Allyson Pollock on the NHS

Keaney Michael Michael.Keaney at
Wed Sep 25 07:46:36 MDT 2002

The threat to the NHS
By Allyson Pollock
Socialist Campaign Group News, July 2002 (No. 178)

The NHS is one our most prized and valuable institutions. However, decades of underfunding have seen its services decline and staff and patients come under growing pressure. Increasingly in the NHS, some services are available only on the basis of ability to pay. The principle of risk pooling underpinning a universal health service has been breached both through the erosion of entitlements and benefits and the increasing privatisation of the delivery system and loss of services. The NHS now faces new threats.

The concordat with the private sector

The NHS Concordat sees a greater role for the private sector. Already companies such as Norwich Union finance, own and operate GP premises while others such as BUPA and PPP provide NHS hospital care to NHS patients paid for by the NHS. These companies currently promote and sell private health insurance as well as privately funded health care. There are no provisions to prohibit the sale and promotion of private health insurance or privately funded health care to NHS patients from NHS purchasers and providers, such as care trusts. Public private partnerships and care trusts blur the boundaries for funding and responsibility for provision making backdoor privatisation much easier, perhaps inevitable.

Long term care

The Royal Commission on Long-Term Care, established by the Labour government in 1997, concluded that no system of private funding, whether private insurance, pensions or charges, could meet the unpredictable and catastrophic costs of personal care. Its core recommendation was that the state should provide personal care through a universal element in state provision met from general taxation. By doing so, it would give 'the best thing society can offer - freedom from fear and a new security in old age'.

Increasingly people who are old or disabled have had cause for concern over charging for personal and social care. In 1975, of all the people going into long term care of one sort or another - whether in nursing homes, residential homes, or long stay hospitals - 25 per cent would receive this care free under the NHS. By 1995 only a tenth of people would be entitled to free long term care. In 1995 only nine per cent of places for the elderly in long term care were in NHS institutions compared with 28 per cent in 1970.

It is unfortunate that having made the case for abolishing charges on redistributive and economic grounds, the NHS Plan of 2000 undergoes an extraordinary volte face: 'The government does not believe that making personal care universally free is the best use of these resources.' Instead of moving forward with plans to abolish charges, as Scotland is doing, the government has published a consultation document on charging for home care and social services confirming that local authorities and primary care trusts under delegated authority can charge.

Care trusts and privatisation

Primary care trusts are intended to evolve into care trusts - a new kind of NHS body - which will bring health care and social services under a single umbrella. They will be purchasers and providers rolled into one. Health care will continue to be free at the point of use but social care will be charged for.

The government anticipates that care trusts will control about 75 per cent of the NHS budget by 2004. Care trusts, like NHS hospital trusts, will have to break even. One way of doing so will be through intermediate care, that is, care provided in order to ease the transition from hospital to home.

'PPPs blur responsibility for provision making backdoor privatisation much easier, perhaps inevitable'
The government wants to create an extra 5,000 intermediate care beds by the middle of 2004. Some will be in community hospitals, others in special wards in acute hospitals, and some in purpose-built new facilities or redesigned private nursing homes. The plan also aims to introduce 1,700 extra non-residential care places. Much of this care will be provided in the for-profit independent sector.

The government has introduced guidance time-limiting NHS care: 'Based on current practice an intermediate care episode should typically last no more than six weeks. Many episodes will be much shorter than this, for example, one to two weeks following acute treatment for pneumonia or two to three weeks following treatment for hip fracture'. Thereafter, means tests and user charges will apply to housing and living costs and to the costs of 'personal care'.

Care trusts and foundation hospitals, laden with PFI debts and health authority deficits, will have a strong interest in redefining NHS care and defining personal care as broadly as possible and encouraging patients to top up care.

All these steps will help them maximise revenue from user charges. Issues are bound to arise over the status of many ordinary tasks. When is giving a patient a bath, for example, medical care and when is it personal care? It will be up to care trusts to say. Such changes could greatly favour the development of an expanded market in private medical insurance. It may be that insurers will offer policies that take effect at the point where the care provided by care trusts ceases to be free. The effect will be to break up the risk pool and introduce new inequities.

A two tier system

Politicians say it does not matter who provides the services so long as they are publicly funded. But redistribution is built into the design of the funding and delivery system through risk pooling and integration. A two-tier system, where some people can gain access to private care outside the NHS, is being accompanied by the break up of the NHS by competition, contracting out, trust status, and user charges. Greater use of the private sector will have the same effect. Unless there is a reversal of privatisation policies, the NHS could become a rump service, where high costs of private sector use will mean a deterioration in access to NHS quality and coverage - and an end to freedom from fear.

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