Integration of health, social care and beyond – mergers, acquisitions or hostile takeovers?

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?

 

A future for social care in a Scottish ‘investment state’?

By Neil Crowther*

I’m really excited to be travelling up to Edinburgh this weekend to support an event hosted by the Independent Living in Scotland project on Monday.  The event is part of ILiS’s ongoing dialogue on the future of social care in Scotland, bringing together diverse social care stakeholders to develop a ‘statement of ambition’, which I am helping to draft.

The reading I have done in preparation is depressing and terrifying in equal measure.  Scotland has already endured massive spending cuts, but with respect to everyday services such as social care the biggest cuts are yet to come.   The Commission on the Future of Public Services in Scotland estimated that the Scottish public sector would face a £39 Billion shortfall between 2010/11 and 2024/5 – the year public spending is forecast to return to 2010 levels. To put that figure into perspective, it is equivalent to funding adult social care in Scotland for 13 years.

In the immediate term there seems little that the Scottish Government is able or prepared to do about Westminster-imposed austerity.  Scotland’s Finance Minister John Swinney recently ruled out using powers to set higher income tax rates in Scotland and froze council tax for a further year.  The grant to Scotland from the UK government will continue to go down in real terms for the next decade as George Osborne pursues a budget surplus.  Since Scotland introduce free personal care for older people in 2003, local council charging for social care has risen sharply, albeit unevenly with councils charging between £18 per hour and zero for home care depending on where people live.  As with the rest of the UK, eligibility for social care focuses on those with ‘critical or substantial’ needs and people who are eligible are receiving less generous packages of support or having their packages cut.

But amidst the gloom, some potential light.  Scotland may have decided to remain part of the UK at its recent independence referendum, but be in no doubt that the political economy of Scotland is developing along very different lines to that in England.

Of particular interest to readers of this blog will be central role that the UN Convention on the Rights of Persons with Disabilities, and human rights more generally, is playing in shaping policy and programmes.  The Scottish Government is presently consulting on its draft delivery plan on the UNCRPD, while the Convention of Scottish Local Authorities (Cosla) is ahead of the game having already published its own CRPD implementation plan.       In December, First Minister Nicola Sturgeon indicated the Scottish Government’s preparedness to consider incorporating the Convention and other international human rights treaties to which the UK is party into Scots law.

Arguably the biggest influence on social care reform in Scotland right now is integration of health and social care.  Following the Public Bodies (Joint Working Act) 2014 National Health and Wellbeing Outcomes have been established for health and social care and there is a requirement for NHS Boards and local councils to integrate health and social care budgets.  Each area will have an integration board by April of this year.   While there are many reasons to celebrate these developments, there is also concern that social care may become narrowly focused on ‘healthcare in the community’, undermining its broader role in supporting disabled people’s social and economic participation.  This is a particular risk if the only new funding to go into social care comes from the NHS.

To those ends, another big change on the horizon is contained in the Scotland Bill: devolution of social security powers related to disabled people.  This will see DLA/PIP, Carers Allowance, ESA and other benefits devolved to Scotland.  On the positive side, this presents an opportunity for Scotland to cultivate an entirely different approach to that which has evolved in England, and in particular to carve out a social security system that genuinely supports independent living.  Yet there is a grave risk that this money could end up plugging gaps in underfunded social services, and indeed Cosla has already proposed that such benefits should be administered by local councils.

More broadly, what I find exciting is the potential for Scotland in time to emulate a Scandinavian model, shifting from a ‘social welfare’ approach to a ‘social investment’ one. Nicola Sturgeon seemed to exemplify such thinking in her articulation of a future SNP government’s policy on childcare when she said this week:

‘Our most transformational infrastructure investment in the next Parliament will be in early years and childcare.  We will provide parents with 30 hours a week of government funded childcare enabling them to return to work, to pursue their careers and to know that their children are being well cared for, well educated and given the best start in life’ 

Social care has not benefited from such framing to date, nor has it enjoyed a research agenda to underpin a narrative that positions it persuasively not as a growing cost, but as crucial part of the national infrastructure ripe for investment.  As I have argued elsewhere, I believe that for independent living to have a future, it also has to be situated within the frame of social investment, not social welfare.

The public spending environment in Scotland is bleak.  Yet choices will continue to be made about how to spend the many billions of pounds that will still be invested in public services over the coming decade. Spending that can be shown to save money down the line, to strengthen communities and which can contribute to economic growth and prosperity is most likely to win out.  Without a narrative and underpinning evidence to sustain the case that social care (and independent living more widely) meet these investment tests, it will I believe continue its journey to the margins.

 

*Neil is writing in an independent capacity