All our lives rely upon functioning infrastructure and on mutually understood and commonly practiced rules and rituals. From the moment we wake up to when we go to bed and on through the night we depend on stuff to just… work. From switching on the light in the morning, checking our Twitter feed, making a cup of tea and getting a shower to catching the bus or train, or driving our usual route to work, to arriving at work, switching on our computer, accessing our emails, using the photocopier, making ourselves a cup of tea, going to the toilet, a post work drink, making our way home, making our dinner in the oven, phoning friends and settling down to watch the TV. Only if these things function seamlessly can we function seamlessly. All the while, multitudes of different actors are each independently ensuring that this infrastructure is working properly.
When the chain ceases to function seamlessly, we can no longer function seamlessly. There’s no hot water to take a shower. The train is cancelled. We do not have an internet connection and so on. Sometimes we wrongly assume that things are going to be there for us when we need them, only to find out too late that they are not – like flood defences, or social care.
To these ends it seems intuitive to welcome coordination and closer integration of different elements of public infrastructure, including health and social care, as a vehicle for creating more seamless support. Yet with such integration come risks of both ‘domination’ and ‘infection’.
There is clearly a trend towards the integration of health and social care. On the one hand this makes sense in removing some of the nonsensical and artificial divisions that exist between the two systems, and in making better use of public resources, in particular through early action and prevention. It also offers the prospect of leveraging resources from the still popular and comparatively protected and well-funded NHS into the still largely unknown, already under-funded and increasingly decimated social care system. Yet there seems a genuine risk that social care simply becomes ‘healthcare in the community’, with health outcomes dominating strategic decision-making and the outcomes attached to individual packages of support. In this scenario social care is increasingly positioned as an answer to the pressures of the NHS and little more – an acquisition or hostile takeover, not a merger – and there is certainly evidence of this in the recent rhetoric of politicians from all sides and from the head of NHS England, Simon Stevens. Despite the Care Act, the role of social care in supporting wider dimensions of ‘well-being’ as ends in themselves, such as participation in family and community life or employment could be overwhelmed.
Regarding infection, the risk cuts both ways: healthcare largely remains a system in which professionals knows best, whereas social care has at least strived to embrace notions of self-directed support. On the other hand, healthcare remains overwhelmingly focused on improving people’s lives, irrespective of means, whereas social work is increasingly focused on gatekeeping ever-scarce resources and on managing risk.
It seems probable that we will soon be talking about how wider public infrastructure might be more closely aligned or integrated, including for example employment support, support with education and social security. The government has recently announced its plans to devolve Attendance Allowance to local councils. In Scotland, to which much of the disability benefits system is to be devolved, the Convention of Scottish Local Authorities (Cosla) is already making a bid to administer the benefits alongside its roles in relation to integrated health and social care. A new ‘Disability and Health Employment Unit’ has been established under the auspices of the Department for Work and Pensions and Department for Health.
Which imperatives will dominate as these areas of policy and delivery become more closely aligned and integrated? What culture and ethos will infect the whole? Can DWP’s culture of behavioural management, conditions and sanctions successfully combine with social care’s goal of restoring self-determination to those requiring support (certainly the experience of the Right to Control pilots suggests not)? Will getting well become an obligation, with people forced into courses of health treatment as a condition of benefits entitlement, especially in relation to mental health for example? Will health treatment increasingly be subject to the same gatekeeping as social care? How can the idea rooted in modern ‘welfare to work’ policy that receiving benefits amounts to dependence be combined with the idea of people receiving money in the form of direct payments from the State to support their independence? And what of public attitudes – which differ markedly in relation to support for the NHS when contrasted with social security or social housing for example? Will greater integration help soften attitudes where they are presently harsh, or harden them where they are currently more benign?
There is a grave risk that we are on a slippery slope towards integration without first asking what the various items that are being integrated were originally for, how they function in different ways and hence what might be lost as well as what is to be gained. How can we harness the ‘added shareholder value’ of integrating public spending and services without the risk that hostile takeovers rob us of those things we hold dear while increasing the influence of those we object to most?