Special Report on commissioning of adult social care

No shotgun marriages

One thing the adult social care green paper is clear on is that
there will be no more wrangling over who pays for what at the murky
borders of health and social care, writes Craig
Kenny.

Ladyman was driver behind the green                         paper

There are to be no shotgun marriages – the language is now
about ‘virtual’ care trusts, closer partnerships
between the organisations, more pooled budgets and sharing of
staff.

Then there is ‘cross-commissioning’, where community
matrons and nurses commission home care, or social workers
commission equipment or health interventions as part of their case
management role.

Meanwhile, adult social services departments will be allowed to
contract out even their statutory functions, while still retaining
overall responsibility for them.

Should this sort of closer working not materialise, the
government warns it may ‘strengthen the duty’ for local
authorities and NHS bodies to co-operate in commissioning adult
services and sharing responsibility.

Two other major green paper themes are the need to give clients
choice and independence and the need to prevent more ill health and
social exclusion, thus saving on complex care needs later on.

New partnership arrangements – Local Area Agreements and
now Local Public Service Agreements – are the means to bring
commissioners together with their communities to address these
themes.

Getting people into primary services

Local authorities see their role as helping people access free
universal services – the preventive part – and as
guarantors of quality for the more complex care packages that they
buy in the marketplace.

“We need to be looking at how do we get people into
universal services, like primary care; to accessing ordinary
services rather than specially tailored individual services which
tend to be stigmatising and expensive,” says John Dixon,
social services director in West Sussex and co-chair of the
Association of Directors of Social Services disabilities
committee.

But a headache for commissioners is that one of the engines of
the choice agenda – direct payments – also threatens to
unsettle their long-term planning and block-contracts with big care
providers.

“I know that providers are very bothered about hundreds of
thousands of people all buying care packages from cards in
newsagents windows and small ads – the potential
destabilisation is horrendous,” says Dixon.

“It’s a myth that social service departments have
been dragging their feet over direct payments. The problem is
service users don’t want the bureaucracy and the risk of
having to assure the safety for themselves. They want someone to
turn to if things break down.”

Local government is therefore keen to see personalised budgets
introduced well before the projected date of 2012. “With
personalised budgets I expect them to be able to buy off of local
authority block contracts, something you can’t do with direct
payments,” says Dixon.

“The local authority can still do the commissioning and users
can go to those providers safe in the knowledge they have been
assessed by the council – there’s much less risk to the
service user.”

Direct payments should not be restricted to social
care

The other sticking point with direct payments is they are not
available to NHS bodies – creating real headaches for any
arrangement in which the NHS and adult social services share
care.

“Direct payments must not be restricted to social care as
service users will look to have the same level of flexibility and
choice in other services, including health care, as this agenda
progresses,” says  Jeni Bremner, programme manager on the
Local Government Association’s community wellbeing board.

“The provision of community based health care such as
district nursing and chiropody can be fundamental underpinnings of
independence. It is essential that the choice agenda in the NHS and
other areas of public service keeps pace with the social care
agenda as it develops.”

There is a way around this bar on NHS direct payments, but
it’s a complex agreement known as a Section 31 arrangement.
Dixon argues: “It should be written into the White Paper that
we will allow the NHS to have direct payments, otherwise someone
who moves from social care to community care loses that
option.”

Boundaries will be blurred, says                      Webber

From the NHS point of view, a big change in commissioning habits
may come once GPs’ practices are again allowed to hold
commissioning budgets. “Patients will have more choice about
what and where they want their care to be delivered,” says Jo
Webber, policy manager at the NHS Confederation.

“There always will be issues around resources”

“Front line professionals have been trying to make care
packages fit round patients, so it’s nice to have that
reinforced in the green paper.

“There always will be issues around resources, but now there
are more open and honest conversations.’

The green paper points to some innovative ideas such as adult
placements (i.e. fostering for adult clients) but is not
prescriptive about new service configurations.

“What you are going to find is some of boundaries between
health and social care workers will get more blurred as time goes
on,’ says Webber. ‘It makes no sense to duplicate going
in to see someone when, with cross training, one person could
deliver a package of care.’