Derek Birrell: reassessing Transforming Your Care
Derek Birrell calls for a much greater emphasis on supporting social care.
The underlying focus of Transforming Your Care accords with thinking in England, Scotland and Wales in responding to demographic change and adopting a shift in emphasis from acute to community based care. The proposals do see social care as a key component in a transformation from acute services but the plans for implementation appear weak and limited in relation to the lack of legislation, inadequate resources, and outdated strategies and structures.
In Great Britain, the transformation agenda has been supported by new legislation; by the Care and Support Act 2013 in England, the Social Services and Well-being (Wales) Bill 2013 and several distinct acts in Scotland, all aimed at strengthening modernisation, support and entitlements.
There is no commitment to put enhanced adult social care provision in Northern Ireland on a similar statutory footing. There has also been a persistent underfunding of adult social care and Transforming Your Care has proposed only a 2 per cent increase in the social care budget, transferred from hospital services, which scarcely seems transformational.
Divergence from Great Britain emerges in the social care modernisation agenda, relating to the integration of health and social care, personalisation and user involvement. It is the treatment of integration that is most problematic. Northern Ireland has a totally structurally integrated health and social care system.
What is the rationale for the key proposal in Transforming Your Care for the creation of 17 integrated care partnerships? One searches in vain through all the Transforming Your Care publications for any rationale beyond vague references to improving integration.
Where is the evidence relating to failures or successes of the existing integrated structure and what are the lessons to be learnt? The ICPs appear to have little formal identity or independent resources or autonomy from the trusts and are sometimes called a network not a structure, yet they have been set up in imitation of a quango model with a representative membership.
Most disturbing is the proposal that of 12 or 13 members only, one will be from the social care field. In Scotland, integrated care partnerships are seen as an equal relationship between health and social care. The danger is that ICPs will actually be an obstacle to the integration of health and social care and marginalise social care.
In reality, the proposals hint at two other possible agendas. Firstly, that the prime purpose is to integrate health services and to involve GPs more in integrated work with hospitals and not with the integration of health with social care. Secondly, that the proposal is a tacit admission that the structure of five delivery trusts is not working and the trusts are too large in terms of population and range of functions.
The proposal for 17 ICPs is remarkably similar in number to the 18 trusts that delivered health and social care. The other two themes of UK modernisation, personalisation and enhanced user involvement received support in the original Transforming Your Care review. However, subsequent documents make limited reference to personalisation with no targets and make almost no reference to user involvement. The existence of a centralised quango, the Patient and Client Council, does little to reduce the top-down ethos and the lack of opportunity for participation and co-production.
Two other issues, to date largely neglected, need to be addressed to achieve a transformational shift to care in the community. Much stronger support for unpaid carers is necessary. The new Care and Support Bill in England gives carers the legal right to assessment and support. The other need is to develop the social care workforce. This includes skilling a workforce for personalisation, undergraduate courses, training personal assistants, management training, and also apprenticeships.
In England, it is proposed to double the number of social care apprenticeships to 100,000 with no age restriction. In Northern Ireland, a decision was made to actually reduce social care apprenticeships and restrict them to people under 25. Overall, a much more evidence-based approach is needed to properly realise the objectives of Transforming Your Care.
Derek Birrell is professor of social administration and social policy at the University of Ulster.
