The white paper Our Health, Our Care, Our Say has separate and distinct origins: the preparation of an authoritative statement about the direction of NHS modernisation from the perspective of primary care and related community health services, and the follow-up to earlier consultations on the future of adult social care.
At one level, the combined initiative made much sense in that the Department of Health had rightly responded to criticisms of silo working in central government.
There was a downside, however: the everpresent fear that the NHS juggernaut would simply sweep up the remnants of social services departments as the adjuncts to medical models and health service care pathways. The 2005 green paper had offered a different future for adult social care at the heart of local authorities promoting “independence, well-being and choice” within sustainable com munities. Could this vision be sustained within a joint white paper?
The prime minister’s introduction to the white paper is unhelpful in this respect. Its reference to social care seems to imply a restricted role, supporting important NHS agendas. Health secretary Patricia Hewitt’s introduction makes no mention of the leadership role of local government. Such omissions illustrate enduring values and attitudes about the two services. The NHS appears as the pre-eminent local service, understood and recognised as such by public and politicians alike.
The local government role in relation to wellbeing and sustainable communities seems poorly understood in the NHS. Yet it is fundamental to the success of any strategy for reducing dependence on acute hospital in-patient services and re-orienting the wider system towards health and independent living.
Fortunately, this approach is sufficiently well recognised in the body of the white paper and in subsequent ministerial statements to suggest that there is everything to play for in its implementation. It offers the possibility of a radically different relationship between primary care, social care and local government, a relationship which is strategic more than operational.
In the past, the primary-social care relationship has revolved around the need for better liaison between GPs, social work and related occupations. However, the proposed appointment of 3,000 community matrons by 2008 seemed to cut across these integrated ways of working. As a nurse-led initiative in case management for people with high-intensity needs, it was not well-received by some in social care. It seemed to ignore their extensive experience of case management and risk establishing parallel systems.
The neurological conditions national service framework provided a corrective steer towards “integrated care planning and assessment processes” within the context of the strategic frame-work set by local strategic partnerships and local area agreements.
The white paper also emphasised the delivery of integrated packages of personalised health and social care services by joint health and social care teams with dedicated case management through a single expert case manager.
Such integrated approaches are intended to achieve a significant shift from hospitals by enabling more people to retain their independence in the community. However, it is necessary to identify the separate inputs and skills different workers can offer as well as the benefits of an integrated case management process.
In the latter’s respect, the white paper’s expectation that, by 2008, primary care trusts and local authorities should establish joint health and social care managed networks or teams should be beneficial. But they will need to value and respect the expertise gained in social care since 1993 if the antibodies of a perceived NHS takeover are to be controlled.
Although some needs are clinical, others are social. The former must be brought under control and managed through clinical interventions and skills. However, high-risk individuals may also need access to social interventions such as financial advice, befriending, home care, meals services, carer support, counselling and community activities to promote health and well-being.
Community nurses are poorly equipped to meet such needs and it would be a misuse of their clinical skills if they sought to do so.
The reality is that each profession can access services and resources generally unavailable to the other. Success in reducing unnecessary hospital stays depends on combining those individual strengths in a single care management process. However, the most perfectly unified processes can only integrate services that exist to be accessed.
Integrated teams and networks need to be supported by decentralised and shared budgets to commission and fund the community resources required to meet the needs they identify. This recognition takes the discussion on to a more strategic plane. For the NHS to reduce hospital admissions, it will need to align practice-based commissioning with other local budgets.
Local government minister David Miliband and the Office of the Deputy Prime Minister are advocating neighbourhood empowerment and budgets to promote social inclusion and wellbeing. These objectives support primary care organisations in extending care at home and a shift towards prevention and well-being. They could also help reduce demand on primary care from frequent attenders with social and emotional rather than clinical needs.
In other words, primary care and local government have a strong mutual interest in forming commissioning alliances to promote well-being and inclusion in sustainable communities. Their impact could be felt throughout the system. Health inequalities could be addressed more successfully, primary care practitioners freed to deploy their clinical skills and hospitals enabled
to meet needs that cannot be met elsewhere.
All this is consistent with the white paper’s aim to secure a “sustained realignment of the whole health and social care system” supported by higher growth “in prevention, primary and community care than in secondary care” and also by resources shifting from the latter to the former.
The key to achieving such a realignment is effective commissioning. First, it must span organisational responsibilities for health and well-being so that people can keep well, be independent and have real choices. Second, it must be effective in redeploying resources between hospital and community services.
Both these tasks are the province of strategic joint commissioning. Both need stronger commissioning capabilities. Indeed, PCTs in partnership with local government could provide an even more effective counterweight to foundation hospitals than reconfigured PCTs alone.
In this context, the 5 per cent reduction in unscheduled bed days for over-75s is a promising outcome from the first year of an Innovation Forum project led by eight local authorities.(1) If sustained, it would suggest that stronger strategic commissioning between local government and primary care, supported by effective operational relationships, might begin to secure a strategic shift towards care systems outside hospital.
Neither organisation has been able to achieve this elusive goal alone. Together, they might just have a real chance of success.
GERALD WISTOW is a visiting professor at the London School of Economics and the University of Durham. He chairs the Hartlepool Connected Care project and is leading the evaluation of the Innovation Forum older people’s project.
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.
Partnerships between social care and primary care have tended to focus on improving joint working between front-line staff. Such partnerships are at least as important today. However, the white paper’s aim of realigning the whole system also demands strong commissioning alliances between local authorities and primary care trusts to shift investment towards independence,
good health and well-being.
(1) G Wistow, D King, Reducing Emergency Hospital Stays for Older People: Innovation Forum First Year Report (2004/05), Kent County Council, 2006
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