How central is social care to the white paper? Does it matter that health wins the lion’s share of attention in the plans? Here, colleagues Chris Ham and Jon Glasby of the Health Services Management Centre, University of Birmingham, debate the issues
When a joint white paper was first announced, everyone in social care agreed that it was a good idea as long as the paper was genuinely joint. Part of the problem with the 1990 community care reforms, many people argued, was that there were separate health and social care white papers, resulting in increasing fragmentation. While no one wanted a repeat of this, there was concern that a joint white paper would inevitably have an NHS focus. This was described in various ways – the paper would be an NHS document with social care featuring in chapter 13 or, as one person put it, the NHS would turn up late and gatecrash the party.
As health and social care begin to digest the implications of Our Health, Our Care, Our Say, how joint does the white paper feel? Well, on one level, the critics may have been too cynical, and there are plenty of things for social care to reflect on: individual budgets, new roles for the director of adult social services, new leadership for social care within the Department of Health and more coterminous health and social care. Philosophically, the tone of the white paper fits well with social care perspectives, and the ministerial team behind this initiative – Patricia Hewitt and Liam Byrne – seem firm allies of a more community-based approach to service provision.
At the same time, however, the cynics weren’t altogether wrong. Tony Blair’s foreword makes it clear that this is an NHS document with social care only as an “add on”. His introduction talks of NHS investment, of patients, of doctors, and of waiting lists, with social care only really appearing in the final paragraphs – not in its own right but in the context of its potential contribution to NHS priorities. Search the full document electronically, and “health” comes up 1,125 times compared with “social care” just 305; “GP” appears 152 times while “social work” gets only 18 mentions; and “PCTs” receive 277 references, “social services” only 35.
Although in one sense the word count doesn’t really matter, it does illustrate a tendency to see the world in NHS terms and to approach the problem the wrong way round. This was apparent from the start when officials began talking of an Out of Hospital white paper – a telling slip of the tongue that defined community services by what they were not, rather than in more positive terms. A similar tension is still evident between a health care notion of prevention (reducing hospital admissions) and a social care perspective (supporting people to live chosen lifestyles), with the former the real issue at stake given the current financial climate.
Given that the green paper focused solely on adult social care, the current white paper seems like a missed opportunity, but it’s probably naive to think that it might ever have been different. All of which is a shame, because one of the few genuinely new and exciting ideas in the green and white papers came from social care – the advent of individual budgets piloted by the national In Control project. Here was something different, something radical and something that might actually work – yet the description in the white paper fails to do justice to one of the most exciting developments for many years in adult social care. Moreover, although the government acknowledges that some people want to extend direct payments and individual budgets to health care (again something genuinely new which could have considerable potential), they rule this out (in a single paragraph) on the grounds that free NHS services are incompatible with means-tested social care – a massively unhelpful distinction that they have previously refused to tackle.
Overall, the green paper seems to have been social care’s day in the sun, and we’re now back to our usual place in the shade.
The white paper’s emphasis on the NHS reflects the political and economic importance of health care. The state of the NHS is a matter of huge importance to the public, and its annual budget of over £70bn means that its efficiency and performance are under constant scrutiny. The NHS will always attract more attention from ministers and the public than social care, and the challenge is to use this to the advantage of social care.
From this perspective, there is much to welcome in the white paper. Having been obsessed with the performance of acute hospitals for the past decade, ministers are now turning their attention to primary care and community health services. Their objectives may not be new – remember the ambition of developing a “primary care-led NHS” set out by the last Conservative government – but their plans are comprehensive and challenging. These plans recognise the critical importance of social care and the need for health and social care to work closely together.
Particularly welcome is the priority given to improving care for people with long-term conditions. The changing pattern of need in the population, including the increased prevalence of mental health problems and conditions such as diabetes, makes it essential that health and social care focus much more on prevention and early intervention rather than crisis response. Leaving aside shop window proposals such as the new NHS Life Check, there are many ideas in the white paper that over time should help to ensure a reorientation of budgets and services in this direction.
These ideas include the greater use of assistive technology to support people in their homes, and the development of joint health and social care teams to provide a co-ordinated response to needs when they arise. The white paper recognises that the experience of social care in implementing care management contains important lessons for the NHS, and it highlights examples of integrated working in areas like West Sussex to illustrate the way forward. Although the main emphasis in the white paper is on service integration to avoid unnecessary hospital admission, a recurring theme is the importance of joint commissioning and service provision in developing services closer to home.
In this regard, there is a real opportunity for the NHS and social care to use the government’s proposals to their mutual advantage. The reconfiguration of PCTs to be coterminous with local authorities, and the emphasis placed on local strategic partnerships and local area agreements in the white paper, send out a clear signal of the need to involve the full range of local authority services in partnership working in future. Further structural solutions have been eschewed in favour of more effective leadership of this agenda, and much will therefore depend on whether the commitment exists locally to achieve closer integration.
A critical question about the white paper is whether the delivery mechanisms exist to ensure its laudable vision can be realised. Much will depend on the effectiveness of commissioners and more guidance is promised on joint commissioning for health and well-being and on commissioning for people with continuing needs. In the NHS, practice-based commissioning will be expected to do much of the heavy lifting, and it is described as the health equivalent of individual budgets in social care.
There is evidence that many GPs are uncertain or equivocal about practice-based commissioning. Even the offer of additional payments for involvement in practice-based commissioning under the new GP contract may not be sufficient to avoid more resources being sucked into acute care. The time lag between developing policy and putting in place the means to ensure policy delivery may yet prove to be the Achilles heel of the white paper.