Select Committee on Health Minutes of Evidence

Memorandum by UNISON, Relationship between Health and Social Services (HSS 80)

CONTENTS

  1.  Introduction

  2.  The Importance of Health and Local Government Services to Health and Wellbeing

  3.  The Case for Evolutionary Change rather than a "Big Bang"

—  Against Radical Change at this Point

—  Takeover of Health by Local Government not a Panacea

—  Merits in Retaining Separation

  4.  Positive Steps within an an Evolutionary Strategy:

—  National Rights and Local Responsiveness

—  Strengthening Organisational and Funding Mechanisms

—  Improving Local Democracy in Health and Local Government

—  Linkages between Primary Care, health and other social provision

—  Training, Skills and Retention

—  Sensitivity to the Needs of Different Communities and Client Groups

—  The Funding Issue

—  Wider Action to Secure Social Justice

1.  INTRODUCTION

  1.1  UNISON, the largest public sector union in Europe, with 1.4 million members spanning workers at all levels in health, local government and the public services, is uniquely placed to make a contribution to the debate over the future of the NHS and local government. It welcomes the inquiry of the Select Committee, coming as it does at the end of an era in which much policy was hostile to the public services, not least to the NHS and local government. There is now an opportunity to rebuild our society, in which the renewal of the public services has a vital role to play in repairing the damage of the last 19 years. UNISON is totally committed to ensuring that health and local government work well together to promote the general good through the provision of seamless and appropriate services. We therefore hope that the Select Committee will consider positively our views on this important question.

2.  THE IMPORTANCE OF HEALTH AND LOCAL GOVERNMENT SERVICES TO HEALTH AND WELLBEING

  2.1  Local government and health services have not always been separated. From the latter half of the 19th Century municipal services of all kinds, including public and curative health services, spearheaded the attack against the damaging effects of laissez-faire capitalism on the health of the population. Local government took over utilities such as water and sanitation that the market either could not provide or do so unsatisfactorily, education became a major responsibility, and health care and housing were gradually transformed into the social rights of citizens. It is now widely accepted that it was the combined effect of these forms of improved social provision, and not just advances in and spreading availability of health care, that led to the massive strides in health and well-being made in the 20th Century up to the eve of the creation of the welfare state [1].

  2.2  When health services became separated from local government in 1948, it was in part dictated by a political compromise intended to reassure a medical profession suspicion of local political interference. It was however also shaped by Aneurin Bevan's determination to fulfil the intentions of the 1946 NHS Act to ensure a truly national and comprehensive system, available to everyone on the basis of need, regardless of where they lived and funded principally by taxation [2]. In consequence, the only significant lines of public accountability of hospitals and general practitioner services were now nationally to Parliament through the Minister of Health. Local authorities were left with a "rump" of public and community health services. Yet it was only a matter of time before this was reviewed, and after much public discussion of a variety of models, Sir Keith Joseph's 1974 reorganisation heightened managerial relationships by merging the remaining health services into the NHS. At the same time Community Health Councils were created and local authority councillors given a strong presence on the new authorities, and coterminosity ensured in most instances between health authorities and new "Seebohm" Social Service Departments. Liaison between these newly unified structures was to be effected through Joint Consulative Committees.

  2.3  Since that time there has been, paradoxically, a growing awareness of the need for closer liaison between local government and the National Health Service, at a time when the changing political and service environment has rendered it more difficult. One of the prime influences has been a linked awareness of the limitations of curative medicine, alongside a revival in public health in which the role of non-medical services to health, such as those traditionally provided by local government, has received renewed emphasis. The Black Report of 1980 [3] particularly on the contribution that an attack on poverty and an expansion of public services could make to reducing health inequalities. The World Health Organisation's Health For All by the Year 2000, and subsequent "Healthy Cities" initiative, signalled the arrival of a "new public health movement" emphasising health promotion through intersectoral "healthy alliances" between agencies, based on a holistic social paradigm of health, and public participation in decision making [4], [5].

  2.4  If public health was one source of a broader model of health intervention, another was the growing shift towards community care. This had been accelerating since the 1950s for people with mental health problems and learning disabilities, physically disabled people, and older people. The problems of "cost shunting" (as it is now called) was in fact first dissected by Titmuss in the 1960s [6] who recognised the "perverse incentive" to discharge people from NHS responsibility into the care of local authorities who had permissive duties and were poorly resourced to carry these out. In 1990 this shift became formalised by the Community Care Act which placed statutory responsibilities on local authorities to provide community care based on assessment of needs. This can be regarded optimistically as a move to establish a right to a "normal life" in the community for those for whom institutional care is not appropriate. Many have seen it also as an attempt to transfer responsibility from a centrally financed system largely free at the point of use, to one subject to local variability, means testing and charges, and privatisation [7].

  2.5  Other areas of collaborative and multi-disciplinary work emerged, notably in service for children under the 1989 Children's Act, services for drug users, and for people with HIV. The focus on environmental health increased substantially through the work of Agenda 21 of the UN's Earth Summit. The growth of poverty, homelessness and social exclusion, and growing numbers of older people also highlighted the need for greater collaboration between health and local government.

  2.6  These shifts strengthened the position of local authorities in relation to health, and underlined the need—which had in fact been there since 1948—for cooperation across local authority and health boundaries. However this occurred at a time when changes in the political, financial and institutional environment made such cooperation more problematic and difficult. The shifts to managerialism and privatisation under the Thatcher and Major Conservative governments served to fragment public services and to multiply the number of providers in the public and private sectors. The prime incentives, based on market or quasi-market models, were towards competition rather than collaboration. The growth of quangos led to accusations that an accountable "new magistracy" had come into being [8]. The democratic deficit increased in health as councillors and trade unions were removed from health authorities in 1990.

  2.7  However, the growth of contracting and separation of commissioning and providing functions in both local government and the NHS did have the effect of creating a convergence towards a "new public management" culture that, alongside the enhanced importance of local government in public health and care provision, created the basis for advocacy of elected local authorities as the single local commissioning authority. The most sustained case was that mounted by the Association of Metropolitan Authorities [9] who argued for it in 1994 on three grounds: democracy and accountability (the elected principle), legitimacy (public involvement in determining priorities), and coordination and regulation (strengthening links between health and other public services).

3.  THE CASE FOR EVOLUTIONARY CHANGE RATHER THAN A "BIG BANG"

  3.1  Thus UNISON recognises the increasing importance of local government provision for health and wellbeing, and the need for much closer "seamless" working between health and local government. Our main argument is that there is need to focus more on objectives than structures. We therefore argue against the merger of local government and health, or a takeover from either direction, on three main grounds:

  Focus more on objectives than structures|

—  Against radical change at this point

—  Transfer of health to local government would not necessarily tackle the most important difficulties

—  There are some merits in retaining separation between health and other local services.

AGAINST RADICAL CHANGE AT THIS POINT

  3.2  Even if the case for integration is accepted in principle, now is not an appropriate moment to merge health and local government services. As far as health is concerned, the government has rightly decided that massive upheaval would have costs in terms of efficiency and create considerable uncertainty among staff, only just recovering from the effects of the 1990 health reforms. Local government has only recently been reorganised and its structures will be reviewed again through a forthcoming White Paper. The creation of unitary authorities and mergers of health authorities into larger units have further distanced health and local authorities from coterminosity. There are differentiated financing systems that do not easily mesh, and it would take a major effort to bring them into line. The future shape of regional government and constitutional reform are also issues that could have implications for relations between health and local government that make a "wait and see" approach sensible at this point in time. Further change should await the evaluation of the implications of the Health Action Zones and the Green Paper Our Healthier Nation, which are seeking to experiment with coordinated local provision for socially disadvantaged people.

  3.3  The main priority at this point should be to foster forms of joint working in a new environment more conducive to collaboration and then evaluate their more general implications.

TRANSFER OF HEALTH TO LOCAL GOVERNMENT NOT A PANACEA

  3.4  Even if health and local government were integrated, much work would still be necessary to coordinate their efforts. Local government is divided between social services, education, leisure, housing, environmental health, economic planning and transport. Although the proposals in the White Paper, The New NHS, will create a more simplified structure, responsibilities will still be fragmented between trusts, Primary Care Groups and Health Authorities. In fact there is a danger of increased fragmentation and a loss of strategic planning as Health Authorities cede much of their commissioning role to Primary Care Groups. These divisions are overlaid by different professional cultures and methods, which inhibit communication, and development of shared values and objectives. Many of the lessons of inquiries, such as those into mental health and child protection cases, have often highlighted the significance of such interprofessional and interagency problems.

  3.5  In addition important forms of social provision lie outside the framework of both health and local government: such as the privatised utilities, social security, police and probation, and the commercial and voluntary sector in health and social care.

MERITS IN RETAINING SEPARATION

  3.6  There is also a strong case for arguing that the seperation of health from local government can have benefits as well as costs. Althought UNISON supports the shift to a more social approach to health, it is concerned that appropriate evidence-based clinical considerations should not become dissipated, and that access to clinical expertise should remain a national right largely free at the point of use. The evidence, where health is an established part of local government, as in Scandinavia, is mixed. There have recently been concerns in Norway, for example, that local variations are unacceptably wide, and corrective policies have been implemented [9]. In Spain, where regional government has considerable powers over health provision, this has led to widespread variations in standards and levels of provision, that would be regarded as unacceptable on equity grounds in Britain. In Northern Ireland where health and social services have been integrated since 1970s, there are clearly advantages to such an integrated system but concerns have been expressed that health provision, and an associated "medical model" approach, sometimes predominates [10]. Transfer of health to local government might also expose the NHS to local political vicissitudes.

  3.7  In other words, a social model is more likely to be implemented where there is a desire and requirement to collaborate, but where local government retains its functional independence from health. This may not only be true at the strategic, but also the day to day level. Thus while there is merit in attaching social workers to GP practices, they will be more able to be advocates of a social approach if they remain employed by social services.

  3.8  UNISON would see debates about appropriate structures informed by more systematic comparative evaluation of the pros and cons of joint working between health and social services in integrated structures, compared with joint working between separate agencies.

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Prepared 10 August 1998