Another money puzzle

Although the ideas in the government’s white paper on health and social care have been well received, there are concerns about how the blueprint for joint working will be funded, writes Natalie Valios. While overleaf Bob Hudson examines the white paper’s vision for social care.

Think of any government initiative from recent years and it will probably merit a mention in the new health and social care white paper. Every Child Matters, Supporting People, Improving the Life Chances of Disabled People, A Sure Start to Later Life: they all appear. There is even a nod to the Respect agenda as the government tries to illustrate the compatibility of its masterplan for joint working between health and social care.

Our Health, Our Care, Our Say: A New Direction in Community Services is striving for more personal and holistic services in the community and support for older people to continue living independently – aims suggested in the choice of title for Independence, Well-being and Choice, the green paper that preceded the policy document launched last week.

These aims, accompanied by proposals including an integrated personal health and social care plan for anyone with long-term needs, can only be a good thing, says Helena Herklots, head of policy at Age Concern England.

But she would be worried if the focus on health and social care excluded other key services, such as housing and transport, that are essential for older people to maintain their independence.

She says: “Of course, there is the question of money. One key thing the white paper is saying is we will focus more on earlier intervention. That’s very good but the question is how can that be achieved initially without extra money.

“Both health and social care, particularly social care, are underfunded. I can’t see how we’re going to get that shift [to earlier intervention] within the current state and that’s the potential weakness.”

Resources, unsurprisingly, is a word that crops up whomever you talk to about the white paper. At its launch, health secretary Patricia Hewitt said that, over the next 10 years, she wanted 5 per cent of resources to be switched from secondary to primary care, to help “make primary and community services more responsive to people’s needs”.

For Julie Jones, president of the Association of Directors of Social Services, one of her concerns is that the resources required to shift investment from acute to preventive services have not been identified. “Five per cent is a good start, but how would the acute sector cope with that reduction?” she asks.

Meanwhile around the country disputes continue over eligibility for funded continuing care costs. Health bodies’ unwillingness to take responsibility in several cases led to the health ombudsman stepping in and criticising them for shunting costs to social services or clients. And just last week a High Court judge criticised Department of Health guidance on determining eligibility. This does not bode well for health’s willingness to shift 5 per cent of resources.

As Jones says: “The white paper doesn’t try to tackle the issue relating to charging or making a contribution relating to cost and that remains a problem for joint working.”

Despite this, on the whole she is optimistic about the proposals in the white paper, as are health representatives. On the proposals to shift resources, Jo Webber, deputy policy director at the NHS Confederation, says: “If you can do this, particularly around long-term conditions, then you can move money around the system in different ways. If you can keep people out of hospitals then you have money…to look at a joint package of care.”

This means the issue of social care carrying out the work while the money sits in the health budget is addressed through a shared care package, allowing the service user to remain at home. “I could see that working,” says Webber.

For Webber, like many, the partnership agenda is at the forefront of her mind. “There is a lot of stuff that we have been asking for – joint care planning and making sure that financial planning cycles are linked should enable partnerships and make people consider how they take their partnership forward in a new way.”

The white paper also makes it clear that the direction of the adult social care agenda is now mirroring that of the children’s services agenda.

“Using community hospitals as joint health and social care facilities links to the one-stop-shop idea of children’s centres. Bringing planning cycles together, looking at inspection regimes, co-location and partnership working are all being done with children’s services,” says Webber.

While the space given to some topics in the white paper came as no surprise, the prominence given to carers did. In an embarrassing misunderstanding in the green paper, carers were merged with volunteers as though they were the same.

This, despite the fact that being a carer reduces opportunities to work and maintain a social life, while increasing the risk to health and well-being. 

Things have moved on since then and there is a range of welcome proposals including a helpline and short-term, home-based respite support in case of a crisis or emergency in every area by 2007-8.

Imelda Redmond, chief executive of Carers UK, says these are exactly what she would come up with. “The government has put a lot of money into breaks for carers over recent years but the problem is the unplanned stuff.

“Our research shows that carers were so worried about something unplanned happening that it was undermining their quality of life, health and well-being, even before it happened.”

The helpline proposal was welcomed by Carers UK which has been calling for one for a long time. The charity’s own helpline is poorly resourced and, with six million carers in the UK, the need for one offering advice on a wealth of subjects, including legal rights and benefits advice, is clear.

Any concern that Redmond has lies with the proposals for more community services. “‘Community’ can mean on your own, at home, looking after a loved one with dementia with someone coming in once a day.

“There is the potential for a backward step and it being an isolating experience for carers unless the professional network understands the role of the family in the delivery of health and social care. It’s not a cheap option.”

Carers are twice as likely to be in poor mental health than the general population and the amount on mental well-being in the white paper was better than expected, says a spokesperson from the Sainsbury Centre for Mental Health. “There is not much about how to achieve mental well-being so we need to have something built into the system. For example, the NHS health check doesn’t say that it specifically addresses mental health issues but clearly that’s one way an existing promise could promote mental well-being.”

Another surprise entry into the white paper was the mention of “stepped care”. Granted it was a small mention, but nevertheless it made it in and “now it’s there in black and white something needs to be done about it”, adds the spokesperson.

Currently, although a GP can treat someone with mild depression and specialist services can deal with someone with more severe mental illness, there is nothing for those who fall in the middle – about one million people in the UK – because there is no stepped care model.

Plans for more talking therapies, included in the white paper and widely trailed before its publication, could be part of the answer.

If primary care trusts were to invest in this type of intermediate care it would mean care close to home, providing patients with talking therapies, support to stay in work, help in managing the condition and general support with day-to-day life.

The Sainsbury spokesperson’s only concern is where the commissioning expertise in mental health is going to come from.

He says: “How are we going to create a set-up locally where health and social care really do work together and there is crossover between the director of public health and the director of adults’ services?”

And at the end of the day, that’s what more than 230 pages boils down to.


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