For better or for worse

Some marriages are relationships of equality between loving
partners; some are more stormy with one partner dominating or
controlling the other. The social care sector is hoping that any
future nuptials with health are of the first type.

Last month, the care services minister Liam Byrne announced that by
the end of the year the government will publish a white paper on
health and social care.

It will take forward the vision outlined in the green paper on
social care as well as addressing out-of-hospital care as part of a
“new alliance between health and local government”.

Since the Labour government came to power in 1997 the link between
health and social care has become stronger, fuelled by joint
working and joint service development at a local level.

Many people feel that the time is right for a joint white paper.
Jon Glasby, head of health and social care partnerships at the
University of Birmingham’s health studies management centre, says:
“For a long time we’ve recognised health and social care are two
different sides of the same coin and people who use services do not
care if it’s branded as health or social care, they just see it as

For John Dixon, co-chair of the Association of Directors of Social
Services disabilities committee, there is little reason not to have
a joint white paper. “If there is an opportunity of joining the
services up and having an integrated approach it has to be the
right thing.”

But does the coming joint white paper mean social care is no longer
an important and distinct service in its own right? Not necessarily
– Dixon argues that social care is still significant because of the
way services are provided and the impact this has on those
receiving them. “It is about whether a service is based on the
health model or on the social care model. The social model of care
is about empowerment and helping people to exercise choice and
control, and that is not the hallmark of the medical model of

But while the white paper has been welcomed by the social care
sector, there is concern that it will be joint only in name and
that social care will be subsumed by its older, more powerful
partner. Mona Seghal, programme manager for community well-being at
the Local Government Association, says it does not want the white
paper to focus on out-of-hospital care in the form of GPs and
health service providers to the detriment of social care. “We are
concerned the vision for social care expressed in the adult green
paper will not be taken forward by the joint white paper as it
would be if it had its own white paper.”

Social care’s part in the white paper is likely to be more advanced
because of the adult green paper and the strong responses it
provoked from the sector, according to Dixon. “There has already
been a lot of discussion around the future of social care,
including its relationship with health. The health side of things
is going to have to catch up a bit.” He adds that the government
has assured the ADSS that social care will not be usurped by

Jo Webber, NHS Confederation policy manager, is equally confident
that the white paper will not ignore the role of social care. In
her opinion, the sector’s fear is unrealistic given that many
government targets are only achievable if health and social care
work together. “It is about time we started talking about a health
and social care system and not a separate health and a separate
social care system.”

As social care and health enjoy stronger ties there could be an
opportunity for social care to argue for increased funding in line
with health which has, historically, been better funded. Doing so
could well work to social care’s advantage. As Glasby says: “This
could mean that social care could be less marginalised than if it
had a separate social care white paper.”

But is there a risk that stronger links with health will be to the
detriment of social care’s relationship with other local government
initiatives, such as regeneration? Or can social care be like the
Roman god Janus, who had two faces, and was able to look in
opposite directions at the same time?

Dixon believes that social care can work effectively with health
and local government simultaneously. “Sometimes we forget we are
local government and we have all of local government’s strengths.
We should be working to enable access to housing, leisure and
transport.” Seghal agrees and says more should be done to ensure a
broader range of local government initiatives are tied in with
social care.

Another concern relates to who will run the consultation on the
white paper. Initial government plans were believed to put primary
care trusts in the driving seat of the process, giving it a greater
health bias, but after gentle pressure from social care the
government is now expected to make the process more inclusive and
involve both services.

Seghal says that it is vital that the consultation, which begins in
September, involves local government: “If this is about people’s
well-being and not just about health services then there needs to
be local government involvement as we already have the track record
for engaging with communities.”

Despite the potential and far-reaching benefits of a joint white
paper, anxiety still exists within social care over what it will
mean for the sector. A statement issued by the Adults Interagency
Group, made up of key organisations including the ADSS and the LGA,
sums up what the government must do to reassure the sector: “The
challenge for government will be to ensure that the synergies
between health and social care are fully exploited and that social
care does not become a marginal part of the white paper.” We will
have to wait until the end of the year to see if the government
heeds this message.

Knowsley council
Knowsley Council became one of the first local
authorities, outside London, to integrate its health and social
care services in 2002. Jan Coulter is deputy director of health and
social care at Knowsley Council and Knowsley Primary Care

She says the decision was made to integrate the two services
because the area has high levels of health inequalities – 18 of the
borough’s 22 wards are classified as deprived. 

“We thought we couldn’t improve health inequalities unless we
combined both organisations’ management teams. Now we have one
leadership team that crosses both organisations.”

As simple as it may sound, one of the key factors in helping
combine both services was locating some health and social care
staff in joint headquarters – actually sitting together has helped
with communication and working practices. Knowsley also has a joint
training and development team and is currently formulating a joint
workforce strategy. 

Coulter says it was decided to make the changes gradually – the
idea was first mooted in 2001 and the PCT was created in 2002 – to
ensure a successful merger. “We didn’t go for the big bang approach
but looked at when opportunities arose to give staff joint roles
across both organisations.”

The experience has been very positive and Coulter says they have
not regretted the decision. Her advice to local authorities
considering a similar move is to put their clients first. “It is
about focusing on particular outcomes for people rather than on the
structure. If you start by looking at the structure it’s really
hard but if you look at what you want to improve for people it’s a
lot clearer.”

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