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Paying for the little extras

Alongside paying our taxes for public services, there has been an increasingly expectation that citizens will pay for those little extras. Once upon time we would have had the following:

  • unlimited refuse collection service that included disposal of bulk waste for households;

  • school services included free meals and text-books for pupils

  • NHS services covered all areas of healthcare, included dentistry, Ophthalmology and prescribed medication.

  • Local Authority’s day care centres included social care and activities for disabled service users.

Since austerity, the trend is towards cutting services to the bare essentials, and making service users pay for those little extras. Day activities, dentistry, opticians, bulk waste collection and library book reservations are amongst a whole range of little extras that service users are expected to pay for in addition to public services, delivered free of charge at the point of need.

This raises important questions about what is considered as essential services and what are the nice little extras. So in hospital, is it a little extra to have good nutritious meals, some entertainment (i.e. access to free television and radio) and opportunities to make and receive telephone calls? Whilst the latter is less important as most people have a mobile phone, nevertheless we should be asking whether any of these extras are essential part of the patient treatment and recovery plan.

If we agree the aim of good care is to promote one’s wellbeing, then purposeful activities should not be viewed as something separate; good care without purposeful activities is going to leave service users feeling bored and isolated. However, a question can be asked whether such activities and services we pay for in our day to day lives should continue to be paid for by the state. We currently pay for stuff such as paying for healthy food and meals, purposeful activities including gym membership which promotes our own wellbeing.

There are some liberals who have suggested that the state should go further and ask service users to pay for a broader range of extras. For instance, if one is living in a care home, then the resident should pay for accommodation and food, just like they would do if residing in their own home. Similarly, one should pay for hospital meals as food is a day-to-day cost that we would pay for even out of means-tested social security benefits. In an effect, the liberals are asking us to pay for similar things that we would pay for in our daily lives whilst using public services.

On preface, it would be the poorest people that would be most disadvantaged from being expected to pay extras associated with necessary services , after all many of us do not actively elect to be treated in hospital or apply for social services, or indeed any other services. Even with the NHSE discounts on offer, many of the poorest people may not pay the dentist or the politician’s fees and charges for essential services. And now I am hearing about disabled people not being able to afford the care packages because they are unable to pay the charges. Disabled people in renting accommodation will still be required to pay for housing regardless where they are residing, i.e. in a hospital or a care home. So, who are the biggest winners of a NHS service that provides free services at the point of need? A disabled person who has brought their own home will actually gain as they are in affect getting free accommodation if they are being treated in hospital or being cared for in a nursing home. Also, the well-off can choose to opt for NHS subsidised rather than private dentistry and other care services.

But, one of the arguments against the extras is that many people using health and social care services do not have a choice. For instance if detained under the Mental Health Act, patients generally would have no choice over their accommodation and over the extras; similarly if one is residing in a care home, it is often because that is where the care is provided and therefore one has no choice over accommodation and the extras – where the state compels a person to be in a specific facility because the care cannot be provided elsewhere, then there is a real argument for everything to be provided free of charge at the point of need.

For me, the bigger issue is that we know the cost of everything and value of nothing. So for example, we know the cost of providing a tasty meal or providing purposeful activities, but ignore the value that such extras have in promoting our wellbeing. If we continue in this vane, we do so at our peril – too often the “extras” are what helps us get through tough times when engaging with public services.


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