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washington Debate over US federal funds for physician-assisted suicide
THE LANCET
DISPATCHES
LONDON
Health and welfare in the UK—is the future private?
he date of the UK election has been confirmed—May 1. Three white papers in the past 2 weeks have set out the government’s proposals. The first is for the privatisation of social services for the elderly, the mentally ill, and the physically disabled; the second is for a new private/public insurance deal for long-term nursing care; and the third is the privatisation of pensions. The first opinion poll following this blitz of policies shows Labour increasing its lead from 18% last month to an unprecedented 25% with just 6 weeks to go. Almost 5 years ago, all ministers in charge of social policy departments were instructed to examine ways in which the boundaries between private and public provision could be redrawn. Although Britain is better off than most developed states in terms of demography, ministers were convinced that the challenge had to be tackled now. If people were going to be required to finance their longterm nursing costs, then they had better be asked to start contributing to private insurance schemes early. What no-one had expected is that the government would unveil their ideas before the election. Asking people to pay for services, some of which are now free, is hardly an election winner. It would be inspiring to report that here was a government putting principle before politics. But the aim was to demonstrate to the electorate that the Conservatives have not run out of ideas. What the Tory strategists failed to recognise is
T
WASHINGTON
the support which the welfare state still attracts and the deep public suspicion of privatisation. The long-term nursing care proposals were not new. They were set out in a discussion document last year but even the Conservative-controlled Commons select committee on health expressed scepticisim
“In the past 20 years there has been a 50% reduction in longterm NHS beds” about their value. Undeterred, ministers are now promising legislation that would introduce governmentsubsidised insurance to cover the cost of long-term nursing care. There is a clear need for better protection from long-term nursing care costs. In the past 20 years there has been a 50% reduction in longterm NHS beds. Hundreds of thousands of elderly patients have been transferred from free NHS beds into means-tested nursing homes where the fees can be as high as £20 000 a year. About 1 in 20 people aged between 75 and 84 is in a residential or nursing home, and 1 in 5 of the over 85s. About 40 000 homes a year are being sold to finance this longterm nursing care. The new policy is designed more to save inheritances than improve the position of nursing care. People who take out insurance will receive more protection from the state against nursing costs. But it does nothing for existing patients, nothing for the low
paid, and would end up subsidising the better-off, the only people able to afford the high premiums. In the USA, from where the Conservatives obtained the idea, fewer than 5% are reported to be taking up the insurance. What is needed is a comprehensive scheme. A national inquiry by the charitable Joseph Rowntree Foundation produced just such a proposal last year under which all workers would contribute towards health and social care in old age, whether in their own home or in a residential institution. Both services would be free but there would be means-tested charges for the “hotel” cost of residential care. Both major parties distanced themselves from the idea last year for fear of embracing hidden “taxes”. Under the new social services proposals, local departments would be restructured so that they commission but no longer provide services. Part of the new package is rhetoric. Social services already only provide 15% of residential and nursing home places. But part is pure dogma: private good/ public bad, which contradicts the purported Conservative belief in choice. Some public homes are bad, but so are some private institutions. One proposal, which should win more support, is the idea of a new independent regulatory agency which would monitor both health and social services. If Labour wins on May 1, it will find itself being pushed to set up just such a system. Malcolm Dean
Debate over US federal funds for physician-assisted suicide
A
US House subcommittee took the first steps towards making it illegal to use federal funds for physician-assisted suicide on March 13. The legislation itself is not very controversial—it would bar the use of federal funds, largely through the massive Medicare and Medicaid programmes, to pay for “any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the suicide, euthanasia, or mercy killing of any individual”. It would also clarify that the withholding or withdrawing of specific treatments, of food or water, or the use of analgesics or other methods of alleviating pain would not be
Vol 349 • March 22, 1997
considered assisting suicide, even if the provision or withdrawal of such services would hasten death. But several Democrats said the panel’s hearing a week earlier made it clear that physicians were inadequately versed in palliative care, or in diagnosing treatable depression in terminal patients. One Democrat offered, as an amendment, to require medical schools to add to their curricula training in pain management, depression identification and treatment, disability awareness, and other issues related to death and dying. Republicans objected to the amendment, arguing that Congress should not be telling medical
schools what to teach. In the end, Republicans voted down the Democrats’ amendment, replacing it with a 1-year study of medical school curricula. But the debate was ironic, given that many who opposed the medical school mandate—and called it a poor precedent—were the very members who in 1996 pushed through Congress legislation overriding a requirement by the national accrediting organisation that obstetrics and gynaecology residency programmes require residents with no moral objections to learn to perform abortions. Julie Rovner
859
DISPATCHES
LONDON
Health and welfare in the UK—is the future private?
he date of the UK election has been confirmed—May 1. Three white papers in the past 2 weeks have set out the government’s proposals. The first is for the privatisation of social services for the elderly, the mentally ill, and the physically disabled; the second is for a new private/public insurance deal for long-term nursing care; and the third is the privatisation of pensions. The first opinion poll following this blitz of policies shows Labour increasing its lead from 18% last month to an unprecedented 25% with just 6 weeks to go. Almost 5 years ago, all ministers in charge of social policy departments were instructed to examine ways in which the boundaries between private and public provision could be redrawn. Although Britain is better off than most developed states in terms of demography, ministers were convinced that the challenge had to be tackled now. If people were going to be required to finance their longterm nursing costs, then they had better be asked to start contributing to private insurance schemes early. What no-one had expected is that the government would unveil their ideas before the election. Asking people to pay for services, some of which are now free, is hardly an election winner. It would be inspiring to report that here was a government putting principle before politics. But the aim was to demonstrate to the electorate that the Conservatives have not run out of ideas. What the Tory strategists failed to recognise is
T
WASHINGTON
the support which the welfare state still attracts and the deep public suspicion of privatisation. The long-term nursing care proposals were not new. They were set out in a discussion document last year but even the Conservative-controlled Commons select committee on health expressed scepticisim
“In the past 20 years there has been a 50% reduction in longterm NHS beds” about their value. Undeterred, ministers are now promising legislation that would introduce governmentsubsidised insurance to cover the cost of long-term nursing care. There is a clear need for better protection from long-term nursing care costs. In the past 20 years there has been a 50% reduction in longterm NHS beds. Hundreds of thousands of elderly patients have been transferred from free NHS beds into means-tested nursing homes where the fees can be as high as £20 000 a year. About 1 in 20 people aged between 75 and 84 is in a residential or nursing home, and 1 in 5 of the over 85s. About 40 000 homes a year are being sold to finance this longterm nursing care. The new policy is designed more to save inheritances than improve the position of nursing care. People who take out insurance will receive more protection from the state against nursing costs. But it does nothing for existing patients, nothing for the low
paid, and would end up subsidising the better-off, the only people able to afford the high premiums. In the USA, from where the Conservatives obtained the idea, fewer than 5% are reported to be taking up the insurance. What is needed is a comprehensive scheme. A national inquiry by the charitable Joseph Rowntree Foundation produced just such a proposal last year under which all workers would contribute towards health and social care in old age, whether in their own home or in a residential institution. Both services would be free but there would be means-tested charges for the “hotel” cost of residential care. Both major parties distanced themselves from the idea last year for fear of embracing hidden “taxes”. Under the new social services proposals, local departments would be restructured so that they commission but no longer provide services. Part of the new package is rhetoric. Social services already only provide 15% of residential and nursing home places. But part is pure dogma: private good/ public bad, which contradicts the purported Conservative belief in choice. Some public homes are bad, but so are some private institutions. One proposal, which should win more support, is the idea of a new independent regulatory agency which would monitor both health and social services. If Labour wins on May 1, it will find itself being pushed to set up just such a system. Malcolm Dean
Debate over US federal funds for physician-assisted suicide
A
US House subcommittee took the first steps towards making it illegal to use federal funds for physician-assisted suicide on March 13. The legislation itself is not very controversial—it would bar the use of federal funds, largely through the massive Medicare and Medicaid programmes, to pay for “any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the suicide, euthanasia, or mercy killing of any individual”. It would also clarify that the withholding or withdrawing of specific treatments, of food or water, or the use of analgesics or other methods of alleviating pain would not be
Vol 349 • March 22, 1997
considered assisting suicide, even if the provision or withdrawal of such services would hasten death. But several Democrats said the panel’s hearing a week earlier made it clear that physicians were inadequately versed in palliative care, or in diagnosing treatable depression in terminal patients. One Democrat offered, as an amendment, to require medical schools to add to their curricula training in pain management, depression identification and treatment, disability awareness, and other issues related to death and dying. Republicans objected to the amendment, arguing that Congress should not be telling medical
schools what to teach. In the end, Republicans voted down the Democrats’ amendment, replacing it with a 1-year study of medical school curricula. But the debate was ironic, given that many who opposed the medical school mandate—and called it a poor precedent—were the very members who in 1996 pushed through Congress legislation overriding a requirement by the national accrediting organisation that obstetrics and gynaecology residency programmes require residents with no moral objections to learn to perform abortions. Julie Rovner
859