SHA Submission to the House of Commons Health Committee 1997
1. A well functioning link between health services and personal social services is vital if we are to provide properly for some of the most vulnerable in our community. Understanding the linkages is fundamental to this.
2. Links are complex, covering a wide range of services and client groups. It is an area which has seen many reforms. The recent growth of 3rd party providers is a key aspect of this.
2. Arguably, there has recently emerged a clearer definition of the different roles of agencies: in particular the distinctions between commissioner, provider, advocate, inspector. Service users are increasingly seen as consumers, and this is generally welcome but the central need for good quality care should not be lost in a forest of management/consumer speak.
4. There is a need for better coordination where different agencies and professions are working with a client, both to ensure consistency of care and to avoid gaps in care.
5. There are a number of financial issues, which can threaten the continuity and consistency of care. These include the incidence of charging for local authority services whose equivalent is free in the NHS and the imbalance and pressure potentially caused where the budget for a range of services is ring-fenced in the local authority but not in the NHS.
6. There are a number of initiatives and mechanisms to better coordinate services between Local Authorities and the NHS. These have had mixed results. All have suffered from either insufficiently clear objectives or insufficient power.
1. Service users to be at the forefront of any package of care – a clear focus on the needs of the user both acts as the focus around which a package of care can be built and serves to tame the tendencies to bureaucratise and compartmentalise.
2. Layers of bureaucracy must be reduced. A clarity of analysis with a flexibility to change is required. The commissioning role, provider role, advocate and inspectorate functions need to balance independence with effective co-ordination.
3. We oppose means testing and subsequent charging for community care services.
4. There should be more effective methods for integration such as, on a case-by-case or pilot basis, through commissioning or providing being the sole responsibility of one agency.
5. What works well in one part of the country may not in others. Although it is important to lay down national guidelines these should be flexible enough to allow for local adaptation.
6. Coterminosity between the boundaries of agencies must be encouraged.
7. Quality must not be sacrificed to price. The move from Competitive Tendering to Best Value is welcome but the emphasis must be on high minimum standards and levering up quality.
8. There should be a review of the current plethora of monitoring bodies. The conflict that can arise arise where one body is both inspector and commissioner/provider needs to be clarified.
9. There should be a move towards a single career structure regardless of provider.
10. Policies for health and social services at the national level need to be far more integrated.
11. Ring fenced budgets should be encouraged particularly for new initiatives.
12. There needs to be greater public accountability for services at the local level.
SHA Submission to the House of Commons Health Committee Inquiry into the Relationship between Health and Social Services.
The following is a very brief submission, highlighting a number of crucial issues and both posing and proposing a number of potential solutions.
It is our view that any work in this area must be underpinned by strong ethical foundations. Ours are of commitment to the basic principles of equality of access and treatment and of a Health Service free at the point of use. We are also firm advocates of the development of primary health care services based in the community, built on foundations of good public health in its widest sense. Getting the relationship between health and social services right is a vital element of the development of such an outcome.
Since 1948 many different models of service delivery have been put in place for health/social services delivered in the community. The range of services has grown and otherwise changed and the boundaries between agencies and range of agencies has similarly changed. The strong voluntary sector involvement in many areas of social care has been one of its strengths and further adds to the complexity of the situation.
There were major changes in 1964 and 1973 which altered the boundaries of responsibility for primary and community services between the NHS and local Councils. Since 1982 the change has been more subtle but in many ways more far-reaching. With the encouragement of the private and voluntary sector through DSS payments for residential care and through the commissioner/provider split created in the early 1990s, a market for health and social care has been created which has left more providers on the scene, with the potential that any one client or service may be ‘shared’ between several different agencies or providers.
Need for Coordination of different roles:
It is a plain and simple truth to any service user or practitioner working on the ground that community care services will be at their most effective when the health and social care agencies are working closely together. The challenge is to ensure that this happens, especially when there is an overlap in the role of different professions.
While your enquiry is directed at the relationship between NHS and Local Government Services, the fact is therefore that there are several different levels to this relationship: for example of commissioner, provider, inspector, advocate, and that the picture is further complicated by the multiplicity of agencies, be they direct provision by the NHS or Local Authority or provision by a third party in the voluntary or private sector.
By way of examples, a mental health service user might have a community psychiatric nurse visiting one day and an Approved Social Worker visiting the next. Although they have a different focus a lot of their work overlaps but their professional, budgetary and reporting lines may not. A frail elderly lady receiving services in her own home may have an intensive home care worker visiting one day and a district nurse visiting the next. Again the focus of their work is different but there are considerable areas of overlap with the same challenges in achieving coordination.
Particular need to avoid gaps in care:
It is a major further criticism of community care services that because of the many different agencies involved – health services, housing department, social services, voluntary agencies to name a few – in the absence of some form of coordination gaps often appear, each agency perhaps expecting another to be doing something that it is not. This was the major criticism of the Ritchie inquiry into the killing of Jonathon Zito by Christopher Clunnis.
There are also a number of anomalies created by the health and social services divide. These can run the risk of jeopardising continuity and consistency of care:
- Services within the NHS are by and large free at the point of delivery and not means tested whereas local authority Social Services are increasingly subject to charging and means testing. The temptation for local authorities in tight budgetary positions is inevitably and increasingly to charge, at increasing levels.
- Some budgets are ‘ring-fenced’ and cannot be diverted to other service areas, for example Local Authority Community Care budgets, whereas NHS Community Care budgets are not. The temptation for cash-strapped health authorities is to make savings in those service areas near the boundary with other providers which are therefore seen as peripheral.
Initiatives to address the above:
There have been a number of initiatives to try to avoid duplication or buck-passing:
- Joint Consultative Committees (JCCs) to encourage better joint working between health and social services.
- Care Management and the Care Programme Approach as attempts to ensure a seamless service with clear lines of responsibility.
- Joint Commissioning, currently in vogue, to ensure effective integration.
These have had mixed results. Arguably, all have suffered from either being insufficiently clear as to their objectives, and vested with insufficient power, to broker or force through initiatives which tackle overlap problems, or of being good as far as they go but being insufficiently broad in their objectives.
The SHA would propose the following measures as going some way towards addressing such issues and anomalies:
1. Service users to be at the forefront of any package of care – entrenched historical or professional boundaries should not act as barriers to putting the needs of users first. This is more than verbiage: a clear focus on the needs of the user both acts as the focus around which a package of care can be built and serves to tame the tendencies to bureaucratise and compartmentalise.
2. Layers of bureaucracy must be reduced. Hundreds of committees, joint planning groups, multi-agency working groups sap the energy of many. A clarity of analysis, with a flexibility to change, is required in order to create a streamlined management of each aspect or type of care without preventing that care from being properly provided. For example, the coordination of services for those with mental health problems may require a different approach to those for the physically disabled, but this must accommodate the client with demands in both spheres. Similarly, the commissioning role, provider role, advocate and inspectorate functions need to retain adequate independence from each other while being sufficiently co-ordinated to work.
3. The SHA is opposed to the means testing and subsequent charging for community care services.
4. There should be effective methods for integration which are not tokenistic (arguably the current JCC system can be viewed this way). This could involve, through piloting, schemes whereby commissioning for one client group e.g. learning difficulty, becomes the sole responsibility of one agency e.g. social services, or where the provider arm of services are integrated under one agency e.g. mental health services under a mental health trust.
5. What works well in one part of the country may not in others. Although it is important to lay down national guidelines these should be flexible enough to allow for local adaptation. It is possible that the Health Action Zone initiative can together with its other objectives be used to pilot initiatives in this area.
6. Coterminosity between the boundaries of agencies must be encouraged. Health, social services and housing departments across the country often have different geographical boundaries. This makes integration a nightmare. Clearly one-on-one mapping may not be feasible in every case but a greater simplicity in the arrangements should be achievable. It should be an aspiration where coterminosity does not exist that its absence will be of no consequence to the user.
7. Quality should not be sacrificed at the expense of price. We welcome the move away from Competitive Tendering and the introduction of Best Value pilots. However, the emphasis must be on setting high minimum standards and levering up quality of provision.
8. There should be a review of the current plethora of monitoring bodies – Health Advisory Service, Registration and Inspection Units, Mental Health Act Commission, CHCs, Health Authority Audit Departments with a view to greater clarity and perhaps smaller numbers. The conflict that can arise arise where one body is both an inspector and commissioner/provider needs to be clarified – not necessarily through separation.
9. Different employers often offer different conditions of employment, for example with different leave entitlements and pay, for essentially the same work. This discourages mobility and encourages a two (or more) tier service, through creating differential staus. Single employment contracts and conditions and/or professional structures across providers would greatly facilitate mobility and reduce the likelihood of variable quality provision of services.
10. Policies for health and social services at the national level need to be far more integrated e.g. funding from the Housing Corporation needs to be more flexible in meeting Community Care needs, the rules by which care budgets of different public sector providers operate need to be more closely aligned or co-ordinated.
11. Ring fenced budgets should be encouraged. Through the experience of joint finance, mental illness specific grant, alcohol and drugs grants it has been shown that such funding can be targeted at areas of most need within a national framework but still allowing for local discretion.
12. There needs to be greater public accountability. Although Local Authority Social Services Committees are far from perfect they do provide a structure for local accountability. By contrast, unelected health authorities tend to be remote and have very little democratic, accountable input from the area that they serve. Various potential models exist, from extending the competence of Local Authority Social Service Committees, through more open and accountable joint working to the democratisation of the NHS.