The road is clear

Rachel Downey examines what Labour has in store for the
structure of social care delivery if re-elected, while the Liberal
Democrat and Conservative spokespeople offer their views on how
services to vulnerable clients should be delivered.

With William Hill quoting Labour as 33-1 on to win the June
election, it is a fairly safe bet that social care will be provided
in the way the current administration has set out with adult
services transferring to the NHS.

The latest Department of Health guidance issued in
March¹ claims care trusts will be partnerships not
take-overs. But some social services chiefs believe this is the
final reckoning for traditional social services departments.

And they are not alone. “Care trusts will be NHS bodies, growing
out of existing primary care trusts,” says Nick Harvey, Liberal
Democrat spokesperson on health. “Though dressed up as a evolution,
the government’s approach is to uproot social services, wrest them
from councils, and plonk them in the NHS.”

The guidance proposes different care trust models for separate
client groups but it is clear the government wants care trusts
based on the primary care trust model. It states: “The importance
of primary care as a focal point for many other services, used both
regularly and intermittently, makes the PCT-based model ideal for
considering the idea of a care trust.”

Labour has been gradually moving towards an integrated structure
over the past four years. The government began with the shake-up to
the health service, with introduction of primary care groups,
initially with the gentle offer of the choice to form larger
primary care trusts, later rescinded by directions to do so. Now
its manifesto clearly states that all local health care will be
organised by PCTs and they, together with care trusts, will control
three-quarters of NHS funding.

“The NHS plan and the national service frameworks in
particularly will lead to highly integrated and increasingly
devolved operational systems, where NHS bodies will probably have
the lead, for example, care trusts,” according to Michael Hake,
chairperson of the Association of Directors of Social Services’
organisation and development committee.

“It seems to me unlikely that social services departments will
exist in their present form in five years’ time.”

However, other commentators present a different vision of the
future. Janice Robinson, head of community care at the King’s Fund,
envisages a mixed bag of provision, akin to the current delivery of
primary care, where single GP’s practices run alongside large-scale
PCTs.

“I would expect to see much more highly developed, integrated
provision, similar to that in mental health and learning difficulty
services. We might see something like that for older people rather
than all-singing, all-dancing, all-commissioning and providing care
trusts.”

And the handful of social services directors who have set off
down the road towards integration appear to have no qualms. To
them, talk of takeovers and the demise of social services
departments is irrelevant.

For Dave Martin, executive director of social inclusion and
health, who is just about to begin a year’s secondment as chief
executive of the local health authority, “there’s a job to be done
in a very deprived community”.

In Sandwell, social inclusion works across the local authority
and health authority and “social care and health are inextricably
linked”, he says.

Building on a background of close co-operation with a range of
different agencies, Sandwell has set up a health and social care
advisory group, comprising all chief officers of all involved
agencies sitting down together. It is moving towards a single
integrated care and health agency, which Martin says may or may not
become a care trust.

The approach has created the chance to “do some fairly
innovative stuff”, says Martin. He argues that if the council had
not taken this approach, the area would not have been selected for
many of the government’s initiatives, including a health action
zone and new deals. “The money that comes in gives us the
opportunity to develop new services in the community.”

It is within this wider social inclusion agenda that
opportunities are rife, according to National Institute for Social
Work director Daphne Statham. Social care staff are in a strong
place to carry out the government’s community development and
participation agenda. ä

“We do not have to confuse structures with what they actually
deliver,” she maintains. “We have been through 17 million
restructures and all too often they have changed nothing at all at
the frontline.”

The flexibility could overcome some of the constraints. “We have
been dug into a corner in the statutory sector and the job has
become more constrained.”

Social workers have argued that they want joined-up services and
too often their clients fail to receive the services they need on
time, she adds. Now they have the opportunity for a truly
integrated service.

Users and carers are rightly concerned that the advances they
have made in working with social services departments to make them
more responsive to service users involvement will be lost inside
the perceived paternalism of the NHS.

Fears about the loss of the social care model are overstated,
Janice Robinson maintains. “Users and carers say that social
services make them too dependent – and NHS staff can also be
enabling. Anyway, the social care model is not being implemented in
social services departments. It’s a false dichotomy.”

Staff anxieties about becoming NHS employees are understandable,
says Statham. The guidance on care trusts is vague – it states that
most staff are likely to transfer to the new organisation under the
Transfer of Undertakings (Protection of Employment) Regulations
1981 but secondments will be possible, as will appointments if and
when posts are created.

Despite the care trust guidance’s promise of “clearer working
arrangements for staff”, many are sceptical. Social workers are
worried they will be marginalised, says British Association of
Social Workers director Ian Johnston. “If we are trying to fight
for the rights of people who are disempowered, we cannot let
ourselves become marginalised.”

On the political front many are concerned at the loss of
democratic accountability with the creation of care trusts.
Although some social services directors might welcome the freedom
to run their departments without what they perceive as
“interference” from local councillors, others fear the loss of
elected members calling departments to account will damage
services.

The Labour Party manifesto also promises to “work with frontline
staff to deliver a revival of our public services”. It talks of
“empowering frontline staff”, describing them as “advocates for
citizens and ambassadors for their service”, and adding that:
“Motivated by an ethos of service, they must be supported to carry
through change.”

But the flattery is aimed at softening up public sector workers
for substantial private investment in the health and education. The
Health and Social Care Act 2001 has already quietly opened the way
for the privatisation of elements of the NHS.

And while the manifesto does not specifically mention social
care professionals, it is highly likely that the substantial
changes to the structure of social care delivery will lead to the
expansion of social care provision in the independent sector.

¹ Department of Health, Care Trusts: Emerging
Framework , DoH, March 2001

Views from the workers on the frontline

Bhaggie Patel, project leader with the Barnardo’s Phoenix
project in Bolton, which supports Asian women and children
experiencing domestic violence:

I would like to see an equal partnership between local
authorities and the voluntary sector because there needs to be
accountability and ownership. Both are integral to the delivery of
appropriate and equitable social care.

Rita McIntyre, outreach support worker in mental health for the
Richmond Fellowship in Liverpool:

None of the political parties have got it right and it’s not for
want of money going in there. I would be very dubious about the
voluntary sector taking over statutory services, although there is
a need for more voluntary organisations in social care.

Simon Southworth, senior practitioner, Kent social services
substance misuse team:

The proposals to expand the use of the independent sector would
spell disaster for social care, further fragmenting the field.
There’s little thought going into how this voluntary system would
be managed – the strategy is virtually unworkable and would only
increase the potential for mistakes in case work going
unnoticed.

Abdul Sattar, social worker with the Family Service Unit,
Birmingham:

The stigma attached to social services that they “take children
away” means black and white families alike find it difficult to
seek their help. Voluntary agencies, however, enjoy a much better
relationship with black families since no such stigma is attached
to them. So any plan for voluntary organisations to provide a
substantial amount of services has to be welcomed provided there
are no cuts in resources.

Julia Saunders, rehabilitation officer, RNIB visual impairment
service, Solihull:

My main concern about future social care delivery is what will
happen if it suffers further erosion by cash cutbacks. Joined-up,
responsive services are unlikely to come about while providers have
to expend energy on accountability and scrabbling for pots of cash
to sustain over-stretched services.

All our election panel members are speaking in a personal
capacity.
On offer from the Lib Dems…

The future of social care depends on effective organisational
structures and governance frameworks, a rejuvenated social care
workforce, and a new vision and practice of building
communities.

The current debate on the constitution of care trusts, which
will integrate health and social care provision, is likely to
continue beyond their legal establishment.

Liberal Democrats propose a structure that would enable local
community input and democratic accountability. Diversity would be
encouraged – there should be no Whitehall blueprint. Health and
local authorities should be equal partners and different care trust
models would then appear in line with local needs.

Commissioners of health and social care services would be
democratically accountable to the population that they serve.
Institutional integration between health, social care and other
locally provided services such as housing, leisure and education,
should enable each individual to receive the services they need.
The fundamental flaw in New Labour’s current proposal is that
integration without accountability means service users lack an
effective voice and means of redress.

In democratising the “command and control” system of the NHS,
Liberal Democrats would devolve the commissioning and public health
functions to local government. NHS Executive regions would be made
accountable to regional government. They would provide strategic
planning and commissioning of health and social care; supporting
for example “centre of excellence” hospitals and provision for low
incidence but high dependency groups, such as those with
challenging behaviour.

High quality social care depends on a highly motivated,
well-trained, and stable workforce. Rejuvenating the status of the
social work and carer workforce is vital. It is a responsibility of
politicians, the media, and the social care workforce to challenge
the culture of “name and shame” and replace it with one of “applaud
and reward”.

“Care in the community” is used, sometimes rightly, as a term of
abuse by those dissatisfied with social care provision. The
challenge over the next decade is to implement polices that
strengthen communities. The erosion of “social capital” – features
of life such as social support networks and trust between citizens
– has hit the vulnerable the hardest. The services provided via
formal public-funded social care is underpinned by a massive
informal care sector of family and friends. Liberal Democrats
propose to abolish charges on personal care, wherever it is
delivered, whether in a person’s home or in a care home.

Looking beyond the next election, imagination and courage is
needed to go that step further. We need to re-examine the role of
social workers, widening their remit from being care managers to
community builders, establishing new ways in which community groups
and informal carers can access public funds to support them in the
self-provision of care.

Most important is raising the profile and respect for all who
need support and provide it.

Paul Burstow is the Liberal Democrat spokesperson on older
people and adult social services.

On offer from the Conservatives

More care than ever is now being provided in the community and
social services have a key role in ensuring that individuals can
enjoy healthy active lives for as long as possible.

The recent legislation on health and social care has heightened
the debate on the delivery of care services in the community. The
introduction of care trusts has fuelled speculation about transfer
in responsibility for the funding and commissioning of care
services from local authorities to the NHS authorities which under
this government are becoming increasingly centralised.

Conservatives, as the party that genuinely believes in local
government, hold the view that democratically elected social
services authorities must have a major role in determining social
care provision and priorities in their area. Care trusts, where
entered into on a voluntary basis, may well be the right mechanism
for the commissioning of services for some authorities. However, we
have grave reservations about the forced establishment of care
trusts and we are delighted to have achieved in the Lords the
removal of the secretary of state’s powers “to direct” from the
Health and Social Care Act.

The Conservative Party is the party of choice and diversity.
Consequently we believe that it matters less who provides care
services, than that the standard of the service provided is of a
high quality and satisfies the criteria set by a truly independent
care standards commission. Conservatives, unlike Labour have no
ideological objections to the use of the independent sector. It is
common sense that care should be delivered by the most appropriate
person in the most appropriate setting, according to the need of
the user.

The current crisis in the nursing and care home sector for older
people highlights Labour’s failure to address the issue of social
care provision during its term in government. It is clear that
responsibility for the current state of affairs lies squarely with
the government, which has failed to provide adequate levels of
funding for social services to reflect increased statutory
responsibilities and higher costs, whilst at the same time
demanding ever higher levels of quality in care for older people.
The Conservative Party supports higher standards but believes that
it is the quality of care, rather than the size of rooms, that
matters to residents. We also recognise that quality improvements
have to be paid for.

Conservatives, on coming into office will review the balance of
the allocation of the additional money which we have pledged for
health and social services between the acute hospital sector on the
one hand, and community and social services on the other.
Allocating a greater proportion of that money to community care and
social services will produce a better delivery of care overall.

Philip Hammond is the opposition spokesperson on health
and social services.