Now it’s our say

Grand visions abound and there is plenty for the social care sector to influence when it comes to funding and implementation. In the first of a series of Knowledge Zone articles on the health and social care white paper,  Bob Hudson offers his verdict on Our Health, Our Care, Our Say.

So we have had the adults’ services green paper, the expensive and lengthy consultation and now the white paper itself.(1) Do we now have a clear sense of what the future holds? The answer is a complex mix of yes, no and maybe.

The good news is that the white paper is underpinned by a vision with which few will disagree – putting people more in control of their own health and care; enabling and supporting health, independence and well-being, and rapid and convenient access to high-quality, cost-effective care. Social care has a part to play in all of these aspirations and the fact that the white paper contains no separate section on social care is not necessarily a problem. 

It was inevitable that the media reaction would be dominated by issues about access to health care – the availability of life checks, the renaissance of community hospitals and so on. At first sight, social care scarcely seems to register, but this is a misleading impression.

First, the white paper proposes a raft of measures to shape the role of social care, including the extension of individual budgets, the creation of integrated front-line teams to support people with long-term conditions, more support for carers, “information prescriptions”, integrated health and social care plans and the creation of a national reference group for health and well-being. There is much to applaud in this package.

However, the potentially bigger news for social care comes in shifting the balance of care from hospital to community, and the renewed focus upon partnership working. Winkling resources out of the acute sector into community services is hardly a new policy pre-occupation but it is one that has hitherto met with little success. The white paper boldly proposes that within 10 years, 5 per cent of the hospital budget (amounting to £2.4bn) will be transferred to community services, and health secretary Patricia Hewitt’s foreword states that this will be “invested in community health and social care”. At long last, then, the funding imbalance between the NHS and social care could be addressed.

Second, there is the assumption that stronger partnership working will drive forward this newly funded extension of community services. It is said that “Local authorities and PCTs will focus on community well-being, with much more extensive involvement of people who use servicesÉtogether they will drive the radical realignment of the whole local system which includes transport, housing and leisure.” Moreover, at last there is a recognition that the government needs to make this task easier by introducing a single set of outcomes, joined-up performance management and aligned financial and planning cycles across health and social care. 

Potentially, this is policy formulation of a cathartic nature. Indeed, with an avowed commitment to “nothing less than a fundamental change in the way health and social care operates” it could hardly be otherwise. Nevertheless it is hard to read the white paper without registering some concerns. 

First, the driving force for change is to be the two key changes in the way NHS provision is commissioned – practice-based commissioning and payments by results – and it is far from clear how these initiatives will relate to social care or the wider “system”. It has never been easy to engage GPs in partnership working other than for initiatives that benefit their own practices, and the idea that practice-based commissioning, PCT commissioning and joint commissioning with councils can cosily co-exist is problematic.

Similarly, payments by results gives the acute sector a financial incentive to suck patients into hospital and discharge them as soon as possible, with social care and other agencies potentially left to pick up the pieces.

This leads into the second issue of funding. With no additional funding on the table, the movement of resources out of acute care is crucial, but there is no guarantee that any of the released money will get past GPs and into social care. The answer here lies in the commitment to partnership working. At a minimum the Department of Health should stipulate that the resources released from the acute sector should be ring-fenced and pooled with relevant local authority resources – joint working without a joint budget is pointless.

There is a further funding issue at the level of the individual. Payments by results will soon be extended to community services with a national tariff determining what will be paid for different elements of a community package – one tariff for diagnostics, one for rehabilitation, one for prevention and so forth. Given the emphasis in the white paper on integrated provision, a further element will have to be added, that of means-tested social care. The transactional and bureaucratic costs of this will be immense – which element of prevention and rehabilitation will be “health” and which will be “social”? The solution, which the white paper shies away from, is to abolish charging for social care.

Finally, there is an alarming black hole in the white paper on implementation. The main lever seems to be centrally prescribed performance management, but the brave new world of joint working needs a firmer steer on governance and accountability. The suggestion that local strategic partnerships and local area agreements can be the basis for integrated governance is interesting but puts undue faith in an untested model.

The glaring need here is for the creation of community services partnership boards, comparable to children’s trusts, responsible for determining the use of the resources transferred from the acute sector to the community. This must be underpinned by a statutory duty of obligation on the key partners otherwise the director of adult services will have responsibility without power.
It is possible to give the white paper two cheers rather than three, but there is still a disappointingly green paper feel to it, with too many of the proposals hedged with qualifications and characterised by vague timetables and expectations.

More fundamentally, it is far from evident that the government has worked out how to reconcile choice and contestability with collaboration. The advantage of this fluidity is that the social care lobby can still shape the final outcome.

Bob hudson is visiting professor of partnership studies at the school of applied social sciences, University of Durham. He is also an adviser on partnership and integration issues to the House of Commons education and skills select committee.

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The health and social care white paper sets a new direction for services outside hospital, including social care. The white paper is underpinned by a strong vision that commands wide support and in principle could revolutionise the health and social care landscape. However, there are unanswered questions and implementation dilemmas that need to be addressed if the vision is to become a reality.

(1) Department of Health, Our Health, Our Care, Our Say: A New Direction for Community Services, The Stationery Office, 2006
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