How can people in end-of-life care look at the comprehensive spending review? Here are some initial thoughts mainly about how limitations on social care development will hold back end-of-life care; I’ll probably come back to this.

The starting point here is two unknowns: the NHS and social care budgets. The NHS budget is edging up in real terms; the Department of Health website says:

For health, the overall budget will increase by 0.4% in real terms. This includes:

• a 1.3% increase in the resource budget;
• a 17% decrease in capital spending
• a reduction in the administration budget of 33%
• reinvestment to support the delivery of NHS services

Social care will receive additional investment, rising to £2 billion per year by 2014-15, through the NHS and local government.

It may not feel like this to people in the NHS and social care for two reasons. One is the demographic factor: an ageing population will require more healthcare, and probably more end-of-life care. To get there, the NHS has to do ‘more with less’, which is why it feels very pressurised. As the DH says:

To meet the rising costs of healthcare and increasing demand on its services, the NHS will release up to £20 billion of annual efficiency savings over the next four years, all of which will be reinvested to meet rising levels of demand and to support improvements in quality and outcomes. This will include, for example:

• continuously improving workforce productivity;
• applying best practice throughout the NHS in the management of long term conditions;
• driving down inconsistencies in admissions and outpatient appointments;
• and a 33% cut in the administration budget, including a reduction in the number of arm’s length bodies from 18 to a maximum of 10 by 2014.

Releasing those efficiency savings through workforce productivity is every NHS and social care person working harder or better, and we all know that there’s not going to be much money saved by the quango cuts.

The DH spending review website is:

http://www.dh.gov.uk/en/Aboutus/Features/DH_120689

The other factor is that money is going from the NHS to local government to support social care, but local government is in total being cut back very substantially, so it’s a little unclear what will happen to social care provision, and this will have some impact on palliative care patients and a lot of impact on older or disabled people nearing the end of life. It’s too soon to say yet what may happen here.

Interestingly, the Today programme this morning covered three Conservative west London boroughs who were thinking of merging some of their functions, starting off with children’s and adult social care. the politician who was interviewed was very relaxed about their capacity to maintain separate political policies while merging functions. This might be easier where the political complexion of the authorities is similar but, even so, I think this is politician naivety. They tend to think that what they believe and make policy about is the most important thing about how policies get implemented. Usually, though, the style and leadership of the professionals, and in particular of the director, has the most impact. This is because most politicians don’t really understand and would rather not know about what staff are doing.  So actually the professional ambience of a department has the major effect on how the job gets done. We all know departments that appear to be broadly similar with similar budgets that the staff in the next door borough would not touch with a narrow-boat bank-prodder because of some ghastly senior management types who fester there.

I sympathise with London boroughs (and other small local authorities). They are much too small to operate services like adult social care effectively, once you go beyond the universal home care and care homes provision. Sharing functions is in principle a good idea.

The letter to directors from David Behan, the DH adult social care supremo, gives the overall info. About £1bn will be taken from NHS capital (no point in building hospitals if you don’t pay for the staff to run them) to revenue to support things in social care. About a third of this will be for ‘reablement’ (NHS activity that helps people to cope better in the community – this is a trendy thing at the moment, but the government hasn’t found out yet that it’s no good getting people physically fitter if you do nothing to help them cope with all the social and relationship aspects of their lives when you turf them out of in-patient healthcare). It will become less trendy when they discover that you have to do more than re-able people physically to enable them to live satisfying lives.

The other two-thirds will be used to support social care services. It’s not clear how they’re going to deal with this, but it looks to me as though it will be kept in the NHS to pay for things that the gp-commissioning pct-replacements want to spend it on. That is, when some hospital or gp can’t get the social care services it wants, it will call on some budget to pay for things to get someone out of a hospital bed or reduce problems for a gp. Not actually a coherent contribution to developing social care. Behan says:

We will expect local authorities and the NHS to work together to agree how this funding should be best used to support social care services. Further details about this support will be published alongside the 2011/12 NHS Operating Framework.

I’m all agog on how they’re going to get this working together to happen. It’ll be ‘we’ve got the money, you do as we say’, in other words, the usual attitude of NHS commissioners.

The social care budget will also be directly uprated by inflation (according no doubt to some measure that will keep it as low as possible) and by an extra £1bn. This not-a-lot-of-money (when you spread it around the country) will also be in the normal funding mechanism, so it’s not ring-fenced and local authorities can spend it how they like. Remembering that schools have been protected, so children’s services, which local councillors are very panicky about, are going down the swannee, I can see a lot of this going towards other things. Here is what Behan says:

In recognition of the importance of social care in communities throughout the country, additional grant funding, rising to £1bn by 2014/15, will be made available for social care. This funding will be allocated in addition to the Department’s existing social care grants, which will rise in line with inflation. In total, grant funding for social care will reach £2.4bn by 2014/15. In order to support local flexibility and to reduce administrative burdens, this funding will go to authorities through the Revenue Support Grant.

And here is what he says about the overall settlement for local government:

Local authorities will receive an overall reduction in revenue funding from Government of 26% when revenue grants from all departments are included – excluding schools, fire and police. This represents a challenging settlement for local government.

Challenging, as we all know, means ‘boy, have you got problems’.

Looked at from the point of view of marginal NHS activities that interact with community health and social care provision (I mean palliative care) it seems that although probably the service will stagger on, there will be pressures around the edges, but the main problem will be ensuring a good standard of community provision, particularly if social care services have to be engaged.

Looked at from the point of view of the ambition to develop end-of-life care, and the wish of DH documents like the National End-of-life Care Programme social care framework to develop end-of-life care for all older and frailer people, the pressures on adult social care mean that we are not going to be making much progress.

To look at the official statements of the CSR, you can go to the Treasury site on the internet:

http://www.hm-treasury.gov.uk/spend_index.htm

You can also look at the pdf of the full review:

http://cdn.hm-treasury.gov.uk/sr2010_completereport.pdf

The Direct gov website provides a categorised and simplified summary:

http://www.direct.gov.uk/en/Nl1/Newsroom/SpendingReview/DG_191708

This of course is all official, so it tells you what the government wants to tell you. For example, the Treasury website is keen to tell you:

The Government has prioritised its Spending Review decisions to support growth, fairness and public sector reform.

If you’re not sure about that, you could look at some of the more neutral news sites, e.g. the BBC:

http://www.bbc.co.uk/news/special_reports/spending_review/

…or the Financial Times, where you get more of a business perspective:

http://www.ft.com/indepth/spending-review-2010

If you only want to read the opposed views, you might like to start from the Guardian:

http://www.guardian.co.uk/politics/spending-review

… or the New Statesman (go here and search for “spending review”):

http://www.newstatesman.com

If you might like the favourable views look at the Telegraph:

http://www.telegraph.co.uk/news/newstopics/spending-review

or the Mail (go here and search for “spending review”):

http://www.dailymail.co.uk/home/index.html

For something with a semblance of economic understanding, try the Economist:

http://www.economist.com/node/17316567.

Returning from Poland yesterday, I meet the press coverage of the cuts. These are the cartoonists’ takes, but what strikes me is the focus on political hostility rather than social consequences (except for Matt on the French pensions and Alex Hughes on Conservative attitudes to the ‘big society’. I can’t cover the Times any longer, because it’s behind a paywall.

Steve Bell in the Guardian

http://www.guardian.co.uk/commentisfree/cartoon/2010/oct/22/steve-bell-spending-review

Garland in the Telegraph (an anti-Ed Mili cartoon) October 22, 2010:

http://www.telegraph.co.uk/comment/cartoon/

Matt cartoon in the Telegraph on the spending review hurting but who knows where:

http://www.telegraph.co.uk/news/matt/?cartoon=8076930&cc=8035832

…a better one on ‘we’re all in this together’ (a child smashes his piggy bank):

http://www.telegraph.co.uk/news/matt/?cartoon=8076939&cc=8035832

…and an even better one on pensions, taking in French retirements:

http://www.telegraph.co.uk/news/matt/?cartoon=8079116&cc=8035832

Alex Hughes (a ghostly Thatcher questions the ‘big society’):

http://alexhughescartoons.co.uk/?gclid=CKfuxpeq5qQCFSL92AoduXJT1Q

Mac in the Daily Mail has (20^th October) a prisoner pleading not to be released early to face the cuts:

http://www.dailymail.co.uk/coffeebreak/cartoons/mac.html

…(21st October) a fat cat sunning himself abroad hears that he can return to his winter fuel allowance:

…(22^nd October) the Queen faces her new budget by ringing Wayne Rooney for a loan.

In the Independent (22^nd October), Schrank has Cameron and Osbourne as Vladimir and Estragon, who have chopped down their tree and are now waiting for growth rather than Godot:

http://www.independent.co.uk/opinion/the-daily-cartoon-760940.html

…(21^st October) compares French and English radio listeners hearing about severe cuts; the Frenchman filling his Molotov cocktail and the Englishman makes a pot of tea:

http://www.independent.co.uk/opinion/the-daily-cartoon-760940.html?ino=2

…(20^th October) has George Scissorhands at the despatch box.

Kal in the Economist is more international. European (anti-cut) and American (republican pro-cut) citizens confront each other, but both want their politicians to listen to them:

http://www.economist.com/node/17323317?story_id=17323317

Seeing that the government hopes that we’re all going to have to reorganise our services as social enterprises before long. you might find an interesting little case study from the north-west useful. It’s not clear in practice how far mass social enterprise devolution is going to be all that different from privatisation and contracting to the voluntary sector, because the people who pay the money (ie local authority treasurers) are going to keep very tight control of the purse strings and will plan to order everyone around for stupid financial reasons as ever; this is not going to be a liberating opportunity for servicer user control (as some of the particpants in the case study recognise). However, in principle, social enterprise has the potential to create independence, flexibility and social value, so it has to be thought about. And with social enterprise devolution there is the possibility of being able to negotiate sensible rather than purely bureaucratic controls.

This study looks at the process of moving from being a local authority service to a social enterprise model, pluses and minuses. In a way it tells you nothing new, because it’s just like the last wave of privatisation in care homes: the important thing is the business model. And the problem with this wave is that the care home privatisation in the 1980s relied on the value inheremnt in an enterprise owning a property in a rising property market. Neither of these two things applies in many care type social enterprises that the government would like to develop. It does look very much like having someone who isn’t local government to blame if something goes wrong. You offload the responsibility, tie up the money with incredible limits and voila! Pilate your way through any difficulties.

On the web at: http://www.localinnovation.idea.gov.uk/idk/core/page.do?pageId=22580780#problems

The national dementia strategy has been updated by the coalition ministers, and points to four priority outcomes:

- Good quality early diagnosis and intervention for all – Two thirds of people with dementia never receive a diagnosis; the UK is in the bottom third of countries in Europe for diagnosis and treatment of people with dementia; only a third of GPs feel they have adequate training in diagnosis of dementia.

- Improved quality of care in general hospitals – 40% of people in hospital have dementia; the excess cost is estimated to be £6m per annum in the average General Hospital; co-morbidity with general medical conditions is high, people with dementia stay longer in hospital.

- Living well with dementia in care homes – Two thirds of people in care homes have dementia; dependency is increasing; over half are poorly occupied; behavioural disturbances are highly prevalent and are often treated with antipsychotic drugs.

- Reduced use of antipsychotic medication – There are an estimated 180,000 people with dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a beneficial effect and there are 1800 excess deaths per year as a result of their prescription.

This gives a good sense of priority and a focus on things that are really important. Otherwise is contains the usual whitter about what they’ve been doing and complicated diagrams about overarching etc objectives. A pity when the priorities set are so clear. Still, at least they’re continuing with an important part of the DH’s work.

Department of Health (2010) Quality outcomes for people with dementia: building on the work of the National Dementia Strategy. London: DH

On the internet at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119828.pdf

Having sat through the first leaders’ debate last night I thought I should start and quite possibly finish my election coverage for the 2010 UK General Election. I didn’t actually see all of it, because our daughter-in-law stranded in California by volcanic ash rang up at the crucial point, not realising that history was being made on UK telly.

I’ve had a look at the main political party manifestos, and give below excerpts about palliative and end-of-life care and social care and social work from each. Of course, nobody much reads manifestos; we rely on news coverage for thinking about what the parties stand for. In general this is sensible, since detailed points in manifestos are likely to be lower priority if any of them get into unfettered power. Probably the best guide to what might happen to end-of-life and social care is the overall picture of the world as seen from a political party, because that’s what we’re going to have to fit in with. You can make the best judgment about that from the press coverage and your view of the general attitudes displayed by the party leaders. On the other hand, end-of-life and social care are so low priority, to politicians and the media-represented public mind, that if some party has bothered to say something specific, it’s quite likely to get taken up afterwards. Why bother to reinvent what you think if you never knew you were thinking it anyway?

One of the interesting features of the main parties, which has not had much press coverage, is the proposal to have more talking therapies (I suspect because people like them more than medication and they’re probably cheaper than doctors dispensing medication and certainly cheaper than putting people in mental hospital).

There’s not much detail about this, but in the Labour manifesto they’re part of the ‘it’ll be cheaper in people’s own homes’ paragraph, alongside tele-care, and note that it’s not for everyone who needs psychological care, but only for those with Alzheimer’s and the like. Good, but scarcely recognising the wish and need for more psychological care.

And for the Conservatives it’s in the public health section and mentions ‘effective talking therapies’. This probably means not clinical psychology (more specific than talking therapies and it would be expensive, whereas rather lesser ‘talking’ therapies would be cheap). Obviously they won’t be supporting anything that doesn’t have a bevy of random-controlled trials to back it up. So that’s all right then, there won’t be a lot of talking therapies to pay for.

Labour Party (2010) The Labour Party Manifesto 2010: A future fair for all. London: Labour Party.

On the web: http://www2.labour.org.uk/uploads/TheLabourPartyManifesto-2010.pdf

This is a chunky document, which as befits the party in power does actually cover the main points. Each main sector of government is covered in separate chapters, which start off with the ‘challenge’ (we don’t of course have problems in modern political discourse) and how their programme of national renewal is going to deal with it (obviously the party in power cannot say it’s gong for change, so we’re all going to be comprehensively renewed)..

Here are the main points on health  (p.4:2)

The challenge for Britain

To build a better health service by protecting NHS spending and by shifting to more preventative and personal care, clear patient guarantees and greater care in the home. The Tories will not introduce the necessary reforms, would fail to guarantee access to services, usher in a care postcode lottery, and put the interests of patients second.

The next stage of national renewal

- Legally binding guarantees for patients including the right to cancer test results within one week of referral, and a maximum 18 weeks’ wait for treatment or the offer of going private.

- Preventative healthcare through routine check-ups for the over-40s and a major expansion of diagnostic testing.

- More personal care, with the right in law to choose from any provider who meets NHS standards of quality at NHS costs when booking a hospital appointment, one-to-one dedicated nursing for all cancer patients, and more care at home.

- The right to choose a GP in your area open at evenings and weekends, with more services available on the high-street, personal care plans and rights to individual budgets.

- Access to psychological therapy for those who need it.

I also looked at the main points on families and older people (p6:2).

The challenge for Britain

To support all families in a rapidly changing world that places new and rising demands on all of us. We will help families to realise their aspirations — whatever their circumstances — and we recognise the huge contribution older people make to society and to family life. The Tories propose a marriage tax allowance that is divisive and unfair, will neglect growing care needs among frail elderly people and disabled adults, and prioritise only the privileged few.

The next stage of national renewal

- More help for parents to balance work and family life, with a ‘Father’s Month’ of flexible paid leave.

- A new Toddler Tax Credit of £4 a week from 2012 to give more support to all parents of young children – whether they want to stay at home or work.

- The right to request flexible working for older workers, with an end to default retirement at 65, enabling more people to decide for themselves how long they choose to keep working.

- A new National Care Service to ensure free care in the home for those with the greatest care needs and a cap on the costs of residential care so that everyone’s homes and savings are protected from care charges after two years in a care home.

- A re-established link between the Basic State Pension and earnings from 2012; and help for ten million people to build up savings through new Personal Pension Accounts.

My searches of the document produced the following – the sole mention of social work as such in any manifesto; obviously Ed Balls has got the presenrtly accepted policy into the manifesto, in spite of the spat about who’s going to run the College:

3:6 …Social work training will be radically overhauled, raising the status and standards of the profession, and we will establish a National College of Social Work. We will publish detailed Serious Case Review summaries that explain the facts, but keep full reports out of the public domain in order to protect children’s identities.

End-of-life care also uniquely gets a mention, but in relation to the voluntary sector role in health care

4:3 We will support an active role for the independent sector working alongside the NHS in the provision of care, particularly where they bring innovation – such as in end-of-life care and cancer services, and increase capacity. We will be uncompromising in expecting high standards from all NHS services – and in the coming period we will expect PCTs to challenge all services to achieve the highest quality. Where changes are needed, we will be fair to NHS services and staff and give them a chance to improve, but where they fail to do so we will look to alternative provision.

They’re also still keen on getting NHS staff to set up social enterprises to run NHS services. Particularly nurses, but no mention of doctors, whose negotiating oomph seemed to scar Mr Blair’s back. Perhaps they think nurses are less business-like, or more pliable and cheaper. They have also heard the message about not keeping on changing everything all the time.

4:4 Central to our agenda for improvement is the hardworking NHS workforce. We will continue the process of empowering staff – freeing them from bureaucracy and ensuring they get proper support. We will expand the role of NHS nurses, particularly in primary care, in line with the best clinical evidence. And across the NHS we will extend the right for staff, particularly nurses, to request to run their own services in the not-for-profit sector. To strengthen local accountability, we will increase the membership of Foundation Trusts to over three million by the end of the next Parliament.

The NHS will benefit from a period of organisational stability: we will make no top down changes to the structure of Primary Care Trusts or Strategic Health Authorities during the next Parliament, and we will ensure stability in the hospital payment system.

Then there is a commitment to palliative care in people’s homes. They’re obviously still bedazzled by the Marie Curie marketing machine, or perhaps they just think someone else has heard of them too; it’s like all of the party leaders in the telly debate mentioning people they met out campaigning in every answer they gave (only those who agreed with them of course, but perhaps party leaders are only allowed to meet people who agree with them). It got irritating after a while, and swooning on Marie Curie has the same effect.

4:5:We will offer more personal healthcare. All cancer patients will be offered one-to-one dedicated nursing for the duration of their care and we will work with Marie Curie Cancer Care and other providers to guarantee everyone who wants it the opportunity to receive palliative care in their own home at the end of their lives.

Like all the other parties, Labour is keen on carers: Keen on Karers will be the new multi-party slogan: they’re so cheap and everyone can agree how wonderful they are. Labour actually admits this is why they’re keen:

6:2 We need services that help families manage these new pressures without creating huge additional costs. We need to go further to secure fairness in later life and ensure that those who plan and save for their retirement are rewarded for doing so. The additional costs and burdens of old age must not fall disproportionately on those who have made provision for themselves and their families.

This leads on a big section on how they are going to do the National Care Service; it mirrors the recent White Paper (see my previous post) and it is actually a good summary of the White Paper. In the context of a manifesto (i.e. something that will be read by non-specialist journalists, re-ablement has become a physio service). Note the regular mention of controlling costs; it’s good to know that physiotherapists will be playing their part alongside social workers in keeping costs down:

6:5-6 The National Care Service and an age-friendly NHS

The cornerstone of a fair future is ensuring everyone who needs care and support, whether through old age or disability, is properly looked after. We will establish a new National Care Service and forge a new settlement for our country as enduring as that which the Labour Government built after 1945. It will be a new settlement for all those who need care, for the carers who devote their time and energy for the good of others, and for families across the country. The care of both older people and disabled adults will be transformed; unfair postcode lotteries removed; more people will be looked after at home; and family homes and savings will be protected from catastrophic care costs. To provide independence and control for everyone with a care need we will continue to expand the use of individual budgets. And to drive up standards, we will develop a skilled and highly motivated workforce.

The first stage of reform will be to create a step-change in the provision of services in the home and in our communities. From 2011 we will protect more than 400,000 of those with the greatest needs from all charges for care in the home, and we will create a national physio support service helping people in every area of the country to regain their independence and confidence after a crisis or the first time they need care. These services are essential if we are to ensure more people are looked after in their homes and overall costs are to be controlled. They will be funded through savings and efficiencies in the health budget and in local government.

During the next Parliament, the second stage of reform will centre on the development of national standards and entitlements to ensure high quality care for all, and an end to the unfair postcode lotteries that affect too many families. We also want to remove the fear that families will lose the family home in order to pay for care bills. So, from 2014, the National Care Service will cap the costs of residential care so that  everyone’s homes and savings are protected from care charges after two years. We will pay for this through our decision to freeze Inheritance Tax Thresholds until 2014-15, by supporting more people over the State Pension Age to stay in work if they so wish, and through efficiencies across the NHS and the care system.

The final stage of reform, after 2015, will be a comprehensive National Care Service, free at the point of use not just for older people, but all adults with an eligible care need whoever they are, wherever they live and whatever condition leads to them needing care. At the start of the next Parliament we will establish a Commission to reach a consensus on the right way of financing this system. The Commission will determine the options which should be open to individuals so that people can have choice and flexibility about how they pay and to ensure that the National Care Service is funded in a fair way.

The Commission will make recommendations in time for implementation of the third stage of reform after 2015, once these proposals have been put to the public at a general election. Across the NHS we will improve and personalise care for the elderly and their families. This will mean more NHS services available in the home, with greater use of tele-care and personal nursing; reform of the GP contract to help ensure those with late-life depression and anxiety are diagnosed and supported; and better services for those with dementia and Alzheimer’s so that every area of the country has access to psychological therapy, counselling and memory clinics.

There will be an end to the age discrimination that has too often seen older people disadvantaged in the provision of health services.

The section on communities (that is, local government) extends the NHS intention to get staff to run social enterprises to provide services. So social workers can run their own child protection teams and get the blame for everything even more directly than at present..

7:5 We will extend the right of public-sector workers to request that they deliver frontline services through a social enterprise. Public-sector workers in the NHS currently enjoy this right. We will extend this to more public services, including social care, with greater community involvement in their governance.

Right, on to the Conservatives.

Conservative Party (2010) Invitation to Join the Government of Britain: The Conservative Manifesto 2010. London: Conservative Party.

On the web: http://www.conservatives.com/Policy/Manifesto.aspx

The main emphasis of this Manifesto is the public involvement argument. It is a fairly thick (I don’t mean stupid, I mean long) document, like Labour’s, but with less on end-of-life and social care. However, the line is much the same. The main point on health also includes a mention of social care (demonstrating joined-up thinking) as follows:

45 Back the NHS

We will back the NHS. We will increase health spending every year. We will give patients more choice and free health professionals from the tangle of politically-motivated targets that get in the way of providing the best care. We will give patients better access to the treatments, services and information that improve and extend lives, boost the nation’s health, and reform social care.

Then we’re on to the public do-it-all-yourself theme, which leads on to a mention of personalisation and independent budgets, merging health and social care funding, although not the actual service as far as I can see. Is this possible? I doubt it, in which case, see below my comments on the LibDems and merging health and social care into a seamless service.  Note though the continuing commitment to cash for children’s hospices (before they’ve only said they’ll look at this, now they’re going for it). More important, they are proposing a per-patient payment for all hospice patients. Once the Treasury sees that it will probably disappear, although they don’t actually say they are going to pay all the costs of the patients, so they could just give voluntary hospices a penny per patient and meet their manifesto.  There’s also positive stuff on carers, as with all the main parties:

48 Take control of your care

Where possible we want to devolve control over health budgets to the lowest possible level, so people have more control over their health needs. For people with a chronic illness or a long-term condition, we will provide access to a single budget that combines their health and social care funding, which they can tailor to their own needs.

48 We will provide £10 million a year beyond 2011 to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and other providers of palliative care.

Then, on to social care: they’re pushing their rather stupid line about death tax, probably because they haven’t heard that this is already what happens when local authorities defer your care payments. However they slide from choice to a focus on (very cheap) help for carers, rather than (impossibly costly) doing something about the real costs of social care for older people.

48-9 We reject Labour’s plans for a compulsory ‘death tax’ on everyone to pay for social care, regardless of their needs. We want to create a system which is based on choice and which rewards the hundreds of thousands of people who care for an elderly relative full-time. So we will allow anyone to protect their home from being sold to fund residential care costs by paying a one-off insurance premium that is entirely voluntary. Independent experts suggest this should cost around £8,000. We will support older people to live independently at home and have access to the personal care they need. We will work to design a system where people can top up their premium – also voluntarily – to cover the costs of receiving care in their own home.

An interesting move is to focus on public health (presumably because they’ll be devolving and privatising all actual health services) although we also get an element of the Conservative view that it’s the unhealthy choices of the working classes that have to be put a stop to. So, instead of taking responsibility for educating people about healthy choices and stopping the food and drink manufacturers profiteering from marketing unhealthy choices, local communities who don’t become healthier will have their health budgets cut back. This ‘paid according to how successful they are in improving their residents’ health’ is inconsistent with the bulleted point that says they will spend most on the poorest areas.

A healthier nation

Lifestyle-linked health problems like obesity and smoking, an ageing population, and  the spread of infectious diseases are leading to soaring costs for the NH S. At the same time, the difference in male life expectancy between the richest and poorest areas in our country is now greater than during Victorian times. We will turn the Department of Health into a Department for Public Health so that the promotion of good health and prevention of illness get the attention they need. We will provide separate public health funding to local communities, which will be accountable for – and paid according to – how successful they are in improving their residents’ health. In addition, we will: introduce a health premium

– weighting public health funding towards the poorest areas with the worst health outcomes;

- enable welfare-to-work providers and employers to purchase services from Mental Health Trusts; and,

- increase access to effective ‘talking’ therapies

That’s the Conservatives; now moving on to party 3.

It’s easy to cover the LibDem manifesto, there’s not a lot to interest us, partly because they’ve gone for briefer and more focused; that is, don’t bother within anything so unimportant as end-of-life and social care. End-of-life and palliative care do not get a mention at all, neither does social work but social care comes up twice, one mention and one item about long-term care indexed to social care. Yes! Don’t faint, but they have an index and their indexer knew that long-term care was about social care.

However, perhaps you’d better practise fainting again, because they’re going to merge health and social care to provide a seamless service. Does that mean remerging children’s social care, too, as the Greens are proposing (see below)? I suspect they haven’t thought about that, because they’re thinking in current silos. Does that mean paying for a totally free social care service on the same basis as the NHS? If not, the differential will be hard to maintain. And does it mean that they don’t care about the interface between social care and housing, social security, criminal justice, youth work and a whole range of local council services which will be made more difficult because social care will then have to kow-tow to healthcare priorities (i.e. healthcare for individual patients and particularly their consultant physicians are god and getting people out of expensive hospitals is the most important thing in the world rather than the broad needs of families and communities)?

Liberal Democrat Party (2010) Liberal Democrat Manifesto 2010. London: Liberal Democrat Party.

On the web: http://www.libdems.org.uk/our_manifesto.aspx

41 Integrate health and social care to create a seamless service, ending bureaucratic barriers and saving money to allow people to stay in their homes for longer rather than going into hospital or longterm residential care.

53 There is a further, serious, long-term crisis facing older people: the sustainability of the systems for providing long-term care. It is unacceptable that this challenge has been treated as a political football. A Liberal Democrat Government would immediately establish an independent commission to develop future proposals for long-term care that will attract all-party support and so be sustainable. We believe that the eventual solution must be based on the principles of fairness, affordability and sustainability.

The Commission idea is like Labour’s proposal (and the LibDems are also into calling problems challenges), but a bit more instant – after all Labour has had commissions before, and they know that when you get the report, it’s harder work to pitch it into the long grass again, so they’re probably going to make sure it says what they want it to say before they start.

Now I’m on to the smaller parties. It’s worth looking at them because they often have clever ideas that the other parties will pick up. And if we get a hung Parliament, some of their better ideas may well get some traction.

Green Party (2010) Green Party General Election Manifesto 2010: fair is worth fighting for. London: Green Party

On the web: http://www.greenparty.org.uk/assets/files/resources/Manifesto_web_file.pdf

The first thing about the Greens is that they’re going for assisted death as a policy, but only if there’s the highest level of palliative care available, whatever that means. So that’s no assisted death in the near future, then. But it does reflect an awareness of what the socially-aware public actually think:

23 Provide the right to an assisted death within a rigorous framework of regulation, and in the context of the availability of the highest level of palliative care.

Then there’s a big section on social care, which is mainly sloppy kisses for carers, rather than applying their mind to what social care services should be about. However, they do suggest re-merging child and adult social care, which a lot of councils are actually doing. It’s a sensible move,because councils have found out that there’s no real symbiosis between the universal education service and highly selective children’s social care. That always was a silly idea. Also, the Greends have realised, as the Conservatives would if they really were thinking about families, that the 1970s reorganisation of social services was about creating a family service, because all sorts of people live in families, including mentally ill, disabled and older people, and you need to deal with the things that are challenging them (see, I’ve learned the modern term for problems) in a coordinated way that looks at the whole family, not sending a whole lot of different people along from different departments to deal with little bits of the family’s…challenges.

13-14  A fair deal for social carers

A vast proportion of social care in the UK is provided by unpaid family carers who  save the NHS £87bn a year. Carer’s Allowance (CA) is an income-capping straitjacket. CA paid to family carers aged 16 and over is the ‘Cinderella Benefit’: £53.10 for a 35-hour week minimum commitment is no real compensation. Child carers under the age of 16 receive nothing at all. They are perhaps our most vulnerable child labourers, often working very long hours and bearing emotional burdens far beyond their years. These children receive no financial support and in many cases work longer hours than their older counterparts. Their schooling and education are often compromised and some simply never have the chance to ‘play’.

The Green Party is committed to:

- A more generous Carer’s Allowance, increased by 50% to £80pw.

- Offering support to people who want to give care, recognising their pivotal position while increasing the amount of care available.

- Healing the rift between adults’ and children’s social services that was created by New Labour.

- Providing more short breaks to families, including disabled people or those with long-term illnesses. Such early intervention schemes have been shown to save money by preventing crises.

- Improving working conditions for professional staff at all levels, paying for preparation time and follow-through, as well as contact time, and providing more in-service training to help cope with the vast spectrum of service user requirements.

- Instituting workforce health checks as advocated by UNISON.

- Repealing the oppressive Welfare Reform Act (2009) as a prequel to supporting people through lifelong development for their own and the planet’s well-being.

- Cancelling the DWP benefit entitlement assessment contracts with private sector.

- Restoring the link between state benefits and earnings.

- Giving carers cheaper local travel on bus, trains, tube and trams.

Finally social care for older people is going to be free á l’Ecossaise (the Greens haven’t learned the correct jargon for ‘the elderly’ yet; or perhaps they realise that nobody else understands the correct jargon). Free social care is actually a very logical move because it means you don’t have to face up to all the boundary disputes about what is health and what is social. The problem is, it costs – a lot:

22  In particular, maintain the principle of a free NHS by implementing in England  and Wales the scheme that provides free social care to the elderly in Scotland. If the Scots can do it, so can the rest of us. This would be phased in, costing about £3bn in 2010 rising to £8bn pa, and could create 120,000 jobs.

United Kingdom Independence Party (2010) UKIP Manifesto: Empowering the people. London: UKIP.

On the web: http://www.ukip.org/media/policies/UKIPManifestoWeb.pdf

UKIP have a short and pithy manifesto, and none of my search terms came up. They major heavily on immigration. But they have two interesting and original proposals. Healthcare, is going to be run by elected ‘County Health Boards’ in their worldview. Perhaps this reflects the reality that they don’t expect to win any seats in the cities, where there aren’t any counties. But actually elected bodies running healthcare as part of, or closely connected to, local authorities, is not a bad idea and (whisper it quietly in their presence) quite a lot of the rest of Europe does it.  They are also proposing to roll all long-term pensions into one pension-type provision and all welfare benefits into one ‘basic cash benefit’ at the same level as jobseekers allowance or income support. This would cover a very wide field, including for example student grants (just welfare scroungers really, none of this nonsense about education). The argument for this is that they can get rid of a lot of bureaucrats (they’re very much a ‘bomb the bureaucrats’ party) because they wouldn’t have to differentiate between and means test for a lot of different benefits. Not a bad idea, although I think they might run into some problems with the Daily Mail and its readers, who still support the centuries-old maxim that the deserving should get more than the others, which means sorting out the sheep from the goats.

Plaid Cymru (2010) Think Different, Think Plaid: 2010 Westminster Manifesto Cardiff: Plaid Cymru.

On the web: http://www.plaidcymru.org/uploads/publications/467.pdf

This proclaims itself as different, because it’s the first one with a publisher’s address outside London. It’s also brief, with lots of big colour pictures and not a lot of text, so it’s the prettiest, but none of my searches came up. However there is one item on social care, which says it’s just nursing really. What I think about this is that we need to improve caring skills in the social care workforce. But I’d rather have a focus in adult residential care on deveoping social lives and family and community relationships, which I don’t think fits with mujrsing skills so well:

Plaid Cymru remains committed to free care provision for older and disabled people and we call for the transfer to the National Assembly of the necessary powers. We oppose means-tested allowances and we will campaign to abolish the distinction between nursing and personal care.

I’m not sure what they mean by means-tested allowances, presumably this does not refer to people paying for their own care, but all social security payments. Could be difficult financially and in gaining public support. However, they also want a ‘living pension’ for older people and others such as disabled people, so there seems to be a consistent view for an old style welfare state. Good heavens, Wales will be just like Sweden next..

I could not find a manifesto yet for the SNP or any of the Northern Ireland parties, although the DUP, Sinn Féin and SNP have a variety of policy statements on their website. If something turns up later, I’ll try to cover it.

Finally, http://www.general-election-2010.co.uk/votes/bnp-policies, a website of the UK Politics Forum, which is a good place to follow the election, says that there is not (yet) a British National Party manifesto, but you can look at policy statements on its website, too.

On the web:

BNP: http://bnp.org.uk

DUP: http://www.dup.org.uk/default.htm

Sinn Féin: http://www.sinnfein.ie

SNP: http://www.snp.org/home

David Cameron the Conservative opposition party leader, made a speech last week on the ‘Big society’, which put forward his thinking on poverty and social intervention generally. As always, they’re against the state doing it, and many people can accept that there is a considerable degree of state failure in social provision. The problem for the Conservatives is that there’s a high degree of market failure in social provision as well. Often everyone accepts that the market is not the place for social interventions, or they have to set up some convoluted quasi-market system that is not really a market, and institutionalises complex state controls over voluntary action.

Voluntary organisations may be wonderful, but to rely on voluntary organisations to deliver wide-scale state services is inappropriate; it twists voluntary action by making it involuntary.

You can see this in the hospice movement. Hospices in the UK are mainly in the voluntary sector because St Christopher’s was originally a demonstration of what was possible in care for the dying and their families at a time when not a lot was done. Now Conservatives routinely say how wonderful voluntary hospices are as an example of how lots of other services should be run. But proper care for dying people and their families is a responsibility of society where government should take a lead and make sure that a high standard of care is widely available. They should not be pleased that they can offload that responsibility because enough sentimental and well-off people will make donations to support it,

Cameron’s speech on the web: http://www.conservatives.com/News/Speeches/2009/10/David_Cameron_The_Big_Society.aspx

The Touchstone blog by Richard Exell has a useful discussion of the speech, with references to many of the past Conservative documents on the topic that many people will not be aware of and rehearses the arguments against it; however, be aware that Touchstone is a TUC (ie trade union) blog:

http://www.touchstoneblog.org.uk/2009/11/david-cameron%E2%80%99s-big-society-speech/

While I’ve been migrating, the Director of Public Prosecutions  has published his guidelines on how he is going to decide whether to prosecute people if they assist suicides. He was forced to do this by the Debbie Purdy case earlier in the year. You can find the consultation at his website:

CPS Consultation : Assisted Suicide.

It sets out a number of factors in favour of prosecution for assisting a suicide and then against a prosecution. These are not totted up: there are major and minor ones and also the CPS should look at the whole situation. It is important to know what the factors are, because people will increasingly ask about it, and practitioners should not rely on press reports.

To avoid prosecution basically someone over 18 has to make a spontaneous and consistently maintained decision that they want to commit suicide, and the assister has to be clearly motivated by compassion, have a close relationship with them and not have an interest. It is better if assisters tried to dissaude them and clearly did it unwillingly in the face of a determined person. This helps, because I have come across people who have been determined to commit suicide, and have pushed their relatives into helping even though they have been against it. Assisters can’t do it for them: that would be murder.

They have to have a terminal condition, a severe disability or a severe degenerative condition from wehich they have no possibility of recovery. They have to do the act in private (no committing suicide for a public cause – you may remember demonstrators setting fire to themselves in a political cause).

The palliative care lobby will note that assisters are less likely to be prosecuted if the victim has investigated and rejected suitable care options.

One of the interesting things for social workers or palliative care professionals is that the definition of assisting is ‘aids, abets, cousels or procures’, so giving advice is relevant as well as practical assistance. A specific factor is that if assisters are paid to care for the victim in a care setting, they’re more likely to be prosecuted. Also, the CPS is likely to be less sympathetic if they are not a close relative or friend or if they gave advice not really knowing them (eg through a website). This makes it very clear that assisting suicide is only to be done in close relationships. therefore, in giving advice, social workers should probably take the line that anyone who inherits obviously should not be an assister, but in reality the requirement that assisters should be close is likely to be in tension. What do you say to assisters whose ‘victim’ (the preferred CPS term) is likely to have to pay carehome costs? They certainly have a financial interest, because they will inherit more if the victim goes ahead with the suicide. As time goes on because this is likely to be a big issue for families of frail older people, and the CPS view is not clear to me.

The DPP is Keir Starmer; one of our nurses saw a photo and said: ‘he’s a bit of a hunk isn’t he?’ This is for me a new view of a Director of Public Prosecutions. See the pic on the Guardian website and tell me if you agree.

Keir Starmer: ‘I wouldn’t characterise myself as a bleeding heart liberal . . .’ | The Guardian

All the debate about the assisted dying case in the House of Lords, which has required the Director of Public Prosecutions to come up with guidelines about who he will prosecute if they help someone die, has led to a lot of public comment. This week the satirical magazine Private Eye joins the club with ‘Assisted Dying latest’. Its front-page bubble photo has Prime Minister Gordon Brown asking a smiling Lord Mandelson: ‘Why have you booked me a holiday in Switzerland?’

And inside, a cartoon shows a scruff on a street corner holding a shot gun, next to a notice saying: ‘Assisted dying – cheap’.

But since I can’t reproduce these, another pic of the new St Christopher’s: you’ve crossed the road, approached the front door via the new sebra crossing, now you come to the new glossy reception area, all curvy light wood. Beyond, you can see one of the main aims of all the rebuilding, the welcoming new Anniversary Project centre: