Rather like continental drift, the evolution of social policy takes time to change the world. The kinds of policies encapsulated in the adult social care green paper, the white paper Our Health, Our Care, Our Say, and the recent Wanless report for the King’s Fund are all slow-burners in this sense, given that even with the best intentions they will develop over many years and even decades rather than months.
Even so, it is hard to be optimistic about the prospects for such policies in the context of the current round of NHS job and service cuts.
New policies are often quick to restructure services, but this is not the type of change that matters. The changes that matter are those that have a fundamental impact on the lives of service users, those that wherever possible give them control and choice, build on their strengths, and enhance their independence and dignity. The white paper’s shift towards community services and the more inclusive proposals in Wanless could achieve these aims more effectively than any amount of restructuring on its own.
What is worrying about the cuts is not so much their scale – the loss of possibly 10,000 jobs, out of the 200,000 created in the past five years and a total establishment of 1.5 million, is hardly seismic – as their focus on the very community services that are supposed to be central to the white paper’s vision. Much of the NHS deficit has fallen on primary care trusts whose reflex reaction has been the same as always, to kick against community mental health services, long-term care for older people and joint provision with local authorities.
Surveys at local level show that day services, early intervention, hostels, respite and rehabilitation are all in the firing line. Resources have been diverted to meet centrally set targets, most of which apply to acute care in hospital settings.
On the geological timescales governing the underlying intentions of social policy, none of this may seem important. But as a guide to the mindset of the health service, it is very important indeed. While the white paper looks forward, health continues to look back. Plans to redraw PCT boundaries hold the promise of more imaginative commissioning but, on the evidence of the past few weeks, it will take more than this to turn the NHS to face the future.