Leading Article: NHS changes: a sense of betrayal

THE NATIONAL Health Service is floundering for lack of a strategy. The public looks on with dismay as a much-valued institution suffers changes that seem to have no understandable goal. Thanks largely to Virginia Bottomley's failure to articulate key principles, reform has bred distrust of the Government's motives. Her outpouring of official statistics is no substitute for policy. In the intellectual vacuum thus created, scaremongering flourishes.

The past few days have reminded us of the Secretary of State's shortcomings. Claims at the weekend that American healthcare firms want to become involved in the provision of NHS services are followed by our report today that private health companies are tendering to build and run a heart unit in Wales. If the Government is neutral on the question of who actually provides health services, as opposed to their quality, these news items offer ministers an opportunity robustly to explain their thinking. When the opportunity is lost, again and again, credibility ebbs away.

Meanwhile, last Friday the Department of Health abandoned its 'cradle to the grave' guarantee to elderly patients. No longer will those needing long-term care be entitled to refuse to move from public beds into private nursing homes. The change means, in effect, that elderly people will increasingly find themselves impoverished by the costs of nursing care that would once have been free under the NHS. The state will fund fees in full only when those affected are down to their last pounds 3,000 of capital.

The new guidance was to a large extent recognition of what has been occurring quietly in several areas for some time. But many people see it as a unilateral betrayal of an implicit contract between themselves and the state. They had understood that a lifetime of tax-paying provided social insurance against such eventualities.

More astute ministers might not be dogged by such controversies. The source of British healthcare, be it from public or private bodies or from foreign firms, should not necessarily matter as long as it is the best that can be afforded. But the Government has not come clean about its plans or the rationale for its changes. As a result, every announcement is viewed with suspicion. In health policy, the balance to be struck on the extent of competition to be sanctioned remains a mystery; the eventual shape of NHS trusts is unknown; the planned long-term relationship between GP fundholding and health authority purchasing has yet to be revealed. 'Ministers have been making it up as they go along,' wrote Professor Chris Ham, a respected health services management expert, in the British Medical Journal recently.

There are also sound arguments for limiting the state's liability for funding long-term nursing care. Laing and Buisson, the independent healthcare consultants, estimate that 1.5 per cent of GDP is at present spent on long-term care for the elderly, three-quarters of that sum being raised from taxation. By 2050, the figure is predicted to rise to 3.5 per cent, certainly more than the Treasury can bear. In any case, it is surely unfair that the state should have to fund long-term nursing care for the better-off simply so that legacies can cascade through generations of the middle classes.

Yet a carefully wrought policy would make allowance for those who had reasonable expectation of state support. The present generation of elderly people mostly have had no opportunity to insure themselves. They would feel less aggrieved if thresholds below which their assets gain absolute protection were raised above pounds 3,000. Spouses - who stand to lose everything except their homes and pounds 3,000 - deserve a better deal. Younger people could be encouraged to take out insurance. Yet the Government has offered neither advice nor incentives. The insurance market for long-term care is in its infancy: companies are still unwilling to guarantee the level of future premiums, even to current policy holders.

The NHS represents a social contract with the British people. Inevitably time requires the evolution of this agreement. But changes should be part of a transparent and accountable system. They must be introduced sensitively. Otherwise, as Mrs Bottomley has found, trust quickly breaks down.