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Grit in the Works

Frogs in a jam-jar

Three BBC programmes have reviewed the impact of the NHS changes of the last decade. They did not emphasise the extent to which these changes are being watched round the world, as other governments look at ways of 'increasing the efficiency' of their state-funded health care [1].

A Welsh correspondent of Bandolier described the change in primary care of feeling like being "frogs in a jam-jar". Add to this the fact that the world is watching ...

Bandolier was struck by the way in which the programmes seemed to follow the frog metaphor. Once the decision had been made to make changes, effort swung into the process of managing the change while minimising the fall-out. Not the fact of the change, not the effects on health care delivery, but the political fall-out. The programmes implied that the effects of the changes would not be studied, because it was felt that to set up such studies would be perceived as a sign of weakness.

Among the original rules for hospitals wishing to become Trusts was one that Trust status would only be 'granted' if the staff voted in favour. That rule did not last long. Once the changes were in place it was rapidly obvious that Trusts would fall over financially unless the rules were bent. All water under the bridge you say, and quite right. Except that the echoes of our Welsh friend's feelings of jam-jar impotence ring in our ears.

Growing old


How many of us understand the minutiae of paying for long-term health care? At what point do you 'leave' the NHS, where care is free, and enter the territory of the local authority, where care is not free? Who makes the decision, and what is the basis of the decision? Bandolier has been struck ( Bandolier is struck so often it is tantamount to abuse) by the level of collective ignorance in this important area.

Lest you think it cannot happen to you, Young [2] cites the 1989 OPCS disability survey estimating that 4.3 million people over 60 in Britain are disabled. That is 70% of all disabled people and 46% of all older people. 'Most (over 90%) older disabled people live in their own homes, and most (over 80%) have only "mild" disability, but many have several types of disability'. Perhaps our interest will perk up when we have to pay a 1.5% tax towards our own demise.

We hope that our clouds of ignorance will be dispelled by reviewing Health Authorities' response to HSG (95) 8, NHS responsibilities for continuing health care.


  1. R Lacey. Internal markets in the public sector. The case of the British National Health Service. Public Administration and Development (in press).
  2. J Young. Rehabilitation and older people. British Medical Journal 1996 313: 677-81.

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