Thursday 3 January 2008

Free Care

The NHS, notionally, is free at the point of contact.

Okay, we pay for prescriptions and eye tests and dental work but, for the most part, it's true that most of the NHS is free at the point of delivery.


Health care is delivered without charge.

But, the huge grey cloud dominating the faint silver lining is that social care is not free. We pay a lot in to social care as taxpayers (over twice what we pay in to health) and then the recipients of social care (when patients) invariably pay for it, too.

If I've a patient who's not coping awfully well at home but can manage with support, they're helped and usually manage in their own home for a goodly length of time, sometimes indefinately. Get a cleaner to do the housework, Social Services to arrange 4 social care visits a day to help with personal care, prompting with medication, checking they're alright (although officially that can't be the reason for their visit), helping heat up a meal for them and acting a resource to sort out problems (letters they don't understand, or whatever). Their loneliness and weary days can be addressed in part through social day care where they've more vibrant company with local folk and ongoing support.

But none of this is NHS work, none of it is free. They pay for their cleaner, they pay for each home care visit, they pay for their meals delivering, they pay for their day care.

The exception . . . if you're detained under section 3 of the Mental Health Act 1983 then you're entitled to section 117 aftercare. The Code of Practice states that this, ". . . require health and local authorities . . . to provide after-care for patients who have been detained under the longer-term provisions of the Act . . . until they are satisfied that is is no longer necessary . . . section 117 obligations have statutory force."
This means if I'm involved in a detained patient's care and consider a care package such as social care visits would be useful, we can't force the patient to spend their money on this (but they have no choice but to be in hospital and have treatment) so any social care is paid for by the local authority (i.e. Social Services). On leaving hospital, both health care and social care is free.

Bit of a puzzle, this. If we manage folk as we do, keeping them in their own homes where they wish to be for as long as possible then their family and they choose a 24 hour care home if things progress and it's necessary, they're enjoying time in their own home (i.e. in the least restrictive setting) and all is well. If we drag them kicking and screaming in to hospital under section 3, when they leave hospital everything's free.

The General Medical Council document from 2006, "Good Medical Practice", states the duties of a doctor registered with the GMC with the first and foremost requirement being, "Make the care of your patient your first concern."
Care, not health. Hmmm. Should we be detaining everyone, so their social care is free?


Jan said...

Fabulous idea, Shrink. BTW, have you thought of a way of diplomatically explaining your rationale to the patients and their relatives when they're going through the "omygodsectioned underthementalhealthact!" phase of the process?

E said...

Shortly before leaving my last community job I was introduced to the concept of direct payments.

“Direct payments are cash payments made to individuals who have been assessed as needing services, in lieu of social service provisions.

They can be made to disabled people aged 16 or over, to people with parental responsibility for disabled children, and to carers aged 16 or over in respect of carer services. A person must be able to consent to have a direct payment and have the capacity to manage one, although they can have assistance to manage their payment on a day-to-day basis.” DoH guidance.

The impression I gained was that as long as a need had been identified by a mental health professional (and presumably this would apply to social services as a whole) then a payment would be made regardless whether the patient had been detained under section 3 and was thus subject to sec 117 aftercare.

I did mischievously enquire that if a patient of mine had identified a “need” for regular sex and if I agreed that not “getting it” on a regular basis was likely to have an unfavourable impact on that individual’s mental state. Could I make an application for my client to pay a monthly visit to madam Fifi’s massage parlour for a bit of light executive relief?

I am still waiting for them to get back to me on that one ;-) .