Long Term Care
Last Updated: March, 2019

Long-term care (also known as Continuing Care) is care given to someone who needs support for a long period of time. This might be provided as in-patient care, but will very often be domiciliary care, residential care, nursing home care or end-of-life hospice care. The priority groups for people requiring long-term care include; elderly people, people with learning difficulties, people with a mental illness and people with a physical disability.

The  National Health Service Act 1946  originally gave responsibility for the long-term care of sick and infirm people to the NHS where it was provided free of charge; frail elderly people were the responsibility of local authorities who applied means-tested charges. From the mid 1960s this parallel system became increasingly blurred, with local authorities being asked to provide more-and-more care for sick and infirm elderly people. Despite this, successive governments were unwilling to invest in new residential homes, nursing homes and domiciliary services.

In the 1980s this inadequacy in the design of our health services (resulting from intense resistance to the creation of the NHS in the first place) was finally exploited by the Thatcher government who started a massive transfer of long-term care from public to private provision, which continued throughout the 1990s. It was not just care for the elderly, the transfer included mass closures of psychiatric hospitals and psychiatric wards - many of which might well have needed closing, but in this context the plan was not to replace them with adequate publicly provided alternatives.

  • Between 1982 and 1993 148,000 NHS supported long-term beds were lost.
  • Between 1982 and 1993 the number of local authority supported long-term beds fell by a third for elderly and physically disabled people and by a quarter for people with a mental illness.
  • Private and voluntary sector long-term beds grew from 89,400 to 205,500 places for elderly and physically disabled residents and from 6,540 to 12,847 for people with a mental illness.
  • In 1979, 16 percent of residential care homes were in the for-profit sector, 20 percent were in the voluntary (not-for-profit) sector, 54 percent were in the public sector.
  • In 2003, 90 percent of nursing home beds and 63 percent of residential care beds for the elderly, chronically ill, physically disabled people in the UK were operated on a for-profit basis.
  • By 2004, over 70-thousand elderly people are forced to sell their homes every year to pay for their care.
  • Approximately one quarter of elderly people live below the poverty line.

The transfer from public to private provision of long-term care was funded with public money by allowing patients in private long-term care facilities to claim social-security benefits to pay for their care in those facilities. As the social-security budget is separate from both the NHS budget and the local authority budget, it gave an incentive to cash-strapped NHS authorities and rate-capped local authorities to encourage patients to withdraw from publicly provided services. It also gave a guarantee to private care home providers, thus setting up the private care home industry. It is worth noting that patients could not claim social-security to contribute towards the costs of housing in a local authority provided care home.

The fact that social-security was being used to subsidise the growth of the for-profit care home industry meant that it was effectively free for local authorities to place an elderly person in a private care home. This had the perverse effect of denying some of the poorest elderly people care in their own homes, because responsibility could be shifted from local authority funded domiciliary care to social security funded private care. In effect these elderly people lost their homes to help pay for the growth of the private care home industry.

The 1990  National Health Service and Community Care Act  then gave all responsibilities for  social care  AND long-term care to local authorities, and it closed the social-security loophole so that the only funding for such care could come from the local authority budget or the patient's own pocket. Moving all responsibility for long-term care to local authorities also facilitated further sales of NHS land and long-term care facilities including many cottage hospitals, some of which are now golf-courses, supermarkets and luxury homes.

Various funding mechanisms including grants that could only be spent in the private sector were used to coerce local authorities into commercially contracting the use of private care homes, at the same time funds for local authorities to invest in their own care homes were cut.

This financial coercion to use private sector care homes, had the effect of encouraging local authorities to sell their own care homes and associated land to private companies at rock bottom prices. By 1996, 12 percent of private care homes had been purchased from the public sector. Dumfries and Galloway Council sold five homes worth a total of £2-million for £1 each (yes, you read that correctly - one pound each!).

In 1998 the Health Minister, Paul Boateng said:

The days when a local authority could get away with an approach to residential care which was always to prefer their own provision before that of the private sector are dead and gone and will not be tolerated... [if a local authority] seeks persistently to undermine the private sector that local authority will answer for it.

By 2003 ~70 percent of care home places were with private providers. This also means that where someone does not have the means to pay for residential care themselves, and the only space available is with a private provider, they will be allocated to the provider charging the lowest fees; and that provider is likely to be providing inadequate care.

But the private care home industry has failed. Large chains of private care homes are owned by the likes of Alchemy - a 'venture capital group' who once tried to buy the car manufacturer Rover. Smaller care home operators are prone to closures. 800 homes closed each year between 2000 and 2003. Re-homing anyone is traumatic, for frail elderly people who are settled it is morally repugnant. It is bad for an elderly person's health and can be life threatening. In 2002 a 108-year-old woman starved herself to death in protest of the closure of her HOME.

The private care home industry as a whole has used blackmail to get the fees paid to it by local authorities raised. In a particularly shocking incident in 2000 a care home owner in Devon threatened to evict thirteen residents just before Christmas unless the local authority paid an extra £45 per week for each resident.

In 2000 Chai Patel was a member of the Department for Health's Taskforce for Older People that advised the government on care home standards. Patel also happened to own one of the largest private care home providers in the UK, Westminster Health Care. Patel was earning an annual salary from Westminster Health Care of £433-thousand. One of the care homes he was responsible for was called Lynde House, where residents were charged up to £800 per week. The families of 3 residents at Lynde House raised issues about the care standards at the home, shortly after they received letters asking them to remove their relatives from the home. An independent inquiry found:

  • Residents left without being bathed for months.
  • Residents left in soiled bed cloths.
  • Unchanged incontinence protection.
  • No access to call bells.
  • Insufficient staff numbers.
  • Inadequately trained staff.

In 2002 Patel stepped down from his role as government advisor when his tenure ended.

The problem is not just one of self-serving individuals, the privatisation of health care for which long-term care has been at the forefront, is a systemic problem. For-profit means that someone somewhere is trying to get rich. To do this they must extract a profit. Profits can only be extracted from labour and service users, I.e. you pay staff as little as possible and charge service users (directly - or indirectly through taxation) as much as possible, therefore the whole paradigm of for-profit health care is a bastardisation of 'Care'.

Local authorities (unlike the NHS) have always had the power to charge for their services. They could charge a flat-rate or means-test. The result of this has been to create a lottery in care provision between different local authorities. The governments of the 1980s and 1990s (Thatcher, Major and Blair) encouraged charging by deducting a fixed amount (30 percent of a regions residential care costs and 9 percent of domiciliary / home-help costs) from the annual government grant for each local authority. This ensured that those local authorities that tried not to charge patients for publicly provided care would be out of pocket.

Saul Becker in Responding to Poverty says:

...the consequence of this process [of charging] was to impoverish many elderly and disabled people. It forced them, by requiring them to spend their savings (or have their assets taken into account), from a position of independence, to a position, ultimately, of dependence on Income Support and local authority funding for the payment of their care fees. Over time, as their frailty progressed and their savings declined, they were transformed from independent citizens in the community, to financially independent users of residential care services, to the dependent poor in institutions.

The concept of forcing people to pay for their long-term care until they are too poor to pay for it themselves is a concept imported from the US, and is called spend down.

In 2001, a system of NHS funded assistance was introduced for those elderly people who had failed the means-test. This entitled them to a reduction in the cost of their personal care with the highest subsidy of £110 per week going to the most needy, and £35 a week to the least needy. These subsidies were paid directly to care home managers, who in some cases (such as with Southern Cross Health Care Services) did not pass the savings onto the elderly people in their care. This is entirely legal as the private for-profit care home providers are under no obligation to reduce fees, and can - and do - treat their patients as 'consumers'.

In 2002 The Scottish government made all personal care for people over sixty-five free. This was the recommendation of a Royal Commission report that was wilfully ignored by the Westminster government. Scottish care home residents are means-tested for assistance with their care home accommodation charges, but not for their personal care.


 Allyson Pollock  et al wrote the book NHS plc (see sources below) partly with the aim of creating a written account of what the NHS was like (the good and the bad) before privatisation began. She did this with the hope that such an account will guide future generations who will have lost the institutional memory of the actual services as they were provided. The concept of long-term care as a right or entitlement has already disappeared.

As the Save South Tyneside Hospital campaign fights for the core acute services at our local hospital, we do so in the wake of numerous smaller hospital and service closures that have already happened over the privatisation years from the 1980s. So, one of the reasons it is very important to hold on to services RIGHT NOW is to keep alive the institutional memory and shared understanding of our entitlement to these services and all forms of high quality health care, locally accessible, and free at the point of delivery.