Health must be on board

Andrew Cozens looks at how services and managers’ roles will change

Tony Blair’s introduction to the white paper, Our Health, Our Care, Our Say, says it marks an important stage in building a world-class health and social care system. He then describes a vision of how the health challenges of the 21st century will be met. But what does the white paper say about the future social care system and how well are local services geared up for delivering it?

Health secretary Patricia Hewitt’s foreword promises real change that will be measurable in five ways. People will be helped to remain healthy and independent. They will have real choices and greater access. Far more services will be delivered in the community or at home. Services will be better integrated, built round the needs of individuals, and will promote independence and choice. Long-term inequalities in access and care will be tackled.

To a social care audience much of the white paper reads like the NHS catching up belatedly with the direction of travel of social care since the early 1990s. Changes to social care were driven by legal compulsion like the requirement to develop the market, a limit on new investment or growth in council services, and direct payments. No such requirements are proposed for the NHS now. The model is of managed change within the existing health care system. New providers will be mainly supporting or complementing, rather than replacing, services.

Not surprisingly, therefore, there are more examples of how the vision might be delivered in social care and through partnership with councils, than radical innovations in either sector. Most of the best come from where local government and primary care trusts have begun knitting together service arrangements in their communities that integrate the complex requirements of central government policy, programmes and expectations.

This requires bravery and creativity because it takes time for inspection and governance frameworks to catch up with the realities of joining up services. One of the most welcome features of the white paper is the commitment to address the bureaucracy that hinders partnership working and the promise that the NHS will become a better partner in local strategic partnerships, local area agreements and children’s trusts.

Another key difference in the ambition for health and social care is the emphasis in the NHS on better public health, early intervention and prevention where there is a solid evidence base, endorsed by the Wanless reports on the funding of the NHS. The evidence about social care and prevention is less clear cut and it will be interesting to see what the Wanless report on the social care of older people says about this.

The perfect social worker, according to a respondent to the adult care green paper, is caring, understands the needs of the service users, follows them through with all the provisions and adaptations, and goes back and checks they are happy with it all. This case management model does not include early identification, the equivalent of inoculation against future care needs, or community screening programmes.

Yet there is a model of social care, set out in the now neglected Barclay report (published in 1982) on community social work, based on the local authority commissioning the elements of a caring community. These may be a key part of a preventive framework that helps reduce the fear of dependency, anticipates future needs, and stops the accelerated breakdown of caring arrangements that can precipitate an admission to hospital or to residential or nursing care.

The challenge set for directors of adults’ social services and directors of public health is to assemble the evidence of community need and to design services that prevent health deterioration and sustain independence. Their approach must also be guided by the need to tackle inequalities in access and inconsistencies in the application of policies and standards, for all service users, including self-carers, and those paying for or arranging their own care.

In this respect it is encouraging to see the white paper refer to Scotland and to endorse local improvement targets that show how councils and the NHS are meeting national outcomes. The approach for the whole council area must be in tune with the different needs of communities and socially excluded groups within it. This requires a harnessing of local effort across a neighbourhood by those living there and providing services to it.

The Connected Care approach in Hartlepool has brought agencies together to develop a coherent approach, backed up by connected care workers on the ground. This approach has the potential to connect the government’s sustainable communities approach more closely to its objectives for health and social care.

Coupled with this community-wide overview, a modern social care system puts users in control and gives them choice about how to use the resources available to them from the state to manage their lives. This repositions the professional support they may seek as advocates, supporters and fixers.

There is no reason why such services could not be relocated into other settings and teams. Other developments in local government will see the roll-out of customer centres for localities providing access to a whole range of central and local government services, as well as voluntary sector services. Many areas are developing healthy living centres and health and social care centres. The white paper showcases the centre in Bromley by Bow, in east London, and the creative use of children’s centres in Brighton.

Access to social care services in a modern system should be easy, timely and fast. The white paper raises again the possibility of a better-connected, national access to social care information. Online assessment and immediate service entitlement and response will require further attention to equity and rights. The proposed national carers helpline will require greater consistency of approach by councils and carers’ organisations. Assistive technology in health and social care still requires a human response when things go awry.

All in all, services in a modern social care system will need to be flexible, local and responsive. In my view this requires a radical shift in the mindset of commissioners and service providers.

This must mark the end of the block contract for services. Service users’ and carers’ views on what they want will shape the system and commissioners will be converting those preferences into reality on the ground, in much closer partnerships with providers. Providers will only be used if they can demonstrate they can respond. This calls into question the way services are designed, arranged and regulated.

If the white paper’s ambition and values are really followed through, social care practitioners and managers will be central to helping promote the values of independence and choice, as well as contributing to building communities that are healthier and more cohesive.

Andrew Cozens is strategic adviser (children, adults and health services) for the Improvement & Development Agency for local government.

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Directors of adult social services and directors of public health will be required to assess the needs of their community and design services that prevent health deterioration and promote independence. This article looks at how social care services should be shaped to respond to the new agenda and what shifts in approach will be required from practitioners and managers.

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