Memorandum by the Sainsbury Centre for
RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES
1. The Sainsbury Centre is a national independent
agency focusing on research and service evaluation, service development,
training and policy development aimed at improving services for
severely mentally ill adults.
2. The Centre has long maintained that the
delivery of care to severely mentally ill people could be improved
by better coordination of services across health and social services.
the agreement of joint local plans
for mental health services;
pooling of health and social care
establishing a suitable joint accountability
mechanism at strategic level;
using a unitary care management model
at operational level to plan and commission care for the individual;
shared and joint training for health
and social care staff.
This approach is compatible with the arrangements
set out in the recent Government White Paper "The New NHS".
It would almost certainly require primary legislation to enable
budgets to be fully pooled.
3. The Sainsbury Centre has produced a range
of reports on this issue which are appended. In addition, the
Centre is currently producing a report on legal barriers to joint
commissioning and budget pooling, which will be available early
in the New Year. A copy will be provided to the Committee once
it is available.
4. Staff at The Sainsbury Centre stand ready
to provide further information or provide other help and information
to the Committee. The contact point is Dr Andrew McCulloch, Senior
Policy Adviser (telephone 0171 403 8790 and 0181 366 2599).
1. Agency Responsibilities
The Sainsbury Centre does not advocate any specific
changes in agency responsibilities. All agencies concerned with
the care of severely mentally ill people need to work together
more closely if coordinated and effective packages of care are
to be delivered.
2. Organisational structures
2.1. Whilst much can be achieved by better
joint working at operational level, some sort of formal joint
mechanism is required between health and social services to enable
joint plans to be agreed and to provide a clear accountability
mechanism. A model was suggested in our papers "New Mental
Health Authorities: Solution or Distraction" [Appendix 1]
and "Statutory Joint Committees for Mental Health: Implementation
Issues" [Appendix 2]. This was taken up by the previous administration
in its Green Paper on mental health as Option 3 (joint mental
health agency). A conference held in April 1997 endorsed this
broad approach and raised many issues relevant to the Committee's
inquiry. A report of that event is attached as Appendix 3. Finally,
the Sainsbury Centre has recently set out, in conjunction with
the NHS Confederation, a coherent policy statement on mental health
services, which addresses issues of interest to the Committee,
and this forms Appendix 4.
2.2. This issue needs to be revisited in
the light of the recent White Paper on the NHS. However, the principle
that a joint body or forum is required to carry out strategic
planning remains valid. Some consideration is needed as to whether
this best happens at locality or Health Authority/Social Services
Authority level. On balance, the latter seems to remain the best
way forward as service planning for severely mentally ill people
requires a clear strategic focus. The Sainsbury Centre notes that
social services input will be required at locality level as part
of the plans set out in the recent NHS White Paper. This will
be helpful, but is not enough in itself to ensure a joint approach.
3. Incentives for joint working
3.1. The Sainsbury Centre believes that
joint working should be a legal and administrative requirement
at both strategic and operational level. Leaving the issue to
incentives means that the best authorities will pursue joint working
and be rewarded. The less good may remain where they are or even
drop further behind. A clear direction is needed from the centre
the signing off of local joint plans
by regional offices; and
a joint performance management system
for mental health.
3.2. At operational level, a unitary system
of care management (absorbing current care management and the
best aspects of the Care Programme Approach) would again build
joint working into the system. Financial incentives for effective
joint working will flow from pooled budgets because these would
provide opportunities for the more efficient deployment of the
total health and social care resource. Pooled budgets are not
an end in themselves but a way of deploying the total resource
efficiently in the best interests of service users.
4. Organisational and funding systems and
processes for planning, commissioning and service delivery
4.1 These will need major changes if the
system is to function more effectively for severely mentally ill
people. At present the structures work against coherent care and
create perverse incentives for health and social care respectively.
For example, health authorities can save resources if they can
prevent bed blocking but this may require greater social support
or the purchase of more residential care by social services. But
there are currently no incentives for social care to respond in
4.2 The issues which need to be addressed
Funding: Joint budgets are required to maximise
efficiency and flexibility and to remove perverse incentives.
Money needs to be able to follow the patient or client across
bureaucratic care boundaries.
Organisation: A forum is required to provide
direction and accountability. This needs to be jointly owned by
health and social services. It needs to generate a single plan
for services which should be constructed following genuine consultation
with all stakeholders such as users and professionals.
Commissioning: Must be undertaken jointly on
the basis of the agreed plan.
Service delivery: Needs to be undertaken by
genuinely joint community mental health teams, with staff answering
to the same management line and working to the same model of care
planning. This can be achieved by using the care management model
across both health and social services and allowing both social
workers and community mental health nurses (or other appropriate
staff) to act as care managers. The best features of the Care
Programme Approach can be retained but must be fully integrated
within care management.
5. Training and Professional boundaries
The Sainsbury Centre has set out a clear agenda
for developing joint and shared training between health and social
care staff in its report "Pulling Together".
In particular, joint and shared training opportunities need to
be developed rapidly, and a benchmarking mechanism set up for
such courses. Eventually, there may be common elements in both
the basic and post-basic training of key mental health staff,
but the separate identities of the existing professions should
be retained. Greater joint and shared training is key to the other
reforms which the Sainsbury Centre advocates.
6. Relative cost-effectiveness of services
and the movement of money between services
6.1 At present efficiency is not being maximised
because of the perverse incentives operating across health and
social care. Fragmentation, duplication, gaps and differing priorities
lead to scarce resources being wasted. For example, patients often
"block" beds in hospital because social or residential
care (which may be cheaper and most cost effective) is not available.
If these perverse incentives can be removed
there is an opportunity for greater efficiency.
6.2 The current system for transfers of
money (eg Section 28A) are based on out of date notions relating
to the resettlement of patients from the old asylums. They do
not necessarily meet current needs. The Sainsbury Centre's report
on legal obstacles to budget pooling will address this point in
7. Recruitment and retention of staff
This is difficult in many areas, especially
inner cities. Staff morale is low and burn out rapid. The joint
policy paper The Sainsbury Centre published in conjunction with
The NHS Confederation sets out an agenda for change (Appendix
4). Urgent action is needed in this area if some mental health
services are not to break down.
8. Barriers and incentives to encourage or
discourage the use of particular services
As already stated The Sainsbury Centre is in
favour of the removal of perverse incentives and barriers to using
services which are not based on cost effectiveness and individual
need. A unitary system of care management across health and social
care, using a single budget and working to a single strategic
plan, will maximise efficiency and benefit for clients. This principle
is likely to apply beyond mental health to other client groups
requiring long term care.
The Sainsbury Centre for Mental Health. Pulling Together.
The Sainsbury Centre for Mental Health: London. 1997
1 The Sainsbury Centre for Mental Health. Pulling Together.
The Sainsbury Centre for Mental Health: London. 1997