House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

Memorandum by the Association of Directors of Social Services

5. ADDRESSING THE LOCAL DEMOCRATIC "DEFICIT"

5.1 ADSS is committed by its values to the provision of social services within a locally democratically accountable context. We understand the new Government is not persuaded of the case for addressing structurally what has been seen as a serious local democratic "deficit" within the health service [17].

5.2 This "deficit" is perhaps one of the obstacles to further joint working and funding of health and social care. Some means must be found for resolving it. We believe local people should be given a real say in decisions affecting their lives and that the continuing concerns about this in relation to the NHS should be addressed.

5.3 Local councillors have considerable influence and local knowledge which is not being harnessed by the health service. A potential consequence can be local opposition to local health changes. This risk could be reduced by positive action to ensure local organisational structures acknowledge that many people turn to local councillors when things are happening locally which they do not agree with or understand.

5.4 What is needed is some means to enable both the NHS and local authorities to develop a common local accountability directly to the communities they serve. This should not detract in any way from achievement of existing joint and separate Department of Health policies and priorities for health and social services. Neither would it necessarily detract from the direct accountability to the Secretary of State for Health.

5.5 The Secretary of State retains the ability to give Directions and Guidance for the exercise of social services functions under the 1970 Act [28]. This is a power which is frequently used in one form or another. It could also be suggested that if the relationship has not always been "crystal clear" then the responsibility rests primarily with successive Secretaries of State for Health (and Social Services).

5.6 One option in reforming the "internal" NHS market, which could be explored, would be for local authorities to act again as partners or providers of NHS community health services within a continuing NHS structure as in other parts of Europe. This could achieve integration and democratic accountability for care at the local operational level and represent a logical development of some existing joint arrangements within a continuing national framework.

5.7 Such an arrangement might include the development of wider primary care teams. If they could be linked to the development of new commissioning partnerships with teams of General Practitioners and other professional representatives, the local democratic deficit could be addressed.

5.8 Local authorities, have considerable experience of the contractor client separation. In principle, there is no reason why similar arrangements could not be applied to community health and elective secondary care services to ensure "seamless" help.

5.9 In summary, the democratic "deficit" could be addressed and collaboration enhanced by exploring one, or a combination, of the options raised in this paper:

— Strengthened Joint Consultative Committees [see 4.2].

— Enabling Local Authorities to act as NHS providers of Community Services [see 5.6].

— Direct Partnerships with General practitioners embracing both the commissioning and providing roles for care [see 5.7].

— Joint inspection arrangements [see 4.4].

6. HUMAN RESOURCES ISSUES

6.1 There is a need to make best and most appropriate use of people with scarce skills. ADSS is committed to effective human resource management as a means of responding to changes occurring within ageing workforces and where competition for staff is increasing [29].

6.2 The availablity of competent staff is seen as the most important aspect in the provision of quality care services in the future. Any review of organisational structures, functions and finance which does not also take into account the needs and skills of people to deliver services is likely to fail.

6.3 Within the NHS, valuable work has been undertaken by the National Case Mix office during the last year [30]. What is equally clear from local commissioning initiatives [31] is that there are a number of practical issues to be taken into account if joint operational working is to succeed. They include:

— Physical proximity of different professional groups.

— Accessibility, coterminousity of interest.

— Shares information and information systems.

— Agreed protocols on methods of working, confidentiality and responsibilities.

— Common values, and shared experience.

— Some element of shared training.

6.4 This means that the human resource aspects of change have to be addressed as an integral part of any discussion of organisational issues associated with the health and social services interface. Simply adding on or creating yet another bureaucratic organisation or process as suggested as one option in the 1997 Mental Health green paper [32] are not likely to improve services.

6.5 We conclude there should be a joint review of the tasks to be done, the skills needed to do them and who might perform them in the most effective manner across the health and social care interface. This would form an integral part of a national agenda to promote integrated and flexible health and social care working linked to improved cost effectiveness of services.

6.6 The GP practice focus to accessing and organising health and social care staffs raises a number of issues about joint working particularly in achieving a coherent strategic framework. It could be consistent, however, with our thinking about how the health and social care interface might develop within a framework which addressed the local democratic "deficit".

6.7 Finally, we would seek a commitment to maximise the contribution of generic National Vocational Qualifications for care and nursing staffs. Role complementarity as well as role differentiation need to be established in looking at both existing and future frameworks. It means finding a model of working and skill mix for the future which is sustainable irrespective of the longer term future of current organisational boundaries.

7. THE IMPACT OF CHANGE AND UNCERTAINTY

7.1 All of us who work at the health and social services interface are under no illusions about the potential for change to be disruptive to relationships, organisations and services to people.

7.2 The 1997 NHS Confederation research report "The People's Health Service?" [33] expressed concern about disruptive effects of change. It suggests major change would involve costs and risk:

— dilution of the NHS as a national service;

— have an adverse effect on services and relationships;

— a negative effect on health commissioning and provision; and

— action in advance of any development of devolved regional government.

7.3 Of all the concerns, only one is really important: disruption of services to people. Change in some form within the NHS and in its relationships with local authorities is inevitable. Whilst the Health Action Zones [34] approach offers the potential for testing out more flexible partnerships at a local level, within existing frameworks, our concern is that such initiatives risk continuing the current organisational uncertainy. There is the potential to reduce the public confusion concerning accountability and responsibility and this opportunty should not be missed.

7.4 The White Paper on the NHS signals a period of further change over several years and inevitably will affect social services. Such NHS based change has the potential to be disruptive of current relationships but continued uncertainty about the future and its mechanisms has tended to corrode the processes of joint commissioning and involve hidden costs. In addition, the process of Local Government Review has had an enormous impact. Put simply, changes have to be co-ordinated, show benefits and last.

7.5 In reconsidering and then challenging some long held views about how things are organised ADSS believes there must clear and identifiable benefits. In thinking about developing current collaboration and the options put forward we have set out the critical tests to establish whether their benefits measure up well against the costs of change. In summary, ADSS wants to see:

— Better local services for people within a national framework.

— Simplified and easier to understand arrangements where the needs of patients, users and carers come first.

— Improved local accountability and decision making as close as possible to patients, users and carers.

— Developed partnerships and role complementarity underpinned by effective links with housing, education and other key agencies.

— Reduced administration and better care value from agreed joint use of resources.

December 1997

8. REFERENCES

[1] Cmnd. 3703 Report of the Committee on Local Authority and Allied Personal Services, 1968. (Seebohm Report).

[2] Cmnd. 4040 Report of the Royal Commission on Local Government in England 1966-1969 (Chapter VIII), 1969.

[3] National Health Service "The Administrative Structure of Medical and Related Services in England and Wales", Ministry of Health, 1968.

[4] National Health Service: The Future Structure of the NHS, Department of Health and Social Security, 1970.

[5] Cmnd. 5055 National Health Service Reorganisation: England, 1972.