Eyes shut to social care

    The familiar refrain of “breaking down barriers between health
    and social care” echoes throughout the government’s recently
    published NHS and social care model to support people with
    long-term conditions.(1)

    In the document’s foreword, national clinical director for
    primary care David Colin-ThomŽ declares that the strategy will
    encourage health and social care communities to “work across
    boundaries” and to “adopt case management approaches… as a means
    of ensuring these patients get fully joined-up health and social

    But you only have to look at Dr Colin-Thome’s job title and his
    use of the word “patient” to figure out on which side of the health
    and social care fence the report sits.

    Its five chapters, three annexes and 48 pages contain no mention
    of direct payments and no reference to transport, housing, benefits
    or employment. None of its good practice examples focus on social
    work, and people with long-term conditions are referred to as
    patients throughout. There is only one specific target in the whole
    document – to reduce the use of hospital emergency bed days by 5
    per cent by March 2008.

    But the most obvious snub to social workers is the report’s most
    radical proposal – the introduction of 3,000 community matrons by
    March 2007.

    Community matrons will be a “new type of health professional”
    who will take on caseloads of around 50 to 80 people whose
    long-term conditions require clinical intervention as well as care

    “They will work across health and social care services and the
    voluntary sector, so that this group of patients receives services
    that are integrated and complementary,” says the report.

    They will, however, be nurses.

    Despite the wealth of experience among social workers who have
    similar case management roles, only those with a nursing
    qualification will be eligible for the new community matron

    It is an exclusion that rankles with Ray Jones, director of
    adult and community services at Wiltshire Council.

    “It totally ignores the skills and experience that social
    workers have as care managers, working and engaging with disabled
    people,” he says.

    “And at a time when nurses are considered to be a scarce
    resource, you have to question whether this is the best use of
    their skills. Do nurses have the knowledge to advise people within
    the broader social context, on their housing options for instance,
    on transport or how to claim benefits?”

    Jones believes that, despite the inclusion of the term social
    care in the subtitle of the government’s report, it is essentially
    a medical strategy, targeted at the high-risk end of the long-term
    disability spectrum. Its principal aim is to keep potentially
    expensive patients out of hospital, he says.

    “This is not a social care model,” says Jones. “It’s a clinical
    model, it’s disease focused and it doesn’t take into account the
    social model of disease. Social care is an afterthought. It’s all
    to do with resources.”

    The Long-Term Medical Conditions Alliance, which last year
    published a manifesto for improving long-term care, has also
    sounded a note of caution. It says that the approach laid out in
    the government’s new model could “result in attention and resources
    being disproportionately focused on the small minority of people
    with the most complex conditions”.

    A warning echoed by the King’s Fund, whose chief executive Niall
    Dickson has stressed the need for a wide range of services “not
    least to ensure that those with less severe needs are not left

    In fact, the government’s new model outlines three levels of
    care that should be made available to people with long-term
    conditions. Level three is aimed at the most vulnerable and at
    those with highly complex multiple long-term conditions. For these
    people, community matrons are to use a case management approach to
    “anticipate, co-ordinate and join up health and social care”. Level
    two is aimed at those with a complex single need or multiple
    conditions, and involves disease-specific care management by
    multidisciplinary teams.

    Level one is based around supported self-care, in which
    individuals and their carers are helped to develop the knowledge,
    skills and confidence to look after themselves.

    But this pyramid of care could be used to “focus resources only
    on people with complex conditions”, warns LMCA chair Elizabeth

    “People shouldn’t be put into rigid categories, and co-ordinated
    care plans should be the right of everyone diagnosed with a
    long-term condition,” she says. “Long-term conditions impact on
    every area of life – it’s not just about keeping people out of

    Nevertheless, Wincott welcomes the recognition of the value of

    “We are pleased that the role of patients as partners in their
    treatment and care has been acknowledged, along with the importance
    of self-management as a means of helping people live with their

    Patient groups have, by and large, welcomed the report, which
    many see as a taster of what may be included in the National
    Service Framework for Long-Term Conditions, which is due to be
    published later this year.

    Diabetes UK has applauded the proposal for community matrons
    although, like the LMCA, the charity has warned “against the
    temptation of just focusing on keeping people out of hospital
    rather than tackling the problems which have made some people so
    vulnerable”. Its director of care, Simon O’Neill, adds: “The new
    model of care is a well overdue and much welcomed initiative. We
    must look at the most vulnerable people and do all we can to avoid
    them having to end up in hospital.

    “But the most effective way to do that in the long term is to
    prevent them from becoming so vulnerable in the first place. It is
    about effective education and support.”

    The Parkinson’s Disease Society has also welcomed the idea of
    community matrons and the recognition of self-management.

    However, the society has stressed that the model must retain
    enough flexibility to respond to the particular individual needs of
    people with Parkinson’s and their carers. It says that while it is
    a good objective to keep more people out of hospital, those
    affected by Parkinson’s disease need to be able to move between
    services and have access to a variety of health and social care
    services at all times.

    There are 17.5 million people in the UK estimated to have
    long-term incurable conditions, such as diabetes, asthma and
    arthritis. Although the forthcoming NSF on long-term conditions is
    expected to focus primarily on neurological conditions, health
    secretary John Reid has already made it clear that this recently
    published model will provide the blueprint for how long-term
    conditions are dealt with in the future. As to whether the desired
    levels of integrated care can be achieved without significant input
    from social care professionals, many have their doubts.

    (1) Supporting People with Long Term Conditions: An NHS and
    Social Care Model to Support Local Innovation and Integration
    available at DoH website: www.dh.gov.uk/assetRoot/04/09/98/68/04099868.pdf


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