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NHS needs plan for all acute, rehabilitative, and long stay care

BMJ 2001; 322 doi: (Published 24 March 2001) Cite this as: BMJ 2001;322:735
  1. Peter H Millard (peter.millard{at}, emeritus professor of geriatrics
  1. St George's Hospital Medical School, London 12 Cornwall Road, Cheam, Sutton, Surrey SM2 6DR

    EDITOR—Everyone sees the world from where he or she stands. Seeing the NHS through American eyes, Leatherman and Blackman believe that the service has fundamentally “got it right.”1 Yet, fundamentally, the NHS no longer exists, for the 1990 Community Care Act changed the legislation in 1948 that underpinned it.

    The NHS, operational research, and rehabilitation were three healthcare legacies of the second world war.2 The operational plan that underpinned the NHS transferred wards full of bedbound patients to hospital care from local government care. From that unlikely beginning the specialty of geriatrics began.3 If the hospital responsibility for providing a free long stay service is taken away then the driving, rehabilitative force that underpinned the NHS ceases to exist.

    During the Thatcher years a cruel trick was played on pensioners, as well as on entrepreneurs. Using the rhetoric of markets, choice, and quality, the government transferred responsibility for long stay care for sick and disabled people from the hospitals to the private and voluntary sectors. Thousands of hospital beds were closed; consultants in geriatric medicine took on general medical duties; general physicians became specialist physicians; waiting lists disappeared; everyone was happy—except, that is, pensioners paying for their own care.

    In April 1993 the government closed the open door. Now, we have the worst of all deals. The NHS no longer exists; pensioners are being told that they should insure for their long term care; nursing is being redefined to exclude personal care (washing, dressing, feeding, toileting); waiting lists are growing; acute hospital beds are full; and the whole pack of cards is collapsing.

    To make matters worse, the generation that fought in the second world war is now in need of care. Yet “new Labour” is moving inexorably away from Beveridge towards a Bismarck model of care for older people4; soon, no doubt, everyone will be means tested for long term care. What is needed now, if a long term vision for health and social care in the United Kingdom is to be achieved, is a coherent, equitable, and efficient plan for all citizens' acute, rehabilitative and long stay care.


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