Select Committee on Health Minutes of Evidence

Memorandum by the Association of Directors of Social Services

RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES (HSS 43)

SUMMARY

  This memorandum, prepared before the publication of the NHS White Paper, considers the need for improved organisational arrangements for health and social services which ensure appropriate provision for local democratic accountability.

  The NHS and local authorities need one another to achieve specific health and social care objectives for patients, carers, and users. These are closely concerned with wider issues of public health, social inclusion, regeneration, early years and the environment. The future of health and social care and processes for joint working should not be considered outside of this overall policy context.

  Any future organisational separation of social services from the wider social inclusion agenda led by local authorities is seen as a retrograde step in terms of planning and involvement of local people.

  The full benefits of closer working together cannot be achieved without a commitment to address other issues. These include long term care; charging; the legal frameworks for community care for adults; the social security interface and regulation of care where Government proposals are awaited.

  Effective human resource strategies are essential. Barriers to change and seamless care are more likely to occur if major change takes place without a review of existing skill mix, professional training, and operational experience. There should be a full joint review of tasks and priorities linked to an analysis of the skills needed to fulfill them.

  The development of locally commissioned and provided health and social care services must take place within consistent and transparent funding mechanisms. Any new organisational arrangements must reinforce local accountability, high standards of care and best use of resources. These should be linked to explicit national requirements or benchmarking provisions.

  The case made is underpinned by a set of supporting principles of which the most important is direct benefit to patients, users and carers.

THE ASSOCIATION OF DIRECTORS OF SOCIAL SERVICES

  The Association of Directors of Social Services [ADSS] is a professional body representing all the Directors of Social Services for England, Northern Ireland, Wales and the Islands. Its values recognise that personal social services must be accountable through local democracy and play their part in achieving cohesive communities inclusive of all.

Contents

1.  The Current Framework—Unresolved Tensions.

2.  The Health and Social Services Interface.

3.  Strengthening Local Voices.

4.  Promoting Joint Working.

5.  Addressing the Democratic Deficit.

6.  Human Resource Issues.

7.  The Impact of Change and Uncertainty.

8.  Text References.

1.  THE CURRENT FRAMEWORK—UNRESOLVED TENSIONS

  1.1  The current broad framework of responsibilities and functions of health and social services has been in place for a quarter of a century. Understanding how this came about is important because the present "unified" social services and health structures were arrived at only after extensive policy review. [1-5] Key questions, therefore, are: Whether the analysis leading to what we have remains valid in present and future circumstances or if in need of improvement how this might be achieved?

  1.2  The intervening years have seen various changes in NHS structures and in the way the NHS operates. More have been proposed in the White Paper on the NHS [6] published as this Memorandum was finalised. During this period social services departments have not been immune from change.

  1.3  Their responsibilities increased significantly as a result of the National Health Service and Community Care Act, 1990. This legislation provided the basis for a transfer of responsibility for both funding and care for adults. This change has sharpened the focus on the health and social services interface. Similarly, the Children Act, 1989, has provided a comprehensive new framework for preventative work. This involves close collaboration with other agencies on the welfare of individual children and their families and increasingly wider action to address social exclusion.

  1.4  Today, social services authorities spend over £8 billion per annum. They have significant and diverse duties as providers, purchasers and regulators of services. These cover the full spectrum of care from primary prevention to protection of life. These responsibilities require close partnerships with Education and Housing as well as with health and other statutory and voluntary agencies. There is a strong emphasis on user and carer involvement and their active participation in decisions affecting their lives.

  1.5  Whilst drawing up the parameters for any review is not easy, the nature of social services roles and responsibilities is such that there is a need to consider allied areas. They are:

—  Reduced NHS provision of long term care for older people under both the social security and community care regimes and unresolved tensions surrounding future funding. [8]

—  Closure of most long stay hospitals for people with mental disorders and reliance on care in the community.

—  Rapid development of GP Fundholding and more recently of "multi funds" bringing new perspectives to the locality commissioning and provision of health and social care.

—  Clinical progress with the progressive development of treatment within shorter timescales and increasingly outside of hospitals in primary care settings.

—  Pressure to develop "intermediate" care in response to changes within the NHS and to manage "Winter Pressures".

—  Increased numbers of older people in total and more especially amongst those cared for at home who might otherwise be in residential or long stay settings.

—  Creation of a "mixed economy" of care for long term and domiciliary care provision in which commissioning for best care value is critical and effective links with providers of care are vital.

—  Pressure for more effective regulation of care for vulnerable children and adults within a wider and comprehensive regulatory framework  [9];

—  The importance of child health and responding to children in need, those "looked after" or have left care.

—  Concern to address wider public health issues and inequality within the Beveridge framework; especially as they affect communities, children and families  [10];

—  Failure by successive Governments to establish a consistent and cohesive legislative structure for community care and retention of the 1948 National Assistance Act Framework;

—  The creation of a "federal" NHS within a unified structure following the 1990 NHS and Community Care Act which provided a basis for separation and is to be reviewed;

—  Escalating consumer expectations and demand, both quantitively and qualitatively right across the range of NHS and social services responsibilities;

—  Loss of coterminousity arising from local government and NHS reorganisation and disruption in essential relationships.

  1.6  For some time not a single Government Minister has had the term "social services" within their title; although "junior" Health Ministers have held the social services brief and demonstrated considerable commitment to it. Titles are important. Social services functions should be recognised both in titles and in ministerial responsibilities. This ommission may be one of the reasons for the feeling that the personal social services may be seen by Governments as an adjunct to their NHS responsibilities and perhaps of lower priority.

  1.7  ADSS supports the view that the personal social services are the "fourth arm" of the welfare state. Local authorities and their social services departments are essential players in the progression of policies addressing the Beveridge's concept of "want"  [11].

2.  HEALTH AND SOCIAL SERVICES INTERFACE

  2.1  The interface between health and social services cannot be considered in isolation from the above issues. The responsibilities of Social Services Departments are extensive and cover many other significant interfaces with education, housing, police, probation and the voluntary and independent sectors. Increasingly we see the interface with social security  [12] and the role of social insurance as critical issues to be resolved as part of the development of a comprehensive vision to update the 1970 Local Authority Social Services Act.

  2.2  This is because one of the key developments of the 1990s has been the transfer of responsibility for public financial support of people in residential and nursing homes. In the areas of housing, welfare and for some disability benefits, we believe the principles of assessment, care management and linking funding to need could be explored further. This could help both local people and the Government to secure better value for current separate expenditures within an overall policy framework.

  2.4  The case for the distinct and separate responsibilities of health and social services to be retained has much to commend it. Only in Northern Ireland is there an integration of health and social services functions and this arrangement reflects the special needs of the province  [13]. Within England and Wales there are many examples of excellent collaboration and co-operation  [14]. There is still scope for encouraging further initiatives at local level within the current legislative framework provided issues of responsibility and accountability can be delineated. Evidence should be sought jointly from those areas where collaboration is working well.

  2.5  The Third Report of the Health Select Commiteee made specific reference to the Northern Ireland Model  [15]. Its applicability to England and Wales has been questioned  [16]. The Northern Ireland experience suggests that there continue to be tensions at the interface between primary [community] and secondary [acute] care. These tensions exist within the NHS in England and have affected the development of primary care services and are reflected in the view "vertical integration" of Trusts is unhelpful.

  2.6  There are equally strong arguments for the development of new arrangements for the better co-ordination of community and primary care led services. Alternative models have been put forward to address the concerns about the lack of local democratic accountability within the NHS [17-19]. In part these develop from the "federal" nature of the NHS itself. Some seek to progress the need to consider these issues within the wider agendas for social inclusion, regeneration and tackling health inequalities. Here sustained and effective local authority involvement is seen as a key element in their achievement.

  2.7  The question being asked, perhaps, is not whether change should happen but when and how it should occur to meet the requirements for better health and social care for patients, users, carers. This process should be firmly linked to improved local involvement and greater accountability to the public consistent with the Government's intentions on "best value".

  2.8  We share the view that circumstances have changed [20] and that now may be the time to consider afresh aspects of the consensus of the last 25 years. This should be based on principles of equity, accountability, the promotion of rights and the discharge of responsibilities in a locally democratic context. It is our intention to examine the NHS White Paper [Cm 3807] with this in mind.

  2.9  In the short term, however, ADSS remains of the view that progress can and should be made within existing legislative frameworks for adults and children. This can be done using regulatory powers where they are appropriate and through a wider sharing of local experience.

3.  STRENGTHENING THE VOICES OF LOCAL PEOPLE

  3.1  Social Services Departments, perhaps more than any other public service, have developed a wealth of diverse experience in working in partnership with users of services and their carers. This is particularly true in the fields of physical and learning disability and more recently in working with children. The NHS could learn much from this experience. This sharing of skills should be a cornerstone of a strengthened health and social care partnership.

  3.2  The need for progress is affirmed in "Listening to Local Voices" [21] which asked for the concerns and values of local people to be reflected more closely in health purchasing decisions. It proposed responsiveness rather than accountability, and saw Community Health Councils as an important component of this process. The previous Government commissioned a review of the role and function of CHC's [22]. A Government response is awaited. The Association's response [23] made clear that CHC's need to be much more accessible and visible to their local people in offering an independent voice within the NHS.

  3.3  We argued that the remit of Community Health Councils should be widened and strengthened in relation to primary care, GP's and developing inter agency planning. Any review of health and social services should consider the future role of Community Health Councils. Local authorities should continue to nominate members to CHC's and formal liason, which already exists in some local authority areas, might usefully be developed. We would want to encourage this dialogue and the scope for development of associated "Health & Social Care Fora" as a means of improving communication and consultation with the public.

4.  PROMOTING JOINT WORKING

  4.1  Joint working is not new to health and social services. Indeed it would have been impossible for the current range of services to have been developed without considerable co-operation between health and social services agencies. This has survived frequent and radical organisational changes within health and through local government reorganisation.

  4.2  The greater choice of lifestyles and independence offered to people with a learning disability and older people are examples of the product of innovative joint commissioning which have included joint management arrangements. ADSS believes that, if they exist at all, "Berlin Walls" between health and social services are very much the exception rather than the rule and the more reflective of unsatisfactory resourcing than relationships.

  4.3  It is recognised, however, that health and social services operate within different legal, constitutional, political and financial settings. There is the risk that as a result the effort required at the health and social services interface to achieve seamless and effective services for patients and users may be becoming disproportionate to the benefits. More coherent national arrangements are required to address the allied issues identified earlier in this submission.

  4.4  Future collaboration and co-ordination of health and social care within a wider framework of social policy objectives is essential. The primary purpose of joint commissioning is to secure added value and improved services for patients and carers. This includes services for children with special needs where, for example, the resourcing of continuing health care services and child and adolescent mental health services are a source of continuing concern. Changes designed solely to produce savings for the NHS should be resisted along with attempts to undermine a comprehensive and inclusive approach to community care.

  4.5  The Regulations for Joint Consultative Committees were last revised in 1996 [24]. This is the formal mechanism for allocation of joint finance [25] and agency consultation. Committees are commonly supported by joint teams of professionals and agency managers from health, social services, education, housing and related agencies with an interest in health and social care; including child care, matters. Such arrangements appear to have had varied success. There is a case for considering whether they have been developed to their full potential and how far these arrangements can be used to improve collaboration where locality commissioning seems likely to become more extensive.

  4.6  Strengthened Joint Consultative Committees are one option which might be explored, alongside others, to see if it could be used as a more positive means of promoting improved collaboration at the health and local authority interface. Some JCC's have explored wider membership. Certainly there is a case for considering the inclusion of fundholding/locality commissioning GP's. This would reflect both their role within the NHS and the need for their full involvement, along with provider trusts, in discussions at a more strategic level.

  4.7  It may be that some extension of terms of reference of JCC's could be considered so as to include oversight of key planning/commissioning and collaborative mechanisms such as:

—  Community Care Plans.

—  Children's Services Plans.

—  Early Years Plans.

—  Annual Health and Social Services Joint Investment Plans.

—  Drug Action Teams.

—  Health Service and Financial Frameworks.

—  Public Health Requirements and Annual reports.

  4.8  ADSS has accepted [26] the concept of joint units for the regulation of nursing and care homes. These could become accountable to such a committee if there was support. Indeed, in the longer term there may be a case for considering whether such committees might be developed into more fully joint bodies. These could include GP's responsible for locality commissioning and provision of joint services for health and social care.

  4.9  More recently concerns about "Winter Pressures" and "Emergency Medical Admissions" has led to formal requirements for expenditure arrangements to be agreed between health and social services.[27] These are likely to reinforce joint working but in turn raise new issues about "charging" and "intermediate" care.

  4.10  However committed we are to joint working, mechanisms alone cannot overcome a failure to resource social care adequately. We welcome the additional funds for the NHS and to address the concerns of Government about Winter Pressures and Emergency Medical admissions. There is a need, however, to respond more generally to an ageing and more vulnerable elderly population.

  4.11  The question is how far can the current approach be stretched and for how long? There is continued Government willingness to experiment and to try out new ideas before extending them. This was the experience, for example, in the manner of the development of GP Fundholding. The concept of piloting further change appears to have taken hold in a way that was unthinkable at the time of the 1970 reforms.

  4.12  This process of incremental change may mean that time is not available for proper evaluation of pilot arrangements before wider change is required to meet the pressures we have described. Some criteria are needed to inform these processes and the general direction of collaboration. We see them as including the ability to:

—  Command continuing public, patient user and carer confidence by securing best care value for each group.

—  Retain clinical and professional judgement exercised independently, whilst audited and benchmarked, where the interests of patients, users and carers are a first concern.

—  Generate greater openness in achieving the aims of the NHS linked to the involvement of local people and the meeting of their legitimate aspirations and expectations.

—  Deliver Health and Social Services priorities in partnership with others and maintain effective commissioning of socially inclusive health, social, community and family care.

—  Reduce current NHS managerial isolation and improve local democratic accountability to local communities.

—  Ensure general practitioners and practice nurses have a sustained involvement in new direct partnerships with commissioners and providers of health and social care.

—  Ensure that national health care, including public health, is planned and delivered through an effective national, regional and local frameworks.

—  Demonstrate the ability to monitor deliverable health care and social care outcomes through comprehensive and effective research and development.

—  Permit effective co-ordination of resources and I funding for local community and primary care priorities without any erosion of local accountability or the unity of the NHS.

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Prepared 20 April 1998