Perhaps care trusts will turn out to be transformational. We may
need to take a leap of faith and implement an untried model in the
hope that it will become a beacon on the landscape of our public
If this happens, it will be in defiance of everything we have
learned about previous changes. Public services in health and
social care spent most of the 1990s implementing structure changes
intended to put the interests of patients and users at the centre
of their care. Purchaser/provider separations, intended to confine
producer interests and enhance customer-driven commissioning, were
the most significant of these.
There have been notable successes – a rapid expansion in
domiciliary care and some highly innovative NHS trusts – but the
prize of citizen-focused public services has eluded both health and
We now have an NHS Plan that aspires to design services around
patients; we have increasingly urgent prompts from government to
cut through the bureaucracy of care management and replace it with
user management through direct payments. We have increasing numbers
of older people going direct to hospital for their care. They do
not pass “Go into community care services” and they often fail to
get back into them, losing the chance to return home.
Setting up the infrastructure of community care in the 1990s
distracted attention from achieving real change in frontline
practice. You could argue that the relationship between social
workers and users barely changed at all. Some would even argue that
it changed for the worse, with staff preoccupied with the
complexities of procuring care, working out its costs and
interpreting increasingly restrictive eligibility criteria.
The ambition of multi-disciplinary assessment, care management
responsibilities shared between agencies, flexible care packages
focused on user need, was very much present then. But, there was
never the commitment and cross-agency energy to address the skill
mix, training and cultural issues necessary to change front-line
services across the whole spectrum of health and social care.
This time around we must support fundamental changes in
frontline practice, and the joint agenda between the NHS and local
government needs to be described in these terms and not in the
terms of structural change.
But why should we presume that the care trust route is the right
one? We now have a range of flexibilities to create pooled budgets
and provide integrated services. We can and must exploit them where
they really count — when we come into contact with those using
The late Sir Roy Griffiths, asked by the government in the late
1980s to look at community care arrangements concluded that
“community care was everybody’s distant relative but nobody’s
baby”. His solutions were inherently based on a model of
personalised and integrated care management. This was the lynch pin
then and it remains so now.
Liz Railton is director of Cambridgeshire social