Proposals beg questions

The health and social care white paper offers a rich vision of integrated services, but will financial realities and cultural differences between sectors intrude? Gordon Carson, Mithran Samuel and Maria Ahmed report.

From promoting closer working between sectors to diverting finances from acute care to prevention, there is much in the health and social care white paper to gladden hearts in the NHS and social care.

Central to the document are the themes of integration, personalisation and prevention.

On integration, the white paper follows in the footsteps of Every Child Matters by proposing more joint working and aligned inspection between sectors with traditionally contrasting cultures and targets.

But while many councils started to implement the children’s green paper reforms before the passage of the Children Act 2004, questions remain about the mechanisms for councils and
primary care trusts to do likewise following the white paper.

Workforce reform is left in semi-limbo while the outcome of the Options for Excellence social care workforce review is awaited. This is expected to produce its first report in the spring.
The roll-out of individual budgets will depend on the results of 13 pilots and, if approved, will only take place in 2009-10.

And the continuing financial pressures in social care and the NHS threaten to undermine the proposed shift to preventive services.

Local government leaders fear that the multitude of measures on joint working proposed in the white paper could be undermined without a formal duty on health bodies to
co-operate with councils.

The Association of Directors of Social Services and the Local Government Association say a duty is necessary to ensure joint working arrangements are successful.

The white paper says the government is waiting on the completion of its consultation on local strategic partnerships, which is considering the case for a duty on them to co-operate with councils.

Care services minister Liam Byrne has suggested he is supportive. Last week he told Community Care that the government wanted the partnerships to be “as constitutionally strong as possible”.

Health leaders are not so sure, though. Jo Webber, deputy policy director at the NHS Confederation, says the government has taken a sensible approach by not enforcing a duty through the white paper.

“They have said that if they feel it’s necessary to add a duty, they will at a later date,” she says. “That incentive is there to help people consider how they are doing their partnerships.”

The LGA is particularly pleased with the white paper’s proposals to place a greater emphasis on local priorities in health and social care, through local area agreements.

Its programme director for community well-being, Jeni Bremner, believes the agreements will be important in combating the financial problems in health and social care by helping local health bodies win more freedom to set priorities in their areas.

The paper also points to greater coterminosity between councils and primary care trusts through the current health service restructuring. But there are concerns that this could be derailed by the forthcoming local government white paper, which may include plans to reorganise councils.

Webber says it would be a “great shame” if all the restructuring failed to result in greater coterminosity. “A lot of partnership working is predicated on coterminosity,” she adds. “It’s incredibly difficult to keep several partnerships going on at the same time.”

Other measures on joint working include an alignment of NHS and local government financial cycles by 2007-8, and joint assessment targets for social care and health based around the seven outcomes outlined in last year’s adult green paper.

The government also expects directors of public health to be joint appointments by councils and PCTs. They will work alongside directors of adult social services to produce 10- to 15-year plans for services.

At an operational level, joint teams will support people with the most complex conditions.

The paper also proposes more joint planning on workforce issues. At a strategic level, Webber would like to see this developing along similar lines to changes in the children’s workforce where all people working with children, in whatever setting, will develop a common core of skills as part of their training.

The white paper promises a “strategic shift” of resources from acute care to services that are preventive and promote well-being.

However, there are no equivalent proposals on how this will happen in social care.

The fact that budget constraints are forcing councils to tighten eligibility criteria is not mentioned (Councils slash services).

In such a climate, the idea of investing in low-level services for people with lesser needs appears unthinkable to many.

Jon Glasby, head of health and social care partnerships at Birmingham University’s Health Services Management Centre, says the government must “double fund” social care, maintaining services for those in acute need and investing new money in prevention. He warns that preventive funding should be ring-fenced to prevent it being sucked into financing acute care.

Liam Byrne is talking up the social care funding bid for next year’s comprehensive spending review, saying it will be heavily influenced by Sir Derek Wanless’s funding review, which may report this month.

There is no doubting the minister’s ambitions, but with the Treasury promising a tight settlement and the sector traditionally being a low political priority compared with  health and education, they could remain unfulfilled.

Giving people more choice and control over their services is one of the white paper’s key ambitions. In social care terms this means direct payments and individual budgets.

It reiterates the adult green paper’s pledge to extend direct payments to groups currently excluded, such as people who lack capacity, and promises a national awareness-raising campaign to raise take-up.

While the paper brings forward the national roll-out of individual budgets from 2012 to, possibly, 2009-10, it indicates this will depend on the success of the current pilots.

However, (Home care is patchy), last month Department of Health national director for social care Kathryn Hudson suggested a roll-out would be conditional on individual budgets not upsetting councils’ financial stability.

She told Community Care LIVE  in Manchester last week: “It’s really important that we look at the stability of budgets within local authorities to see how we can achieve these changes without destabilising them.”

The white paper rejects the case for extending individual budgets and direct payments to health services, arguing this would violate the NHS’s defining principle of being free at the point of delivery.

However, David Pink, chief executive of the Long Term Medical Conditions Alliance, argues that the government should have been more radical. He says: “There are areas of health care where direct payments could make a real difference.”

Instead, the paper says practice-based commissioning, in which PCTs devolve budgets to GPs to buy services, is the “health equivalent of individual budgets”, given GPs’ closeness to service users.

However, Pink says: “The worry here is that we mustn’t see GPs as the voice of service users. We need to build user voice into practice-based commissioning.”

The paper also promises a personal health and social care plan – initially for those with the most complex needs. This will be available to everyone with both long-term and social care needs by 2008, and by 2010 for those with long-term conditions.

For further white paper coverage see Peter BeresfordAnother money puzzle, and Now it’s our say.


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