NHS reform – impact on social care

Andrew Lansley’s much-vaunted white paper on the future of the NHS was published yesterday afternoon, promising widespread reform, including the abolition of PCTs and SHAs and giving commissioning power to GP consortiums. But what will it mean for social care? Here are a few of my initial thoughts.

Firstly, there are concerns that the reforms focus on general services and that people with learning disabilities, mental health problems and dementia have been largely ignored – this came through strongly on Twitter yesterday, from what I saw.

To test this, I did a quick word search of the white paper to gauge how many times certain phrases were mentioned; mental health is mentioned 8 times in the 61-page document, Alzheimers or dementia receives one mention [as @seetheperson pointed out to me], and learning disability – or learning disabilities – never crops up.

To me, this is shocking. Considering that people with learning disabilities, dementia and mental health issues make up a significant chunk of those that use NHS services, the lack of attention given to them is a worrying omission.

Specialist services are often a lifeline or those who use them and an acknowledgement of this – and preferably a commitment to give them at least some degree of protection – would have been reassuring to the many service users who are already distinctly nervous about what government cuts will mean for services.

Hopefully the government is planning for learning disability and mental health services separately…

Also, do GPs, who will now have power over which services are commissioned in their area, have the specialist knowledge that is often required in MH/LD to be able to give an authoritative view on what sorts of services are needed? Mental health charity Mind’s chief executive Paul Farmer has already questioned this and called on them to talk to experts and “tap in to the personal knowledge of patients and mental health charities about what works.” 

There is also cynicism over whether GP commissioning will work from some within the profession. For example, the GP for hire blog gives a distinctly lukewarm reaction to the proposals, saying it will put more pressure on salaried and locum GPs, and could lead to divided interests for those doctors involved on a consortium.

Also, will GP consortiums not exacerbate the postcode lottery, which was supposed to be got rid of? If commissioning a service depends on the decision of the GP consortium – a group of individuals with their own opinions – surely there is the risk that one consortium would approve it, but the one next door would not.

It hardly improves patient choice if they find that their needs are rejected in one area but available in another.

But there were some good points in the white paper. For instance, it talks of promoting the joining-up of health and social care services and promoting preventative action. I can’t argue with that principle – health and social care are closely linked, so that is a no-brainer and could help to reduce duplication of information and bring about efficiencies. Also, preventative action is generally accepted to reduce the need for costlier, more complex services down the line.

The white paper also says that the government’s vision for adult social care will be outlined later this year, and indicate that it will be a continuation of the current personalisation drive towards choice and control for service users. A white paper will follow next year. Nothing new there, but it is good to have the timeline in place.

In conclusion, the government’s reforms are certainly ambitious, but they are also risky. Social policy think-tank Civitas has warned that considerable resources will be needed to enact the restructuring – I’m not sure how that sits with the aim of saving £20 billion by 2014 – and if it is got wrong it could lead to a dip in the NHS’ performance for at least a year.

That will be the acid test of these reforms – will it make services better for service users? I’m sceptical, but only time will tell, as ever with any reforms.

This white paper provides so many points for discussion so it is more than likely that I will blog on aspects of it again later in the week.

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1 Comment

Filed under adult social care, health care, learning disabilities, Mental health, social care

One response to “NHS reform – impact on social care

  1. Dave Neenan

    When mental health patients asked the Department of Health under Labour what steps were being taken to extend Patient Choice to NHS mental health services they were informed by the Department that so few people with mental health difficulties now used Consultant led NHS services that the issue wasn’t worth pursuing.

    The implication was that the majority of patients with mental health difficulties were receiving treatment through their GPs and the Department’s response also reflected the paradigm shift of focussing away from patients with severe mental health difficulties and higher support needs on to patients with milder forms of depression and the worried well.

    It’s a divisive policy but it’s obviously proved very popular in marketing a particular view of mental health and stigma.

    Mark Brown of One in Four magazine concurred with the Department’s view and also argued that Patient Choice in mental health was irrelevant to the mass New Horizons vision of Personalised treatment and care in keeping with the leading mental health charities who were at the time pushing for more CBT /Mindfulness therapies and hoping through partnership with Government, which I am sure they are now exploring with the Coalition, to secure contracts for providing more mental health training, employment and job retention schemes to lift people off benefits and into work to help combat what they saw as stigmatising dependency culture.

    Now you report that the mental health blogosphere is rattled because mental health wasnt singled out for special attention in the Coalition Government’s Whitepaper on NHS restructuring but isn’t that a direct consequence of mental health being normalised through massive public campaigning and now being treated much like any other condition that GP’s are expected to deal with?

    As you say, the Whitepaper indicates that the Coalition are going to respect and stick to the Personalisation agenda and timetable so given the two year transition period to devolution of commissioning to GPs and, presumably, the evolotion of more patient centred , choice and participatory structures and mechanisms around that commissioning , what clarity were people really expecting on mental health yesterday?

    We know that patients will be able to choose any GP , that GP Consortia will be able to purchase more specialist mental health expertise and services , if they so wish, that their will be a Commissioning Board and Watchdog body with powers yet to be defined but obviously enough to make sure that GP Consortia dont squirrel the NHS billions away into off shore bank accounts and there’s also a good chance that closer dovetailing of health and care may well result in greater efficiency and more responsive services.

    The BMA are upbeat and bodies as diverse as the Patient Society and the Kings Fund are optimistic but of course wary about how it will all work in areas like mental health , traditionally a cinderella service , because all we have to go on at the moment are intentions rather than deeply fleshed out plans, detailed models and working pilot schemes.

    So overall it’s a bit of a mixed bag, maybe more of a sold but unseen ‘ cat in a bag ‘ as the Germans say, but lets not pretend the monopoly service providers and commissioners bureaucracy the Coalition aims to move away from is worth defending. PCT’s were not a force for good, certainly not in mental health and commissioners had precious little contact with patients and carers , even less concern for them and faced no great consequences for screwing up .

    The foundation Trusts look like they’ll have to kiss goodbye to their monopoly service provider status too as hopefully the GP commissioning thing will allow people to obtain out of area services where more appropriate or choose between the servicesof different MH Trusts. To some people this is beyond the pale but a lot of mental health service users got trapped between monopoly services and monopoly commissioners and ended up with no servicesat all or being punished for daring to openly question services they were disatisfied with.

    Given the intense background pressure for savings, I’m also worried about how exposed Labour have left mental health service users to attack on the benefits front as the Coalition seem keen to continue Labour’s assault on incapacity and DLA and it’s clear that claimants with mental health profiles are going to bear the brunt of whatever arbitary targets the Government
    has decided on for disability benefit and allowance reduction and that these targets will be achieved in a random way.

    Along much the same lines, a lot of the noises we’re hearing from the mental health charities at the moment around the alleged unwillingness and incompetence of GPs to manage commissioning properly or the percentage of service users who believe they have been stigmatised by their GPs is pretty self serving. One suspects that the charities , who were allowed to exercise deeply conflicting dual service provider and advocacy roles under the old monopoly Government knows best arrangements really just feel slighted and are perhaps rather anxious that GPs , and patients too, will opt for more local and personalised mental health services and social enterprises without them. Certainly there will be a scramble to provide local mental health services now that GP’s have more financial say , potentially exploitative commercialism obviously but by the same token the monopoly commissioning Trusts and baggy corporate charities stifled innovation and the development of real choice mechanisms ,local initiatives and markets.

    The cat is really thrashing around in that bag …..

    I know a lot of service users I’ve spoken to about these planned changes want to see greater choice and support at locality level, including equal consideration for the not so popular and marketable diagnoses and marginalised mental health patient groups, but they don’t want to use services run by large bureaucratic organisations that also claim to represent them. People have got to be able to , at the very least , choose away from what doesn’t work and still have a choice .

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