Partnership Working and Eligibility Criteria: What Can We Learn from the Implementation of Guidance on Continuing Health Care?

Current government policy places great importance both on clinical governance and on partnership working between health and social services. Separately and together, these policy emphases require greater clarity in and between organizations about who should provide what care where than has often been achieved in the past. A study of the implementation of continuing health care policies suggests that clarity about appropriate long–term health and social care provision was difficult to achieve in the 1990s quasi–markets, because there were too few financial and structural incentives for agencies to cooperate in developing and implementing precise and comprehensive eligibility criteria. This problematic interplay between financial and structural factors is being addressed by a number of government initiatives designed to stimulate joint working, although the difficulty of drawing a clear boundary between health care (free at the point of delivery) and social care (which can be means–tested) remains.     

Nursing Homes in England and their Capacity to Provide Rehabilitation and Intermediate Care Services

The numbers of older people living in residential and nursing home care in the UK have risen exponentially since the early 1980s when the closure of long–stay geriatric wards and changes in social security funding of care home places led to a rapid expansion of the care home industry. While the implementation of the 1990 National Health Service (NHS) and Community Care Act shifted the responsibility for the commissioning and funding of these services to local authority social services departments, the provision of most health services (such as general practitioner care, physiotherapy and specialist nursing services) to nursing home residents remains the responsibility of community–based NHS practitioners. Recently, the attention of policy–makers in the UK has been focused on the need to improve the throughput of the acute sector. Older people who have received treatment but are not yet able to return to their own homes are to be transferred into intermediate care facilities, often by using nursing home beds, with the aim of supporting short–term rehabilitation outside of the acute sector. This paper presents evidence from a study of health service provision to older people living in nursing homes in England. It examines whether nursing homes have the capacity to fulfil the rehabilitation and intermediate care function envisaged by policy–makers. It concludes that shortfalls in the provision of NHS services to nursing homes and difficulties faced by nursing homes in paying for health services themselves may hinder the rehabilitation potential of intermediate care placements in nursing homes.     

Access to Services as a Civil and Social Rights Issue: The Role of Welfare Professionals in Regulating Access to and Commissioning Services for Disabled and Older People under New Labour

This paper draws up a theoretical framework of citizenship, based on Marshall's thesis, that encompasses the idea of access to welfare services (using the example of community care services for disabled and older people) as a civil and social rights issue. The authors critically examine current policy developments in the NHS and local authorities under New Labour that emphasize partnership, particularly the proposals and provisions made in 'The New NHS' and 'Partnership in Action'. Their theoretical framework is used to explore issues concerning access to and the commissioning of health and social care services under New Labour. They conclude that the role of welfare professionals, particularly GPs and social services workers, and their relationships with service users, patients, carers and their families under New Labour presents a continuing challenge to the citizenship status of disabled and older people.     

Ensuring equitable access to public health care: Two steps forward,one step back

Advancements by the federal government to extend access to health care to Medicaid eligible populations have been countered by state government efforts to curtail program benefits and eligibility. Fiscally and philosophically-based legislation and Medicaid waivers have created a patchwork of state policies that contradict the original civil rights orientation of the program. This examination of equitable access to Medicaid programs and services reviews individual and community factors and fiscal and institutional barriers that contribute to discriminatory practices and then explores ways in which the Patient Protection and Affordable Care Act (ACA) addresses those issues. We find that the ACA funding authorizations for numerous innovative programs strives to substantially redress issues of discriminatory and inequitable service provision.     

Placed and paid for: a national overview of the use of private and voluntary day care facilities for children in need

This paper examines day care provision for children in need, who are placed and paid for by local authorities in non local authority services. The England and Wales Children Act 1989 placed a new duty on local authorities to provide day care services for children who are defined as being 'in need', and the guidance accompanying the Act encourages the use of independent sector services for this purpose. This paper brings together the main findings from a survey of all English local authorities, an analysis of local authority documentation and secondary analysis of government statistics to provide a national overview of the use of sponsored day care places for children 'in need'. It concludes that the majority of English local authorities value the contribution of independent day care providers, but that there are potential problems with adopting a market approach to welfare services, such as low levels of training and support for such providers, and a shortage of suitable service provision in the areas where they are most needed. These require further consideration by policy makers and local authorities.     

Reconciling Cash and Care: Home Care Charges and Benefit Checks in Social Services

Correspondence to Pete Alcock, Health and Community Studies, Sheffield Hallam University, Collegiate Cresent, Sheffield S10 2BP Summary This article contains the report of a small research projecton the development of welfare rights checks for home care clientsin social services departments. Welfare rights take-up activityhas become an important feature of provision by local authoritysocial services departments, frequently targeted on particulargroups of clients known to experience problems in claiming fullbenefit entitlement. Users of home care services are such aclient group. Take-up work with home care clients is also, however,a product of the impact of community care policy changes andof financial pressures on local authority social services. Thesehave resulted in the introduction of charges for home care servicesby many authorities, and the use of rebates from such chargesto protect low income service users. Welfare rights work hasthus become an important feature of the reconciliation of thesenew charging policies with the continued service needs of poorhome care clients. The research examined a successful take-upinitiative, linked to home care charges, in Sheffield and contrastedthis with similar activities in other authorities throughoutthe UK. The conclusion is reached that levels of non-take-upof social security benefits are particularly low amongst homecare clients and that benefit checks can secure significantadditional income for them, which may also have the indirecteffect of increasing the income to social services departmentsfrom the charges for home care services.     

A critical review of mental health and mental health‐related policies in China: More actions required

In China, there are over 170 million people suffering from mental illness. However, there is a lack of a critical review of the policies governing the provision of mental health services. Drawing on the framework of mental health policy developed by the WHO, this article critically examines mental health policies regarding legislation, financing, model of care and delivery, as well as manpower and the training of mental health professionals in China. This analysis raises a number of policy‐related questions concerning the lack of community‐based psychiatric services, inadequate coverage of mental health services in the rural areas, poor standard of education and an insufficient number of trained mental health professionals, and insufficient protection of the human rights of people with mental illness. The article ends by urging the various levels of governments to make a firm commitment to improve mental health care for people with mental illness in China.     

Genetics After the Act: A Specialist Health Service Amid NHS Reform

This article considers the impact of the recent reform of the National Health Service (NHS) on specialist regional health services. A case study of medical genetic services is presented to highlight some problems arising from the implementation of the 1990 NHS and Community Care Act. New financial arrangements introduced by the Act have led many regional health authorities to devolve the finance and organization of specialist health services to districts. The introduction of competition and devolved budgets may pose especial problems for some specialist health services. In the case of genetic services these difficulties are exacerbated by new pricing rules. The paper explores these issues and suggests that the imposition of the market model on health care overlooks some vital, human elements which do not fit neatly into such a model.     

Collaboration between Health and Local Authorities: Why is it necessary?

In contrast with current proposals, collaboration with local government was a dominant factor in the 1974 reorganisation of the NHS. Four categories of such collaboration are identified in this paper: the sharing of services; coordination of service delivery; joint planning; and joint prevention. The need for each is discussed in the context of the reorganisation debate and of subsequent events. In essence, the DHSS case for collaboration — and in particular, its emphasis on joint planning — is seen as both a cause of reorganisation and a consequence of the form which that reorganisation eventually took. Emphasis is placed upon the potential role of collaboration as a vehicle for a preventive health strategy and as an important instrument for the development and implementation of major central government policy objectives. Finally prospects for the continuing evolution of joint working are considered in relation to NHS restructuring. It is concluded that the present government's approach to the structure and management of the NHS is likely to undermine its substantive policy objectives especially in the field of community care.     

Social Policy and Inequality in Latin America: A Review of Recent Trends

Most Latin American countries have extensive social policies which absorb high levels of state spending. Despite this, Latin America continues to suffer from high levels of inequality in terms of income and access to basic services. This article explores this apparent paradox. It focuses on three aspects of social policy in the region: patterns of resource allocation, the distribution of welfare entitlements and differing capacities to take advantage of these entitlements. It applies this framework to study the distributional effects of education, health and social security policies, paying particular attention to recent changes and developments. The article shows that these three factors combine in various ways to benefit higher-income groups and exclude the poor. Recent changes have marginally improved provision for low-income groups, but the fundamentally inegalitarian nature of social policy in the region remains largely unchanged and unchallenged.     

Organization and Supply of Long‐term Care Services for the Elderly: A Bird's‐eye View of Old and New EU Member States

This article provides an overview of the organization of formal long‐term care (LTC) systems for the elderly in ten old and 11 new EU member states (MS). Generally, we find that the main responsibility for regulating LTC services is centralized in half of these countries, whereas in the remaining countries, this responsibility is typically shared between authorities at the central level and those at the regional or local levels in both institutional and home‐based care. Responsibilities for planning LTC capacities are jointly met by central and non‐central authorities in most countries. Access to publicly financed services is rarely means tested, and most countries have implemented legal entitlements conditional on needs. In virtually all countries, access to institutional care is subject to cost sharing, which also applies to home‐based care in most countries. The relative importance of institutional LTC relative to home‐based LTC services differs significantly across Europe. Although old MS appear to be experiencing some degree of convergence, institutional capacity levels still span a wide range. Considerable diversity may also be observed in the national public–private mix in the provision of LTC services. Lastly, free choice between public and private providers exists in the vast majority of these countries. This overview provides vital insights into the differences and similarities in the organization of LTC systems across Europe, especially between old and new MS, while also contributing valuable insight into previously neglected topics, thus broadening the knowledge base of international experience for mutual learning.     

Facing Up to Underfunding: Equity and Retrenchment in Community Care

Local social services departments in the UK are expected to distribute their cash-limited budgets for community care in ways that achieve an equitable allocation of resources in situations where, with present levels of funding, they cannot meet all the needs with which they are presented. This paper discusses a case study of the introduction of a "needs-based" formula to allocate a local authority's budget for home care services and a follow-up survey to investigate whether services reached the people intended to benefit. The article argues that the "gatekeeping" role of community care assessments is important to safeguard equity without the inflexibility of highly standardized tests of eligibility. However, with the new Labour government seeking to reduce dependency on public expenditure, and a growing lobby for national standards of social care, it will be increasingly important that local authorities justifiy their different practices with evidence about how they relate to local needs.     

Part of the Problem or Part of the Solution? The Role of Care Homes in Tackling Delayed Hospital Discharges

As part of current UK policies to reduce the number of delayedhospital discharges, a number of commentators have identifiedan alleged crisis in the care home market as one of key contributingfactors. With local authorities under pressure to cut costs,it is argued, the number of care homes is reducing, and delaysin hospital can often result. Behind this diagnosis is a seriesof assumptions about the role and nature of care home provision,the appropriateness of this form of service for many older people,and the need for more care homes to reduce the number of hospitaldelays. In order to explore and critique these assumptions,this paper reviews the role of care homes in tackling delayeddischarges, and argues the need for fewer and different carehome placements rather than more of this type of provision.     

"Bridging the Gap": New Relationships between Primary Care Groups and Local Authorities

Current policy places great emphasis on the development of "partnerships", particularly between NHS and local authority services, with the aims of increasing service coordination and delivery and improving health. To this end, primary care groups (PCGs), at the forefront of NHS organizational developments, are required to include a social services representative on their governing boards; similarly, primary care trusts (PCTs) have a social services representative on their executive committees. Drawing on a representative longitudinal national survey of English PCGs, the paper evaluates the contribution of these new governance arrangements to the development of inter-agency partnerships. Despite poor histories of collaboration and some major organizational barriers, there are some signs of progress, with social services representatives playing an active part in PCG affairs and having clear lines of communication about PCG matters with their employing authorities. Equally significantly, PCGs have also quickly established a wide range of contacts directly with other local authority services and departments. However, these early gains risk being limited by traditional professional inequalities between social work and medicine and, in particular, by the prospect of further organizational upheaval as PCGs merge with each other and/or acquire trust status.     

A Brave New World of Personalized Care? Historical Perspectives on Social Care and Older People in England

Social care policy for older people in England continues to generate extensive discussion around the need to break with the past and to deliver a personalized response to need. This article explores the extent to which this represents a complete break with the past by looking at four key reports from the past, namely the Rucker Report (1946 ) on the break up of the Poor Law, the Seebohm Report (1968 ) on the personal social services, the Griffiths Report (1988 ) on community care and The Royal Commission on Long Term Care ( Sutherland Report, 1999 ). Each is interrogated in terms of how social care is defined, how services are to be delivered, how quality is understood and the assumptions made about who will be able to access services. This analysis is used to draw out key continuities in policy assumptions such as the primacy of family and the ongoing debate about ‘What is social care?’ and how it can be distinguished from health care. The article also argues that the voluntary sector has always been seen as a ‘key player’ in social care. Finally, the analysis of the four reports is used to trace the ever changing role of local authorities in the planning, purchase and provision of social care services for older people.     

Integrating Health and Social Care at the Micro Level: Health Care Professionals as Care Managers for Older People

A common problem in the provision of coordinated long‐term care is the separation of health and social care. The present government has been increasingly concerned with promoting convenient, user‐centred services and improving integration of health and social care. One arrangement that could contribute to this for some older service users is for health care staff to act as care managers, coordinating the provision of both health and social care. This paper presents the findings of a survey of arrangements in place in local authorities for health staff to work as care managers for older people. This was designed to provide details about the range and scope of care management activities undertaken by health care professionals. Key areas of enquiry included: which kinds of health care staff undertook care management and in what settings; how long the arrangements had been in place and how widely available they were; whether there was a distinction between the types of cases and care management processes undertaken by health care staff compared with their social service department counterparts; and what management and training arrangements were in place for the health care staff.     

GPs and Contracts: Bringing General Practice into Primary Care

This paper argues that the terms on which GPs entered the NHS, as self-employed contractors, have proved remarkably resistant to the managerial pressures which have come to dominate other sections of the National Health Service. However, this traditional mode of financing and organizing the delivery of a key element of the National Health Service has become increasingly incompatible with wider health policy objectives—the development of an integrated network of good-quality, equitable and well-coordinated primary and community health services which are responsive to local needs. Furthermore, primary health services have themselves come to play a crucially important role in securing other strategic changes in the wider health policy arena, such as securing and sustaining a shift in the traditional balance between hospital and community-based health services and controlling expenditure in a needs-led service. The paper argues that, notwithstanding the change of government, the 1997 NHS (Primary Care) Act and the White Paper "The New NHS" are both integral to the achievement of wider strategic health policy objectives, such as improving the quality and coherence of services, and increasing professional accountability for the financial consequences of clinical decisions. However, the greatest significance of these and other related measures is that they shift the emphasis of health policy from commissioning and purchasing by primary care to commissioning and contracting for primary care. They thereby extend the exposure of GP-based services to managerialist scrutiny and control.     

Older People and the Health–Social Care Boundary in the UK: Half a Century of Hidden Policy Conflict

The boundary between health and social care services has been an important focus of both social research and policy reform in many western and northern European countries. In the UK there is a history of particularly sharp divisions between the centrally funded NHS and locally run social services. A consequence for older people, especially those with less acute or "intermediate" needs, is that they may be rationed out, ignored, or treated inappropriately on either side of the boundary. This paper seeks to go beyond explanations in terms of financial, administrative and professional divisions by using now-available public records to show how the boundary between health and social care was set in stone in the immediate postwar years and resulted in a constant battle between the two services over the needs they would meet. The first part of the paper examines a largely hidden history of health and social care policy. The second part examines the new NHS Plan and the extent to which it is likely to resolve the problem of the boundary.     

The Impact of New Labour Health Policy on Social Services: A New Deal for Service Users' Health?

Summary The health policies of the Labour Government of 1997–2001included an increased emphasis on social services departments'(SSDs) contribution to promoting health. Three dimensions ofthis policy shift are discussed: first, the drive towards organisationalfusion between elements of the NHS and SSDs; second, the newmechanisms for conjoint funding of health and social services;and, finally, the new policy focus on tackling health inequalitiesby combating social inequalities on a national and localitybasis. In each case, the touchstone of our analysis is the consequencesfor the health and well-being of SSD service users as membersof socially disadvantaged groups. We conclude that New Labourhas taken some steps, particularly reducing child poverty, whichwill have long lasting health and social benefits for actualand potential service users. However, inadequate funding ofSSDs undermines their effectiveness as a partner in integratedhealth and social care. As signalled by service user initiatives,SSDs potential for promoting more equal chances of health andwell-being in ill-health will also not be realised without substantialchanges to current SSD policy and practice.     

In their Own Right: Translating the Policy of Carer Assessment into Practice

Successive legislation has underscored the importance of assessmentsthat are sensitive to the needs of carers and take into accounttheir ability and willingness to continue caring. This papersynthesizes qualitative and quantitative findings from a continuingprogramme of carer-related research that began in 1993 and hascontinued in parallel with legislative changes. It considersthe process and characteristics of carer assessment from theperspectives of carers for individuals with a range of healthand social care needs, and practitioners. This paper exploresthe assessment of carer need over time and highlights the considerableand enduring gap between policy and practice. It considers practitioners’reluctance to offer separate carer assessments, identifies confusionrelating to the interpretation of eligibility criteria and documentsthe limited contribution of health service staff. The need foran evidence-based framework for good practice, that distinguishesbetween carer needs, service provision and carer outcomes, ishighlighted. The paper concludes by identifying key changesthat are necessary to promote future good practice, such asstaff training and information strategies and the need for practitionersto engage with carers as partners in the care process.