The Personal Touch

If community care minister Stephen Ladyman is to be believed,
the adult green paper heralds a revolution in social care.

“The care services we end up with if we go down this path will
be chalk and cheese compared with what we have at the moment,” he
proclaimed last month.

Independence, Well-being and Choice, he argues, is an antidote
to a social care system that for too long has been based on
inflexible services restricted to people in acute need, with a
professional-knows-best attitude among staff. Ladyman also claims
it will meet the challenge of the predicted quadrupling in the
number of people older than 85 and the exacting expectations of an
ageing baby boomer generation.

Although reactions to the green paper have been more tempered
than Ladyman’s rhetoric, the government’s vision has won the
backing of a broad-based coalition spanning social care, local
government, health and the voluntary sector. Aside from the
inevitable opposition from the Conservatives and the Liberal
Democrats in the run-up to the general election, dissent has been
restricted to the care home industry, which sees the green paper’s
focus on independent living as a threat.

There is little doubt that a social care system built according
to the green paper’s principles would look very different to the
status quo. The call for investment in preventive services for
people with lower level needs would reverse a decade-long trend
that has increasingly seen social services deal with fewer, but
frailer, people. And the seven anticipated outcomes of the green
paper go well beyond traditional social care boundaries to include
health improvements and tackling poverty.

In particular, its prospectus for personalised services heralds
significant change: self-assessment, individual budgets for most
users and, implicitly, the decommissioning of many existing
services, particularly those in residential settings.

The scale of the change explains why the government believes it
will take 10 to 15 years to implement. Although few argue with the
green paper’s vision, many in the sector believe that it will take
more than just time to achieve it.

The green paper’s claim that its provisions are cost-neutral and
can be delivered by redesigning services has been met with a
mixture of scepticism and incredulity. But a closer look at the
government’s position on funding reveals that it is more flexible
than its cost-neutrality claim suggests. While social care funding
is set until 2008, Ladyman has indicated that the Department of
Health may have to lobby for more money in the summer spending
review on the back of the green paper consultation.

Derek Wanless’s review of funding care for older people, which
is sponsored by the King’s Fund, is due to report next spring and,
should it dismiss the cost-neutrality claim, the government will
come under strong pressure to increase funding. But with the
Institute for Fiscal Studies claiming the chancellor will need to
raise £11bn in taxes to meet existing spending commitments,
this could be pressure the Treasury is minded to resist.

Within social care, there is no room for any ambiguity on
resources: the green paper can only be delivered through a
significant increase in funding because of the costs of both
preventive and personalised services.
John Ransford, director of education and social policy at the Local
Government Association, says the level of personalisation demanded
by the government will remove the efficiencies of scale accrued
from long-term, block contracts. “If we are going to change to a
needs-based service so that people make their own decisions, then
that almost by definition is a more inefficient service. The way
you get efficiencies in the care market is to pile them high and
sell them cheap, like a supermarket.”

This problem is exacerbated by the fact that councils are under
pressure to find £684m in efficiency savings from adult social
care over the next three years, as a result of last summer’s review
of the public sector by Sir Peter Gershon. One of Gershon’s
suggestions was regional procurement of social care, an idea that
flies in the face of greater personalisation, as even Ladyman has
admitted.

But Simon Duffy, of the Valuing People Support Team, argues that
personalisation can be a route to efficiency. Duffy has been
seconded to lead Mencap’s In Control project, which has been cited
by the green paper as an example of how individual budget holding
can work. The scheme, which is being piloted in six areas, allows
people to assess their own needs, puts a value on the level of
support they are entitled to and lets them plan their own services,
with the help of a care broker if necessary.

He says: “What we claim is that people manage their funding
well, they prioritise the use of funding more sensibly and they
make the money work harder for themselves when they actually have
control of it.”
The logic of the argument is that individual budgets knock down the
Berlin Wall between informal caring and state-commissioned
services, allowing people to plan their support more
intelligently.

“People’s current inability to combine paid and unpaid support
leads to greater crisis and people being institutionalised earlier
than they could be,” says Duffy.

He is scathing about the claim that long-term block contracting
has brought efficiency.

“The guarantees provided to the social care market are far
greater than anyone else would expect in any other industry. Have
these led to good cost control, improvements in quality or
innovation? No.”

Few doubt the green paper’s logic on prevention: that investment
in low-level services today will eventually pay for itself by
reducing the demand on acute care tomorrow. The problem lies in
paying for acute care today.
Ransford says: “There’s going to have to be double funding. As you
redesign services you will have to keep running existing
services.”

John Knight, head of policy at Leonard Cheshire, says the
implication of a shift to prevention is, in the immediate term,
making more people eligible for publicly funded care. He says: “A
lot of the disabled people I’ve spoken to [about the green paper]
have asked whether there is money attached to it. I pay for my own
care. Even though I’ve got substantial needs I don’t satisfy the
eligibility criteria. I’m fortunate, I earn a salary, but many
don’t.”

The government is not deaf to these arguments. The prime
minister’s strategy unit’s paper, Improving the Life Chances of
Disabled People, suggested the DoH lobby for “invest to save” money
to fund preventive services in next year’s spending review while
the green paper suggests giving councils and their partners
“financial incentives tied to outcomes” to make the shift, but
fights shy of making commitments.

One solution to the funding conundrum, mooted by Ladyman, is for
NHS resources to flow into social care on the basis that this will
save money for acute health care over time.

The government is planning to place a duty on councils and
primary care trusts to set up strategic partnerships to plan the
adult care needs of their populations over a 10 to 15-year period.
Ladyman expects this will encourage more “whole system thinking”
and lead to an increase in Health Act 1999 partnerships, which
allow budget pooling and even care trusts.

Jo Webber, policy manager at the NHS Confederation, suggests
that the introduction of payment by results in the health service
could provide an added incentive for PCTs to invest in social care.
The system is designed to end block contracts between PCTs and NHS
providers, with the latter paid according to the volume of work
they do.

She says: “Payment by results will make people look at how they
deliver services and use it to reconfigure what they’ve got to
better fit the needs of patients, so they have their care delivered
much closer to home.”
Funding is not the only sticking point for green paper sceptics,
however.

David Johnstone, director of social services at Devon Council
and chair of the standards and performance management committee at
the Association of Directors of Social Services, says the
regulatory systems in social care and health remain firmly oriented
towards acute care.

He says: “At the moment so much of the emphasis of performance
assessment in social care is around higher level,
institutional-based care. Even if you look at domiciliary care
services they are focused on intensive home care.”

He cites the key performance indicator on helping older people
to live at home as only focusing on those with significant needs.
“We expected that to be changed last year but it wasn’t. Now the
green paper is out it’s even more of an anomaly.”

A shift towards preventive services also needs changes to the
regulation of health, he adds. “There would have to be alignment
between PCTs’ and social services departments’ performance targets
around the strategy. If you don’t do that it’s just tokenism.”

The plan to merge the Commission for Social Care Inspection’s
adult function and the Healthcare Commission by 2008 – while
unpopular in social care – could be a route to alignment. More
broadly, the government is working with the CSCI to work out how
the green paper’s seven outcomes – covering health, quality of
life, economic well-being, choice, dignity, freedom from
discrimination and contributing to society – can be inspected in
practice. Early results from this work are expected by the
summer.

Unlike the children’s green paper Every Child Matters, the adult
care green paper has not been criticised for being
over-prescriptive. It is not dictating that councils and PCTs must
set up care trusts and is clear that it is up to local
authority-led partnerships, headed by directors of adult social
services, to manage change locally. And although it suggests that
directors should take on a broader portfolio of adult services –
for instance housing and lifelong learning – the government will
not make this compulsory.

The government’s localism has been endorsed by the ADSS and the
Local Government Association, but are councils ready to shift away
from the sorts of services they have historically delivered and
commissioned?
Knight, who used to work in local government, says: “There must be
a manifest change in local authority commissioning, which is led by
crisis and event rather than vision and prevention.”

But he says councils are up to the challenge: “Local government
has been a great advocate of the social model of disability and is
well prepared to take up the challenge laid down by Ladyman.”

Over the four-month consultation, the ADSS, the LGA, the NHS
Confederation and their voluntary sector allies will be lobbying to
secure the means they believe they need to deliver Ladyman’s vision
locally, including more funding and prevention-based
regulation.

Assuming Labour is re-elected, a white paper is due this autumn.
We will learn then whether Ladyman, health secretary John Reid and
Tony Blair are in listening mode, and perhaps whether the vision
has the potential to become reality.

As Ransford says: “There’s a massive will behind it to succeed,
but it has to be implemented carefully if expectations are not to
be dashed.”