Plan of action or vague wish list? Ladyman signs off the final draft

    Last April, community care minister Stephen Ladyman said he
    wanted a “new vision for adult social care”, which would be
    published that summer.

    Several deadlines later, the adult green paper remains
    unpublished.

    With the general election expected in May some fear the paper will
    not appear until later in the year. But the smart money is that it
    will come out just before the election.

    It is understood that Ladyman has signed it off and it is now in
    the hands of a cabinet sub-committee headed by former health
    secretary Alan Milburn. The paper is expected to be released
    alongside a Department for Work and Pensions strategy for older
    people as part of Labour’s election offer to pensioners.

    But for Ladyman and many in social care, the green paper is more
    than an electoral ploy. Ladyman wants to tackle “the
    professional-knows-best culture” that he believes still pervades
    social care and is a barrier to services being truly focused on the
    user.
    Ladyman has been open about the green paper’s contents: he has
    repeatedly suggested how his three headline principles –
    personalisation, pro-activeness and seamlessness – could be
    applied; and social care leaders have seen early drafts.

    More recently, he revealed the paper would bear close resemblance
    to the Prime Minister’s Strategy Unit’s recent disability paper
    Improving the Life Chances of Disabled People.

    The green paper will not be the last word on the future of adult
    care. One source close to the publication says it has become
    “increasingly green,” suggesting it will provide less a statement
    of policy than a series of questions.

    Social care leaders have already formed a group to lobby on the
    green paper. Given the success of the equivalent children’s group,
    they will be confident they can exert similar influence on adult
    policies. Already they have had some effect with proposals for
    independent assessments appearing to have been dropped, because
    leaders said budgets would rocket sky-high.

    But, the paper is likely to call for greater self-assessment, with
    users playing a role in determining their level of need and even
    the resources required to support them. The government’s belief is
    that people will not over-assess their needs.

    Following the strategy unit’s lead, the green paper is likely to
    call for individualised budgets, which people will be able to take
    as direct payments, services commissioned by councils or a mixture
    of the two.

    The strategy unit suggests these budgets could fund other services,
    such as leisure or transport. The green paper is expected to follow
    suit. Individualised budgets raise significant questions about
    councils’ role. As Ladyman has said, there are tensions between
    personalisation and councils’ efficiency targets, which suggest
    large-scale commissioning. There are also concerns that individuals
    controlling their own services could fall victim to bad
    providers.

    The green paper is likely to call for councils to invest in
    advocacy services and act as “brokers” between providers and
    users.
    For John Dixon, social services director at West Sussex Council,
    this will mean “there is a role for local authorities to have a
    commissioning infrastructure in place [for users to choose services
    from]. What we will need to become better at is predicting what the
    aggregate of individual budgets will produce.”

    Personalisation will be complemented with a strong emphasis on
    independent living. The strategy unit paper calls for disabled
    people to be given a right to request independent living, which
    could be extended to older people in the green paper.

    It will also call for a significant expansion in extra care housing
    at the expense of residential care, though Ladyman has admitted
    that this could take 20 years to achieve.

    In several speeches Ladyman has called for a social care system
    that promotes independence through preventive services such as
    housing, leisure and transport. A similar message was apparent in
    Improving the Life Chances of Disabled People.

    Such a move would signal a complete reversal of the long-term trend
    for social care to focus on people with the most acute needs,
    through ever tighter eligibility criteria. Its implication is
    significant: upfront investment in prevention on top of existing
    funding for acute cases.

    Jon Glasby, senior lecturer at Birmingham University’s health
    services management centre, says: “We’ve got to carry on down that
    course while we also invest in longer term preventive measures that
    may not bring in cost savings for a number of years. That will take
    some form of double funding.”

    The strategy unit says the government will have to give councils
    “invest to save” funding, and calls for the Department of Health to
    bid for extra money for pilots in next year’s spending
    review.

    One way forward could be through local public service agreements,
    in which councils are given money to revamp services to meet
    targets agreed with government.

    Dixon suggests the government’s response to the King’s
    Fund-sponsored Wanless review of older people’s care is cause for
    optimism about funding. He says: “I’ve been encouraged to see the
    DoH saying they will be considering whether to come in behind the
    Wanless review.”

    For some outside local government, funding is only part of the
    problem about a shift to prevention – councils must change
    too.
    John Knight, head of policy at Leonard Cheshire, says: “We’d like
    to see the DoH say something directive about councils adopting a
    more preventive approach in their commissioning strategies.”

    A DoH leak in December sparked speculation that the government
    would impose compulsory commissioning partnerships on councils and
    primary care trusts – so-called virtual care trusts.

    This has since died down. Glasby says: “The DoH seemed very
    surprised. They said it wasn’t something they were actively
    considering.”

    There is sure to be a push for greater integration but many believe
    this will be along the lines of the Children Act 2004, with
    outcomes set by the centre and areas given the flexibility to
    pursue them.

    But some even see some danger in this, in the potential for health
    priorities to swamp social care values.

    Knight says: “I’d like to see the green paper almost celebrate the
    importance and sanctity of the social model… [That’s] what’s
    going to make independent living work.”

    Given the emphasis on prevention, there will also be calls for
    closer integration between social care and services like housing,
    transport and leisure.

    On paper at last?

    Personalised services
    Probable:

    • Individualised budgets.
    • Self-assessment.
    • Extra care housing.
    • Promotion of Homeshare schemes in which older or disabled
      people share with key workers or young people.
      Personalisation is expected to be the keynote of the green
      paper.

    Less likely:

    • Independent assessments.

    Seamless services
    Probable:

    • Greater integration between health and social care.
    • Closer working between social care and community services.

    Less likely:

    • Care trusts, virtual or otherwise.

    Proactive services
    Probable:

    • Social care to be much more preventive.
    • “Invest to save” pilots to test how this could work.

    Less likely:

    • A strong commitment on social care funding.

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