The government has recently, as part of its agenda to reduce government expenditure, proposed to merge the general social care council (GSCC), the English regulator of the social work profession, with the heath professional council (HPC).  What are we to think about this?

The first thing to say is that the GSCC has not been well-run, as we have seen in the replacement of the chief executive this year; it remains to be seen how effective the new chair and chief executive would be in rectifying the problems. The original report on the GSCC’s problems made it clear that part of the problem was in the original legislation: it focuses on conduct rather than service quality.

It was, of course, an HPC man who did the review of the GSCC, and so therefore his criticisms might reflect a prejudice in health care or the HPC about the way you should regulate a profession. But you can’t really complain about quality of service outcome as the main criterion of regulation, rather than some fairly arbitrary rules of conduct. However, this rather rejects the importance of the codes of practice as statements of good conduct that you might expect from a social worker; there is a tradition of things like codes of ethics in some professions to help people decide the appropriate reaction to particular situations.

On the other hand, as I have been arguing in various books and articles for many years, the reality of social work is that social workers are asked to make moral decisions on behalf of society about who is a good parent, what is good parenting, what is good care for adults, what is need, what is risk and so on. And the codes of practice and ethics are not detailed enough, and never could be, to help us with the infinite variety of human activity that we deal with. Instead, what they do is identify the areas of our activity where things are complex.

For example, the old ethical rule that clients should be self-determining – nowadays we might talk about autonomy. The problem is that the autonomous may be constrained in how they can be self-determining by widely accepted social rules that we all have to follow. You can be as autonomous as you like, but you should not be beating up your spouse. So self-determination is not really a rule, it’s really a flag of danger. If you come across a situation in which someone is not following widely accepted codes of behaviour or is trying to be self-determining and there are many obstructions, you are really being asked to think hard about the balance between rule-following and self-determination in this situation.

So I’m not all that concerned about these codes as absolute standards of behaviour, but I am concerned that there is a process that checks out whether and how appropriate decisions were made in one of these difficult situations. I also feel a lot happier about codes that are created within the profession and represent its values, rather than something that is imposed by the government – yes I know there were all sorts of consultations, but I think professional analysis in something like a college of social work (back to that move again) is perhaps a better way of doing it. Get the government out of these issues; they have too many smelly fish to fry.

So, a plus is that by moving it out from direct responsibility of the Secretary of State, there is a chance that the work that the GSCC does will be led by the interests and concerns of social workers and their service users, rather than the directions of DH political policy. This is a good thing because it means a basic reference to the quality of service provided to service users, rather than meeting the latest prejudices of the political parties in power at the time.

Does it mean that a non-social work body will take over responsibility for the regulation of our profession? Well, what did you think the Department of Health was: an enthusiastic supporter of social work professional values? The HPC has a record of doing this job for quite a few professions in a reasonably neutral way. And it has been responsive to professional pressures; my inside information (and indeed the public struggle in the press) tells me that the psychotherapists and counsellors have had a torrid time and a lot of influence in trying to construct an appropriate form for regulation for their fractured professional groups.

You may also be worried that it’s going to cost a lot more: at least double it seems, perhaps more. But as I’ve said in this blog before, if we want to have independence from the government, we are going to have to ante up for it.

It’s irritating that the recommendation comes in a document about the NHS (the DH is still unable to include social care adequately in the things it does) and I am worried that it might lead to too much of an emphasis on healthcare rather than social professions. But we might have some supporters there among the psychologists – this is one of their beefs. That is why I propose, since it’s going to have to have a new title: the Care and Community Professions Council. Let’s emphasise where the priorities should be: care and the community, not health.

The change will require primary legislation, and you might think that will never happen; but I presume the legal arrangements can be maintained within some sort of notional merger.

Another issue is what is going to happen with education. Personally, I never have quite see the point of registering students: where they are dealing with the public, it is their supervisor who should be held to account or whatever the current jargon for practice educator is, and that should be a qualified social worker. And I know from many students, including my daughter, that the GSCC has not been a particularly efficient manager of grants.

I think it would be a pity if there is no system for evaluating and checking on the quality of social work education – it’s not clear this would stay with the HPC, or post-registration education. But how about the American solution: there the association of schools of social work runs the accreditation of courses at all levels, it’s an inclusive and representative way of doing it, it pays for itself, and it is really feared because you know you’re going to be looked at by people who really know what running a social work course is about. And you only have to look at the excellent, comprehensive and detailed University Quality body’s (the QAA) benchmark for social work courses to know that this is a much better statement of what’s required in a social work course than the few asinine government requirements.

And palliative care: again, the GSCC has been too beholden to DH priorities, which are the forms of local authority social work. It will be much better to have an independent body that looks at all social work specialties, not just what the government is interested in.

We should go for independence and be prepared to pay for it.

I have excerpted the statement from the Arms-length Bodies Review, below. This is not the only thing relevant to social care in the Review, so I’ll be coming back to it again.

General Social Care Council (GSCC)

3.36 The General Social Care Council is an Executive Non-Departmental Public Body responsible for the regulation of social workers and social work students in England. It is anomalous as the only professional regulator answerable directly to the Secretary of State for Health.

3.37 We see no compelling reason why the General Social Care Council should remain as an Executive Non-Departmental Public Body in the arm’s-length bodies sector, and we see potentially significant benefits from putting the regulation of social workers on a similar footing to the regulation of health professions. This involves the regulator being funded through registration fees charged to those registered, set at a level to cover the regulatory functions. In this way members of a regulated profession buy into their professional standards, which are set independently of government, and have an incentive to ensure these are upheld throughout the profession.

3.38 Therefore, we intend to abolish the General Social Care Council and move the regulation of social workers out of the arm’s-length bodies sector to make it financially independent of government. We believe that in future, the most appropriate model for the ongoing regulation of the social care workforce is to transfer responsibility for these functions to the Health Professions Council, a well established and efficient regulatory body currently regulating over 200,000 registrants from fifteen professions. The Health Professions Council – which will be renamed to reflect its new remit – operates a full cost recovery scheme and currently charges an annual fee of £76 per year, which is considerably less than the likely registration fee if the General Social Care Council were to operate alone on a full-cost recovery basis.

3.39 The Health Professions Council has an existing comprehensive and cohesive system of professional regulation which would apply to social care workers. This differs from the General Social Care Council model in several ways:

• the Health Professions Council is solely responsible for setting standards of education and training for its registrants, whereas it is the Secretary of State’s function to ascertain what training is required to become a social worker;
• unlike the General Social Care Council, the Health Professions Council do not register students, though as part of the approval process the Health Professions Council requires all Higher Education Institutes delivering pre-registration courses to operate a fitness for practice system for students;
• unlike the General Social Care Council, the Health Profession Council does not in practice approve post-registration courses apart from those related to prescribing drugs, although it has the power to do so.

3.40 We anticipate that the differences would be explored through a review of social care regulation. The abolition of the General Social Care Council, the transfer of functions in relation to the regulation of the social worker workforce and related changes will require primary legislation. The timing of these changes is dependent on discussion with the Health Professions Council and the General Social Care Council to ensure an orderly transition.

3.41 Finally, the General Social Care Council is also responsible for the payment of Education Support Grants, and we propose that if this function is to continue it should transfer to another body.

The full review on the web: Department of Health (2010) Liberating the NHS: Report of the Arm’s Length Bodies Review. London: Department of Health: 21-23 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118053.pdf

This post is about the new Condem coalition’s healthcare WhitePaper and what it says about end-of-life care and social care.

Department of Health (2010) Equity and excellence: Liberating the NHS. (Cm 7881) London: TSO.

On the web: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf

You can find consultations and other documents at:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353

There has been a lot of press comment that the Conservatives promised no top-down reorganisation of the NHS and in Andrew Lansley’s White Paper (WP below) on healthcare reform, have done exactly that. Gone are the days when White Papers were white, or at least cream: this one is covered in tasteful tones of mauve. However, the design is the same and the contents are mainly high-level generalisations about policy direction. Here’s a bit of a novelty: an analytical strategy (AS below) has been published alongside it. This means they’re telling you why they’re thinking what they’re thinking; fancy that. In reality, it sets out the things they’re consulting on: there are several consultations on the main philosophies that close in early October.

There’s another tranche of detailed stuff on information management (i.e. cutting the IT budget) and so on to come later.

General

The main aims are stated as:

i. Putting patients and the public first;

ii. Focusing on improvement in quality and healthcare outcomes;

iii. Autonomy, accountability and democratic legitimacy; and

iv. Cutting bureaucracy and increasing efficiency. (AS, p 2)

This is the vision: an NHS that:

Is genuinely centred on patients and carers;

Achieves quality and outcomes that are among the best in the world;

Refuses to tolerate unsafe and substandard care;

Eliminates discrimination and reduces inequalities in care;

Puts clinicians in the driving seat and sets hospitals and providers free to innovate, with stronger incentives to adopt best practice;

Is more transparent, with clearer accountabilities for quality and results;

Gives citizens a greater say in how the NHS is run;

Is less insular and fragmented, and works much better across boundaries, including with local authorities and between hospitals and practices;

Is more efficient and dynamic, with a radically smaller national, regional and local bureaucracy; and

Is put on a more stable and sustainable footing, free from frequent and arbitrary political meddling. (WP, 8-9)

It then goes on to some political meddling, and judging by the three-year programme set out, this will be frequent, although because it’s a programme, perhaps it won’t be arbitrary.

This leads us on the the main points: more patient choice and greater control of their records, GP commissioning (emerging from present experiments) and less bureaucracy, PCTs reduced in size, local authorities responsible for public health: we’ve seen it all in the press. You can’t imagine GPs doing more than sitting on a few advisory boards, so presumably this means that staff in the PCTs will divide themselves up among a larger number of local bodies and try to administer the system. A few central offices and strategic thinkers will be got rid of.

There are three things to say about this. One is, it will be conservative (with a small ‘c’, you notice). This is because people involved in day-to-day stuff will go with the things they know, not with new-fangled nonsense. So the cancer, renal, heart and chest physicians will retreat to not thinking about the reality that their patients are dying from their conditions, but will carry on doing more and more to cure them rather than making sensible judgements about when they’ve come to the end. And of course they will persuade a lot of patients that that’s what they want too. So end-of-life care that thinks: ‘what will give the best quality of life for someone who is dying’ will go out of the picture.

Second, overall planning and strategic thinking will reduce because smaller groups covering smaller areas will have less incentive to look at the big picture, and the local authorities will concentrate on stopping people smoking to get their health premium (there are more ways of political meddling than normal people can conceive of).

And third, most important, it is easier to save money when you have a larger number of spenders because they all try to keep within their budgets, whereas large spenders have more flexibility to vire resources between budgets.

How does it deal with the interests of this blog, palliative, end-of-life and social care? Not surprisingly, given the high level of generality of this mainly policy statement, they are not offering a lot of detail on particular specialities, but there’s some on end-of-life care and some on social care.

End-of-life care

The material on extending choice contains this on end-of-life care:

The Government will…

Introduce choice in care for long-term conditions as part of personalised care planning. In end-of-life care, we will move towards a national choice offer to support people’s preferences about how to have a good death, and we will work with providers, including hospices, to ensure that people have the support they need; (WP, p 17)

So hospices get a mention, naturally because they are the best example in healthcare of independent organisations actually making a large contribution, and this supports the Conservative ‘big society’ agenda. Choice is supposed to be not about just what treatment you get and where, but what that treatment feels like to the patient (and family, I hope, although it’s not too good on family participation because it’s stuck like the medical model on patients).

End-of-life care also comes up under quality improvement, because they are thinking about financial incentives for improving quality:

The government will…

review payment systems to support end-of-life care, including exploring options for per-patient funding; (WP, p25)

So we’re back to this again. Will this mean GPs who choose to do it will get some money? Or does it mean cheapo will win? This foundered the last time on the difficulty of defining what palliative care might mean and it got down to numbers of days, and completely got lost when the Treasury found out they didn’t pay for most of palliative care, so they would have to pay outside bodies to do the job. But note they’re not talking palliative care here, it’s end-of-life care, which will not primarily mean funding high-end palliative care, So if anything at all, it’s a small subvention for hospices or hospital palliative care, but some extra for (mainly private sector) care homes who save the NHS some money.

That’s it on end-of-life care.

Social care

The executive summary includes social care into democratic legitimacy:

To strengthen democratic legitimacy at local level, local authorities will promote the joining up of local NHS services, social care and health improvement. (WP, p 4)

This means giving local authorities the responsibility to promote partnership between health and social care, not the NHS. This realistically assesses the chance of the medically-lef NHS doing anything about social care as nil, so they’re letting the more community-led local authorities have a go. This also includes health improvement: again, realistically bearing in mind the NHS culture, this is turning the NHS into an illness service and putting positive public health with the local authorities. You can see the possibility, if it goes well, of other policy development for health going to the local authorities in the future. They need to grasp the opportunity, at least partly because the main point of the White Paper is GP commissioning. There is, therefore, not going to be a lot of public policy making among the local commissioners. For one thing, they will have a lot of detailed fish to fry. Also, they will be covering areas that are too small and too non-coterminous with anybody else’s areas to have much influence.

Also on this area:

We will strengthen the role of the Care Quality Commission as an effective quality inspectorate across both health and social care. (WP, p 5)

As it’s only just started, and so they have no real evidence that a giant multi-purpose regulator is going to work, you could see this cynically as making sure that the mass of private sector providers that we have and the bigger mass that we’re probably going to get are not going to be properly regulated. However, it’s more likely to be because they are against quangos and they’ve got to have a regulator, so they might as well have a supergirl. My sense is that regulators who really know their professional territory are likely to be much more effective; this one is going to be too amorphous really to have a handle on the huge range of its responsibilities, and because it’s so large it will have so much bureaucracy to keep it on track it will never get anything done. Ask me if I’m right in three years time.

Then, social care gets a mention in the ‘our values’ section on ‘liberating the NHS’, because the Condems have not yet managed to put a stop the Department of Health speak that says social care every time it says health care:

The NHS is about fairness for everyone in our society. It is about this country doing the right thing for those who need help. We are committed to promoting equality and will implement the ban on age discrimination in NHS services and social care to take effect from 2012. The NHS Commissioning Board will have an explicit duty to address inequalities in outcomes from healthcare services. (WP, p 7)

We’re now onto the main document from the exec. summary, by the way. Does this mean that nobody will have a duty to address inequalities in outcomes from social care services? I’m looking forward with interest when I retire (it may be longer than I think, judging by some of the decisions being made about retirement age) to mounting a court case or two on how equal the outcomes of local authority care are.

Another section is on ‘Improving the NHS and reforming social care’ – I wonder whether it’s worse to be improved or reformed? This section is about the Department of Health delegating to local authorities (localisation in action here) responsibility for public health, including the spending of a ‘premium’ (i.e. extra cash) to improve public health and reduce health inequalities. The question is, do you get your extra if you’ve been good and improved it, or if you’ve failed and you’ve still got a sickly population with lots of fat smokers? Remember this is about incentives. I think we should be told.

However, the Department is not giving up on social care (ostensibly a local authority responsibility so if it were really going for localisation, here is a good thing to delegate):

The Department will continue to have a vital role in setting adult social care policy. We want a sustainable adult social care system that gives people support and freedom to lead the life they choose, with dignity. We recognise the critical interdependence between the NHS and the adult social care system in securing better outcomes for people, including carers. We will seek to break down barriers between health and social care funding to encourage preventative action. Later this year we will set out our vision for adult social care, to enable people to have greater control over their care and support so they can enjoy maximum independence and responsibility for their own lives. The Department will continue to work closely with the Department for Education on services for children, to ensure that the changes in this White Paper and the subsequent public health White Paper support local health, education and social care services to work together for children and families. (WP, p 10)

It’s not clear but what this seems to be about is getting families to take responsibility for preventing problems in their own child and elder care. The question is just the same as it is with the health premium. Are you going to pay more for those who don’t because they have more problems or those who do, because they need an incentive for not having problems?

It covers their proposed commission on long-term care (every new government has to have one so that we can all be reminded how difficult it is and why they can’t do anything about it fro another Parliamnet because they won’t spend the money – perhaps you remember my prophecy that nothing will be done until the early 2020s, because that’s when the care home figures will start to bite):

The Department will establish a commission on the funding of long-term care and support, to report within a year. We understand the urgency of reforming the system of funding social care. The Commission will consider a range of ideas, including both a voluntary insurance scheme and a partnership scheme. As a key component of a lasting settlement for the social care system, we will reform and consolidate the law underpinning adult social care, working with the Law Commission. (WP 10)

Good to see the mention of the Law Commission report on adult social care law – an eminently sensible document covered before in this blog. This is easy to say of course because Law Commission reforms are supposed to be politically neutral, so it never says anything to upset anyone. But it does need to be done, and at least someone in the Department of Health has noticed and slipped it in. Finally:

The Government will bring together the conclusions of the Law Commission and the Commission on funding of long-term care, along with our vision, into a White Paper in 2011, with a view to introducing legislation in the second session of this Parliament to establish a sustainable legal and financial framework for adult social care. (WP, p 10)

Wait and see, then; by which time of course, bearing in mind the difficulties of keeping a coalition government in line, it might all have turned out to be too difficult again.

Moving on:

Here’s another quango system in the making then: Monitor (the people who check on the finances of foundation trusts) will look at financial information, HASCIC will check on the outcomes data and CQC will check on the quality of anything they manage to organise to get to see, when they’ve written their huge volumes of criteria.

We will ensure the right data is collected by the Health and Social Care Information Centre to enable people to exercise choice. We will seek to centralise all data returns in the Information Centre, which will have lead responsibility for data collection and assuring the data quality of those returns, working with other interested parties such as Monitor and the Care Quality Commission. We will also review data collections with a view to reducing burdens, as outlined in chapter 5. The forthcoming Health Bill will contain provisions to put the Information Centre on a firmer statutory footing, with clearer powers across organisations in the health and care system. (WP, p 15)

Social care turns up again in an unexpected place:

The government will…

Develop a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care. This will incorporate GP out-of-hours services and provide urgent medical care for people registered with a GP elsewhere. We will make care more accessible by introducing, informed by evaluation, a single telephone number for every kind of urgent and social care and by using technology to help people communicate with their clinicians. (WP, p18)

So social care emergencies will come through the health system. What does this mean for concerns that have elements of social care?  Before you say ‘jolly good thing’ to integrate the two, think about ‘Oh God not a palliative’ an article in this month’s Palliative Medicine (Vol 24(5): 501-9). This shows that emergency doctors do not like being presented with nasty things that involve spending time talking to people, instead of giving them pills and being off to the next thing (what one of the respondents called ‘proper doc’ work and then realised he shouldn’t have said it – even if he meant it). Their call centres pressurise them to get on to the next thing quickly. Moreover the study shows that patients do not trust or value the work of emergency doctors and that most out-of-hours doctors are motivated only by the good money. We do not want social care decision being made in organisations like this. Neither do we want anything that sounds as though it might cause problems to a ‘proper doc’ (i.e. human relationships) fobbed off onto the social care aspect of the service, when it really needs a doctor with the skills and motivation to do a good piece of interpersonal medical work.

A significant aspect of the patient-centred approach of the White Paper is picking up the social care practice of personalisation:

The previous Government recently started a programme of personal health budget pilots. International evidence, and evidence from social care, shows that these have much potential to help improve outcomes, transform NHS culture by putting patients in control, and enable integration across health and social care. As part of personalised care planning, the Department will encourage further pilots to come forward and explore the potential for introducing a right to a personal health budget in discrete areas such as NHS continuing care. We also recognise that introducing personal budgets is operationally complex and the Government will use the results of the evaluation in 2012 to inform a wider, more general roll-out. (WP, p 18)

Note the extreme caution about the possibility of a right to a personal health budget and only in discrete areas (i.e. nothing that’s going to cost us) and the particular mention of continuing care. That is, we’ll give you the money, you can add what you like so we’ll try not to give you too much, now go away and ‘take patient responsibility’.

Another new quango will be HealthWatch England with its local offshoots: community health councils are back again, to comment on the new commissioning arrangements:

Local HealthWatch organisations will ensure that the views and feedback from patients and carers are an integral part of local commissioning across health and social care; (WP p 20)

HealthWatch England will provide advice to the Health and Social Care Information Centre on the information which would be of most use to patients to facilitate their choices about their care. (WP. P 20)

Note the integration of social care into local commissioning arrangements (and so therefore dominated by the interest of GPs, instead of the broad social resilience role of local authorities?) and information about patients and their care, not broader social issues. A recipe for the medicalisation of social care, whose objectives are not to help GPs when they can’t or don’t want to cope with longterm care needs, but to promote social solidarity.

Another healthnsocialcare omnibus:

The current performance regime will be replaced with separate frameworks for outcomes that set direction for the NHS, for public health and social care, which provide for clear and unambiguous accountability, and enable better joint working. The Secretary of State, through the Public Health Service, will set local authorities national objectives for improving population health outcomes. It will be for local authorities to determine how best to secure those objectives, including by commissioning services from providers of NHS care. (WP, p 22)

So are the outcomes for social care an element of public health? Social care disappears from the rest of this paragraph. It should have its own performance criteria and they should not be commanded by health needs, either public health objectives (which are mainly about smoking and obesity) of NHS needs (which are mainly about medical and nursing treatment).

It is essential for patient outcomes that health and social care services are better integrated at all levels of the system. We will be consulting widely on options to ensure health and social care works seamlessly together to enable this. (WP, p 23)

Yes, well after 50 years of trying to do this, I’m sure we’ll believe everything they suggest. Of course, they’re politicians who have to believe that their policies change the world.

The next attempt to change the world is to set policy standards:

Each standard is a set of 5-10 specific, concise quality statements and associated measures. These measures act as markers of high quality, cost-effective patient care. They are about excellence, derived from the best available evidence and are produced collaboratively with the NHS and social care professionals, along with their partners, service users and carers. The standards will be developed in a way that makes sense for patients, and they will extend beyond NHS care, informing the work of local authorities and the Public Health Service. They will include information for clinicians and patients on relevant and ongoing research studies that are key to improving evidence for better outcomes. (WP, p 23)

With the increasing importance of coherent joint arrangements between health and social care, the standards will cover areas that span health and social care. We will expand the role of NICE to develop quality standards for social care. The Health Bill will put NICE on a firmer statutory footing, securing its independence and core functions and extending its remit to social care. (WP, p23)

There has been comment in the social work press about what this means for the Social Care Institute for Excellence (SCIE), and the stupid comment made by the minister apparently was that it was a charity so they couldn’t give it statutory responsibilities (tell that to the NSPCC). Actually, it was set up with similar intentions, hence the similar name, but social care knowledge is not in  the same place as healthcare knowledge, mainly due to successive governments not bothering to spend much money on social care research. This might begin to change as recent developments in research have influence over the next 20 years. However, SCIE (and its Scottish equivalent IRISS) has done a good job at collecting and making available knowledge resources and this ought to be continued.

I also think that there is a lot to be said for the extension to NICE responsibilities, because they have developed a very good decision-making model. What I would want to be sure, however, is that social care decision-making is not dominated by doctors, who know nothing about it and mostly couldn’t care less, and is prepared to look at some of the softer areas of knowledge where robust collection of information and knowledge could be very beneficial. One is not given much hope by the inane example of a NICE standard quoted in the White Paper, but the record of NICE is reasonable in this regard.

Then an attempt to produce more incentivisation in the payment by results system leads us to this:

The Department will…

implement in 2011/12 further incentives to reduce avoidable readmissions and encourage more joined-up working between hospitals and social care for services following discharge; (WP p 25)

Yes, but what about some joined up working in making the decisions about service-planning during periods in hospital and about discharge. If you had an adequate social work provision in hospitals and really engaged it in people’s care, you’d get a lot further than leaving it to hospitals to decide when to throw people out, with never a concern for integrating health and social care throughout. Remember, most of the medical care is done by GPs and community health services, not hospitals, and the hospitals should not be taking the lead in decisions about the use of community health services for their organisational and financial benefit (particularly when they are encouraged to be independent profit-making stand-alone bodies that can decide to do what they like for financial rather than total care system reasons).

Now on to the responsibilities of GP consortia:

GP consortia will have a duty to promote equalities and to work in partnership with local authorities, for instance in relation to health and adult social care, early years services, public health, safeguarding, and the wellbeing of local populations. (WP, p 29)

Well that’ll be a new one, GPs having a duty to work in partnership on safeguarding; who is the most common absentee (they’re so busy, poor dears, unlike anyone else of course) from case conferences and strategy meetings? But of course only the consortia have the duty, so they can approve the policy and still not bother to take part.

Now the responsibilities of our national leaders on the National Commissioning Board:

setting commissioning guidelines on the basis of clinically approved quality standards developed with the advice of NICE in a way that promotes joint working across health, public health and social care; (WP, p 31)

and the NHS role of the Secretary of State:

The legislative and policy framework. Responsibility for Department of State functions will remain with the Secretary of State. This includes determining the comprehensive service which the NHS provides, and developing and publishing national service strategies which will enable the roles of NHS, public health services and social care services to be better coordinated. (WP, p 33)

Accounting annually to Parliament for the overall performance of the NHS, public health and social care systems. (WP, p 34)

Finally, on democratic legitimacy:

The Government will strengthen the local democratic legitimacy of the NHS. Building on the power of the local authority to promote local wellbeing, we will establish new statutory arrangements within local authorities – which will be established as “health and wellbeing boards” or within existing strategic partnerships – to take on the function of joining up the commissioning of local NHS services, social care and health improvement. These health and wellbeing boards allow local authorities to take a strategic approach and promote integration across health and adult social care, children’s services, including safeguarding, and the wider local authority agenda. (WP, p 34)

These arrangements will give local authorities influence over NHS commissioning, and corresponding influence for NHS commissioners in relation to public health and social care. While NHS commissioning will be the sole preserve of the NHS Commissioning Board and GP consortia, our aim is to ensure coherent and coordinated local commissioning strategies across all three services, for example in relation to mental health or elderly care. The Secretary of State will seek to ensure strategic coordination nationally; the local authority’s new functions will enable strategic coordination locally. It will not involve day-to-day interventions in NHS services. The Government will consult fully on the details of the new arrangements. (WP p 35)

Then on local authorities’ responsibilities:

Each local authority will take on the function of joining up the commissioning of local NHS services, social care and health improvement.

Local authorities will therefore be responsible for:

- Promoting integration and partnership working between the NHS, social care, public health and other local services and strategies;

- Leading joint strategic needs assessments, and promoting collaboration on local commissioning plans, including by supporting joint commissioning arrangements where each party so wishes (WP, p 35)

This set of arrangements does provide a useful possibility of local democratic involvement with an understanding of and involvement in social care in healthcare; in the long-term, will the hospitals become independent and all community health be back with the local authorities? It’s a possible model if things go in that direction, and it’s what a lot of Europe does; why not us too? Britain is too centralised. But it’s against the trend of British politics and government over the past sixty years. It might be the end of separation between community health and local government, which go logically together. And that might mean a more rational engagement between community health and social care. But only if you stop the hospitals seeing it as their right to dominate the use of resources in favour of acute treatment, and to evade responsibility for long-term conditions and care.

On to regulation. The intresting feature here is using Monitor, the foundation trusts regulator, as an economic regulator for the proposed market and choice system:

As now, the Care Quality Commission will act as quality inspectorate across health and social care for both publicly and privately funded care. In addition, we will develop Monitor, the current independent regulator of foundation trusts, into an economic regulator from April 2012, with responsibility for all providers of NHS care from April 2013. Providers will have a joint licence overseen by both Monitor and CQC, to maintain essential levels of safety and quality and ensure continuity of essential services. (WP, p 37)

Monitor will be turned into the economic regulator for the health and social care sectors, with three key functions: (WP, p 38)

Monitor’s powers to regulate prices and license providers will only cover publicly-funded health services. However, its powers to apply competition law will extend to both publicly and privately funded healthcare, and to social care. (WP, p 39)

Here, we can see that private sector social care (mainly care homes at the moment) will also be regulated by Monitor. If the plan to increase engagement by NHS organisation in social enterprise, so that your local hospital might be a John Lewis Partnership of its staff, can social care organisations or groups of social workers be far behind? Mainly, they are talking here about fairly large organisations, but there is some mention of local community organisations becoming social enterprises. These will need economic regulation, too. You could not have the local safeguarding body disappearing because it got its finances wrong. And to round it all off nicely:

We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management. Within that context, we are committed to reducing the overall burdens of regulation across the health and social care sectors. We will therefore undertake a wide-ranging review of all health and social care regulation, with a view to making significant reductions. (WP, p 44)

They’ve started this in their bonfire of the social care quangos. More on that in a later post, because I think it’s not so easy.

Local authorities’ new functions will help unlock efficiencies across the NHS, social care and public health through stronger joint working. (WP, p 45)

I’ve suggested that I think this is possible and hope it will happen. Legislation will include:

Placing the Health and Social Care Information Centre, currently a Special Health Authority, on a firmer statutory footing, with powers over other organisations in relation to information collection; (WP, p 49)

Making the National Institute for Health and Clinical Excellence a non-departmental public body, to define its role and functions, reform its processes, secure its independence, and extend its remit to social care; (WP, p 49)

Giving local authorities new functions to increase the local democratic legitimacy in relation to the local strategies for NHS commissioning, and support integration and partnership working across social care, the NHS and public health; (WP, p 49)

Establishing HealthWatch as a statutory part of the Care Quality Commission to champion services users and carers across health and social care, and turning Local Involvement Networks into local HealthWatch; (WP, p 49-50).

In summary then

It’s quite hard to see how palliative care and, separately, end-of-life care will come out of this. GP consortia may want to do more themselves. Will they want to pay for it in hospitals? Some of my colleagues in hospitals think not. Will they want to commission more from hospices because they are cheaper than hospitals and cause less work for the GPs? Perhaps, but will they think hospice in-patient units are too expensive and only pay for home care or will they think that district nurses could do it all? I think hospices had better start finding ways to prove what their CNSs offer that a well-trained district nurse doesn’t.

For social care, we can all support the aim to get greater engagement in healthcare, provided you don’t let the financial needs of hospitals to throw their patients out when it suits them dominate how you run community services in both health and social care. And provided you incorporate social care objectives aiming at social resilience and solidarity into health care objectives: that way really lies the ‘big society’.

Understandably, the media comment on on the Condem re-write of the NHS Operating Statement (the government’s instructions to the NHS about what to do) has focused on the removal of the waiting times requirements – your GP no longer gets a kick if (s)he makes you wait longer than 48 hours for an appointment and your A&E can keep you on a trolley longer than 4 hours (but they’re told the removal of the target does not mean that they should not try harder; I’ll wait to see, but I think these targets have been useful).

However, there is stuff on better cooperation between health and social care, particularly on re-ablement (that is, getting everybody back to work and not claiming government social security payments) and a commissioning document.on end of life care is still expected later this year; so that is where we should look for the improvements they’ll be going for, and the incentives that they’ll be offering to Pcts and others to do their bidding.

The operating statement:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_116860.pdf

When you go to hear politicians, the announcements are often bland and sketchy; you go to hear the subsonics about how they’re thinking about what should happen. Here’s a classic from Lord Freud, now the Minister for Welfare Reform; he’s the guy that’s advised both Labour and now the LibComs on cutting budgets. With a name like that, you’ve just got to look at the subconscious.

Obviously he’s got the lordship and the ministerial role to achieve quick results (for results read cuts). He made this speech to organisations interested in getting people off social security benefits. There’s a new bit of jargon for you ‘off-flows’ – the flow of people off benefits and into work that doesn’t cost the government so much.

What he’s saying here is that they’re going to be looking for organisations to help people off benefits: what sort of organisations will they be and how should they work? Listening to this, can the same principles be applied across government to other voluntary sector charities, say in palliative care of social work?

Here’s a bit of what he said:

To keep up the pace of progress we envisage, we will need well-capitalised and well-resourced groups that are prepared to take up the challenge of competition in this area. Given the greater off-flows we expect to see through migration from Incapacity Benefit to ESA (Employment and Support Allowance) under the new Work Capability Assessment, we will need companies with the scale to make an impact. And in view of the difficulties that we are all familiar with in targeting support to some of the hardest to reach, we will also need groups that already have – or can co-opt into consortia – the skills and expertise needed to provide real change to people’s lives. Consortia formation, financing and management will, I am convinced, lie at the heart of the successful operation of the sector. So if you represent a medium or larger organisation, you might want to accelerate your thinking about how you can work with partners with resources in other areas or locations. Many of you, I know, have already elaborated strategies in this area.

In other words, if you are a voluntary sector organisation wanting to get resources to do things on behalf of government, get big. Small local organisations, local contacts, representation may be truly lovely, but they want results, so big means easier to cope with for the government and more likely to bring widespace results. If you’re small and local with existing local connections this is gives feel-good, but get in a consortium with others so that you can get big.

Hospice managements: now apply this to yourselves. How are you going to get big and help with the government’s off-flows?

Want to see more of the speech: http://www.dwp.gov.uk/newsroom/ministers-speeches/2010/02-06-10.shtml

Not to be St C’s-focused about it, there are two other honours that mention palliative care, MBEs, in the Queen’s birthday honours list:

Dr Constance Ada Mary LLEWELLYN-MORGAN

Chair of Trustees, Ty Bryngwyn Hospice,
Llanelli. For services to Palliative Care in
Carmarthenshire.

Professor Edwin John PUGH

Consultant in Palliative Medicine, North
Tees and Hartlepool NHS Foundation Trust.
For services to Medicine.

Who gets honours then and is it appropriate? Leaving aside the remnants of empire in the British system, all countries honour people who make a particular contribution Legion d’Honneur in France and congressional medals in the US, presumably following their own cultural criteria. For the UK, here is of course a committee that advises about who should get one, and anyone can put someone up for an honour, but my ercxperience of the voluntary sector suggests that many organisations plan this rather carefully to assure their recognition. Some people reject one or ask not to be put up of course. Senior civil servants also get a good whack, more or less routinely: you can tell who blotted their copybook or did a specially acceptable job by looking at the levelof what they got.

Even so, should it be quite so bound up in political and policy considerations? The head teacher who became a dame would have been less likely before Labour decided a while ago to honour contributions to teaching at the grassroots. Should it be entwined with political decision-making?  And, looking at a field such as palliative care, or social work, one wonders who keeps an overview. Since charitable activity is an important part of a field such as palliative care, people seem to receive honours for chartiable activity which in a way is a bit of a extra to their professional role: does that mean that palliative care gets a higher proportion than other health and social care specialties? If so, it might be because charities think about these things mroe carefully as a strategy in the fund-raising, reputational game.

Of course, one asks the same question abot royal patrons; again this is a routine part of the British charitable system, and other countries have their equivalents. but have we really looked at how far we want royalty entwined with charity?

As expected Andrew Lansley (Conservative has become the Secretary of State for Health; he is pictured on the DH wensite being introduced to staff, but…

Click this link: is he looking to the future, or just looking for the NHS: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_116035.jpg

Here’s the link to the other health ministers: http://www.dh.gov.uk/en/Aboutus/MinistersandDepartmentLeaders/Ministers/index.htm

• Minister of State – Paul Burstow MP
• Minister of State – Simon Burns MP
• Parliamentary Under Secretary of State – Anne Milton MP
• Parliamentary Under Secretary of State – Earl Howe

Only Lansley has a bio on the official DH site:

Mr Lansley was educated at Brentwood School, Essex and the University of Exeter, where he was President of the Guild for Students. He began his own career as a civil servant, working at the Department of Trade and Industry.

In 1992 Mr Lansley was awarded a CBE for running the Conservative campaign for the 1992 General Election. In 1997 he was elected MP for South Cambridgeshire, and joined the Shadow Cabinet as Health Secretary in 2003.

Mr Lansley lives in South Cambridgeshire with his wife and their two children, he also has three children from his first marriage.

However, these are the Party bios (Burstow is a LibDem); I’ve edited these to take out some of the political wiffle. All have some background in health, although less in social care, and Milton is a nurse.

Paul Burstow

Paul Burstow was born at St Helier Hospital, Carshalton. He comes from a family of tailors and seamstresses. His father was a Saville Row tailor.

Paul Burstow has been MP for Sutton and Cheam since 1997. Prior to his election he headed up the Liberal Democrat’s Local Government Unit and was on Sutton Council – 1986-2002.

Since 1991 when he was appointed to chair the Council’s Disability Forum, Paul has taken an active interest in disability issues. He was responsible for establishing a multi-agency group on disability issues and for pushing through the Council a comprehensive disability policy for the Borough.

He stood as a Liberal Democrat Parliamentary candidate for Sutton and Cheam in 1992 achieving the biggest swing to the Liberal Democrats in Greater London. He fought the seat again in 1997 defeating the incumbent Conservative MP and won again in 2001 and 2005.

On election to Parliament he became a junior frontbench spokesman on local government. In the autumn of 1997 Paddy Ashdown appointed him to lead the Party’s local government team in the Commons. In 1999 Charles Kennedy offered him the older people brief, outside the Shadow Cabinet. After the 2001 General Election Paul joined the Shadow Cabinet with the cross-cutting brief of older people and social services. The brief involved shadowing Government policy and performance on a wide range of matters effecting the vulnerable. From October 2003 to May 2005 Paul headed the Party’s Health Team as Shadow Secretary of State for Health, and between July 2005 and March 2006 he held the position of Shadow Minister for London. In March 2006 Paul was elected by his parliamentary colleagues to take on the role of Liberal Democrat Chief Whip.

In September 2003 Paul Burstow was named by the Guardian newspaper as one of the most influential people in public services and social policy in its ‘Influencers 100′.

According to the Guardian it considered four main criteria: influence over policy, delivery of services and professional practice; transformative power – the ability to change institutions, places or perceptions; financial clout; and political muscle – judged either by proximity to Tony Blair and Gordon Brown, or by robust and influential independence from Downing Street.

Mr Burstow was one of just five Members of Parliament listed by the paper, the others where Oliver Letwin, Frank Dobson, Steve Webb, and Frank Field.

The Guardian described Mr Burstow as: “One of the most knowledgeable and effective politicians on older people’s issues, the Lib Dem spokesman at times seems the only parliamentarian taking a real interest in elderly care, and has almost single handedly kept older people’s issues on the political agenda. He constantly wrongfoots ministers and has played a key role in exposing scandals of over-medication and elder abuse.”

Simon Burns

Simon was born in September 1952. He was educated at Christ the King School, Accra, Ghana; Stamford School, Stamford, Lincolnshire; and Worcester College, Oxford, where he obtained a BA Honours Degree in Modern History. He also has an Honorary Doctorate of Philosophy from Anglia University. He has a daughter, Amelia, and a son, Bobby.

Simon was Member of Parliament for Chelmsford from June 1987 – April 1997, for West Chelmsford from May 1997 to April 2010, and elected Member of Parliament for Chelmsford in May 2010.

From 1975 to 1980 he was Political Adviser to the Rt. Hon. Sally Oppenheim MP. From 1980-83 he was a journalist and company director of What To Buy for Business magazine, and from 1983-87 was on the Policy Executive of the Institute of Directors. He has been active in politics since 1970 when he was a founder member of the Rutland and Stamford Young Conservatives, and founder and Chairman of the Stamford School CPC.

In 1972 he worked for Senator George McGovern in his presidential election bid against Richard Nixon. In December 2007/January 2008 he spent 10 days working on Hillary Clinton’s Presidential Campaign in the New Hampshire Primary. From 1973-75 he was a committee member, Political Action Officer and Secretary of Oxford University Conservative Association, and a member of the Oxford Union.

Simon has been Parliamentary Private Secretary to Timothy Eggar MP, and the Rt. Hon. Gillian Shephard MP, at the Ministry of Agriculture, Fisheries and Food until July 1994. He has also been Assistant Government Whip (1994-1995), Lord Commissioner of Her Majesty’s Treasury (1995-1996), & Parliamentary Under-Secretary of State at the Department of Health (1996-7).

In June 1997 he was appointed opposition Front Bench Spokesman for Social Security, a position he held until August 1998 when he was appointed Front Bench Spokesman for Environment, Housing and Planning, until June 1999. He was elected a member of the executive at the 1922 Committee in July 1999 and Treasurer of the 1922 Committee in November 1999. He was a member of the House of Commons Health Select Committee from 1999 – 2005.

In September 2001 Simon was appointed Shadow Health Minister and was reappointed to this position in May 2005. From December 2005 to May 2010, he was the Senior Whip in the Opposition Whip’s Office and since May 2010, he has been Minister of State at the Department of Health.

Aside from his Shadow Ministerial duties, one of Simon’s proudest achievements in Parliament since 1997 was successfully piloting through Parliament his Private Member’s Bill – the Football (Offences and Disorder) Act 1999 – to tighten up the law on football hooligans, and pressuring the Government to strengthen legislation further in 2000 by giving the courts the power to withdraw hooligans’ passports and prevent them from causing trouble abroad.

Anne Milton

Anne was born in 1955, is married to Graham (who is a doctor) and has four children. She was educated at Haywards Heath Grammar School in Sussex, and trained as a nurse at St Bartholomew’s Hospital in London. Anne worked for the NHS for 25 years. Anne has a wide range of experience in the NHS. She has nursed in hospitals, as a district nurse (and yes, with a bicycle!), worked in research and supporting GPs and nurses working in palliative care. She also pioneered a scheme to look after people who were sent home early from hospital. Her last job in the NHS was to give medical advice to councils and housing associations.

Anne loves gardening, has been a keen runner (although better on stamina than speed!), and is an avid reader, although her family are at the heart of her life. With two children still at school and two a bit older, Anne can rely on them to keep her in tune with all the issues that come up for young people.

Anne has lived in Surrey since 1994 with her family and was thrilled to have been elected as Member of Parliament in May 2005. Having been bought up in Sussex she understands only too well the problems facing the South East in general and Guildford in particular.

Anne became involved in politics in the early 1990’s, though in the past she was a union steward for the Royal College of Nursing and was also involved in the National Childbirth Trust. Before being elected as an MP for Guildford Anne was a borough councillor for five years in Surrey. She was Conservative Group Leader and was also Vice Chairman of the Conservative Medical Society.

In Parliament Anne was appointed to the Health Select Committee in 2005 until she was made Shadow Minister for Tourism, Gambling and Licensing.  She was appointed Shadow Minister for Health in 2007, with responsibility for policy on mental health, maternity services and healthcare associated infections.

Earl (Frederick) Howe

Earl Howe was born in 1951. He was educated at Rugby School and Christ Church, Oxford, where he read Mods and Greats. After leaving University in 1973, he joined Barclays Bank and served in a number of managerial and senior managerial posts both overseas and in London. In 1987 he was appointed London director of Adam & Co. plc, the Scottish-based private bank, where he remained until 1990.

Having inherited his title from his cousin in 1984, Lord Howe left banking to concentrate on his parliamentary activities and on running the family farm and estate in south Buckinghamshire. In 1999 he was appointed Chairman of LAPADA, the country’s largest trade association for the fine art and antiques trade.

Amongst a number of charitable appointments, Earl Howe is President of the National Society for Epilepsy, President of the South Bucks. Association for the Disabled, Patron of the Chiltern Society, a Patron of DEMAND, Honorary Treasurer of the Trident Trust, a member of the Committee of Management of the RNLI, President of the Abbeyfield Beaconsfield Society, a trustee of Milton’s Cottage, a trustee of RAFT (Restoration of Appearance and Function Trust), a trustee of Sir William Borlase’s Grammar School, Marlow and Hereditary Governor of the King William IV Naval Foundation.

He is married with three daughters and a son.

In 1991, Lord Howe became a government whip in the House of Lords with responsibilities, successively, for transport, employment, defence and environment. Following the General Election of 1992 he was appointed Parliamentary Secretary (Lords) at the Ministry of Agriculture, Fisheries and Food; and in 1995 Parliamentary Under-Secretary of State at the Ministry of Defence, a post he relinquished at the 1997 General Election.

He has been opposition spokesman for Health and Social Services in the House of Lords since 1997. He is an elected hereditary peer under the provisions of the House of Lords Act 1999.

Apart from his frontbench responsibilities, Earl Howe’s special interests include penal affairs and agriculture. He is a member of the all-party groups on penal affairs, abuse investigations, pharmaceuticals, adoption, mental health and epilepsy.

And looking at the new minimal DH website gets me to the total content for management resources:

Promoting business success and improvement through flexibility and partnership, best practice and a culture where staff are encouraged to develop new skills and expand their knowledge.

Frankly I do not want my health service focusing on business success, I want it focusing on effective healthcare. I shall continue to point out the unnecssary businessifcation of the health and social care system.

You’ll be asking what it says about social care; here it is:

The Department of Health works to define policy and guidance for delivering a social care system that provides care equally for all, whilst enabling people to retain their independence, control and dignity.

I’d like to point out that the concept of delivery is fundamentally inconsistent with the concept of care. Think again boys; try renewing your rhetoric.

As a result of the change of government, the whole Department of Health website as been archived, and there is very little on it at the moment. Does that mean that everything that was ever available has vanished into the national archive? Or is some ConLib special adviser going through each page for ConLib political correctness as we speak? Actually boys (they are mainly boys) there was lots of useful stuff there for people who are actually doing the job and most of it was profoundly non-political.

First, two of the parties in government in particular nations of the UK.

Of those I have not previously looked at, the DUP (the Democratic Unionists in Northern Ireland) have a quite detailed manifesto compared with many others. It wins out on palliative care, among all the manifestos I have seen:

The World Health Organisation recognizes that palliative care incorporates physical, psychological and spiritual needs and it is important that all elements are properly resourced.Three quarters of people indicate that they would prefer to die at home, and this must be respected as services are commissioned.Those in receipt of such care should be informed about benefits available to them and given sound advice around finance and other personal matters as they plan for the end of their life. (p 45)

Can’t say fairer or more thoughtful than that. Then, their final objective on health:

• greater delivery of end of life care in primary and community settings rather   than secondary care (p 32)

Then, mentions of social care:

Opportunities should be freed up for charities and other providers with a proven track record to deliver services.The third sector has much to offer
in social care provision in areas such as mental health,dementia,learning
disability and acquired brain injury. (p 29)

The recommendations of the Bamford Review of Mental Health should be implemented. Approximately 24,000 people currently suffer dementia in Northern Ireland, and this figure is expected to climb to 50,000 by 2051. Health and social care costs for dementia of £200 million will double within twenty years.We need to be well-equipped to treat and support these individuals. A comprehensive dementia strategy for Northern Ireland is required. (p 45)

As well as these specific points, they are good examples of the way the health agenda is markedly preventive and community oriented; it rather nicely recommends asking NICE to identify existing practice that is non-cost-effective, as well as new things that are. There’s a fairly positive section on valuing older people. There’s also a lot on poverty and inequality -  of course they’re sticking up for the protestants against the catholics.

The Scottish National Party has a smallish manifesto; however its summary puts older people right up there at the front:  a fair deal for pensioners with pensions rising in line with earnings and a guarantee to protect free personal care and concessionary travel (Page 4 after the photos). A lot of the manifesto is about being champions for the interests of Scots people; for example:

we believe Scots must not lose out as a result of policy decisions for england. That means there should be no new taxes or contributions, or changes to attendance allowance or Carer’s allowance that will impact on Scots, to pay for reform of care for the elderly down south.

Referring to Sinn Fein, the other power-sharer in Northern Ireland, there still seems to be no manifesto, but there are campaign statements:

Website for these: http://www.sinnfein.ie/election-campaign-statements

I’d like to comment on the Respect Party manifesto, but my browser will not download it. However, the website does not reveal much interest in health and social care, or older people; it mainly focuses on anti-racism and equality issues, particularly around housing, education and work; a party for the working man, I decided.

The website: http://www.therespectparty.net/breakingnews.php?id=864

The British National Party has now published its manifesto; searches for palliative, end of life and social care drew a blank. However, it does mention ’social work’; apparently the police are doing too much of this, politically correctly, and it’s got to stop.

Looking more broadly at the manifesto, NHS funding would be increased if there (in your dreams) were a BNP government by removing the foreign aid budget, and old age pension and public sector pensions would be sorted out. Housing and other public services would be relieved by not having to provide services to any immigrants, and human rights and equality legislation and organisations would be removed. Serious criminals will be similarly removed to South Georgia (the little British colony miles from anywhere in the Atlantic) and the death penalty would be applied to lots of nasty people, especially rapists.

They are also into compulsory volunteering: ‘a Community Award Scheme for our young people which will take the form of a compulsory one year period for all school leavers during which they will work in the community as the final element of their education. This scheme will allow young people to choose between a variety of community service options which might include, for example, caring for the elderly or disabled people, environmental or heritage restoration projects or military training. The final choice of direction in this regard will be dictated by the school leaver’s scholastic record, preferences and suitability. These courses would be character building and would instil discipline, social and community values and work ethics in all young people.’

That’s going to be popular with the gap year middle classes. Yes, when I’m elderly, I want to be cared for by some lout forced to look after me. Volunteering should mean what it says; you should want to do it.

You would laugh at all this, or weep about the attitude to other human beings. But these views are the attitudes of many pub bores across the country. You can imagine them poking you in the chest to emphasise their points, as they down yet another pint. How is it that we are educating people in social and personal understanding so badly that this sort of approach to the world still exists?

Website: http://bnp.org.uk/pdf_files/BNP-Manifesto-2010-online.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