990 came into force, and local authorities took over the budget for publicly financed and residential care.

According to Dr Sylvia McLauchlin, director general of the Stroke Association, this has meant thousands of patients falling into a gap 'between' health services and social services. 'It is a matter of definition, of what exactly is a hospital patient,' she says.

Care in the community has raised the question of who should be responsible for this group but few health or local authorities have got to grips with the answer. No one has wanted to take on the responsibility - or the cost - and it is left to the families, Dr McLauchlin says.

As a result, the voluntary and charity organisations say, people who in many cases are themselves elderly and in poor health are being forced into impossible situations, or into poverty, as they try to care for, or find nursing home fees for, elderly relatives. Life savings are being raided, houses and personal belongings sold, and the concept of 'leaving something for your children' - a relatively new idea for many - vanishing fast.

Gill Pitkeathley, director of the Carers' National Association, says: 'The majority of the population assume that as long as they pay their taxes and National Insurance contributions they will get the care they need when they need it. It comes as a terrible shock to them to find it isn't there.'

She has welcomed the NHS ombudsman's decision because at long last it will force the debate about long-term care and who pays for it into the open.

'If all social care is going to be means-tested, and large numbers of people are going to have to provide for nursing care when they are infirm, then at least they should know about it, and be warned to provide for it. But those who need care now, who haven't had time to provide for care in the future, also have rights.'

Last week's ruling offers a glimmer of hope for them, and an ominous message to the Government and the NHS.

(Photograph omitted)