The politics of a cradle to grave NHS

BMJ 1995; 310 doi: (Published 18 March 1995) Cite this as: BMJ 1995;310:692

National Health Service provision from “cradle to grave” has been a popular commitment by British politicians, from Winston Churchill onwards, for the past 50 years. It is also a definition from which they are reluctant to retreat. The modern version, cited by health minister John Bowis last week, is that state health care “starts before the cradle, but cannot go beyond the grave.” The point at issue nowadays is how far short of the grave should it stop?

Mr Bowis was giving evidence to the Commons health committee after the publication of new guidance on NHS responsibility for continuing care (4 March, p 550). The guidance is intended to deflect criticism that the NHS is defaulting in its duty of long term care, particularly of very elderly people.

In that respect the document is something of a landmark. It admits current shortcomings and also commands the health service to reinvest in a “full range” of long term care facilities. These can now be expected to absorb a significant share of NHS growth in coming years. The guidance also clarifies who will be entitled to continuing care: here the new rule of thumb is that the patient should require consultant supervision at least weekly.

In reasserting NHS responsibilities for long term care ministers deny that there has been any policy shift in the boundary between health care and social care which has existed since 1948—though demography dictates that far more people now come into the latter category. Since NHS care is free and social care is means tested it matters to patients and their families where they end up. Should people needing nursing supervision 24 hours a day get it on the NHS? Last week the MPs seemed to think so, but the minister said not unless they also needed medical care. The new guidance probably takes the NHS as far as it is obliged to go, short of becoming a nursing home service. It still falls short, however, of what taxpayers expect.

It is the discrepancy between free and means tested care that the political parties hesitate to address. The health committee now has the opportunity to give a lead. The most clear headed statement so far came from Labour's social justice commission last year. It conceded that the NHS cannot be expected to provide care and help with everyday activities and that means testing is reasonable even at the cost of the next generation's inheritance. Not surprisingly, that finding is quoted more often by Tories than by Labour.

Meanwhile the prime minister, John Major, wants new Tory thinking on the issue in time for the next election. Early ideas point to easing the impact of means tested care for elderly people, perhaps by leaving the value of their home out of the assessment. If the state does move to protect inheritances in this way it could, after all, be said to be offering care beyond the grave.

And what about the cradle? As it happens, a simultaneous meeting at the Commons was gloomily contemplating the government's U turn on the advertising of baby milk. Having proposed a ban on promoting infant formulas, the government last month changed its mind and allowed the continuing promotion of formulas in NHS premises.

Midwives, paediatricians, and breast feeding campaigners met Labour front bench spokesman Martyn Jones to plan a counterattack. The government remains deaf to persuasion, but the campaigners did not come away empty handed: it is now Labour party policy that baby milk should not be promoted.—JACK WARDEN, BMJ

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