Will intermediate care be the undoing of the NHS?

British Medical Journal, August 12, 2000 by Allyson M Pollock

In the US providers have not been compelled to spend the extra money they receive for higher dependency patients on patient care. Nor have they been required to maintain higher levels of staffing: in US long term care settings 37% of expenditure is on staff; in the NHS the figure is 65%.[8 9] The US experience also shows how tying reimbursement to levels of disability can provide perverse incentives for homes to accept residents who are more disabled and allow them to become more so.[10] A similar picture is emerging in Australia.[11] Before 1997 a set percentage of the funding received by care home owners had to be spent on care and could not be diverted to non-care staff, capital maintenance, or profit. This requirement was removed in 1997, and staffing levels have since fallen, with experienced nurses being replaced by those who are less costly to employ. This has led to scandals about the quality of care and claims by the Australian Nursing Federation that the industry is facing a quality of care crisis.[12]

A government committed to a universal, comprehensive, high quality NHS would not embark on this path. It would restore the risk pooling model of universal provision by bringing the nursing and care elements of the workforce in the private sector under NHS control. This would bring it into line with its policies for the rest of the NHS, where under the private finance initiative bricks and mortar are owned and operated by the private sector but clinical services remain under the control of the NHS.

Allyson M Pollock professor Health Services and Health Policy Research Unit, School of Public Policy, University College London, London WC1H 9QU [1] Secretary of State for Health. The NHS plan: plan for investment, a plan for reform. London: Stationery Office, 2000.

[2] Department of Health. Shaping the future NHS: long term planning for hospitals and related services: consultation document on the findings of the National Beds Inquiry. London: Department of Health, 2000.

[3] Secretary of State for Health. The NHS plan: the government response to the Royal Commission on Long Term Care. London: Stationery Office, 2000 (CM4818-II).

[4] Laing's health care market review 1999/2000. London: Laing and Buisson, 1999.

[5] Klein R. Big bang health care reforms: does it work?: The case of Britain's 1991 NHS reforms. Milbank Quarterly 1995;73:299-337.

[6] Harrington C, Pollock AM. Decentralisation and deprivatisation of long-term care in UK and USA. Lancet 1998;351:1805-8.

[7] Pollock AM. The American way. Health Service Journal 1998;9 Apr:28-9.

[8] The guide to the nursing home industry 1998-1999. Baltimore: HCIA and Arthur Anderson, 1998.

[9] Shaoul J. Charging for capital in the NHS trusts: to improve efficiency? Management Accounting Research 1998;9:95-112.

[10] Harrington C, Carillo H, Thollaug SC, Summers PR, Wellin V. Nursing facilities, staffing, residents and facilities deficiencies 1992 through 1998. San Francisco: Department of Social and Behavioral Sciences, University of California, 2000.