At the Welsh Liberal Democrat Spring Conference held in Swansea in February, Peter Black AM, the Welsh Liberal Democrat Shadow Health Minister introduced a consultation document on possible options for the future of social care within Wales, exploring options around joint working and structures with health care.
There has been significant interest in the paper, and Freedom Central has decided to post it online so anyone can read it and add their voice to the debate.
The Welsh Liberal Democrats want to know your views, whether you are a service user or are employed in the sector, to make sure that the proposals that result from that consultation are the ones that will make the biggest difference to the lives of those who need our services.
We want to know your views. To respond to the consultation please write to Peter Black AM, Welsh Liberal Democrat Shadow Health Minister, National Assembly for Wales, Cardiff, CF99 1NA or e-mail firstname.lastname@example.org
There has long been a conflict between the intersecting responsibilities of primary care and social care. This can result in patients receiving the wrong type of care, for example being forced to stay in a hospital unnecessarily rather than being cared for at home, a delay in care while it is agreed who will pay for it, or in some cases not receiving care at all. This can also occur as each organisation attempts to reduce the demand on their own inevitably restricted budgets by shifting the responsibility and the budgetary burden to the other organisation.
There are substantial overlapping responsibilities between social care and health care, and the gap between them can become a stumbling block for patients who are in need of statutory services.
It is for these reasons that some Local Authorities and health organisations have decided to consider models of providing social care in conjunction with primary care. The aim is to provide higher quality services more cost effectively and to improve outcomes and experiences for both employees and patients. This can be done in a number of different ways.
One option would be to look at how health and social care provision can be delivered through integrated arrangements via a partnership between local Authorities and a Health Board. A Local Authority in England became the first place in the country to appoint a single Chief Executive for both the Council and the Primary Care Trust.
Under this model, the Primary Care Trust and the social care functions of the Local Authority are run by a Joint Management Team who are jointly employed by the Local Authority and the PCT., although certain members are appointed by either the Council or PCT.
Of course, this could be a difficult model to implement in this form in Wales because the boundaries of the Local Authorities and Local Health Boards are no longer coterminous after the recent re-organisation of the health service. The exception to this is Powys, where similar proposals are already being developed.
A crucial aspect of this model is the creation of the Integrated Commissioning Directorate. The creation of a fully integrated commissioning team would enable a focus on the holistic needs of individuals and populations. Wales has abolished the English model of a split between the commissioners and providers of health, so this may not be easy to replicate.
It should be considered whether elements of this deep partnership model, particularly involving integrated commissioning between primary care and social care, could be
effective in Wales. It should also be considered whether this model could be extended to cover Children’s Services. This would be particularly important to facilitate a smooth transition to adult services for young people who will need support as adults and for families who have parents with care needs. However, Children’s Services are complex and involve far more than just the provision of care.
Alternatively, some Local Authorities have gone beyond a partnership model and established a separate independent organisation in the form of a social enterprise to which to transfer some of its social care functions. In the case of one Local Authority in England, the decision was taken to register the organisation as a charity, both for tax purposes and to provide reassurance that any profits would be retained within the trust for the development of future services. This Community Caring Trust is a company limited by guarantee as well as a registered charity.
This model is significantly less complex than that of integrated commissioning, but it does not address the issue of the conflict between social care provision and primary care provision. It should be considered whether it would be possible to adapt this model to include primary care functions.
Staff and unions will inevitably have initial concerns in any reorganisation that improvements in quality would fail to materialise and efficiency savings would be made by reducing front line services and employee pay and conditions. It is obviously important to involve staff and unions from the beginning of any restructuring process, as their engagement with the process will help or hinder it accordingly.
Change however should be focussed upon patients and not just staff. But it would be necessary to develop a shared vision across the entire organisation. It would be important to decide whether front line staff pay and conditions should match that of the Local Authority or vice versa. Initial and ongoing Local Authority support would be vital, as would placing a high value on staff in terms of innovation as well as motivation.
However, in any organisation, concerns about cuts to front line services may be realised if there is an insufficient budget to meet demand. Therefore, it is necessary to consider the most appropriate means of funding social care and primary care provision. It could be the case that the Government could fund Local Authorities’ social care provision and expect them to fund Local Health Boards’ primary care provision or vice versa.
Alternatively, the Government could directly fund an independent organisation fulfilling both functions. In an integrated commissioning model the arrangements for charging for social care would need to be clear.
An independent social enterprise model that is registered as a charity however has access to grant funding for capital investment. It could have the capacity to tap into a wide range of funding streams particularly for innovative development work, and has the option of creative cash flow within the organisation to use income from popular services to benefit poorly funded services.
Whatever, the model, it could be argued that the Government ought to be providing sufficient resources to fund the efficient yet comprehensive provision of social care and primary care that is needed by patients on a daily basis.
But these are not the only options. If we want to amalgamate social care and health care, do we necessarily need a brand new structure to do so? Instead of combining the two under a new body, why not give the responsibilities of the area to the other body that is already in existence?
This could take the form of giving social care to Health Boards. The advantage of this would be the de-politicisation of care. It would no longer be run by a council influenced by party politics, but instead by an independent board of people used to dealing with the issues and finances of those who are in need of support. This has an obvious attraction, but while depoliticisation sounds like a good idea, it would also mean the loss of any democratic accountability.
And not all local authority functions around care would fit with health boards. How would they deal with children’s services, which are far more complex than the provision of care? Would we want to see social services functions lost from local authorities?
This could also be achieved the other way around, by giving primary care to our local authorities. The strength of the previous Local Health Board and NHS Trust system was in it’s locality, and this could be one way to restore that link with both local people and social care. But would it be dangerous to put so much of the running of the day to day functions of primary care under more direct political control? Would the health parts of the budget be squeezed to pay for other services?
And with both of these options, how would this be funded? Much of what would be included in these two models is paid for centrally, while other parts are paid for by local authorities through the revenue support grant and council tax. How would we make this fair to government, councils and the taxpayer?
Having considered all of the above, it is necessary to devise a liberal way forward for social care. The question remains as to whether social care and primary care functions should be combined so as to avoid conflicts of liability, and if so what would be the most appropriate model?
It needs to be decided whether it would be best to establish an integrated model and if so how that structure would work in the context of non coterminous boundaries, or whether it would be best to assess the possibility of an independent social enterprise, either with or without the inclusion of primary care.
And is such a reorganisation going to be welcomed by both patients and the workforces involved after significant changes to our health service so recently? Which of these options would deliver the best services for patients of all our health services? Which of these options best represents a liberal approach to dealing with the future of social care, as well as the future of primary care? Or should we just stick with the status quo and try to improve upon partnership working to prevent people from falling through the gaps within the system?
Conference is asked to look at these options and to highlight potential problems, and potential successes, and suggest which (if any) of these options should become the thinking behind future Welsh Liberal Democrat policies for social care.