The care of the elderly has always been controversial.

Thomas Paine, in 1791, wrote: 'When, in countries that are called civilized, we see age going to the workhouse and youth to the gallows, something must be wrong in the system of government.'Today's nursing homes are almost certainly an improvement upon the work-house, but they come at a cost: upwards of £325 per week.

If the care is provided by the NHS, it is free to the patient.

If the care is provided by the social services department it is means tested, and either paid by the patient or (if his or her means are insufficient) by the local authority.The community care reforms were aimed at reducing the spiralling cost of such care, by encouraging the elderly to remain in their homes for as long as possible.

Unfortunately this trend was exploited by a number of NHS trusts, who simultaneously reduced their geriatric long stay wards; thereby shifting the cost of caring for the elderly from the NHS to the social services.The consequences of this were emphasised in a highly critical report by the NHS Ombudsman.

The report was followed by adverse press coverage including a Panorama programme, showing a number of exceedingly frail elderly people who had apparently been discharged from hospital in very distressing circumstances.The government has responded by issuing guidance on 'NHS responsibilities for meeting continuing health care needs [HC(95)8 / LAC(95)5]'.

The guidance re-asserts the importance of the health service as a provider of continuing care for the elderly, in partnership with social service departments.

It confirms that NHS patients cannot be discharged into private nursing or residential care homes against their wishes if it means that they will be responsible for the home's charges.

Where a patient refuses to be discharged in such circumstances the guidance states that 'it may be necessary for the hospital, in consultation with the health authority, social services department and, where necessary housing authority, to implement discharge to the patient's home or alternative accommodation, with a package of health and social care within the options and resources available'.The guidance has created a review procedure for contested hospital discharges, such that the 'patient or his or her family and any carer have the right to ask the health authority, ....

to review the decision which has been made about eligibility for NHS continuing inpatient care', and that the NHS should respond to this within two weeks, and in general refer the question to 'an independent panel who will consider the case and make a recommendation to the health authority'.The NHS/social services divide will become an increasingly controversial subject, as the cost (and quality) of elderly care services rise.

The issue is doubly contentious as it involves the question of society's treatment of the elderly; whether it is the role of the extended family to provide such care or whether society copes better by isolating and institutionalising the frail elderly.