Will reforms suit users?

Bob Hudson is visiting professor of partnership studies
in the school of applied social sciences at the University of
Durham. He has written and researched on partnership issues for the
past 20 years, and is a specialist adviser to the House of Commons
Education and Skills Committee on partnership and integration
issues.

Public sector reform is set to be the centrepiece of Labour’s third
term of office. The government has gone through two necessary
phases of change that are now at an end – “emergency repair” and
mechanistic reform around centrally driven performance.

The task now is connecting services more directly to people, and
shaping them around their needs. But what do the public sector
reforms mean for those working in children’s and adult care
services?

There are certainly sufficient similarities to see an emerging
pattern of change. Perhaps the most obvious one is the long-term
and transformational nature for social care and its partners of the
anticipated reforms. The children’s services changes, now well
under way, are seen as a 10-year programme. Those planned for adult
social care will, it is said, require 10-15 years’ development. The
prime minister’s desire to leave an enduring legacy of public
sector reform is nowhere better represented than in these two areas
of policy. Unfortunately, the government seems to believe that
transformation and cost-neutrality are compatible – surely an
untenable position.

The next point in common is the discovery of outcomes-based policy.
Outcomes are the effects or impacts on the welfare of service users
and should be distinguished from outputs, which are service
products. Consultations with service users and their
representatives are said to drive both sets of reforms.

The identified outcomes for children’s and adult services
respectively show striking resemblances.

Four of the five children’s services outcomes have a direct
counterpart in the adult services green paper – being
healthy/improved health; staying safe/freedom from discrimination
or harassment; making a positive contribution; and economic
well-being. Enjoying and achieving might be said, at least in part,
to equate to “improved quality of life” while “personal dignity”
for adults should arguably be a sixth outcome for children’s
services. This leaves only one major difference – “the exercise of
choice and control” – where the balance of risk and protection is
different for children and adults.

The main way in which the adult care green paper foresees greater
exercise of choice and control is through an extension of direct
payments – the key “big idea”. Few would disagree that this will be
the right option for some people. But it is also important that
choice and control are meaningful for people for whom
“independence” might have less direct resonance. Independence means
different things to different people, and it is not always clear
what it means in the green paper. Independence can be living
independently, but it can also be getting the most out of life.
This might mean accepting dependence upon others for support with
the activities of daily living to pursue other important
goals.

What this also raises is risk. The two sets of reforms are finding
it difficult to strike a balance between risk and protection. In
the case of children’s services, one of the main criticisms is of
the proposed database of all children, which some see as
unnecessary and intrusive. By contrast, the adult care green paper
swings the other way, with a bold acknowledgement that services
designed to promote independence will involve greater risk.

This all forms part of the prime minister’s broader view that
modern societies are loading government bodies with too many
detailed and restrictive protective responsibilities.

While both reforms explicitly address “risk protection”, they
uncritically endorse “choice” as a self-evident good. In principle,
we would all like more choice – the populist attraction is
undeniable. But the emphasis upon individual choice and autonomy
sits uncomfortably with parallel concerns about ensuring
cost-effectiveness. How can there be individual choice when
services have to be rationed in a cost-neutral exercise? In
addition, the reforms do not seem to recognise the limitations, as
well as the benefits, of choice. Questions of the collective good,
as well as of individual interest, need to be taken into
account.

The similarity of approach across the two sets of reforms is less
evident when it comes to implementation. Having guiding concepts
that shape a vision of public sector reform are one thing; turning
them into practical proposals is another. The changes in children’s
and adult services seem to differ markedly in this respect – while
children’s services are characterised by a tight and ambitious
implementation timetable, the adult services reforms are barely off
the starter’s block.

For children’s services, the implementation strategy tries to
ensure the identified ends – the “outcomes” – are underpinned by
the “means” – the different levels of activity at which a joint
approach is required.

This starts with interagency governance at a national level, moves
down through an integrated strategy and processes, to the front
line where delivery of services takes place through the efforts of
social care, education and health specialists.

In this rational model each of these levels needs to be addressed
simultaneously. Failure at any one level could undermine the
chances of achieving the desired outcomes.

Implementation of the Every Child Matters reforms is anything but
easy as the Commons education and skills select committee recently
argued. But at least there is coherence to the implementation
strategy.

The proposals for adult social care, on the other hand, are much
less well articulated. Arguably, a green paper is meant to indicate
only a general direction of travel. But following a year of
consultation and gestation, many of the concepts and proposals
remain disappointingly poorly developed.

The implementation model, however, does miss out an important outer
layer – the degree of inter-departmental coherence at national
level. It is not good enough for central government departments to
require local agencies to join up in ever more ambitious
arrangements, when fragmented messages are being sent down from
separate central silos.

In the case of older people, for example, the National Audit Office
has identified 14 separate government departments that have a stake
in policy.(1) Yet Independence, Well-being and Choice misses the
opportunity to identify and strengthen these connections.
Meanwhile, as the education and skills select committee notes, the
Department for Education and Skills alone is managing to run two
contradictory policy streams on education and children’s services
respectively.

The general thrust of the public sector reform model has wide
support – notions of choice, independence, proactive intervention
and seamless care are understandably attractive. But what matters
is what this will mean in practice for users, carers and those
professionally involved in service planning and delivery. On that
score there are still more questions than answers.

Reforms and outcomes
Children’s services
* Being healthy.
* Staying safe.
* Making a positive contribution.
* Economic well-being.
* Enjoying and achieving.

Adult services
* Improved health.
* Freedom from discrimination or harassment.
* Making a positive contribution.
* Economic well-being.
* Improved quality of life.
* Exercise of choice and control.
* Personal dignity.

Training and learning
The author has provided questions about this article
to guide discussion in teams. These can be viewed at
www.communitycare.co.uk/prtl and individuals’ learning from the
discussion can be registered on a free, password-protected training
log held on the site. This is a service from Community Care for all
GSCC-registered professionals.

Abstract
The government is looking to fundamentally reform the
way social care services for children, young people and adults are
planned, commissioned and delivered. This article explores some of
the key principles underpinning these reforms. It argues that
although the two sets of reforms have much in common there are also
differences, and that much remains unknown about what the services
of the future will actually look like.

References
(1) National Audit Office, Developing Effective
Services for Older People, HC 518, 2003

Further Information

• Latest information on the Every Child Matters reforms can be
  found on www.everychildmatters,gov.uk.
• Details on Independence, Well-being and Choice are available at
  www.dh.gov.uk.
• Papers and speeches relating to the Institute for Public Policy
  Research are at www.ippr.org.uk.
• An independent review of issues relating to the adult social
  care proposals by the author and colleagues can be downloaded from
  www.york.ac.uk/inst/spru/

Contact the author
bob@bobhudsonconsulting.com