Vision for Community Health and Social Care: A Perspective for Collaboration between Agencies

Restructuring of health and social care is forcing many services to close or become streamlined and managers have had to find new ways to ensure they get financial support to continue services’ delivery. In the current climate of rationing services, preventative care should be re-in fenced to minimise accidents and service users’ health deterioration at home. The measure is intended to save health and social care money in the long run. By contrast, due to drastic cuts across the public sector organisations, unfortunately preventative services are often the first to be axed. This actually tantamount to negligence at core, which later challenges the existence of our prime services – to manage complex situations such as the critical and substantial care needs. Therefore, what is the rationale behind this policy decisions?

Nonetheless, it could be argued that such decisions are accredited to the tunnel vision of some senior managers. In hindsight, some of them can only see within the parameters of their corporate responsibilities that is “to save money”. In reality, it is only the older people and the other vulnerable groups in society that would suffer the consequences of such irrational decision-making. Thus, the aims of this article is to illuminate how the managers could make the case for continuing care delivery in a changing economic environment in relation to; demographic change and linear family units in the 21st Century and beyond.

On reflection, best practice would suggest that in a time of economic and budgetary constraints, collaboration with the local primary care trusts, community organisations and the third sector institutions would prevail. This would ensure that the vulnerable service users will be supported adequately to become more independent in their homes. Partnership working between agencies has the propensity for sharing resources such as, staff, information technology, offices, intelligence etc. If we are to emulate the private sector, mutualisation would help in reducing unmet needs and service breakdowns in the community. Sharing responsibilities would also promote health and psychosocial well-being among service users as well as reducing the need for admissions into nursing homes or hospital admissions.

Managing community services require organisational cultures and political change, which would give rise to the sharing of intelligence between the collaborated organisations who are working for the benefits of service users (older people, learning disabilities or mental health). This approach is intended to provide opportunities in reducing services’ duplications, costs and antagonistic relationships between agencies. Whilst capitalising on intelligence sharing, a lot of soft evidences could turn to hard evidences, this coming directly from community health practitioners such as community nurses and social workers. This data would show for example, figures on how many older people or the other vulnerable groups that were admitted to hospital after a fall or care breakdowns and what these cost the NHS and social services in after-care.

Looking at the frequency of falls and care breakdowns among the service users in a given period, the estimated figure would provide a relative forecast for the number of incidents that could lead to hospital admissions in future, costs to local primary trust and cost of care packages to social services. These results would be instrumental to future planning for community base services and implementation of strategies appropriate in reducing falls or care breakdowns at home. The projected cost savings could be reinvested to preventative services in line with continuing safe environments, where older people and other service users could be rehabilitated to minimise falls.

In practice, good risk assessments provide the opportunity for service users to be assisted in a safe environments, this could be in their own home or in a residential setting. These should be incorporated into day-to-day operations and will often run alongside equality monitoring of services. This is about getting the balance right between planning, delivery of services and managing information. This approach should be robust and prudent as to ensure cost recovery and quality care management for service users and their informal caregivers. Information gathering and monitoring of services would intensify support for community services while users are able to make choices and control of their support networks.

Another important source of evidence is feedback and “quotes from service users”. This adds to the richness of evidence. Hence, the service users know what they want and the standards they are used to, rather than the professionals prescribing for them. This signals the process for change and how services could be delivered in future. The service users and their families should be part of the new thinking in a modernising health and social care sectors and they have rights like any other citizen of the state to make informed decisions and choices.

For health and social services to remain in the premier league of services delivery within the wider welfare and universal service frameworks, it is imperative that investment in research and development is forthcoming. This provides an apparatus for good evidence based practice, where data could be shared, analysed and put to action as a mechanism in maintaining safety net. In the light of this, there is every indication that unless mutualisation is considered each of the organisations would not be able to meet the increasing needs of the growing service users now and in the future.

Inevitably, advancement in technology is changing our world and the methods of working. Thus, capturing quality practice based evidence from service users and their families could be made simple by developing and implementing scorecard systems so that individuals who come to the service can tell us things. This could be on a scale of one to five for example, telling us how depressed they feel about their care; how they feel about their health; how many falls they had in the last one month and how to improve services further. These questions or survey could be repeated every three to six months in order to compare and contrast findings. The information gathered would help determine investment in human resources and hospital avoidance strategies necessary to support older people and the other vulnerable groups to be cared for in the community for as long as possible.

All things being equal, Data Protection Act (1998) and Freedom of Information Act (2005) could constrain sharing and flow of information between agencies and this would influence services delivery in the community. If that is the case, duplication of services would continue to be present coupled with poor information sharing between agencies. In practice, duplication of services and assessment works against the best interest of the service users, hence this can create anxiety, repetition of information and exacerbation of stress amongst the users. Equally, duplication of services could lead to costs escalations between agencies and these defies the objects for cost effectiveness and strategies for recovery and business turnaround (Ugwumadu 2011).

Rethinking Community Care in the 21st Century: The Perspective for Marketisation of Social Care

The agenda for marketisation of social care revisited familiar themes around the enhanced involvement of users in service delivery, upholding choice and control, increasing accountability and developing these by integrating a role for self-organisation and independent living within services. The modernisation of the social care market, drawing on the principle of provider/purchaser split (NHS and Community care Act (DoH 1990), managerialism in welfare services and best value cost effectiveness, provided a focus for delivering social care. Both the Conservative/Liberal Democrats government and New Labour administrations have pursued these ideologies. It also has included the privatisation of care for older people, raising the issue whether the for-profit sector in indeed likely to be the best option for good quality care, especially for frail older people.

A key feature of marketisation policy is about breaking down large-scale organisations providing social care and using competition to enable exit or choice by service users. The ideological position is to increase flexibility in the social care market as this would bring about equilibrium of demand and supply in the market. Individuals and groups at different positions on the political spectrum have promoted the idea of users’ rights to exercise choice in their use of public services. Progressive self-help movements have argued for choice as a means of promoting market-based solutions and curbing the power of the state (Clarke et al 2000; Leadbeater 2004; Cameron 2010; Ugwumadu 2011).

Marketisation significantly centred on issues of cost efficiency, consumerism, and responsibilities and cost savings, whereby the allocation of cash for care rather than services raised concerns as to the accountability of government monies.  Marketisation policy clearly presents significant opportunity for delivering personalisation of services through direct payments and individual budgets model and related support structure in the future social care market (Leadbeater 2004; Hasler 2006). According to Zarb and Nadash (1994) and Hasler (2000, 2006), they argued that direct payments is around 40% cheaper than direct provision. New Labour government assured in its positioning of direct payments and individual budgets as part of a wider marketisation of social care, established initially through the 1990 Community Care Act. This framed the market as an instrument for accessing choice and diversity in social care provision through the development of local care markets (Hasler 2006; DoH 2008).

The central doctrines for the Conservatives/Liberal Democrats government and  New Labour government’ agenda are: a focus on managerialism not policy and on performance appraisal and efficiency; the disaggregating of public bureaucracies into agencies which deal with each other on a user-pay basis; the use of quasi-markets and contracting out to foster competition; cost-cutting; and a style of management which emphasises, amongst other things, out-put targets, limited-term contract, monetary incentives and freedom to manage (Hood 1991; Osborne and Gaebler 1992; Leadbeater 2004; Cameron 2010). These ideological policy frameworks are fundamental principles behind the Big Society’s agenda to enhance the welfare systems. The Big Society project is claimed to offer the opportunity to deliver the personalisation agenda and to maintain cost effective social care.

However, many people would disagree with this position on the grounds illuminated below. For example, changes in delivering personal social services are accompanied by an increasing tendency to define home care intervention in terms of narrow tasks. This has resulted in complaints of unmet needs and lack of opportunities for more generalised social interaction between carers and service users (Sale and Leason 2004; Ugwumadu 2011). The continuous changes within social services’ policy and practice have influenced social work practice and social care delivery. According to Morris (1993a) and Glendinning et al (2002, 2009), changes in policy meant that social workers were no longer in a position to uphold social work ethical practice, but had to participate in a policy that deprived users of their rights and choices, as outlined in the National Health Services and Community Care Act (DoH 1990).

It is also possible to see the Community Care (Direct Payments) Act (DoH 1996 a & b), and the Carers and Disabled Children Act (DoH 20001 b) as an attempt by government to promote a distorted and flawed notion of empowerment by exit, shifting responsibilities to users. The aim was to control and reduce an escalation of public expenditure. In such a service, Leece (2000) claimed that it would be left to local authority social services departments to balance the books and reconcile the very real demand for direct payments with already stringent budget constraints. Pearson (2004a, b and 2006) noted the contradiction and tension between the legislation and practice.

The Conservatives/Liberal Democrats government has largely intensified the marketisation approach as the basis of their broader modernisation programme in social care with its increasing focus on personalisation services. The Big Society project and Personalisation of services are very potent but, highly contested and ambiguous idea that could be as influential as a privatisation was in the 1980s and 1990s in reshaping public provision.

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