Focus: Westminster: The lottery of long term care

BMJ 1994; 308 doi: (Published 19 March 1994) Cite this as: BMJ 1994;308:742
  1. J Warden

    Britain last week acquired a minister for the family. The unofficial title was bestowed on health secretary Virginia Bottomley. It signifies her new responsibilities for coordinating Cabinet policies concerning the family. This seems a natural extension of the health secretary's statutory functions in respect of adoption, child law, and the registration of births, marriages, and deaths. And if Mrs Bottomley's ministerial duties now extend beyond the confines of health care, the move is even more appropriate in relation to those at the top of the family tree - the growing population of the very elderly, whose care is also fast becoming beyond the scope of the NHS.

    On the same day that Mrs Bottomley was ordained into her new role MPs on the ombudsman select committee were agonising over the very issue of long term care of elderly patients, prompted by a recent ruling by the ombudsman. A patient who was severely brain damaged by a stroke was discharged after 18 months in Leeds general infirmary to a nursing home, for which his family had to pay.

    The ombudsman ruled that the NHS should have continued to provide care free of charge. The NHS accepted the ruling. The man was reinstated to its care and his wife was reimbursed the nursing home fees she had incurred. The ombudsman, William Reid, used the case to focus public attention on NHS responsibility for patients with chronic conditions.

    Seeking clarification the select committee examined Sir Duncan Nichol, chief executive of the NHS, on what was his last day in post before he becomes professor of international health care at Manchester University. If this means Sir Duncan crossing the divide between theory and practice, he left MPs with the impression that the same thing is happening to NHS policy on long term care. His message was that where the NHS accepts a medical assessment that continuing care is needed there is no ambiguity and it discharges that responsibility within the limits of its resources and without seeking payment.

    The Community Care Act had not vitiated NHS responsibility, he said, though it introduced a joint assessment process led by the social services, with the option for placement in a nursing home for which there might be a means test. “That is the system we are asked to administer,” he said. “One cannot guarantee that the relatives will welcome the recommended course of action.”

    Against this, the NHS has repeatedly affirmed its legal obligation to provide nursing care for those who cannot or do not wish to pay for it. The most recent parliamentary answer states that the NHS has “a responsibility to provide long term care for people who need it for reasons of ill health.” Such statements are dissembling rather than reassuring.

    The reality is that for 15 years long term care has progressively moved into the private sector. Fear of ending up in an NHS geriatric ward meant more customers for private nursing homes. Public funding followed them, with state support for people in residential and nursing homes rising rapidly from a mere pounds sterling 10m a year to a staggering pounds sterling1.6 billion. It is to stem that open ended commitment that the support budget is being transferred to local authorities under new community care arrangements.

    The early signs are of improved hospital discharge of the elderly - though with concomitant damage to the principle of free health care. Patients are being put under pressure to move into private nursing homes which bleed away their lifetime savings if they have capital of more than pounds sterling3000. There are a few NHS nursing homes, but many health authorities no longer purchase long term care. Geriatricians who don't want their acute beds blocked are themselves under pressure to recommend discharge to a private nursing home, leaving others to work out who pays. Patients are seldom dealt with frankly.

    Government policy is more pragmatic than principled. For the million patients currently on the NHS waiting list the only question is when they will get the free treatment they need. For the million elderly people over 80 it is already a question of whether they will get the free care they need.

    For the NHS to pretend that it can cope is no longer tenable. It looks an ideal subject for a minister for the family to tackle.

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