Will prevention be a cure-all?

John Dixon, Association of Directors of Social
Services’ disabilities committee

“Many social care developments over the past 10 years have
caused concern to service users and dismay among staff.

They include:

·                    

Eligibility criteria used as a rationing device to attempt
financial management as much as to demonstrate entitlement to
service.

·                    

Average care packages have become ever more intensive which has
reduced the overall numbers of people served.

·                    

Perversity of many performance indicators which drive services away
from national and local policy direction, including prevention and
plurality of provision.

They have also served to obscure the advances in professionalism
that have taken place in the services provided. We now need to use
the green paper to reverse that trend.

The ADSS is committed to working with colleagues in the public and
independent sectors, and with the government, to make this process
a reality.

Especially important will be the chance to work with the voluntary
and community sector (VCS) within a different framework. The green
paper proposes a different compact between the state and its
citizens. We should be looking for this to be matched by a change
in the relationship between the public sector and the
VCS.

Driven by the move towards ever greater intensity of services,
local authorities have tended to see the VCS increasingly as a
provider of services, and less in its other role as an advocate
both for individuals and for policy principles. The new roles
suggested in the green paper (navigators, brokers) and the shifts
of control anticipated indicate a reliance on the VCS to come
forward in that other role.

If this partnership is to develop, local authorities need to see
themselves increasingly as enablers of others. The VCS has to spend
too much on survival. If we provide a more conducive environment,
it can devote attention to those low-intensity services that make
for real service improvements”.

Jeni Bremner, programme director, education and social
policy, Local Government Association

“What does prevention mean in the context of adult social
care? The simple answer is actions taken now that prevent the need
for intensive or intrusive interventions later, and strategies to
promote quality of life and engagement with communities. But this
is a simple answer to a complex question. When we deliver social
care services we aim to sustain a person’s independence by
building “interdependence” through networks and
coalitions of individual, family, carers and community
capacity.

Promoting prevention means tackling social exclusion. And this
requires us to tackle social stigma, including ageism, to build
community capacity and to support communities of interest, as well
as geographical communities, to look after and manage their own
affairs. Local authorities have a critical role working with
partners – often in the voluntary and community sectors – to build
community capacity.

This agenda is much broader than the statutory sector. The
voluntary and community sectors are major contributors. They are
major direct service providers, but their role expands beyond
service provision. They are active in community capacity building
at a local level, representing the needs and aspirations of
different parts of our communities. Not least, they often act as a
‘critical friend’ – challenging existing models of
service provision and leading innovation.

At the heart of prevention is the belief that investment in
services which promote well-being will both improve a
person’s quality of life and reduce or delay the need for
intrusive and often expensive interventions later in
life.

This does mean, however, that there will be a need for some
double-running of services over a period of time. We hope the
review led by Derek Wanless for the King’s Fund will provide
useful evidence to support greater investment

in prevention”.

Jo Webber, policy manager, NHS
Confederation

“The challenge for all of us as we refocus on preventive
health and social care is to ensure services are maintained while
this shift is happening. This won’t just happen
automatically, and there is a danger that the day-to-day challenges
of ‘getting the job done’ and
‘firefighting’ will continue to dominate the agenda.
Investment needs to focus on ensuring that preventive work is not
squeezed out.

The voluntary and community sector is already an important part of
service provision, but this involvement needs to be strengthened
through genuine partnership working.

The NHS Confederation is part of the Inter-Agency Group on Adult
Social Care, a coalition of 14 organisations representing service
users, carers, communities and staff who are all calling for a
shift of focus from acute care to prevention in social care
services.

This is a valuable forum for discussing our common ground and
exploring our differences.

Statutory organisations need to be smarter in working with
voluntary and community organisations – and vice versa – so that we
can develop a better understanding of our different cultures and
ways of working. That is a cultural shift just as great as the
shift from firefighting to prevention, but it is crucial for us to
achieve”.

Heléna Herklots, head of policy, Age Concern
England

“If the green paper failed to bring about the full range of
changes it proposes, but succeeded in ensuring preventive services
are available to all who need them, we would count it as a success.
But there are some caveats.

Prevention must not be defined narrowly as ‘preventing the
need for more intensive services’. It is equally about
promoting quality of life and well-being. It can delay or prevent
the need for more costly services, but it is also good in itself
because it improves people’s quality of life. It means
provision of practical support. It is also about social contact and
involvement. It works best if it addresses all the elements of
well-being.

So what needs to happen to achieve this? Can it happen, as the
green paper suggests, on a cost- neutral basis? Thousands of people
develop and provide preventive services, and many work in the
voluntary sector. Although recent years have seen welcome
government grants and initiatives, prevention has received no
sustained resourcing.

A preventive approach should produce savings down the line. But,
initially, additional funding must be provided or support for the
more vulnerable could be compromised. The government should
‘invest to save’.

The voluntary sector, working in partnership with others, is
crucial in a shift to prevention. However, we need support from
national and local government to play our part. The voluntary
sector compact should be honoured so we can become equal partners
in working to improve the quality of life of all those who need
social care”.

Angela Greatley, chief executive, Sainsbury Centre for
Mental Health

“Mental health and well-being are influenced by many factors,
from family relationships to the wider community. Promotion of good
health has to encompass the needs of everyone, including those who
have sought help from mental health services or their GP and those
who have never sought that help.

The green paper does not show any great ambition to tackle these
vital questions. A short paragraph on preventive services suggests
the new connected care centres will have a vital role in promoting
social inclusion. Work with community and voluntary sectors will
also play a part.

But none of these ideas are spelled out with any radical vision
about how to tackle current mental health problems. And there is no
mention of the pound signs or the commitment of people’s time
and expertise that would have to go with any programme.

Discrimination against people with mental health problems and the
stigma they feel create massive barriers to health and well-being.
The headlines are full of negative stories that discourage people
from seeking support early on. Employers and work colleagues can be
wary, preventing people with mental health problems from finding
and keeping work. Housing is difficult to get if you have a mental
health problem.

The green paper offers little original thinking on how to tackle
these problems, or on the leadership that is required to address
these challenges. Overall, it offers a disappointing agenda for
action to promote health and well-being. It needs much more work to
ensure social care plays its part in implementing the Choosing
Health white paper and tackling discrimination against people
with mental health problems”.

Independent View

Jon Glasby, senior lecturer and head of health and social
care partnerships, Health Services Management Centre, University of
Birmingham

“One thing everybody seems to agree on in social care is the
need for more prevention. With tightening eligibility criteria and
financial shortages, workers often have to concentrate on those in
crisis, leaving people with lower-level needs to deteriorate until
they qualify for services. This cannot be the right outcome for
service users and is not a sensible use of public money.

Against this background, it is to the government’s credit
that it has charged local authorities with developing preventive
services. Working within existing resources, councils will have to
take a corporate approach. By itself, social care can never tackle
the problems its service users face. Working with other services,
it could achieve a whole that is greater than the sum of its
parts.

One way to do this might be to make current health and social care
grants available to a wider range of local authority departments,
and to develop a smaller number of joined-up targets – in effect,
making the whole system responsible for the various community care
user groups rather than just social care”.