CHANGES IN POLICY DURING THE STUDY

Since this study was completed there have been changes in the political and financial environm ents which change the context of some of the principal findings.

8.3.1 Political Policy

The Governm ent’s commitment to close “many" of the psychiatric institutions through the introduction of community care by the year 2000 set out in the Green Paper for Health o f the Nation (HMSO, 1991) disappeared in its White Paper in 1992 and is no longer mentioned as policy. The expression “Community Care” itself is now out of fashion being replaced with “Spectrum of Care” (Dorrell 7/96 interview with the Times) which he stated “does not necessarily m ean the closure o f the institutions “ and “I can’t wave a wand and deal with all the inadequacies

overnight”. General Practitioners support for the provision of individual primary care for those in

nursing homes is being challenged (BMA press release, October, 1996) as possibly no longer available in the future unless General Practitioners are additionally recompensated. They argue that the additional burdens o f Primary Care, for which they have already received additional funding, have overloaded them.

The issue of w ho pays for the care of the elderly has been extensive and occupied many column inches of debate in National newspapers. The re-possession and sale of the homes o f the elderly by local authorities to pay for their care amounts to 40,000 homes sold in 1995 to fund nursing home care, (Wood, 1996) and has highlighted this issue to the public.

The debate has included insurance paid care, dedicated funds derived from additional taxation (as adopted by the German Government), tax break incentives (US style) for savings to be devoted to care in old age. There was even a suggestion following a review ordered by the Prime Minister carried out by the Downing Street policy unit that the Government would pay for the nursing element but not the hotel cost of long term care (Times 19/9/95). The debate concluded in September 1996 when the Health Secretary, S. Dorrell, announced (29/9 DoH 1996 - press release) that this matter could not be settled within the remaining space o f this Governm ent as it was "too complex ... requiring another phase o f consultation" and "will be dealt with after the election in May 199T.

8.3.2 Financial Policy

The financial environment changed significantly during the period of this study. The first set of problems emerge from the operation of the purchaser/provider arrangements (plans for Cases 1 & 2 were agreed before these took full effect). Purchasers faced with, as they see it, intractable cost pressures are very cautious and want very detailed information on the full final cost of contracts before they will proceed.

Purchasers therefore will regard it as out of the question to enter into any community based care contracts unless their liabilities are absolutely determined. This leads to the second set of problems.

Capital funding is, for practical purposes, not available within the NHS. The examination of options through the Private Finance Initiative (PFI) must be the first route to be followed by the NHS. The PFI requires the examination of whether the private sector could fund, design, build and operate (presently with the exception of direct clinical activities) NHS services. Both political parties agree (with some differences) this is the "new w ay”. The PFI process has successfully funded roads, bridges, equipment purchases and prisons. At the date of writing it has been, other than for equipment, a complete failure in the NHS and so far has deferred significant capital expenditure in the NHS for over two years.

One o f the significant differences between conventional and PFI procurement is in the virtual exclusion of the client/user from the detailed planning. The case studies showed that

com prehensive user involvement in design, results in more acceptable schemes and this seems to be a retrograde step. The PFI process requires a preferred bidder to be selected based on a design and price in which the client has only been permitted to give “outputs” (e.g. numbers of episodes, case mixes of patients). Once the price is fixed any change becomes difficult. The Audit Commission investigating the need to change completed PFI schemes (the new NHS HQ in Leeds is one example) because they do not meet the client needs, not surprisingly is raising questions.

Kenneth Clarke, Chancellor of the Exchequer in his budget speech o f 26 November 1996 claimed an extra £7 billion of public investment was being provided by the PFI, (of which £900 million would be provided to the NHS over the next three years). The Independent newspaper reporting on the budget the following day quoted a recent International Monetary Fund study which had concluded that “the PFI was contributing no extra money but substituting for investment that would othen/vise be funded by normal methods” (W alker 1996). Until PFI can be made to produce the capital funds the NHS needs or conventional Treasury finance is re­ instated, it is difficult to see how the momentum of change can be maintained in reproviding services for the mentally ill in a community setting.

The capital budget of the NHS, already reduced by a third in two years, was reduced by a further 16% in the 1996 Budget (The Red Book HMSO London 1996). The NHS capital budget was projected to be £2.2 billion in 1992 (Social Services Stats 1993) and now must be little more than £1 billion which has to meet the costs of replacing equipment, introducing new technologies and maintaining existing infrastructure.

Many of the hospitals in this survey are enmeshed in the process o f seeking capital and in the final year of the survey very few of the hospitals without agreed plans were willing to hazard a date when they would have funding and have a programme in place.

8.3.2.1 Cost pressures developing In the system

The research demonstrated that hospitals with and without reprovision programmes acquire more complex case mixes. Those with smaller populations have higher staff patient ratios and lower ward occupancy levels. All these factors mean that the remaining institutions become more costly to operate. General Practitioner fundholding decisions can reduce budgets available to purchasers to fund these costs and General Practitioner’s are seeking to increase charges for their services to patients in the community.

In the meantime these old buildings provide poor accommodation which, in the absence of significant maintenance funds, will decline further in quality. PFI may be seen as the way forward by government but the delays it is causing make the cost of reprovision escalate both in revenue and capital terms.