A happy couple?

Care services minister Liam Byrne describes his plans for an
integrated health and social care white paper as part of the
“intellectual architecture” that will be used for the Department of
Health’s submission to the spending review in 2007. Work on
developing a national improvement strategy across health and social
care has been assigned jointly to the new Care Services Improvement
Partnership (CSIP) and the local government Improvement and
Development Agency (IDeA).

What are we to make of these developments? On the positive side: it
is nonsense for health and social care policy to continue to
develop in parallel when it might more fruitfully be integrated.
One of the errors of the Thatcher era was to produce two white
papers on health (Working for Patients) and community care
(Caring for People) that avoided any mention of each
other. In contrast, the quest to “bring down the Berlin Wall”
between the two services is one that has exercised Labour
governments since 1997, yet the solution remains elusive. In
seeking improved partnership between health and care, however,
Byrne is following a well-trodden path and will do well to heed the
lessons of experience.

A white paper that addresses both the health and social care agenda
is an ambitious one. The scale of that ambition is evident in the
extent to which the green paper showed so little awareness of and
connection with the NHS agenda, despite the recognition of
“well-being”, while changes in the NHS seem equally unaware of
social care. Indeed, the green paper has scarcely registered on the
radar of many primary care trusts. An integrated document would,
therefore, be a major achievement.

At present, a model for strategic working between the NHS and
social care is lacking, and the white paper will need to tackle the
parallel tracks and ensure more coherent integration. The biggest
danger is that the existing work on the “out-of-hospital” white
paper will continue with social care partners being late arrivals
at the party or perceived as NHS gatecrashers. This would be the
worst of all worlds: an NHS document with lip-service paid to the
wider agenda. We have been there before – the NHS Plan of 2000 was
a classic example of such an approach. The major reduction of key
staff in the DH has severely affected social care, and the loss of
knowledge and expertise does not bode well for steering the white

The development of practice-based commissioning in the NHS
highlights some of the difficulties. Initial developments and
guidance appeared to have had little to say on the relationship
with other key local commissioning strategies.

The publication on 28 July of advice on commissioning a patient-led
NHS may signal a welcome change of emphasis. This letter to PCTs,
strategic health authorities (SHAs) and social services chief
executives may have been heavily criticised as “intellectually
incoherent” by the NHS Confederation for its directive that PCTs
should in general stop directly providing services, but it does
seem to have some things right.

In establishing the right configuration for commissioning, the
advice stated that SHAs should co-ordinate a review by “engaging
PCTs, other stakeholders, including local government and NHS
staff”. Moreover, “as a general principle”, reconfigured PCTs will
be expected “to have a clear relationship with local authority
social services boundaries”. This at least is a start, as is the
emphasis on coherent access to integrated health and social care

In terms of a strategic relationship, the role of the new director
of adult social services needs to be pivotal. The green paper
referred to the director as having co-ordinating responsibilities
beyond the organisational boundaries of adult social care. For this
to be a reality, there need to be much stronger incentives for the
NHS to engage as partners. There are particular opportunities for
approaches to commissioning. Whether the director should have
statutory responsibility for developing an adult social care
strategic plan is open to debate. This could be a valuable tool in
assessing locality needs and developing plans with partners.

However, the plan itself is but a means to an end, and there would
be a danger of returning to the old approach of the community care
plan in which all too often the focus was on the plan as an end in
itself, with little or no underlying strategy. A strategic planning
role is essential, but the form this needs to take is probably best
worked out at local level rather than through central diktat. The
issue remains, however, of what leverage and incentives there need
to be to engage effectively with key partners.

The other major challenge for the integrated white paper is the
extent to which this agenda is much bigger than health and social
care. The green paper paid little attention to how the social care
agenda could relate to developments around neighbourhoods being
promoted by the Office of the Deputy Prime Minister and also failed
to link the social care agenda into key strategic shifts, such as
local area agreements and local strategic partnerships. There are
even greater risks that these critical junctures will be beyond the
scope of the white paper, and it is essential that this is not the
case. The role of CSIP and IDeA will be especially important in
taking forward this wider regeneration agenda.

In announcing the next steps, Byrne acknowledged that “we may need
to supplement the white paper vision with additional work”. It is
unclear what this means, but if it is an acknowledgment that the
integrated document will not offer the comprehensive and coherent
vision that is required, we might as well give up before we start.
This is precisely what must not happen. The decision to develop an
integrated white paper is controversial; there are fears about the
extent to which the two cultures can be melded successfully, and
whether the dominance of the medical model can be resisted.

On the other hand, this is an unprecedented opportunity which
offers a chance to look at the shape and direction of health and
social care through a whole-systems lens. That integration has to
be comprehensive; an NHS white paper with a few optional social
care add-ons would be bound to fail. Byrne has said that we should
judge him on his results and on what the document looks like. The
minister is taking a considerable risk in this strategy; the easy
answer would have been to pursue the traditional but fundamentally
flawed twin tracks. The integrated white paper will be much more
difficult to achieve, but has the potential to offer a far more
ambitious and satisfactory outcome.

Melanie Henwood is an independent health and
social care analyst with particular interests in community care,
older people and their carers. She is also a lay member of the
General Social Care Council.

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.

Training and learning
The authors have 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

The government is to take forward the green paper on adult
social care by expanding that already being taken forward on NHS
care outside hospitals. There are strengths and weaknesses in this
approach. In this article we explore the issues and consider the
prospects for a genuinely integrated whole systems approach, or for
a poor quality compromise that is fundamentally flawed.

(1) Department of Health, Commissioning a Patient-led
, DH, 2005

Further information

  • M Henwood and B Hudson, Independence, Well-being and
    Choice: Response of the ADSS
    , from www.adss.org.uk, located in the
    consultation responses section
  • B Hudson and M Henwood, “Social care and the NHS: the final
    countdown?”, Policy and Politics, 30(2), pp153-66,
  • The role of the Care Services Improvement Partnership can be
    found at www.csip.org.uk
  • The role of the Improvement and Development Agency can be found
    at www.idea.gov.uk

Contact the author
E-mail: melanie@henwood-associates.co.uk
and bob@bobhudsonconsulting.com

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