If whitehall could just let go

Debate about the organisation of social care has never been more
important. Structural change, enshrined in the Health and Social
Care Act 2001 is firmly on the government’s agenda. In anticipation
of the Laming Inquiry report, changes in the organisation of
children’s services are the subject of speculation.

It is tempting for politicians to assume that restructuring
services provides a panacea for all problems. It may simply “move
the furniture” by giving an illusion of progress by doing something
visible. It must also be said that structures and organisations are
not an end in themselves but a means to an end, logically
subordinate to values, principles and desired outcomes.

The biggest problems in social care are undoubtedly the recruitment
and retention of well-qualified staff (aggravated by poor public
image) and the consequent lack of overall capacity. Hence the
familiar cry “it is not reorganisation we need, but more good
people”.

As a public service paid for by national taxation, social care must
be publicly accountable and this is a fundamental factor in
determining the way it is organised.

The classic means of achieving public accountability is through
democracy, which obtains a mandate for public action through
periodic elections. However flawed this may be, a better
alternative has yet to be identified. Various measures can be used
to augment democratic accountability, such as public consultations,
scrutiny rights, the involvement of user groups and the application
of consumerist principles, but they cannot in themselves provide an
adequate substitute.

I would argue that public services delivered locally – social care,
hospitals, schools – cannot meaningfully be held to account by
central government. Sheer numbers, distances and lack of detailed
knowledge make it impossible. Democratic accountability for social
care can be obtained at the local level only.

Lack of local accountability has always caused problems for the
NHS, despite many attempts to compensate by establishing links with
local councils. When issues of rationing became critical, it was
evident that the lack of genuine accountability made it impossible
to devolve major ethical decisions to unelected health
authorities.

The pressure for central rather than local accountability comes not
only from the top down but from public expectations of equity.
Where once it was acceptable, local autonomy is now challenged when
it leads to significant disparities. The “post code lottery” all
too easily provides a rationale for centralised, top-heavy command
and control structures, of which the NHS is the prime
example.

The accountability which local authorities deliver to their
communities provides a framework for the governance of social care
as responsive, integrated and holistic services which recognise the
interdependence of people. Moreover, communities, families and
individuals are more likely to accept and value social care,
particularly interventions in sensitive areas such as child
protection or mental health if there is some sense of common
ownership and mutual benefit. The authority which social care must
have cannot depend on the force of law but is instead derived from
its democratic legitimacy, its “connectedness” to the community it
serves.

Social care and local government share the same goal – that of
individual and collective well-being, and each needs the other to
achieve that goal. Yet current government policy seeks to
incorporate social care in NHS care trusts.

Governance of care trusts is conducted by NHS boards with
councillors from local authorities appointed as non-executive
members. Thereafter, the local authority has the same scrutiny
rights that it exercises in relation to primary care trusts.
Councillors on the board are nominated by the council and appointed
by the NHS appointments commission along with other non-executive
members. They are expected to act not as delegates from the local
council but as corporate managers of the care trust, in the
interests of the trust. According to this model of governance,
democratic accountability is reduced to scrutiny powers.

Realistically, there is a trade-off between the accountability and
the effectiveness of a public service. Might care trusts provide a
better service? So far, only one care trust – Somerset – has been
evaluated. The two-year evaluation by the Institute for Applied
Health and Social Policy at King’s College London found that joint
commissioning and provision of mental health services in Somerset
had failed to produce significant benefits to users over its first
two years. They advised “learn from Somerset but don’t copy it.
Significant change is best home-grown”. The evidence base for care
trusts is not in place, but their development as an integrated
health and social care model remains government policy.

Social care faces pressure for joint working from a range of
agencies and professions. Its ability to do this will be impaired
if its structure is dictated solely by the demands of the health
service. Instead of pressing ahead with the implementation of care
trusts, the Department of Health should focus on specifying
outcomes, as in national service frameworks, provide an effective
regime of inspection to drive improvement, and allow more local
freedom to deliver. Health act flexibilities can achieve the
desired outcome without resorting to care trusts.

The restructuring of children’s services is also under
consideration. There is the possibility that child protection will
be passed from local government to a new, justice-based
organisation. Children’s needs are best addressed in the context of
their family, their school and community and a separate child
protection service could make matters worse by creating another set
of boundaries across which professionals have to work. Even if a
separate agency handled investigation responsibility and
registration of children at risk, social services departments would
continue to be the key agency in delivering services to child and
family.

There are better alternatives. Serving Children Well, the
recent report from the Local Government Association, the
Association of Directors of Social Services and NHS Confederation,
recommends local strategic partnerships as the focus of
responsibility for integrated children’s services. Local
initiatives are achieving service integration by bringing together
multi-disciplinary teams on single sites to deliver unified
services, such as single assessment services for child protection,
which involve police, nurses, educational psychologists and social
workers. Greenwich is just one local authority already doing
this.

A reconfiguration of services by Hertfordshire County Council
involved the amalgamation of its education department with social
services, to form a children schools and families department. All
children’s services, including child protection, have been merged
with education, the youth offending team and youth services, all of
whom work to a unified management.

Looking to the longer term, the way social care is organised will
depend on political decisions – about the need for public
accountability and the level of confidence in local government. If
the perceived need is to decentralise, then the democratic renewal
of local government and the extension of devolution to English
regions may have implications for the organisation of social care
and health services. Devolution to Scotland and Wales is already
having an impact on social care policy.

The white paper on devolution to the English regions proposes
selective devolution after referendums, and involving parallel
changes to unitary authorities. Part of a regional assembly’s remit
will be to join up the work of different regional stakeholders. It
would also scrutinise existing regional activity and organisations
in the public sector.

Pressure for regional devolution remains largely absent in south
east England, but is persistently strong in the North East, North
West and West Midlands. The case for regional autonomy is supported
by the need to alleviate overload at Whitehall and to introduce an
element of accountability to the considerable governmental and
quasi-governmental activity already at regional level. Both
arguments are relevant to the NHS, which lacks accountability and
whose stated objective is to move to a devolved structure within a
regulatory framework.

From a social care perspective there is a compelling logic in the
argument for relocating the present health and social care
directorates into multi-functional regional settings, rather than
continuing to have them locked into the Department of Health
hierarchy, where NHS considerations are dominant. At present they
are not even coterminous with the nine government offices.

Social care inspection, which is likely to be integrated with
health inspection, will continue to need a regional network and
elected regional assemblies are likely to interest themselves in
the findings of independent inspection commissions, which will
assist their scrutiny function.

Theoretically, a situation could emerge wherein accountability lost
locally, for example by a wholesale expansion of care trusts, might
be compensated by the emergence of new democratic structures
regionally.

A radical solution to structural and accountability problems would
be to integrate health and social care responsibilities in a way
that could be locally accountable. Instead of taking social care
into the NHS, the commissioning of social care and health could
pass to local authorities. The NHS would confine itself to
providing health services. The whole purpose in having a “care
market”, and a “health market” was to separate purchasing from
providing in order to introduce elements of choice – shaping
services around the individual – while freeing experts to deliver
services.

At present, the commissioning of primary and secondary health care
rests with the providers of primary care, primary care trusts,
which also have responsibility for community health services
(including some community hospitals formerly in NHS trusts) and a
range of functions, including prevention, health promotion and
public health. If, as current policy intends, PCTs progress towards
care trust status, they will also take charge of social care. It is
questionable whether PCTs are appropriate bodies to take so much
responsibility for the local health economy.

Local government commissioning is not necessarily unrealistic. The
next 20 years could see positive results from the government’s
democratic renewal policies. If the current trend is sustained
there will be an increase in the competence of local government in
health matters as Health Act flexibilities are deployed to deliver
integrated health and social care services. Added to this will be
the accumulated experience of health service scrutiny as well as
strategic responsibilities for health improvement and the overall
well-being of the community. If this is accompanied by acceptance
that micro-management of public services from Whitehall is
counterproductive, the idea of health and social care commissioning
within local government may not seem so fanciful.

Anne Davies is an independent policy
analyst.

The big debate

The report From Welfare to Wellbeing: the Future of Social
Care will be published on 17 October and launched at the
National Social Services Conference in Cardiff. The project was
commissioned from the Institute for Public Policy Research by the
Association of Directors of Social Services and Community
Care.

Community Care is publishing a series of articles based on
the chapters of the report to engage the social care workforce in a
debate about future services. The series ends next week with
conclusions from Liz Kendall, associate director, IPPR.