Although there are positives for social workers in the health White Paper, there remain many questions about power and accountability, says Richard Humphries (pictured) of the King’s Fund
The NHS has been no stranger to reorganisations and social care services have often been caught in the slipstream. The coalition government’s new White Paper, Equity and Excellence: Liberating the NHS, would, if fully implemented, represent some of the most sweeping changes to the NHS since it was established in 1948. Attention has focused on the central proposal to hand over £80bn of primary care trust commissioning budgets to consortia of GPs, but we should look beyond the headlines.
On the face of it, the White Paper has a lot of positive messages for people who use and work in social care. First, it makes a clear commitment to achieve a sustainable adult social care system that gives people support and freedom to lead the life they choose; the commission on funding care and support will be announced soon and a new vision for adult social care is pledged in the autumn.
Second, it recognises that people often have overlapping health and social care needs and it restates the importance of bringing services closer together. It plans to strengthen the roles of councils in leading local partnerships, and to break down the funding barriers between the two services – a pledge that will be remembered as the financial climate worsens.
Third, the White Paper signals important new responsibilities for councils, including health improvement. The proposed new health and well-being boards will allow them to take a strategic approach and promote integration in health and adult social care, children’s services, including safeguarding, and the wider local authority agenda. There is potential here for councils to become a local democratic buttress for the way NHS resources are used.
Although some of these pledges are not new, coming so early in the life of a new government they are important signals against which its future actions can be judged. So the document has a lot to say about social care – unusual for a White Paper about the NHS.
And the general rhetoric – devolving power to frontline professionals, freeing staff from bureaucratic controls and top-down targets – will be music to the ears of many Community Care readers.
The questions pile up when we consider whether the aspirations can be matched by reality. There are some significant tensions between key aspects of the White Paper. How exactly will GPs work jointly with local care services? Will they want to (the evidence is mixed)? And what happens if they don’t? Replacing 152 PCTs with 500-plus GP collaboratives may well put GPs in the driving seat but, at a stroke, will destroy the co-terminosity of PCT and council boundaries. It could also dissolve the personal chemistry between key local players and will make aligning resources and care planning for individuals’ needs more complex. There remain unanswered questions about accountability and governance.
Another anomaly is between the government’s desire to devolve power and resources within the NHS yet retaining a vice-like grip on the funding of local care services. It is difficult to join up health and care locally when government treats their funding in separate and disconnected ways, though the spending review is an opportunity to address this.
Widening role of nice
Some of the White Paper’s proposals – such as extending the role of Monitor as an economic regulator to social care – will need careful thinking through. Widening the remit of the National Institute for Health and Clinical Excellence to social care seems unnecessary because Nice already works with the Social Care Institute for Excellence to jointly produce quality standards, for example the recently acclaimed work on dementia.
Finally, trying to implement the biggest set of changes in the history of the NHS when both health and social care are facing unprecedented financial pressures carries massive risks. Although NHS budgets are “protected” from real-terms cuts, the service still has to find £20bn in productivity savings over the next four years and the immediate prospects for social care budgets look bleak.
The White Paper’s changes involve profound shifts in money, people, organisations and professional cultures – it will be like rebuilding a house during a raging storm.
Richard Humphries is senior fellow in social care at the King’s Fund, and a former social services director and Department of Health civil servant
This article is published in the 22 July 2010 edition of Community Care under heading “The risks of rebuilding the NHS during a storm”