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Are the elderly being short-changed by the NHS?
Public Health
(1992), 106, 181-183
© The Society of Public Health, 1992
Editorial
Are the Elderly being Short-changed by the NHS? A frequently broadcast television advert is one which seeks to persuade the viewer to join a health care insurance scheme. One sees high-technology investigations, modern premises, courteous medical attendants, pretty nurses, in short the whole paraphernalia of advertising industry images. The recipients of such care are young, normally fit individuals or perhaps the hale and hearty middle-aged. Well, what's wrong with that? We are talking about insurance--the guarding against the unforeseen event. If people want to take out this sort of cover, it's a free society and we can spend our m o n e y as we wish. True, but isn't it a bit economical with the truth? A minister of state is reported as saying he didn't have such insurance because he didn't think he needed it. Also very true and this is why such undertakings, whether by a profit-making organisation or a mutual association, target the younger age groups: on the whole they don't need it. One cannot blame the businesses selling such insurance because in the last essence they have to balance their books. This intellectual dishonesty here is the assumption that this activity makes a real contribution to the nation's health. Does health insurance actually solve health problems? The D e p a r t m e n t of Health has recently circulated a small booklet entitled 'Health and Healthy L i v i n g - - A Guide for Older People'. t It gives excellent advice to the elderly, provided they do not have impaired vision and have the skill and habit of acquiring knowledge through the written word. One is, however, left with the question 'What if one follows all this advice, what then?' 'Adding years to life and life to years' won't guarantee the avoidance, eventually, of a period of disability requiring nursing care. Such a period can be very protracted. The care of our citizens in this position is one of the fundamental problems of modern society. There was a time, a few years ago, when it appeared that there was a genuine attempt to respond to this challenge. Is there now? It would appear not. Insofar as health services are concerned, the elderly at home will only get what care purchasers are prepared and able to buy after they have met the bills from hospitals. Can one honestly believe that such services as the provision of incontinence supplies can survive to an adequate level in the contracting environment? If our elderly person, who hasn't smoked, has taken regular exercise, only drunk alcohol in extreme moderation and has had all his annual health checks, requires long-term care that can only be practically provided in an institutional setting, he's in trouble. H e will get short shrift in an NHS hospital and will soon be shipped out to a private nursing home. Whatever help he gets from the State, this move will eventually cost him money. His private health insurance can't help. H e stopped that 20 years before, when he retired, because he could no longer afford the premiums. One could argue that he should sell his house, spend his money on this care and not pass it down to ungrateful relatives when he dies. (This was a semi-official line a few years a g o - - w e don't hear so much of this argument nowadays.) It is, of course, not so
182
Editorial
simple as that--his estate is also his wife's e s t a t e - - s h e may survive him by many years with much depleted or exhausted savings. There is also another issue. Our elderly gentleman has paid his national insurance all his working life and has also paid and is still paying his taxes. When he wants help, it is restricted. Even if he gets a sizeable subvention from the State, because he has no savings left it will be limited and will only purchase an austere level of care. Is this fair? O f course, if he wants a vasectomy, no difficulty: he will be admitted promptly to a shiny new trust hospital and it will cost him nothing. What is the answer to this problem? It is doubtful whether private insurance, even if very positively encouraged by the State, can make more than a marginal, though possibly valuable, contribution. There is a state machinery for responding to this problem. For those with limited savings, the D e p a r t m e n t of Social Security funds, to a given level, care in a private nursing home. Shortly, the responsibility for managing this support will be transferred to local authority social services departments. The intention of this step is to remove the financial incentive to admit people to nursing homes and to encourage the provision of care in a person's own home. With the current track record and problems of local authorities, it is more likely to encourage the provision of no care. Some idea of what the situation is going to be like is given by the appearance of the drafts of forthcoming assessment forms, with many pages of many questions, to be filled in by many individuals. We are going to see the traditional recourse of organisations when faced with the need to disburse m o n e y - - c o n t r o l it with a fearsome bureaucracy. The signs are already there. To extract monetary assistance for nursing home care under these arrangements, an elderly person will have to be very fit and determined. Now this is quite wrong, The merit of the current system, whatever its imperfections, is that it does grant to the recipient a sort of right, even if it is hedged about with restrictions. The new arrangements remove this right by the exercise of a bureaucratic determination of a person's needs. Why do we treat old people like this? Using the example given above, a young man has a right to a vasectomy but an old man has no right to nursing home care. It is not just a matter of resources. A considerable sum has been found for this programme already. There seem to be two problems here. The first is the official refusal to face up to issues of this sort. For example, this problem gained no mention in 'The Health of the Nation'.; The second is the obsession which governments, whatever their political persuasion, have with control. This fixation derives from the experience all developed countries have had with the provision of acute medical care, where it appeared that the demand could be infinite. This is certainly not the case with nursing home care, whatever our worries about the problem of an ageing population. A nursing home, even if very comfortable, is the last recourse. No, officialdom believes that if such care was a right, families would rush to dump granny in a nursing home and go off on holiday with the proceeds of the sale of her house. There is a mean-mindedness about the situation in that first, if a person has savings, he has to pay these out for medical care, when fellow citizens don't have to pay anything for all other types of care. Second, if he doesn't have any savings, he is at the mercy of bureaucratic procedures during any attempt to obtain this care. Looking again at the place of personal health insurance in solving health problems, it would seem that, for most people, faced with the need for nursing home care, there is very little that health insurance can do to help. When one can afford it, the risk is
Editorial
183
very small and remote. When the risk is great, one can't afford insurance. The paradox of the Health Service is that, through the implementation of the internal market, it is attempting to compete with the sort of service that persons and companies can buy through health insurance, which will always have an edge because it serves a selected population, and is neglecting health problems where health insurance can only help a very small proportion of those at risk. References
1. The Department of Health (1991). Health and Healthy Living: A Guide for Older People. London: HMSO. 2. The Department of Health (1991). The Health of the Nation, Cm 1523. London: HMSO.
(1992), 106, 181-183
© The Society of Public Health, 1992
Editorial
Are the Elderly being Short-changed by the NHS? A frequently broadcast television advert is one which seeks to persuade the viewer to join a health care insurance scheme. One sees high-technology investigations, modern premises, courteous medical attendants, pretty nurses, in short the whole paraphernalia of advertising industry images. The recipients of such care are young, normally fit individuals or perhaps the hale and hearty middle-aged. Well, what's wrong with that? We are talking about insurance--the guarding against the unforeseen event. If people want to take out this sort of cover, it's a free society and we can spend our m o n e y as we wish. True, but isn't it a bit economical with the truth? A minister of state is reported as saying he didn't have such insurance because he didn't think he needed it. Also very true and this is why such undertakings, whether by a profit-making organisation or a mutual association, target the younger age groups: on the whole they don't need it. One cannot blame the businesses selling such insurance because in the last essence they have to balance their books. This intellectual dishonesty here is the assumption that this activity makes a real contribution to the nation's health. Does health insurance actually solve health problems? The D e p a r t m e n t of Health has recently circulated a small booklet entitled 'Health and Healthy L i v i n g - - A Guide for Older People'. t It gives excellent advice to the elderly, provided they do not have impaired vision and have the skill and habit of acquiring knowledge through the written word. One is, however, left with the question 'What if one follows all this advice, what then?' 'Adding years to life and life to years' won't guarantee the avoidance, eventually, of a period of disability requiring nursing care. Such a period can be very protracted. The care of our citizens in this position is one of the fundamental problems of modern society. There was a time, a few years ago, when it appeared that there was a genuine attempt to respond to this challenge. Is there now? It would appear not. Insofar as health services are concerned, the elderly at home will only get what care purchasers are prepared and able to buy after they have met the bills from hospitals. Can one honestly believe that such services as the provision of incontinence supplies can survive to an adequate level in the contracting environment? If our elderly person, who hasn't smoked, has taken regular exercise, only drunk alcohol in extreme moderation and has had all his annual health checks, requires long-term care that can only be practically provided in an institutional setting, he's in trouble. H e will get short shrift in an NHS hospital and will soon be shipped out to a private nursing home. Whatever help he gets from the State, this move will eventually cost him money. His private health insurance can't help. H e stopped that 20 years before, when he retired, because he could no longer afford the premiums. One could argue that he should sell his house, spend his money on this care and not pass it down to ungrateful relatives when he dies. (This was a semi-official line a few years a g o - - w e don't hear so much of this argument nowadays.) It is, of course, not so
182
Editorial
simple as that--his estate is also his wife's e s t a t e - - s h e may survive him by many years with much depleted or exhausted savings. There is also another issue. Our elderly gentleman has paid his national insurance all his working life and has also paid and is still paying his taxes. When he wants help, it is restricted. Even if he gets a sizeable subvention from the State, because he has no savings left it will be limited and will only purchase an austere level of care. Is this fair? O f course, if he wants a vasectomy, no difficulty: he will be admitted promptly to a shiny new trust hospital and it will cost him nothing. What is the answer to this problem? It is doubtful whether private insurance, even if very positively encouraged by the State, can make more than a marginal, though possibly valuable, contribution. There is a state machinery for responding to this problem. For those with limited savings, the D e p a r t m e n t of Social Security funds, to a given level, care in a private nursing home. Shortly, the responsibility for managing this support will be transferred to local authority social services departments. The intention of this step is to remove the financial incentive to admit people to nursing homes and to encourage the provision of care in a person's own home. With the current track record and problems of local authorities, it is more likely to encourage the provision of no care. Some idea of what the situation is going to be like is given by the appearance of the drafts of forthcoming assessment forms, with many pages of many questions, to be filled in by many individuals. We are going to see the traditional recourse of organisations when faced with the need to disburse m o n e y - - c o n t r o l it with a fearsome bureaucracy. The signs are already there. To extract monetary assistance for nursing home care under these arrangements, an elderly person will have to be very fit and determined. Now this is quite wrong, The merit of the current system, whatever its imperfections, is that it does grant to the recipient a sort of right, even if it is hedged about with restrictions. The new arrangements remove this right by the exercise of a bureaucratic determination of a person's needs. Why do we treat old people like this? Using the example given above, a young man has a right to a vasectomy but an old man has no right to nursing home care. It is not just a matter of resources. A considerable sum has been found for this programme already. There seem to be two problems here. The first is the official refusal to face up to issues of this sort. For example, this problem gained no mention in 'The Health of the Nation'.; The second is the obsession which governments, whatever their political persuasion, have with control. This fixation derives from the experience all developed countries have had with the provision of acute medical care, where it appeared that the demand could be infinite. This is certainly not the case with nursing home care, whatever our worries about the problem of an ageing population. A nursing home, even if very comfortable, is the last recourse. No, officialdom believes that if such care was a right, families would rush to dump granny in a nursing home and go off on holiday with the proceeds of the sale of her house. There is a mean-mindedness about the situation in that first, if a person has savings, he has to pay these out for medical care, when fellow citizens don't have to pay anything for all other types of care. Second, if he doesn't have any savings, he is at the mercy of bureaucratic procedures during any attempt to obtain this care. Looking again at the place of personal health insurance in solving health problems, it would seem that, for most people, faced with the need for nursing home care, there is very little that health insurance can do to help. When one can afford it, the risk is
Editorial
183
very small and remote. When the risk is great, one can't afford insurance. The paradox of the Health Service is that, through the implementation of the internal market, it is attempting to compete with the sort of service that persons and companies can buy through health insurance, which will always have an edge because it serves a selected population, and is neglecting health problems where health insurance can only help a very small proportion of those at risk. References
1. The Department of Health (1991). Health and Healthy Living: A Guide for Older People. London: HMSO. 2. The Department of Health (1991). The Health of the Nation, Cm 1523. London: HMSO.