Plan of action or vague wish list? Ladyman signs off the final draft

Last April, community care minister Stephen Ladyman said he
wanted a “new vision for adult social care”, which would be
published that summer.

Several deadlines later, the adult green paper remains
unpublished.

With the general election expected in May some fear the paper will
not appear until later in the year. But the smart money is that it
will come out just before the election.

It is understood that Ladyman has signed it off and it is now in
the hands of a cabinet sub-committee headed by former health
secretary Alan Milburn. The paper is expected to be released
alongside a Department for Work and Pensions strategy for older
people as part of Labour’s election offer to pensioners.

But for Ladyman and many in social care, the green paper is more
than an electoral ploy. Ladyman wants to tackle “the
professional-knows-best culture” that he believes still pervades
social care and is a barrier to services being truly focused on the
user.
Ladyman has been open about the green paper’s contents: he has
repeatedly suggested how his three headline principles –
personalisation, pro-activeness and seamlessness – could be
applied; and social care leaders have seen early drafts.

More recently, he revealed the paper would bear close resemblance
to the Prime Minister’s Strategy Unit’s recent disability paper
Improving the Life Chances of Disabled People.

The green paper will not be the last word on the future of adult
care. One source close to the publication says it has become
“increasingly green,” suggesting it will provide less a statement
of policy than a series of questions.

Social care leaders have already formed a group to lobby on the
green paper. Given the success of the equivalent children’s group,
they will be confident they can exert similar influence on adult
policies. Already they have had some effect with proposals for
independent assessments appearing to have been dropped, because
leaders said budgets would rocket sky-high.

But, the paper is likely to call for greater self-assessment, with
users playing a role in determining their level of need and even
the resources required to support them. The government’s belief is
that people will not over-assess their needs.

Following the strategy unit’s lead, the green paper is likely to
call for individualised budgets, which people will be able to take
as direct payments, services commissioned by councils or a mixture
of the two.

The strategy unit suggests these budgets could fund other services,
such as leisure or transport. The green paper is expected to follow
suit. Individualised budgets raise significant questions about
councils’ role. As Ladyman has said, there are tensions between
personalisation and councils’ efficiency targets, which suggest
large-scale commissioning. There are also concerns that individuals
controlling their own services could fall victim to bad
providers.

The green paper is likely to call for councils to invest in
advocacy services and act as “brokers” between providers and
users.
For John Dixon, social services director at West Sussex Council,
this will mean “there is a role for local authorities to have a
commissioning infrastructure in place [for users to choose services
from]. What we will need to become better at is predicting what the
aggregate of individual budgets will produce.”

Personalisation will be complemented with a strong emphasis on
independent living. The strategy unit paper calls for disabled
people to be given a right to request independent living, which
could be extended to older people in the green paper.

It will also call for a significant expansion in extra care housing
at the expense of residential care, though Ladyman has admitted
that this could take 20 years to achieve.

In several speeches Ladyman has called for a social care system
that promotes independence through preventive services such as
housing, leisure and transport. A similar message was apparent in
Improving the Life Chances of Disabled People.

Such a move would signal a complete reversal of the long-term trend
for social care to focus on people with the most acute needs,
through ever tighter eligibility criteria. Its implication is
significant: upfront investment in prevention on top of existing
funding for acute cases.

Jon Glasby, senior lecturer at Birmingham University’s health
services management centre, says: “We’ve got to carry on down that
course while we also invest in longer term preventive measures that
may not bring in cost savings for a number of years. That will take
some form of double funding.”

The strategy unit says the government will have to give councils
“invest to save” funding, and calls for the Department of Health to
bid for extra money for pilots in next year’s spending
review.

One way forward could be through local public service agreements,
in which councils are given money to revamp services to meet
targets agreed with government.

Dixon suggests the government’s response to the King’s
Fund-sponsored Wanless review of older people’s care is cause for
optimism about funding. He says: “I’ve been encouraged to see the
DoH saying they will be considering whether to come in behind the
Wanless review.”

For some outside local government, funding is only part of the
problem about a shift to prevention – councils must change
too.
John Knight, head of policy at Leonard Cheshire, says: “We’d like
to see the DoH say something directive about councils adopting a
more preventive approach in their commissioning strategies.”

A DoH leak in December sparked speculation that the government
would impose compulsory commissioning partnerships on councils and
primary care trusts – so-called virtual care trusts.

This has since died down. Glasby says: “The DoH seemed very
surprised. They said it wasn’t something they were actively
considering.”

There is sure to be a push for greater integration but many believe
this will be along the lines of the Children Act 2004, with
outcomes set by the centre and areas given the flexibility to
pursue them.

But some even see some danger in this, in the potential for health
priorities to swamp social care values.

Knight says: “I’d like to see the green paper almost celebrate the
importance and sanctity of the social model… [That’s] what’s
going to make independent living work.”

Given the emphasis on prevention, there will also be calls for
closer integration between social care and services like housing,
transport and leisure.

On paper at last?

Personalised services
Probable:

• Individualised budgets.
• Self-assessment.
• Extra care housing.
• Promotion of Homeshare schemes in which older or disabled
  people share with key workers or young people.
  Personalisation is expected to be the keynote of the green
  paper.

Less likely:

• Independent assessments.

Seamless services
Probable:

• Greater integration between health and social care.
• Closer working between social care and community services.

Less likely:

• Care trusts, virtual or otherwise.

Proactive services
Probable:

• Social care to be much more preventive.
• “Invest to save” pilots to test how this could work.

Less likely:

• A strong commitment on social care funding.