Insecurely into old age: Care of the elderly is being privatised, but not because of government spending cuts, argues Nicholas Timmins

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THERE will be no privatisation of health care, neither piecemeal, nor in part, not in whole, not today, not tomorrow, not after the next election, not ever while I am Prime Minister. The words are John Major's at the Conservative Party conference in 1991.

Yet last Friday that pledge, in effect, was broken. New draft guidance issued by the Department of Health said that the NHS would continue to provide long-term care to those with 'complex or multiple' needs. But for 'the significant majority' needing continuing nursing care - and we are talking here about nursing not residential care - the expectation now is that they will depend on means-tested social services for home nursing or a place in a nursing home.

When acutely ill, everyone will continue to be looked after medically by the NHS. But once the doctors judge that a patient's condition cannot be improved, they will then decide whether the case fits into the imprecisely defined category of 'complex and multiple' cases for which the NHS will continue to fund care. That judgement will be taken not according to nationally agreed criteria, but according to policies that have been set locally. Health authorities, that is, will determine their own criteria for eligibility. And while ministers insist that health authorities must provide some long-term care, they will have to provide it 'within available resources'.

In other words, the decision will be taken by an individual clinical team operating within policies that are different in different parts of the country. And that decision will determine, for instance, whether the NHS continues to provide for the brain haemorrhage victim left speechless, doubly incontinent, brain damaged and unable to feed himself, while needing daily physiotherapy and medication. Any layman would say that such a person needed health care, not just the social care of a hand around the house and meals-on-wheels. A clinician, however, might define the care differently.

It is a reflection of the changed times in which we live that Labour's official reaction to the Government's broken pledge was not to howl condemnation and accuse John Major of approving (as he is) the growing privatisation and means-testing of a part of NHS provision. Instead, David Blunkett, Labour's health spokesman, who is not usually backward about coming forward on such issues, called for a Royal Commission.

It was left to those in their seventies and eighties who have already seen the new system in operation to voice the charge of 'betrayal' - and articulate their bitter sense that, having paid their dues all their lives, they are no longer entitled to NHS care when they or their relatives need it.

For while the new guidance does formally mark an end to the 'cradle to grave' commitment of the NHS - and it is important to recognise such Rubicons when they are crossed - it actually does no more than adjust official guidance to a reality that has been emerging for a long time.

Ever since the foundation of the NHS in 1948 there has been a distinction between free health care provided by the NHS, and means-tested social care for the frail and elderly provided by local authorities. At the start, the NHS did have long-stay wards, and even hospitals for the elderly, some of which generated scandals over mistreatment similar to those that afflicted the old lunatic asylums.

But these hospitals closed, and the elderly were moved to ordinary wards at the same time as medical advances meant both that more could be done, and that more people survived handicapped. Throughout the period, the steady ageing of the population meant that more people required long-term care.

A significant change can be dated to 1979, when the already fine line between 'health care' and means-tested 'social care' became further blurred as the Government started to allow social security cash to be used to fund places in private and voluntary nursing and residential homes.

Government spending on care in such homes rocketed from pounds 10m in 1979 to pounds 2.5bn by 1992, the number of people supported rose from 11,000 to more than a quarter of a million.

This dramatic and entirely unplanned growth helped not just those needing social care, but the health authorities. A significant number privatised their provision. They closed their long-stay hospital beds, allowing social security to pay where patients qualified for Income Support, while buying some places in the homes themselves. A few health authorities, however, and no one seems clear quite how many, failed either to retain any long-stay places or to fund any new ones in independent homes. In 1970, 28 per cent of elderly people cared for outside their own home received free NHS care. By 1992, that figure had fallen to 12 per cent - but 12 per cent of a much larger population.

Yet it is doubtful whether overall government spending on this type of care has fallen, although this is an area where the figures are notoriously difficult to interpret. The number of NHS beds designated for the elderly has dipped rather than tumbled, and the huge growth in government spending on independent homes almost certainly means that much more is being spent. Long-term care is being increasingly privatised. But this is not because state provision has been cut. It is rather that people are being forced to pay for their own care because care funded by the Government has failed to match rising demand.

As a result, the old guarantee that 'no NHS patient should be placed in a private nursing or residential care home against his/her wishes if it means that he/she or a relative will be personally responsible for the home's charges' has become increasingly honoured in the breach.

For those on Income Support, free care remains, either within the NHS, funded by the NHS, or funded by local authorities under the new community care arrangements. For everyone else, if the NHS locally decides the case is not sufficiently 'complex and multiple', care becomes means-tested.

The implications of this for the glib Eighties assumption that wealth would cascade down the generations as children inherited their parents' houses and savings, are enormous. Some families will see that. Others are watching savings and homes disappear at the rate of pounds 400 a week or more - pounds 20,000 a year. Inheritance has become much more of a lottery, while some of those who bought their houses and saved enough to lift themselves above Income Support in old age will wonder why they bothered.

Yet no one has a simple solution. The costs of picking up the tab nationally for long-term care are daunting - which explains Labour's muted reaction to Friday's announcement. Private insurance for long-term care is available - reasonably cheaply if done below the age of 40, increasingly prohibitive thereafter.

Unless something changes - and the challenge will be the same whichever party is in government - independent nursing homes will increasingly house an odd and unequal mix of patients - some paying for themselves, some funded fully by the NHS and some completely or only partly paid for by social services. Moreover, angry battles are likely to be fought locally over what constitutes a 'complex and multiple' case for which the NHS will still pay.

The one big silver lining to Friday's announcement is that those health authorities which had simply ceased to provide any long- term care even for the most desperate cases will now have to provide some. The decision about who receives it, though, will still seem a lottery to those who do not.

Meanwhile, as we wallow in Sixties nostalgia, those who hope to leave houses and savings to their children might well consider the words of the song: 'hope I die before I get old'.

(Photograph omitted)