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As New Labour wins a mandate for another term, many are left wondering what the new administration has up its sleeve for social and public services. Linda Steele takes a look at who the potential winners and losers might be in the plethora of promised and forthcoming legislation in the fields of mental health, learning difficulties and adoption

Public services have finally made it to centre stage in a general election. Schools, hospitals, transport, crime and welfare through work will be key for Prime Minister Tony Blair's newly-elected government. But what do the coming months hold for social care?

First, the ever closer integration of social care and health - known to some as the health takeover - will continue apace. Care trusts got the go-ahead in the Health and Social Care Act just before the election. "We're worried that local, democratic control, provided by social services and local government, is not sufficiently valued by this government," said Unison's social services officer, Owen Davies. "Joined-up services are a good thing but our concern is that care trusts could become the normal or preferred model of provision."

Julian Le Grand, social policy professor at the London School of Economics, thinks the writing is on the wall. "Will we see child care go to education and care of the elderly go to the NHS [in care trusts]? Yes, we will," he said. "It's fairly clear that the day of the generic social worker is over."

But that's further down the line. More immediately, the newly-appointed ministers - or reappointed, in the case of health secretary Alan Milburn - will get together with the whips to decide what will make it into the Queen's Speech on June 20.

This will be the moment when the government sets the tone for the kind of administration it wants to be. Competition to get bills in will be immense - where it's not a foregone conclusion.

The widely applauded learning difficulties white paper, Valuing People, could be an early victim. Mencap will be campaigning hard to get learning difficulties onto the agenda. Richard Kramer, the charity's head of campaigns, says they will be "seeking an effective framework for decision-making for adults who do not have the capacity to communicate their wishes themselvesÉ[and] the introduction of a new 'abuse of trust' law to outlaw sexual relationships between care staff and those they are caring for".

As in 1997, New Labour's first session of parliament is likely to be a long one - 18 months - with between 12 and 18 bills. It will be a showpiece session, so anything that's not a top priority could wait till November 2002.

There's a chance that the reform of the Mental Health Act 1983 could be delayed, but campaigners are fairly optimistic that a bill (which is probably already being drafted) will appear in November. Although one expert has voiced concern that the plans for detention of those "dangerous people" with antisocial personality disorders could go ahead separately from the wider reform, this seems unlikely. Uncoupling personality disorders and generic mental health services, brought together in the white paper Reforming the Mental Health Act, would require much reworking, administration and extra legislation.

But the bill, however and whenever it appears, will not get through unchallenged by lobbyists. "There's no legal right to an assessment and services. This legislation is a fantastic opportunity to introduce that," says Mind's campaigns manager, Sue Brown. And the personality disorder proposals and plans for compulsory treatment in the community will be opposed. But the bill is unlikely to be the government's biggest hurdle in mental health.

New Labour has acknowledged that services must be expanded and improved dramatically - currently around one person in three with a serious mental health problem doesn't get help when they seek it. Andrew McCulloch, head of policy for the mental health charity the Sainsbury Centre, says: "The Sainsbury Centre estimates that 8,000 new staff will be needed in mental health services alone to implement modernisation plans. And, without a radical skill mix and working smarter, it's hard to see where people will come from, given staff shortages."

In fact, implementation across the board will create difficulties for second-term New Labour. Crippling staff shortages exist in social care, and elsewhere in the public sector. Without another look at salaries and an overt commitment to valuing workers and the public service ethos, it's hard to see this huge problem melting away.

While the new delivery unit in the Cabinet Office may succeed in chivvying up the civil servants in the big spending departments, there's no magic formula for delivering on the ground if staff are demoralised and in short supply.

Another problem will be the disparities in long-term care with the Scottish executive's promise to introduce both free personal and nursing care. The government is sticking to its position of means-tested personal care in England, despite the tensions the stance will inevitably create.

The flash point could, however, be public-private partnerships, with public sector unions already promising to oppose further incursions by the private sector. A report from Downing Street's favourite think-tank, the Institute for Public Policy Research (IPPR) which is due out in a fortnight, is likely to suggest that private contractors should be allowed to run many more publicly owned services.

The recommendations may not touch directly upon social care, about half of which is already delivered by the independent sector, but will cover organisations that social services work closely with, such as primary care groups.

"Blair will be told by the IPPR that privatising public services is the key to winning a third term. But it's a policy certain to create a backlash from a public that wants better services - not the costly failure privatisation will inevitable turn out to be," said Malcolm Wing, Unison's head of local government.

Le Grand, who sat on the commission that drew up the report, disagrees: "It's not going to be an unequivocal cheerleader for the private sector - it'll be quite critical of PFI [private finance initiative], for example. I think it will present a balanced view."

But not everything will be controversial. Campaigners are happy about the likely reintroduction of the Adoption and Children Bill, which ran out of time before the election. Felicity Collier, chief executive of British Agencies for Adoption and Fostering, said: "I think adoption will have a high profile and I'm very pleased." But, alluding to the fact that some felt that consultation and the drafting of the bill were rushed, she says: "There must be adequate time for debate in the legislative programme. It's desperately important that we get it right."

While Labour's manifesto only promised consultation on extending the role of the national children's rights director, there is speculation that a children's commissioner may be announced in the autumn. In the meantime, children's charities will be lobbying politicians. "The children's commissioner is an achievable goal if the political will is there," says Michelle Mitchell, the NSPCC's parliamentary adviser.

And the ambitious pledge to end child poverty by 2010 will remain a high priority. "One of the implications of the size of its majority is that the government will now be able to think over a much longer term and develop a radical programme," says Stephen Burke, Daycare Trust director. "But it takes a long time to turn around services. The comprehensive spending review in 2000 promised 900 new neighbourhood nurseries, but they won't be visible till 2004."

And delivery of high quality social care and other services is crucial to New Labour this time around. Blair knows that voters will judge his government on whether public services improve, and are seen to improve.

Tougher regime ahead

One of the first tasks facing new home secretary David Blunkett will be to choose between the options outlined in a sentencing review by civil servant John Halliday. It's likely that shorter sentences could be divided between prison and probation, with inmates being electronically tagged, a scheme dubbed "custody plus".

But there's a feeling abroad that, whatever Blunkett goes for, it won't be a more lenient regime. One criminal justice expert says: "Blunkett has put it about that he will make Straw [the previous home secretary] look like a screaming girl's blouse."

Cracking down on persistent offenders will be the big target, and as many as 9,500 extra prison places could be on the cards.

"But he will bring a background in education and there will be an emphasis on the redemptive power of education and work," says a spokesperson for Nacro, the crime reduction charity. Skills training and education will be seen as important, both in prison and in the community.

The Youth Justice Board is likely to take over responsibility for 18-21-year-olds in jail. For the under-18s, there will be a bigger emphasis on restorative justice and community reparation, with young offenders atoning for their crimes through activities such as cleaning graffiti. And there will be a greater use of intensive supervision and surveillance programmes for young offenders. Under these programmes, organised by youth offending teams, young offenders have a strictly monitored timetable of activity, such as life skills training, visiting mentors and college.

Joyce Moseley, chief executive of RPS Rainer children's charity and Youth Justice Board member, says the programmes were "a means of getting appropriate help to young offenders to stop them reoffending, giving them the potential to move on - and keeping them out of custody".

Drugs debate intensifies

Mental health campaigners are demanding that quality of life considerations should prevail over issues of cost in the debate about who should get new anti-psychotic drugs. Sarah Wellard reports.

New evidence submitted last week to the National Institute for Clinical Excellence (Nice) adds further weight to the campaign to increase the availability of new and relatively expensive drugs for treating psychosis.

A survey carried out by the Mental After Care Association looked at the treatment regimes of 189 people, and included the observations of both service users and staff about the effectiveness of treatment. It found that the new atypical anti-psychotic drugs are associated with improvements in people's quality of life and mental health, and with reduced side-effects.

Maca also found evidence that older people are being discriminated against within the mental health system. The research found that older people, often from long-stay hospitals, are more likely to be prescribed cheaper conventional anti-psychotic medications than young people.

Gil Hitchon, chief executive of Maca, says the finding reflects the tendency of psychiatrists to stick with what they know. "If a person has remained apparently well there's less incentive for a review of their medication unless it is specifically requested. For an elderly person who has a history of problems, or who has come out a long-stay institution, there's a tendency not to ask whether there is scope for improving the quality of their mental health."

Campaigners are hoping that Nice will recommend that the new drugs should be the first line treatment of choice for people diagnosed with schizophrenia. The institute is presently collating evidence from drug companies, user organisations and professionals as part of an appraisal of atypical anti-psychotics, and will be publishing guidance on their use at the end of the year.

The medical world remains divided on the issue. Research published in the British Medical Journal in December recommended that conventional drugs should be considered first, and atypicals used only if a patient failed to respond. This study, based on clinical trials with more than 12,500 patients, found that although atypical drugs caused fewer side-effects, the improvement in symptoms was very similar.

Stephen Hirsch is professor of psychiatry at Imperial College School of Medicine in London and a spokesperson for the Royal College of Psychiatry. He is not convinced that the new drugs are necessarily better than the older type.

He says: " The best reviews of the evidence suggest that if you use lower doses of standard drugs you get lower side-effects and similar benefits. But it does depend on the patient." He points out that for some people atypicals can also have unpleasant side-effects, including massive weight gain. But, he concedes: "If you want to reduce the risk of losing a patient's confidence because of the side-effects you would start with atypicals."

Some experts believe it is too simplistic to draw a "new drugs good, old drugs bad" dichotomy. David Taylor, a pharmacist based at the Maudsley Hospital in
London and chairperson of the UK psychiatric pharmacists group, explains: "It's important to separate out the new drugs. It's very clear that Clozaprine is more effective than the rest. It works with people with resistant schizophrenia who don't respond to anything else."

The Maca findings reinforce those from another much larger survey of users' experience, conducted by the National Schizophrenia Fellowship, Mind and the Manic Depression Fellowship. This survey found that people diagnosed with schizophrenia or manic depression overwhelmingly preferred the new atypicals and reported fewer side-effects.

Gary Hogman, head of policy and campaigns at NSF, says: "For some people, atypicals have worse side-effects than the typicals. But they are a minority. A lot of people with mental illness don't want to leave their older drug because they feel comfortable with it. It's not necessarily the best and most efficient, but they don't want to change."

The NSF/Mind survey also found that people using the older typical anti-psychotics were significantly more likely to have stopped taking their medication than those on atypicals. In the context of Nice's emphasis on cost-effectiveness, this finding is particularly important because it puts people at risk of breakdown, of missing work or ending up in hospital. Most worryingly, non-compliance is a major risk factor for suicide. The official confidential inquiry into suicide and homicide found that one in five people known to mental health services who committed suicide was not taking their medication at the time of death.

Hitchon believes that the relatively high cost of the atypicals means that health authorities and trusts are reluctant to make them more widely available. The new drugs cost around £40 a week per patient - up to 10 times as much as conventional anti-psychotics. However, Nice says that affordability is not a consideration in its deliberations. A spokesperson explains: "We look at cost-effectiveness, not affordability. The process does allow for the Department of Health to comment on affordability, but so far this hasn't happened."

Hirsch agrees that cost is a significant factor influencing psychiatrists' prescribing practice. He points out people will be taking drugs for 30 years or more. "An oncologist may be treating a patient with cancer drugs costing £50,000 but they aren't on them for life," he says.

Ultimately, it is up to psychiatrists to determine which drugs are best for individual patients. But when Nice draws up its recommendations, let's hope that the views of users will be uppermost in their minds. Two thousand pounds a year seems a small price to pay for enhancing or saving someone's life.