How true is the government’s aim when it comes to the pledges it made in the joint health and social care white paper, published a year ago?
The white paper Our Health, Our Care, Our Say promised to draw health and social care closer together and to improve community services provision for users, and commissioners and practitioners alike. It pledged: “There will be a radical and sustained shift in the way in which services are delivered – ensuring that they are more personalised and that they fit into people’s busy lives. We will give people a stronger voice so that they are the major drivers of service improvement.”
But a major problem over the past year has been the impact of the financial instability in the NHS both in terms of organisational change and funding. Former chair of the British Association of Social Workers Ray Jones believes this is having a knock on effect on delivering the white paper aims.
“Joint working and new initiatives have been hindered by an inward-looking NHS and there has been too much personnel change to deliver joint agendas,” he says. “Put with that the limited funding in social care, as reflected in the latest CSCI report, and in reality we’re going backwards.”
For critics like Jones, the widespread tightening of eligibility criteria is leading to heavy rationing of social care, when the white paper should have pushed greater balance between health and social care. Service users have also voiced reservations over progress towards meeting the white paper aims.
Peter Beresford, the director of the user organisation Shaping Our Lives, is particularly concerned about mental health services.
He agrees there are some “positive arrangements on the ground” in mental health but notes the various setbacks in the sector since the white paper came out, most notably the problems with the Mental Health Bill. He calls for “a much more deliberate attempt to reconnect the white paper with the issue of mental health policy and practice”. And he suggests the creation of a commission with strong user involvement to take the sector past its “short-term focus on the issue of control”.
The white paper followed on from the vision set out in the social care green paper Independence, Well-being and Choice, and is based on four key themes for transforming services:
1 Better prevention services with earlier interventions for improved health, independence and well-being.
2 More choice and a louder voice for individuals and communities.
3 To do more on tackling inequalities and improving access to community services.
4 More support for people with long-term needs.
These goals are all very laudable but do those at the sharp end of service provision, some of whom were recognised in the white paper – believe things have changed for the better since it was published?
Better prevention services
The rationale behind this pledge is that preventing ill-heath and enabling people to play a full role in their communities is not only positive for individuals but also ties in with the government’s work on regeneration and creating sustainable communities.
In particular, the white paper says it will promote well-being and health in old age by encouraging physical activity, social engagement, and continuing to increase the uptake of evidence-based disease prevention programmes among this client group.
One example of preventive work in action is Knowsley Council’s community older person team’s well-being service. The service is run by qualified social worker Shelia Slinger and district nurse Maureen Sweeney.Together they work to reduce the number of hospital admissions for people aged over 65 by providing an integrated health and social care approach. They share a caseload of about 30 clients, working with them for however long is necessary, and take referrals from a variety of agencies.
Slinger believes locating the well-being service within the multi-disciplinary community older people’s team is a huge benefit:
“Our other colleagues know they can come to us about their clients. I honestly don’t know who they’d go to if it wasn’t for us.”
Joyce Davies, aged 79, is one of the well-being service’s clients. A diabetic, she has been a carer since 2005 for her widowed sister Elsie who lives next door. She prefers seeing two professionals together as she says it makes communication easier than dealing with separate services: “Shelia and Maureen make suggestions to me and each other about how they might help me. I like it very much because there are no secrets.”
Slinger says: “We have been looking at how to mainstream our service, and I believe the government needs to focus more on this.” She is also keen for the government to learn from Knowsley’s approach and urges it to fund more preventive services, adding “Prevention should always be on the top of the agenda, not just when the government thinks it should go on the agenda.”
To ensure the health and social care system can be developed, the government wants to give people greater control and choice over the services they use, and to ensure everyone has their voice heard. Plans to improve this include strengthening local links with the voluntary sector and community sector and supporting social enterprises. The white paper praises Camden Primary Care Trust’s sexual health clinic patients’ network for encouraging staff to inform and consult clients about their treatment.
The network reaches out to “under-represented minority groups” and has become an independent patient network responsible for its own recruitment, organisation and membership.
Ibrahim Ismail, men’s sexual health co-ordinator for the Naz Project in London believes asylum seekers are one group which has seen no benefit from the white paper pledges. Despite the aim to make users’ voices heard and give them choices, Ismail says HIV-positive asylum seekers are excluded through regulations.”
Asylum seekers have no access to HIV treatment and services until they get a decision on their asylum claim, which can take years. Some people have no option but to interrupt their treatment when their asylum application fails.”So what would need to improve in the coming 12 months so Naz’s clients experience the white paper’s stated goals?
“All people’s health needs need to be considered. Accessing HIV services should be available to all who need them.”
Tackle inequalities and improve access to services
Many people do not know what social services they are eligible for. The government plans to address this by encouraging local health and social care commissioners to work jointly to tackle inequalities. One area the white paper identifies as requiring improvement is rapid access to mental health services.
It praises Birmingham and Solihull Mental Health Trust for its home treatment team, which was established in 1994 to assess people experiencing a psychiatric crisis and avoid unnecessary hospital admissions.
Jenny Tucker, manager of the Yardley and Hodge Hill home treatment team, says it has had a huge impact on practitioners: “I can remember when if someone went into an acute psychiatric period you had no other option than hospital admission because of the lack of support services.” Now clients receive support in their own homes, are more comfortable accessing the service and “treatment and support is more user-focused”.
Tucker believes further developments strengthening the work of primary care since the white paper’s publication have had a positive impact on the home treatment service. “Now we get a more speedy response so that people don’t have to go on to secondary services.”
More support for people with long-term needs
Addressing the needs of people with long-term conditions is vital as 70 to 80 per cent of these clients rely on self-care. The white paper will support people to “take better control of their care and condition”, including the expert patient programme (EPP). Currently, the EPP trains 12,000 people who live with a long-term illness to take effective control of their lives. By 2012, the government wants to train more than 100,000 people and is trebling its investment in EPP and supporting its transition to a social enterprise organisation.
Weston Area Health Trust and North Somerset Primary Care Trust’s peer adviser group for diabetes is noted in the white paper for its work. Parag Singhal, a consultant in diabetes at Weston General Hospital, has trained 10 people with diabetes to become peer advisers on a 20-week course. Each peer adviser has since twice attended the diabetes clinic Singhal runs to observe doctors and offer patients advice. He says: “Patients take it better from their contemporaries. When they see a doctor they can feel bombarded with information but when they see a peer adviser they can discuss it more informally.”
So successful has the initiative been that Parag Singhal and the peer advisers are considering involving their local GP surgeries and setting up a 24-hour helpline. However, Singhal believes the government needs to go further than the white paper and improve the situation for all patients by funding the development of disease specific training programmes.
Retired police commander Richard Brook is one of Weston’s peer advisers. He has had type one diabetes for 36 years and has learned to manage it effectively, which inspired him to be an adviser. “I learned more about diabetes and could swap stories with others.” He is keen to help other men with diabetes because when he was first diagnosed he had no one to talk to.
He says: “If you are in the company of fellow diabetics you don’t have to be in denial. It helps get over the block of admitting you have the illness.”
This article appeared in the 18 January issue of the magazine, under the headline “The aim is good”
Other feature articles this week
Home care services for people with life limiting and long term conditions. Research from the Influencing Palliative Care study
Next Steps… winners of the Community Care Awards learning difficulties category 2006
Diagnosing mental illness among teenagers. Preventive services key to treating adolescents with mental health problems (Children’s sector)