A Survey of Approved Social Work in England and Wales

Correspondence to Prof. P. Huxley, Department of Psychiatry, University of Manchester, Mathematics Tower, Oxford Road, Manchester M13 9PL. Summary A survey of approved social workers (ASWs) was undertaken withlocal authorities in England and Wales, to review the provisionand organization of ASW services, and the contribution theymake towards the establishment and maintenance of a comprehensivemental health service. The findings show some variation in provisionwhich is in itself indicative of a variety of factors operatingto produce local and regional patterns of provision. Some ofthese are related directly to policy decisions, others to demographicand geographic variables, while still more are related to teamstructure, workload demands, and generic/specialist issues.The future pattern of mental health social work following theimplementation of the NHS and Community Care Act is consideredin the light of the findings from the survey.     

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.     

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.     

Eligibility Criteria and Entitlements: Defining Need for NHS Continuing Care

The 1995 guidance HSG(95)8 "NHS Responsibilities for Meeting Continuing Health Care Needs" required health authorities to develop local policies and eligibility criteria for a range of continuing care services. The role of criteria in defining health need, and the potential effect on open-ended rights to NHS care, need to be considered in light of the prior erosion of rights associated with changes in continuing care provision. This paper examines whether the development of eligibility criteria has led to a loss of entitlements to NHS care. Analysis of empirical evidence from a study of the policies and criteria of six health authorities found that criteria for fully funded care were generally well defined and restricted access to those with very intense and specialist needs, thereby constituting a loss of rights. In contrast, the criteria for community-based services left eligibility dependent on professional discretion but often failed to clarify the relationship between individual need and levels of service provision. The research found that resource limits are likely to remain a factor in the allocation of services and this will affect the status of the criteria as potential entitlements.     

Promoting Healthy Routes Back to Work? Boundary Spanning Health Professionals and Employability Programmes in Great Britain

Between 2003 and 2011, the Pathways to Work (PtW) initiative was established across Great Britain, as policymakers sought to address the ‘health‐related, personal and external barriers’ faced by people who were out of work and claiming incapacity benefits (IBs). In the first 18 districts that PtW was rolled‐out, the Public Employment Service (Jobcentre Plus) and National Health Service (NHS) organizations worked in partnership to deliver ‘condition management programmes’, which helped IB claimants to cope with health problems. Evaluation research has identified significant health benefits associated with these condition management programmes, but there has been less discussion of the role of frontline NHS professionals in ensuring that services worked effectively on the ground. This article deploys the concept of ‘boundary spanning’ to explore the role of NHS professionals within PtW. Drawing on more than 50 in‐depth interviews, the article concludes that these NHS staff played a key boundary spanning role in facilitating partnerships, based on an ability to engage with the values/practices of other partner organizations (especially Jobcentre Plus) and a willingness to challenge established professional boundaries and ways of working. The article notes that recent policy initiatives have abandoned the PtW partnership approach in favour of more familiar models of contracting out, and that NHS professionals have been excluded from the delivery of health/employability services. It is argued that these recent changes may negatively affect the quality and range of health‐related services available to people on IBs.     

The Reformed National Health Service: A Commentary

This article presents an overview of the current state of the reforms of the British NHS instigated by the NHS and Community Care Act (1990) following the White Paper Working for Patients (1989) and introduced in England and Wales in 1991 and in Scotland and Northern Ireland in 1992. The reforms were not only wide ranging—affecting virtually all aspects of health care organization and delivery—but also ongoing. Moreover, there has been little systematic evaluation of the impact of the reforms. While making reference to other aspects of the reforms this survey article concentrates on two important issues of central concern to the NHS—efficiency and equity—and highlights some of the associated research and literature.     

Overcoming Barriers to Serving the Aging/Mental Health Client

This paper presents a model, based upon a series of state-level initiatives in the Commonwealth of Pennsylvania, for improving coordination between the aging and mental health systems to better serve elderly persons with mental health problems. The mental health needs of the elderly are discussed and service delivery obstacles - systemic, individual, and agency/staff - are reviewed and synthesized. Policy initiatives by the Commonwealth of Pennsylvania that relate to these issues are presented as a case study, with a focus upon a series of regional conferences held around the state for providers in the aging and mental health networks to encourage better coordination of services. The process and outcomes of these conferences are discussed, together with an analysis of the implications for practice, policy, and teaching.     

"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.     

ANCILLARY AND SPECIALIST HEALTH SERVICES: THE RELATIONSHIP BETWEEN INCOME,USER RATES AND EQUITY OF ACCESS

Australia's public health system currently provides substantial funding to, amongst its other objectives, ensure access to hospital, medical and pharmaceutical services by all families irrespective of income (McClelland, 1991, p. 6). However most ancillary services are not similarly subsidised and there is some evidence that income presents a barrier to the use of these services. There is also evidence that low income might also reduce access to specialist medical practitioner services which, while funded through Medicare, are less likely to be bulk billed than general practitioner services, and which therefore attract higher out-of pocket costs. In this study, the 1989–90 National Health Survey is used to examine whether there are indicators that low income reduces access to a range of ancillary services such as physiotherapy, optician services, chiropractic and dental services and to specialist medical practitioner services.     

Exploring the Role of Localities in Health Commissioning: A Review of the Literature

The emerging pattern of NHS purchasing has prompted many health authorites in Britain to experiment with a variety of different approaches to locality-based commissioning. But published accounts of these experiments are few and little attempt has been made to analyse the resulting experiences in policy terms. This paper reviews the specific literature on locality commissioning in health services and some of the reasons for its emergence. It is also argued that since initiatives of this kind typically seek to address a wide agenda, involving a wide range of stakeholders, there is also a case for examining the wider policy background, including the literature on community development, decentralization and joint collaboration. An account is thus presented of the policy context within which locality commissioning experiments are taking place, and hence the principal issues which are likely to prove contentious or otherwise problematic.     

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.     

Reducing waiting times in the Italian NHS: The case of Emilia-Romagna

In 2015, the Emilia-Romagna Regional Government implemented a plan to reduce waiting times for elective outpatient procedures. The objective set by the regional government establishes that at least 90 per cent of specialist services are to be provided within the following maximum waiting times: 30 days for the first specialist consultation, and 60 days for diagnostic tests. The plan adopted by the Emilia-Romagna Regional Government is of particular interest because it encompasses a combined strategy. Some of the interventions envisaged in the plan aim at increasing the supply of specialist services. Others address the demand side, seeking to reduce inadequate requests and discourage no-shows by patients. And others focus on combining supply and demand and neutralizing the effects of some perverse incentives. The Emilia-Romagna plan appears to have had a successful outcome. In the first 4 years of implementation, the 90 per cent target has not only been achieved but also widely exceeded.     

Towards the Disintegration of Child Welfare Services

This paper examines market issues in the provision of children's services in the light of the changing role and practice of local authorities contracting for welfare services. In adult services, where there has been a legal requirement to reorganize on market lines, the services have had to modify some of their earlier contracting practices to take account of the complex requirements of health and welfare services and it is argued that relational contracting offers a more appropriate paradigm for these. Following the implementation of the Children Act 1989, although not a requirement of the Act, many of the organizational systems in relation to markets, originally developed for adult services, have been adopted for children's services. Two areas of services for children, day care and fostering services, are discussed in order to demonstrate that these contracting systems are inappropriate and often dysfunctional for the children concerned. It is argued that there is a widening gap between contracting systems in adult and children's services which needs to be addressed. In general, it is concluded that the philosophies of the market place are flawed when applied to children's services.     

In the Eye of the Storm: Civil Servants and Managers in the UK Department of Health

In the wake of the 2008 financial crisis, the UK government faces some tough choices over public expenditure, and these choices will have important implications for both the future of health policy and the way in which health services are managed. In this article, we examine the organization and leadership of the UK Department of Health and weigh its suitability to meet such challenges. We find an organization that is culturally split between public servants and managers, highly reliant on the ability of its key personnel to bridge these divides, and extremely responsive to the political goals of government ministers. We explore the modern DH using three types of evidence. First, the history of the department shows clear political efforts to reduce civil service discretion and focus the DH on the management of the English NHS. Second, the recent organizational structures of the DH show a bifurcation between policy direction and NHS management tasks. Third, an analysis of the top ranks of the department since 2005 shows the implementation of political preferences that are consistent with managerialism but inconsistent with the perceived characteristics of traditional civil servants. The result is a department which has changed just as frequently as the health service it oversees – a department which has been moulded by successive ministers into one for the management of the NHS. Our findings raise important questions about the value and purpose of long‐term organizational knowledge in policy formulation.     

Older Americans Act Service Consumers

Two consumer groups of the Older Americans Act programs were compared in this research: the homebound and the users of nutrition programs. Comparisons were made on demographic characteristics, health and functional status, personal security, social resources, life perspective, and on knowledge about and access to services. Not unexpectedly, findings from this research revealed that the homebound are older, more socially impoverished, more impaired on health and functional status, have more limited resources, poorer life perspective, and less access to services. These findings clearly indicate that needs of those who benefit from Older Americans Act programs are great and many of them would be unable to continue their community living without these services.     

Is GP Restratification Beginning in England?

English National Health Service general practice is being restructured through the introduction of primary care groups (PCGs) and trusts (PCTs), and the personal medical services (PMS) schemes. Theories of GPs' professional organization have to be modernized accordingly. Past theories have tended to concentrate on the occupational level rather than consider the effects of different forms of market and quasi–market on practitioners' income and their ability to control their everyday practice. This paper extends the theory of professionalization, as an occupational group's strategy for control over its work, to cover these matters, and thereby hypothesizes an explanation of GP responses to current changes in NHS primary health care. Case study data from four PCGs and four PMS pilots suggest that general practitioners are responding in some cases by defending enclaves of traditional general practice; in others by concentrating on clinical rather than managerial interests; and in others again by forming a new dominant coalition with NHS managers. Restratification seems to be beginning in NHS general practice although other policy developments may yet prevent it. Researchers should monitor this potentially important change as PCTs form.     

‘Creating NHS Local’: The Relationship between English Local Government and the National Health Service

Following recent reforms of both local government and the National Health Service, there is significant emphasis in both services on improving inter‐agency collaboration, user involvement and strategic commissioning. In response, this article reviews historical debates about the relationship between local government and health care, before arguing that these two ‘partners’ need each other now more than ever. If local government is to be a ‘place‐shaper’, then it needs significant influence over local health services, while the NHS needs to learn from the best of local government if it is to gain sufficient local legitimacy to take the difficult decisions it needs to take. Against this background, the article reviews different options for future joint working, exploring various options for enacting a new relationship between local government and the NHS.     

Local Voices in an Internal Market: The Case of Community Health Services*

This paper presents findings from a study of contract specification and implementation in community health services (CHS). In this paper, we focus on one aspect of that study: the role of local people in informing the assessment of health needs and in determining the provision of community health services in the context of the NHS “internal market”. The paper is based on fieldwork undertaken in three districts within one region. Analysis of data obtained from these localities suggests that while there appears to be a genuine commitment to the principle of local involvement, ideas about how that involvement can be built into the activities of either purchasers or providers are less transparent.     

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.     

Who volunteers?

Summary The 1990 NHS and Community Care Act outlined an extended rolefor volunteers and voluntary organizations in the provisionof services for disabled adults and older people. In broad terms,the Act assumed an untapped pool of volunteers, ready to contributeat little additional cost to the provision of care. More recentpolicy developments, including Millennium Volunteers (ScottishOffice 1997) have made similar assumptions. For organizationswhich involve volunteers, the expectations of their increaseduse in service provision present considerable challenges, notleast in attracting new recruits and retaining existing volunteers.The research presented in this paper builds on previous workto explore the current practice and organization of volunteeringand to examine critically how far the reality matches the politicalrhetoric about the role of volunteers in the mixed economy ofcare. The paper begins with a critical review of recent policyand practice in volunteering to set the context which providedour key questions. The research methodology is briefly describedand the findings from a survey of 117 active volunteers workingwith adults with learning difficulties, mental health problemsand physical disabilities, and with older people in the Northof Scotland are presented. The research examines the demographyand personality profiles of the volunteers. It examines theirperceptions of volunteering as these relate to motivation, recruitment,selection, training, support, rewards and reasons for leaving.Finally, it examines volunteers' perceptions of the organizationof volunteering. The results are reviewed in relation to thepolicy assumptions about volunteering in the mixed economy ofcare.