Jean is feeding a teatime snack to her son, gently scolding him when he throws his half-eaten sandwich on the floor. It’s an intimate moment, familiar to anyone with a young child.
But Ben, her son, is not a toddler. He is ten, and impatient to be out of the house and on his way to Scouts. The problem is, he has epilepsy and cerebral palsy, which means he is wheelchair-bound, has difficulty speaking, and depends on his mum to feed him, bathe him and take him to the toilet. Jean, a single parent, has been on anti-depressants for the past four years.
Their social worker is not too sympathetic. She tells her she is over-mothering Ben; that there are more urgent priorities. In her north London borough, as in so many authorities, social care is a shambles.
Ben needs round-the-clock support, and a bigger, adapted flat where he can move around. All they can get is occasional help with showering, and the offer of a hard-to-let flat on an estate full of drug addicts, syringes and rats.
Things are bad for this family. But they could get a whole lot worse if the government’s latest money-saving scheme goes through unchallenged. This month, a national plan for modernising the health ser-vice will be launched. At its core is reported to be a proposal – first floated by the NHS Confederation – for the health service to take over social care commissioning, initially for elderly and disabled services.
The argument goes like this. Despite talk of breaking down the Berlin Wall between health and social services, the barriers remain. Meanwhile, 40 per cent of NHS resources and two-thirds of hospital beds are used by the over-65s. An effective way to ease bed-blocking would be to make community care services more readily available. So why not put the NHS, via the new primary care trusts, in charge of it all, creating one smooth, seamless service?
It sounds attractive, and for the Health Secretary, Alan Milburn, it holds the seductive promise of bringing down NHS waiting-lists at a stroke. The government has already combined top jobs at the Department of Health to help drive the merger programme through. For social service and local authority chiefs, however, the proposal is anathema. There have been warnings of organisational chaos and “blood on the carpet” if the plans go ahead.
The reason for their hostility is transparent: to transfer such a large chunk of council spending to the NHS would put another nail in the coffin of local government, and probably spell oblivion for social services departments as presently constituted. But the real reason to be alarmed about the NHS takeover is that it will mean even less money being allocated to social care – and even more bureaucratic barriers in the way of people trying to access services.
Life is grim enough for millions of “informal” carers; the unpaid parents, spouses and offspring of the sick, disabled and old. They do what they do out of love, duty, guilt, lack of choice. Tony Blair calls them the country’s unsung heroes. In truth, no one gives much of a damn about what they do, until the pressure becomes too much for even the most dedicated carer to bear.
That’s when social services crank in- to action, with their assessments, case conferences, eligibility criteria and care packages. Months later, the help arrives, often in mean little portions; half an hour here, a quarter of an hour there, usually delivered by an ever-changing round of agency staff. Elderly and disabled people used to get help with housework and shopping. That’s mostly stopped. Many home care services used to be free. Now they are charged for nearly everywhere.
Sometimes the carers crack up completely. There are tragic cases such as the Hampshire man who tried to gas himself and his wife, an Alzheimer’s sufferer, after social services threatened to withdraw their home help. Or the mother on the Isle of Wight who could take no more, and ended the lives of her two adult sons who were suffering from severe cerebral palsy.
Ever since the community care reforms of the early 1990s, when long-term care was handed from the NHS to local authorities, social services staff have struggled with inadequate budgets to meet the soaring demand for home and residential services. Beneath the Tories’ flannel about empowerment and care in the community lay a barely concealed cost-capping, service-cutting agenda. Now, a decade on, a Labour government is proposing to hand community care back to the health service to meet much the same financial imperatives: this time, the rhetoric is of seamless partnerships.
The upshot is a demoralised, underpaid social care sector, forced to ignore all but the most serious calls on its time. Fear of litigation and a sensational press has made matters worse, leading to defensive, hands-off practice.
Jeremy Oppenheim, a former social services manager in the London Borough of Hackney, believes the very terms “carer”, “user”, “needs assessment”, “care package” are all ways of ignoring that it’s a person, not a “case”, who needs help. A lot of managers don’t want to get their hands dirty or face up to the emotional consequences of their decisions, he says; for example, refusing an old lady a stair lift, or a parent some much-needed respite care.
It’s an approach that has been refined still further in recent years, with the introduction of painting-by-numbers performance-management techniques. Hundreds of performance indicators, new standards, priorities, outcomes and objectives have landed on managers’ desks, with the veiled threat that any new monies will be tied to delivery. The model for regulating social services this way is the NHS.
Oppenheim is not particularly bothered who commissions care services: what concerns him is whether the service-provider relates to the person in front of them. The organisation he now runs, Jewish Care, does. The elderly participants at the day centres talk warmly about the family atmosphere: the Yiddish songs, the salt beef, the staff’s willingness to chat.
Jean, too, values the support she gets from outside the statutory sector: from a local self-help carers organisation, the Markfield Project. Unlike social services, she says, it relates to the whole family, “taking us as we are”. Ben gets to join in the play activities without anyone being embarrassed; her stroppy teenage daughter has joined the siblings’ group. Jean has met other parents in the same boat.
Julian Lousada, a senior lecturer in social work at the Tavistock Clinic, says this is what people want; to be listened to. Social work deals with messy, individual problems – with people, usually at the poorest end of the social scale, for whom things have gone badly wrong. “There are often no easy answers, and it takes time to talk things through. The culture of ‘outcomes’, the hysteria about modernisation, are all attempts to short-circuit this process.”
To Milburn, this probably sounds like psychobabble. He has a “war on waiting” to win, beds to unblock, and health service managers to bring onside. The NHS Confederation admits that absorbing social care into the health service fold will not, in itself, create any new investment in social services. Needy people will still be means-tested for the social care bits of their seamless care packages. Vote-sensitive health services will still win priority over mundane care needs. Jean and her son will still be left waiting for their care worker and their adapted home.
The only winners will be the auditors and regulators who will have one big, centralised budget – and no need to justify local authority care cuts to angry voters.