Eyes shut to social care

The familiar refrain of “breaking down barriers between health
and social care” echoes throughout the government’s recently
published NHS and social care model to support people with
long-term conditions.(1)

In the document’s foreword, national clinical director for
primary care David Colin-ThomŽ declares that the strategy will
encourage health and social care communities to “work across
boundaries” and to “adopt case management approaches… as a means
of ensuring these patients get fully joined-up health and social
care”.

But you only have to look at Dr Colin-Thome’s job title and his
use of the word “patient” to figure out on which side of the health
and social care fence the report sits.

Its five chapters, three annexes and 48 pages contain no mention
of direct payments and no reference to transport, housing, benefits
or employment. None of its good practice examples focus on social
work, and people with long-term conditions are referred to as
patients throughout. There is only one specific target in the whole
document – to reduce the use of hospital emergency bed days by 5
per cent by March 2008.

But the most obvious snub to social workers is the report’s most
radical proposal – the introduction of 3,000 community matrons by
March 2007.

Community matrons will be a “new type of health professional”
who will take on caseloads of around 50 to 80 people whose
long-term conditions require clinical intervention as well as care
co-ordination.

“They will work across health and social care services and the
voluntary sector, so that this group of patients receives services
that are integrated and complementary,” says the report.

They will, however, be nurses.

Despite the wealth of experience among social workers who have
similar case management roles, only those with a nursing
qualification will be eligible for the new community matron
role.

It is an exclusion that rankles with Ray Jones, director of
adult and community services at Wiltshire Council.

“It totally ignores the skills and experience that social
workers have as care managers, working and engaging with disabled
people,” he says.

“And at a time when nurses are considered to be a scarce
resource, you have to question whether this is the best use of
their skills. Do nurses have the knowledge to advise people within
the broader social context, on their housing options for instance,
on transport or how to claim benefits?”

Jones believes that, despite the inclusion of the term social
care in the subtitle of the government’s report, it is essentially
a medical strategy, targeted at the high-risk end of the long-term
disability spectrum. Its principal aim is to keep potentially
expensive patients out of hospital, he says.

“This is not a social care model,” says Jones. “It’s a clinical
model, it’s disease focused and it doesn’t take into account the
social model of disease. Social care is an afterthought. It’s all
to do with resources.”

The Long-Term Medical Conditions Alliance, which last year
published a manifesto for improving long-term care, has also
sounded a note of caution. It says that the approach laid out in
the government’s new model could “result in attention and resources
being disproportionately focused on the small minority of people
with the most complex conditions”.

A warning echoed by the King’s Fund, whose chief executive Niall
Dickson has stressed the need for a wide range of services “not
least to ensure that those with less severe needs are not left
out”.

In fact, the government’s new model outlines three levels of
care that should be made available to people with long-term
conditions. Level three is aimed at the most vulnerable and at
those with highly complex multiple long-term conditions. For these
people, community matrons are to use a case management approach to
“anticipate, co-ordinate and join up health and social care”. Level
two is aimed at those with a complex single need or multiple
conditions, and involves disease-specific care management by
multidisciplinary teams.

Level one is based around supported self-care, in which
individuals and their carers are helped to develop the knowledge,
skills and confidence to look after themselves.

But this pyramid of care could be used to “focus resources only
on people with complex conditions”, warns LMCA chair Elizabeth
Wincott.

“People shouldn’t be put into rigid categories, and co-ordinated
care plans should be the right of everyone diagnosed with a
long-term condition,” she says. “Long-term conditions impact on
every area of life – it’s not just about keeping people out of
hospital.”

Nevertheless, Wincott welcomes the recognition of the value of
self-care.

“We are pleased that the role of patients as partners in their
treatment and care has been acknowledged, along with the importance
of self-management as a means of helping people live with their
condition.”

Patient groups have, by and large, welcomed the report, which
many see as a taster of what may be included in the National
Service Framework for Long-Term Conditions, which is due to be
published later this year.

Diabetes UK has applauded the proposal for community matrons
although, like the LMCA, the charity has warned “against the
temptation of just focusing on keeping people out of hospital
rather than tackling the problems which have made some people so
vulnerable”. Its director of care, Simon O’Neill, adds: “The new
model of care is a well overdue and much welcomed initiative. We
must look at the most vulnerable people and do all we can to avoid
them having to end up in hospital.

“But the most effective way to do that in the long term is to
prevent them from becoming so vulnerable in the first place. It is
about effective education and support.”

The Parkinson’s Disease Society has also welcomed the idea of
community matrons and the recognition of self-management.

However, the society has stressed that the model must retain
enough flexibility to respond to the particular individual needs of
people with Parkinson’s and their carers. It says that while it is
a good objective to keep more people out of hospital, those
affected by Parkinson’s disease need to be able to move between
services and have access to a variety of health and social care
services at all times.

There are 17.5 million people in the UK estimated to have
long-term incurable conditions, such as diabetes, asthma and
arthritis. Although the forthcoming NSF on long-term conditions is
expected to focus primarily on neurological conditions, health
secretary John Reid has already made it clear that this recently
published model will provide the blueprint for how long-term
conditions are dealt with in the future. As to whether the desired
levels of integrated care can be achieved without significant input
from social care professionals, many have their doubts.

(1) Supporting People with Long Term Conditions: An NHS and
Social Care Model to Support Local Innovation and Integration
available at DoH website: www.dh.gov.uk/assetRoot/04/09/98/68/04099868.pdf