When a previous government appeared to put off implementing the Beveridge report which ushered in the modern welfare state, the future Labour health minister Barbara Castle piped up: “We want jam today, not jam tomorrow.” Those who have dared to hope for Beveridge-style universal entitlements to adult social care found the current government in much the same “jam tomorrow” mood as its predecessor when the comprehensive spending review was announced last month. While local government found the prospect of 1% annual increases in funding particularly unappetising, the dish was improved by the promise of a green paper in a year’s time on the funding of social care. The government’s intentions are hard to divine, but health secretary Alan Johnson’s references to Sir Derek Wanless, whose landmark report last year advocated a partnership model for funding older people’s care, point the way to radical reform.
The partnership model would give a universal entitlement to a minimum level of free care, although the Johnson version sounded like Wanless-lite – less generous to the better off and dashing hopes of an end to means-testing. The abolition of means-testing, Johnson said, would result in “the poor subsidising the rich”.
His admission shortly after the spending review that rapidly rising demand is freezing seriously needy people out of social care has concentrated minds not just on the funding of the system, but on the fundamental approach to delivery. Here the government was characteristically generous with its views, if not the taxpayers’ money, particularly in the review’s accompanying public service agreements setting out public sector priorities.
While there were few startling initiatives in the PSAs, they should redouble efforts to move towards a more preventive, personalised and inclusive service, at least in those areas where the relevant targets are adopted. The fact that councils will be able to pick from a smaller menu of outcomes-based targets has been welcomed as giving more local autonomy to focus on users’ quality of life. Local area agreements will be a key tool here.
Social exclusion task force director Naomi Eisenstadt has expressed concern that one of the more ground-breaking PSAs, aiming to increase the proportion of socially excluded adults in jobs, training and housing (No 16), could be overlooked. Potentially, it benefits core client groups such as care leavers and people with learning disabilities, pooling the resources of agencies to help users lead more independent and productive lives.
For Eisenstadt this is the heart of prevention, giving people the right support at the right time so that they are less likely to become dependent on high-cost services. The message is reinforced in another PSA (No 17) to tackle poverty and promote independence and well-being in later life. One of its performance indicators will assess the extent to which over-65s receive the support they need to live independently at home, “reflecting a wider view of ‘help’ than simply the narrow definition of services provided by or via the local social services department”.
Once again this “wider view” is supposed to lift the blinkers from councils whose only contact with service users occurs when they have substantial needs requiring intensive support from adult social services. “This is certainly a step forward,” says Gerald Wistow, visiting professor of social policy at the London School of Economics and former chair of Hartlepool primary care trust.
“Social services are gradually connecting into more universal services rather than providing everything themselves – things like leisure, recreation, libraries and sports are all being looked at in terms of how they can contribute to the lives of people with significant needs and promote their broad inclusion.”
Last year’s health and social care white paper, Our Health, Our Care, Our Say, talked of caring for more people outside hospital and closer to home by putting in preventive and “reablement” services to promote and maintain independence. True to its word the government has published an independence indicator for all ages in the PSA Promote Better Health and Wellbeing for All (No 18). It looks at how much lower level support is provided in community settings “preventing or postponing need for more intensive care packages or residential care”, while the next PSA, Ensure Better Care for All (No 19), adds fuel to the fire by insisting that health and social care do more to give people with long-term conditions control over their lives.
The white paper spoke of levering resources out of NHS acute care to pay for these community services though, as Wistow points out, the often quoted figure of 5% of hospital budgets by 2014 is an “urban myth”. PCTs were supposed to produce plans setting out how resources would be transferred, but hopes of this look increasingly forlorn, given their continuing financial troubles. Yet PSA 19 makes the size of the challenge clear: 15 million people with long-term conditions should be handed the “choice, control and convenience they want from services”, helped by a massive expansion of the expert patient programme from 12,000 places a year to more than 100,000 by 2012.
“If social services get 1% it’s not clear that it will be sufficient to meet the increase in demand that they currently face, let alone a growing share of the whole system as envisaged by the white paper,” Wistow says. “You would expect the NHS to work with local authorities to shift the balance of spend in line with the PSAs, but there are reasons to question how effective this partnership is going to be.”
The PSAs make it clear that the pilot projects set up to test prevention and personalisation will be rolled out nationally, managing only a polite nod to the evaluations whose final results will not be known until next year. Broadly positive initial findings from the 29 Partnerships for Older People Projects (Popps) intended to keep people out of hospital and the 13 individual budget pilots intended to give people choice and control are plainly all the evidence the government needs.
Andrew Reece, who heads an individual budget pilot in Coventry, agrees with the general direction of travel. “The vision is here, although, while central government asks the questions, local government still has to find the answers. These targets are much better than the old ones, but it’s a first stab.”
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