The background.
Today’s discussions on the crisis in social care – the heavily privatised provision of home care and care homes for older people and for people with serious and long-term mental health problems, learning difficulties and physical disability – seldom make any reference to the fact that many of people receiving these services used to be provided for by the NHS.
Thousands of long-stay specialist beds for older patients (geriatric beds) provided care for patients free at point of use: all of these have since closed, to be replaced by largely private sector provision of home care services and a mix of for-profit and non-profit private provision of nursing home care: this was the biggest area of privatisation in the NHS.
In 1987 the NHS had 127,616 acute hospital beds (handling emergency and elective care) and another 52,273 geriatric beds, giving a “general and acute” beds total of 180,889. 20 years later geriatric bed numbers had been cut by over 60% and acute beds by 20%, to give a total of 122,374. Since 2010 the category of “geriatric beds” has disappeared and the total of general and acute beds at the last count has fallen to 101,598 – a reduction of 44% in 32 years.
The Thatcher government, tearing up the “consensus” policies of much of the first 30 years of the NHS, began to shift the argument in 1981 with the publication of a White Paper Growing Older (DHSS 1981) and a consultative document Care in the Community (DHSS 1981), both of which centred on the drive to transfer patients and services out from hospital settings into “the community.”
The consultative document suggested that funds for community-based services would depend upon the sale of surplus land and buildings. These discussions took place under a growing cloud of well-founded suspicion that the NHS was looking to community care as a smokescreen to cover its abdication from responsibility for a growing area of care for the frail elderly and people with chronic mental illness.
The Social Security Act, endorsing a policy which began to be applied in 1979, gave DHSS offices the discretion to meet the costs of residential or nursing home care for elderly patients from the social security budget. At first only a trickle of patients from NHS hospitals were to receive care paid for in this way: but this was soon to increase to a flood.
Growing numbers of health authority and hospital chiefs spotted that this was the ideal means to shift the bill for caring for an expensive group of patients from their cash-limited NHS budgets onto social security: and they followed this by closing down the vacated NHS geriatric beds.
The process that ensued was one of rapid, unannounced and almost unchallenged privatisation. For the frail elderly, the concept of care free at the point of use and funded from taxation was rapidly disappearing.
More than half of the elderly people in residential homes were paying their own fees. Many of those who moved into the dwindling number of council-run residential homes (which almost halved in number from 116,000 to 69,000 places over the same period) were obliged to pay for the privilege: 36% of the costs were being “clawed back” from residents through means-testing – paying charges totalling around £1 billion a year in the mid-1980s, eight times the annual revenue from prescription charges (Lister 1998:76).
But it was nursing homes that were set to become the biggest area of business growth. In 1979 it cost the DHSS £10m to finance 11,000 clients in nursing homes. By 1993, 281,000 people were receiving state-funded care in private homes, at a cost of £2.575 billion.
The resultant 1988 “Griffiths Report” (Community Care; Agenda for Action) proposed the transfer of responsibility for continuing care of the elderly from the NHS (where it was still provided free of charge at time of use) to local government (where it would be subject to means-tested charges). It amounted to the consolidation of privatisation and means-testing, with an end to the direct use of social security funding.
This was a Tory policy supported by Labour local authorities but which David Blunket described as a ”poisoned chalice” for local authorities.
It marked the beginning of the funding crisis for social care and the separation of social care from the NHS the adverse consequences of which have been tragically highlighted by Covid 19. It also led to the Continuing Healthcare issue highlighted in earlier blogs.
Views 