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    The White Paper says social care must give people ‘choice, control, and support to live independent lives’ through ‘outstanding quality and tailored care and support’ which they must find ‘fair and accessible’. No one will argue with any of that. If achieved, most will agree that the Prime Minister’s promise to ‘fix social care’ had been delivered.
    But there is a problem. This vision is no different from the vision set out when the personalisation strategy was launched in 2007. Nor is the vision any different from a re-launch in 2011 by Think Local Act Personal (TLAP), the body entrusted by Government to progress the personalisation strategy. TLAP gave it the title ‘Making It Real’ – the ‘it’, we may believe, being personalisation – making the implicit assumption clear that personalisation had not happened. And when the first iteration of ‘Making It Real’ failed to make it real, the strategy was re-launched in 2018.

    So the White Paper represents, incredibly, the fourth launch of a strategy with a 14 year history of repeated failure.
    Government shows no curiosity as to why the personalisation strategy has failed. There are three key elements of the strategy – direct payments and personal budgets, empowerment of people with information to navigate the system and exhortations to councils and their staff to change their behaviour. Each has proven problematic.

    Direct payments and personal budgets

    The White Paper sees these two mechanisms as a ‘vital way in which people can have more choice and control over their care and wellbeing’. However, meaningful personal budgets do not and cannot actually exist while it has been known for twenty years that direct payments work only for the small minority evidenced to be able to manage their own support systems in a harsh environment.

    The original idea of personal budgets was as an entitlement to a ‘fair allocation’ of money ‘up-front’, sufficient for the person to purchase the supports that would give them ‘full citizenship’. The New Labour government was enthusiastic, but before implementation, dealt it two blows that were fatal.

    The first blow was in changing the idea of a ‘fair allocation’ to be just a fair allocation of whatever budget the local council happened to have.

    The second and final blow was to declare that the ‘up-front’ allocation was not an entitlement, just an ‘indicative’ amount. What people actually got would be known once the council had decided what needs it would meet and with what resources.

    These two blows killed personal budgets at birth. The Care Act of 2014 introduced the term ‘personal budget’. But it could not be clearer that it was nothing more than an administrative costing exercise taking place at the very end of the process. A ‘personal budget’ under the Care Act is not a budget in any meaningful sense of the word. It is in reality a completely pointless exercise.

    It is an extraordinary act of manipulation of the public’s mind that personal budgets are even seen to exist, let alone have a transformative impact. A key part of that achievement was to conflate personal budgets with direct payments as if they were the same. But they are completely different. When direct payments were introduced in the 1990’s they allowed disabled people to step outside the mainstream provision to employ their own Personal Assistants and so control their support. It worked then and it still does. Up-front allocations, however, played no part then and play no part now. But by showcasing the successes of the small number of people self managing with a direct payment – about 8% of all long term service users – and parading them under the banner of being a form of ‘personal budgets’ TLAP has been able to keep the personal budget mythology alive.

    Empowering people to navigate the system

    The White Paper says people ‘struggle to understand the system’. This state of affairs is fundamentally disempowering. Yet provision of information as a means to empowerment was a key part of the personalisation strategy from the very beginning. Why have councils failed over so many years in what is surely a very simple task?This invites further hard questions. Do councils actually want to empower service users? Will empowering service users actually impede their operations? Or is the system so complex and obscure that it is not even navigable?
    So far Government has not shown sufficient curiosity to investigate the issue. Instead it has committed a modest £5M to ‘pilot and evaluate new ways to provide personalised advice to help people navigate local adult social care systems’. What point is there in such work without first answering the obvious unresolved questions?

    Exhortations to change

    The White Paper is packed with promises to change the behaviour of councils and their staff – to be person centred, to be empowering. They are the same promises made in each of the previous three launches of the personalisation strategy. Indeed, with only minor changes to the wording, the exact same promises can be traced back even further to the Community Care reforms of the early 1990’s.
    Yet, again, Government shows absolutely no curiosity as to why these positive behaviours, which councils readily sign up to, have not happened. The hard question neither central nor local government seem to ask is whether there is something about the system that is conditioning the disempowering, resource-led behaviour of councils and their staff? If there is, unless it is addressed, the promises are not worth the breath required to speak them.

    The Care Act

    The White Paper is, however, surely right when it says the 2014 Care Act ‘particularly its focus on wellbeing, provides a strong foundation for our vision’. The problem is that it then picks out five features of the Act but completely misses out the two most critical to delivery of the Act’s vision. The Act places specific duties on councils to;
    1. identify all needs a person has for their wellbeing, which can have no regard to resource availability
    2. have regard to the need to ensure that sufficient services are available for meeting the needs for care and support in their areas

    Neither of these requirements are being delivered. The second, indeed, cannot be delivered without the first. And the first is not delivered because Government policy is to maintain the traditional system whereby a need is a need only if there is resource to meet it.

    This is the effect of the ‘eligibility’ system. Councils calibrate what they deem to be a ‘need’ calling for council resources to that for which they have resource. Anything else is simply a non-need, a mere want or wish, but not a need. This circular, resource-led way of defining ‘need’ explains why there is a 60% disparity in how much support different councils give their service users. It also explains why councils never have any information about unmet need.

    Eligibility operates covertly. Councils tell their public that they follow the national criteria. These say that all needs that are ‘important to the person’ due to having a ‘significant impact on their wellbeing’ are treated as ‘eligible’. This is, of course, hopelessly undeliverable. No council could afford it. The real eligibility decisions are made behind closed doors.

    And, of course, it requires a process that destroys any prospect of being person centred or empowering. People have to be fitted into whatever types of needs their council will consider ‘eligible’, cutting across the uniqueness of need upon which the notion of being person-centred rests. And only the professionals are allowed to work out if there is a ‘need’, cutting across any notion of people having any control over the way their needs are defined.

    Two systems of social care

    There are two version of social care in this country – the official, glossy brochure version and the real one. They are worlds apart. Most people only find out when they have to seek help. The glossy brochures dupe the public into believing all needs important to each person’s wellbeing will be met, that personal budgets give people control and empower them, that national eligibility criteria ensure equity and fairness, that decisions are made in an open and transparent way. In the real world there is gross inequity, decisions are made behind closed doors, budgets, not importance to the person, determine priority and many hundreds of thousands of people with support needs go unhelped. Of course people find the system unnavigable. It is a complex web of false leads, mixed messages and downright untruths. It has to be that way if central and local government are to maintain that their glossy brochures tell the truth.

    Prospects for change

    The White Paper introduces some changes that will be broadly welcomed. The reduced severity of the means test, some attention to the workforce and a kick start to more housing options. But these are peripheral to the core challenge the White Paper itself identifies – the need for a system that empowers the individual to create personalised support. Yes, there are pockets of excellent practice dotted around the country. But that is no different from how it was in 1986 when the Audit Commission found, in a sea of mediocrity, ‘champions of change’. With exceptional drive and imagination, they were people and organisations that performed well despite the system or by by-passing the system. But their work has never been scaled up, and when the ‘champions’ went, their work usually went with them.

    It is either a great irony, or an act of great hypocrisy, that the Government is promising visionary change whilst clinging to the system that guarantees it can never be realised. The Government shows zero appetite for real change. Why should it? It’s a system that allows them to spend as much or as little on social care as they choose, and the system will deliver. The system is constitutionally built not to overspend whilst always meeting its statutory responsibilities. There is never the inconvenience of unmet need. It has allies in Think Local Act Personal who supply a steady stream of material for the glossy brochures. It is politically low risk.

    The White Paper is right in saying the legislation is in place. However, we await political leadership that has the strength and integrity to implement it in full. It will not actually cost a penny more to do so. But it will require political leaders to not only talk big but who act big. Political leaders must allow the professionals to work in authentic partnership with service users to identify and cost all the needs for wellbeing of every individual in need of care and support. They should set a standard for wellbeing. The United Nations* definition of Independent Living has international credibility and is an obvious candidate. They must then be big enough to hear how much money they must find if all are to have the level of wellbeing political leaders have said they want for them. And they must have the integrity to accept with good grace that their commitment to the wellbeing of people in need of care and support will be transparently tested. It will be measured by the action they take and at what pace to close the gap that will have been exposed between needs and resources.


    The Local Government Association has released a statement that 91% of 600 councillors support a campaign for reform of social care launched by a partnership called Social Care Futures. As part of re-building society post-pandemic, their campaign calls for social care to serve the purpose of enabling people in need of care and support to: ‘live in the place we call home, be with the people and things that we love, in communities where we care about and support each other, doing the things that matter to us’.
    This is a warming vision whose worthiness few will dispute. But before committing to it political leaders are likely to want to know the cost. The Chancellor will certainly want to know the cost before his colleagues commit. However, with this vision so different from the current realities of social care, testified by the 500 people who responded to a survey by Social Care Futures, the cost is simply not known. All that Social Care Futures can say is;‘Government resources must be increased to the level that allows people the funding they need to live a life like other people’.

    Social care has not lacked for a vision similar to this for a long time. The most recent is a vision based on wellbeing in the Care Act of 2014. Before that the ‘personalisation’ agenda of the noughties. Neither have happened, with sector leaders claiming lack of funding.
    But there is a chicken and egg situation. While social care leaders say they cannot deliver a visionary service without more money, in the absence of the vision being costed, political leaders will not give sector leaders more money. It is an impasse.

    Breaking the impasse – a parallel campaign
    Coincidentally there is another campaign to reform social care concurrently being launched. It has been developed by a national collaboration of disabled peoples’ organisations. Included in its proposals is a route to break the impasse. It comes in the form of endorsement of the principle of ‘progressive realisation’ of the resources required through ‘concrete action’. This is a concept taken from the United Nations vision of Independent Living, which is a vision almost identical to Social Care Futures’ vision. The UN recognises that the resources required for people to lead the lives right for them is a political matter, not a legal right. Much as we may like the world to stop still while social care gets the funding it requires first, it is most unlikely political leaders will be so moved by the Social Care Futures vision that that will happen. The concrete action that must be taken is the key.

    Concrete action

    The action required to make progressive realisation a reality relates back to the very reason why social care leaders do not know how much it would cost to give people the lives they should have. In the NHS, clinicians diagnose and recommend treatments based on what they see before them. Waiting lists act as the financial safety valve if clinical need outstrips resources at the operational level, and as the weather vane and information source for funding requirements at the strategic level.
    This is not so in social care. Resources determine what is recognised as ‘need’. Managers determine ‘eligibility’ thresholds in order to ensure demand matches the local budget. It is the reason why sector leaders have no idea how much it would cost to resource the Social Care Futures vision or any other vision.

    The action required is to abolish the resource led definition of need – the eligibility process. Councils must require their front line practitioners to identify and cost all the needs each individual has to live the life described by whatever vision is adopted. On a case by case basis, councils must decide what can be afforded and what cannot. The needs unmet must be aggregated and put in the public domain. In this way, unmet needs in social care can sit alongside waiting lists in the NHS to inform future budgets. This is an approach that has recently been adopted by the Equality and Human Rights Commission (please see link below). It recommends the Secretary of State should periodically set out plans to close the gap between needs and funding.

    Delivering change – problems for Social Care Futures
    At the core of the action required is the axis between needs on the one hand and resources on the other. A founding principle of the NHS was that need must precede resources. In social care, from the outset, the opposite applied. The concrete action required is to reverse the polarity putting social care on the same basis as the NHS. Whilst simple in concept, it will require a change in the both the culture and modus operandi of the way councils deliver their part of the social care system that will shake the system to its roots. But this creates a problem for Social Care Futures. It is a partnership involving the key leaders of the sector – the LGA, the Association of Directors of Social Services, Skills for Care, Social Care Institute of Excellence. But the sector consistently and collectively denies the need for change in the way councils operate, citing only lack of funding as preventing them from delivering the personalisation vision.

    But the evidence not only undermines this position, it points to a seriously dysfunctional system;
    • In 2009/10 (at 2019/20 prices) £21.4BN was spent on social care, which included £1.3BN of NHS money. In 2019/20, £22.4BN was spent, which included £2.3BN of NHS money. Spending in real terms has thus actually increased by about 5%.
    • Whilst sector leaders point to increased demand from increased demography thus suggesting an effectively cut, they are silent on levels to which demand has – or should have been – reduced.
    • One of the selling points of the personalisation agenda was that it would reduce demand. By matching resources to the personalised needs of individuals, better outcomes at lower cost would follow.
    • Over the past decade the sector has proclaimed great success in delivering a range of demand reduction strategies. Chief amongst them has been what is called ‘strengths based practice’, designed to eliminate the dependency on services. However, while all councils have adopted the practice, sector leaders offer no information as to how much this may have saved.
    • In 2009/10, 1.7 million people were served. In 2019/20 that had reduced to 1.1 million. Spend per service user has therefore increased by some 35%. Why does the Social Care Futures survey find people seriously under-supported?
    • According to the LGA’s own figures, shared confidentially with councils but not released to the public, the highest centile of councils spent 60% more than the lowest in 2018/19. However, there is no suggestion that the highest spending councils have broken the mould any more or any less than the lowest.

    These figures point to a dysfunctional system. Until and unless sector leaders acknowledge as much and the parts they have played in its design and delivery, they will remain a central part of the problem, not the solution.

    The immediate needs for increased funding within the existing system are beyond dispute. In particular the low level of pay for the care workforce and the unfairness of the charging regime and pricing that risks market collapse should be addressed without delay. However, hopes for funding levels beyond the immediate that rest on the belief that government will be so moved by a new vision that it will commit regardless of cost is at best naïve. Worse, how can government have the confidence required to entrust new funds to a sector so dysfunctional and incapable of making best use of the resource it already has.
    It is easy to sign up to Social Care Futures’ vision. Who wouldn’t? But if we want a system of social care driven by that vision, or any variation of it, it will only happen if government listens more to the call for the fundamental systemic change that the disabled peoples’ movement includes in its agenda for change.


    Colin Slasberg is a social care consultant

    This post makes an important contribution to the debate on the provision of social care in England and is not a reflection of the SHA’s policy.


    Many readers may be aware that this is a major issue, but I am going to do my utmost to condense its main aspects into this blog. Obviously different people will have a varying spectrum of knowledge on this subject, but I am writing here from the perspective that many might be unaware or have limited knowledge of the issues involved.

    What is a PEEP?

    PEEP stands for a Personal Emergency Evacuation Plan. Its purpose is to provide people who are unable to self evacuate unaided from a building, or to a place of safety, with a plan to help ensure that they can.

    Not everyone identifies as disabled or with a health condition, and whether they do or not, some people may not realise that PEEPs exist, or that they could benefit from one. I know I didn’t.

    Some might need a PEEP for a temporary period, e.g. while they have a broken leg, whilst others need them long-term, and the PEEP may need to be updated as needs change. I would argue it is in everyone’s interests for PEEPs to be readily available, not only as a principle, but also because nobody has any idea if they might need one, either on a short-term basis or permanently. I have not been disabled for most of my life, for instance.

    Brief Background

    It is utterly shameful, to put it politely, to think that 42% of those who lost their lives in Grenfell were disabled. None had PEEPs, and it seems to me there has been no will by Government or those who make such decisions, to even try and increase access to PEEPs.

    Four years on, and only now has the Government recently opened a consultation. This has been due to what has (and continues to) come out of the Grenfell Inquiry. It isn’t an easy listen or read. More poignantly, bereaved families, survivors and others have fought the injustice throughout, including going to court over this major issue. That should never be forgotten. We would not be having this consultation otherwise, even though it has taken far too long.
    It should also be noted that PEEPs are nothing new: they have existed for decades. Although I think it is clear that current law legislates for them, arguably this has been and is being continuously contested by various parties. Due to the current situation, as described below, I will not focus on that here, for reasons that will hopefully become clear.

    My Experience

    When major fire safety issues were found in our building, our evacuation procedure changed from ‘stay put’ to simultaneous evacuation. It was assumed that all of us could self evacuate. Those who could not were not even considered, let alone acknowledged. Maybe it did not occur to those involved in making this decision? So installing a Gerda box (secure and fireproof for the storage of PEEPs) turned out to be pure tokenism. Initially it gave me hope, thinking that finally we were going to have PEEPs stored where the Fire and Rescue Service could easily access the necessary information. I had been refused a PEEP countless times and advised that I needed to ‘stay put.’ That because I am disabled I would have to wait to be rescued, while my neighbours, who can self evacuate, should do so. But I had to wait.

    Can you imagine being told that? Many disabled people will have been told this already. I know people who have. Sadly, more people have a similar experience than a positive one. Something else to have to fight for on top of everything else, when some of us are also at risk of losing our homes and having no choice but to declare bankruptcy, due to the huge fire safety remediation work that would be necessary, and other associated costs. The failure to include the cost of complying with a PEEP assessment in the service charge shared by everyone is discussed later.

    However, a company kindly undertook a PEEP assessment with me, without charging a fee. As a wheelchair user with complex needs, including support to leave their flat, the PEEP advised a specific model evac chair that I would need to safely evacuate with a ‘buddy.’ In my situation, my ‘buddies’ include: my partner, my Personal Assistants and neighbours. If nobody is with me and there is a fire, I can contact neighbours via text. I keep my phone near me at all times in case.

    This advice was not accepted by my managing agent, management company or the Fire and Rescue Service. There was not even a discussion, just people in offices or zoom meetings, making this decision without me. Not a trivial decision, but one that could, in the event of a fire, leave me injured or worse. This is about all the lives unnecessarily lost already, about my life and anyone’s who can’t self evacuate. It is about all those people who have lost loved ones and those who care about disabled peoples’ safety. It is yet another example of disabled people not being classed as equal. Classic ableism.

    If able bodied people were told that they had to be rescued and only disabled people could evacuate first, do you think that would be accepted? Do any of these people making such decisions wonder what it would be like for them or someone they care about to be in this situation? Physically trapped and in my case, as in many others, in a building that was built unsafe. This obviously increases the risk of a fire and therefore of injury and death.
    If the building had been built to higher safety standards, then I feel that the risk of living on the third floor is a reasonable one for me. Others may disagree with that, but then to ‘stay put,’ in my experience, either before I became disabled or after, was standard and I wasn’t aware of other options. Now the situation is very different and yet I, like so many others, are plainly refused.

    Such a decision made me feel extremely upset, angry and as previously explained, that my life and disabled peoples’ lives aren’t viewed as equal. We know this already, but even in such serious situations, it is often the case. Surely being rescued should be a last resort, not your only option. For some people there might not be an alternative or one they feel comfortable with, and/or some may prefer to be rescued. For me and so many others, that is not the case.

    There should be financial support for aids and adaptations to enable evacuation. As a reasonable adjustment, disabled people should not legally have to pay and the cost should not be added to service charges. It should apply generally, let alone during the current building safety crisis. Having huge bills, or expecting them, is a recipe for disaster and can lead to hate crime. I have known it to happen: disabled people being targeted by those worried about their precarious financial situations. This can and does happen, whether people are impacted by the building safety crisis or not.

    This has not been my experience, although my management company made me aware that if my PEEP was accepted, that it would be added onto the service charge. The recommended equipment tends to not be viewed in the same way as installing a new door, a new light, or having car lifts repaired. Not everyone uses everything that is included in the service charge, but evacuation aids are seen differently from other things included. Up to a point, I understand, as it should be classed as a reasonable adjustment, but anger should not be directed at the disabled person. There should be a central fund that people can apply to, and PEEPs need to be offered as standard. In some places they are, in Oldham, for example: but this is not typical by any means. If the Government is really serious about reducing fire risk to a vulnerable group of people, then they need to provide adequate funding. Local councils cannot be squeezed even more.

    In addition, PEEPs should be made available to anyone who cannot self evacuate, regardless of building height. Currently the Government are focussing on buildings 18 metres and above. PEEPs should be person-centred and not building-centred. Fire does not discriminate in terms of height. If you need help to evacuate, then you need help, however high the building you live in.

    So after a lot of thought and in desperation, I decided to crowd-fund for the evac chair. Within 3 days, mainly people I didn’t know kindly donated enough to reach the target amount. A couple of days after, the evac chair was delivered and my buddies have been trained how to use it.

    I’m only one person impacted, but not everyone can crowd-fund for equipment – and nobody should have to, under any circumstances. It is shameful.

    My fear was that without a plan there was a risk of injury or death, either to myself or others trying to help me, who would not feel able to leave me behind. This is not just about me, but about people who care about me. Now I have a plan and appropriate equipment, that reduces the risk to all. Several months back we nearly had an electrical fire, which made the potential situation even more real to me. We did not have to evacuate, but it made me even more aware of the fact that I could not even if I needed to. This petrified me and the feeling has stayed with me. Hopefully there will not be a fire, but if there is, I am as prepared as I can be though my management agent still has not accepted my PEEP, or acknowledged that I need one.

    Who are Claddag?

    Claddag is a Direct Action Group for Disabled Leaseholders and those with health conditions, impacted by the building safety crisis/cladding scandal. I am one of the co-founders. I was painfully aware that disabled people were not being considered or included in any part of the response to the building safety crisis and not only wanted this to change, but believed it had to. Another disabled activist, Sarah Rennie, was trying to do the same and although we’ve never met in person, via social media we founded Claddag.

    Obviously PEEPs impact a much wider range of people than those at whom Claddag is primarily aimed. It affects people in different circumstances, across housing tenures, whether impacted by the building safety crisis or not. So part of our campaign is focusing on PEEPs and this consultation is extremely important. It will inform legislation that is vital to those who need evacuation plans.

    Further to our open letter, we are making progress!

    The Government has been forced to think again on whether disabled people have the right to an evacuation plan within blocks of flats. Here is a recent Channel 4 report highlighting the dangerous situation disabled people are in, and the refusals of landlords/agents to agree evacuation plans.

    Call to Action – How to Help?

    The consultation on evacuation plans (known as ‘PEEPs’) has a short window for response. We know there will be a lot of opposition and so it is vital that disabled individuals, allies, MPs, DDPOs and charities make their voices heard. We need as many responses as possible.

    We are simply asking for:
    • PEEPs for every disabled resident
    • PEEPs must be the responsibility of the Responsible Person
    • PEEPs must be clear and accessible
    • PEEPs must be secure and up-to-date

    We are happy to distribute our draft response to anyone who might find it useful. If so, please contact us. Our contact details are on our website (link included below). The deadline to respond is 19 July 2021. Examples of lived experience is invaluable, so please encourage the groups and individuals you know and/or meet to respond.

    Some disabled people are struggling to get the consultation in alternative formats, so please let us know if you hear anything concerning that, which we should raise with the Home Office.

    Any questions please let us know. It would be very, very helpful to know if you do submit a response.

    More materials/stories about the impact of the building safety crisis can be found on Claddag’s website (



    The consultation on evacuation plans (known as ‘PEEPs’) has a short window for response. We know there will be a lot of opposition and so it is vital that disabled individuals, allies, MPs, DDPOs and charities make their voices heard. We need as many responses as possible.

    We are simply asking for:
    • PEEPs for every disabled resident
    • PEEPs must be the responsibility of the Responsible Person
    • PEEPs must be clear and accessible
    • PEEPs must be secure and up-to-date

    We are happy to distribute our draft response to anyone who might find it useful. If so, please contact us. Our contact details are on our website (link included below). The deadline to respond is 19 July 2021. Examples of lived experience is invaluable, so please encourage the groups and individuals you know and/or meet to respond.

    Some disabled people are struggling to get the consultation in alternative formats, so please let us know if you hear anything concerning that, which we should raise with the Home Office.

    Any questions please let us know. It would be very, very helpful to know if you do submit a response.

    More materials/stories about the impact of the building safety crisis can be found on Claddag’s website (


    Through the decade of austerity, the Welsh Government is to be commended for its efforts to maintain the sustainability of our social services, in contrast to other parts of the UK. Socialist Health Association – Cymru (SHAC-C) welcomes the initiatives to promote greater joint working with other key agencies such as the NHS, housing, and education. The cap on the costs of domiciliary care and the increased thresholds for residential care provides Welsh residents with a more generous provision than elsewhere.

    We also welcome the proposals to improve the status of the social care workforce through its increased professionalisation and to seek remuneration solutions through the Social Care Forum. The initiatives to reduce the prevalence of zero hours contracts and to enhance the choice of the care workforce should help to bring some stability to the sector.

    Innovative initiatives such as the Children’s Commissioning Consortium Cymru has provided a strategic response of humanely addressing some of the most difficult challenges in Children’s Services provision.

    During the Covid-19 pandemic the Welsh Government recognised the vital role of its public sector partners as being pivotal in its response rather that embark on a wasteful and incompetent embracing of the private sector. It acted quickly to learn important early lessons by intervening to provide care home providers with personal protective equipment and to institute a regular programme of staff testing.

    In this period of crisis, partnership working across organisational boundaries happened to an unprecedented extent. It showed what is possible – with proper leadership and the political will to make things happen. These achievements were on a par with those inspired by the “Spirit of 45” which followed WW 2.

    SHA Cymru fully supports the Welsh Government’s £500 bonus payment to our frontline social care staff. It is a pity that the UK Government did not have the generosity of spirit to reciprocate.

    Despite these commendable policy initiatives, SHA Cymru feels the consultation underestimates the scale of the challenges that the social care sector faces. The present substantially privatised provider model is in crisis at all levels from children’s services to services for older people. It is not at all clear what are the continuing advantages of this model. There is an underlying premise that it is possible to achieve the necessary improvements in quality through commissioners purchasing and procuring services from non-public services bodies.

    Social care should not be a market. The approach of ‘switching suppliers’ may work for consumers of electricity, but it doesn’t work for social care. It does not matter who provides your electricity, the product is the same and it is just a matter of price. It does matter who provides your social care. Who delivers the care can determine what care is given.

    The NHS was conceived as a national service, designed to meet the health needs of both individuals and communities. Provision was rationally planned and provided. Individuals accessed it when needed. Their needs were not assessed and then the market searched for the product. This is very much the “for profit” and insurance model where you justify your claim in line with means testing and eligibility criteria.

    In the past a combination of pro-market ideology and determination to drive down costs was the rationale for the current model. As time has gone on it is becoming increasingly obvious that there is a price to be paid for this dogma – in terms of quality of care, workforce retention and training as well overall sector stability. SHA Cymru welcomes the view arising from the two-year review of A Healthier Wales that further work will be done to…” rebalance social care and address the barriers which have made it difficult for the public sector and not-for-profit organisations to be major providers of care.”

    We accept that there will be an element of disruption if there was a precipitate switch to a public service model of care. However, we believe that this can be done in stages e.g., i) establishing national terms of service for care staff ii) national fee structures iii) taking domiciliary care services in-house and remodelling others into mutual/social enterprises iv) provision of new all-life housing as an alternative to residential care in advance of any wholescale transfer of residential care provision.

    This consultation document recognises that the market is not working. Its responses are substantially proposals to re-shape the market. SHA Cymru asks if it is time to consider alternatives to the market itself. We believe this, in line with a substantial investment, is the only way to address all key problems that this consultation is trying to address. The inherent tension between the use of the for-profit sector to deliver public services is threatening the quality of care for service users and is undermining the attainment of the employment environment which the consultation wishes to achieve. In the event of market failure, it is the public sector that must pick up the pieces.

    SHA Cymru supports the establishment of a National Care Service. This is the first step in addressing many of the consequences of the present fragmented provision model. This national model would have many of the features of the NHS which are so valued by people in Wales, but we do not support the “take over” of social care by NHS.

    Social care is a service which not only interfaces with health care, but it also interfaces with many other sectors including education, housing, the world of work and training, the welfare system as well as culture and recreation. Social care and its workforce have a different range of values and professional standards which do not readily fit with the mainstream medical model.

    A National Care Service must promote a more uniform set of standards of across Wales while recognising the diversity of our population and the diversity of its needs. These standards would include what citizens can expect from social care as well promoting a working environment that values the staff which will deliver the service.

    Such a service must be free at the point of use. The present means testing system is long out of date as it catches more and more people on relatively modest means into its clutches following the growth in home ownership since the 1980s. There is a strong view that those who pay for care also contribute a premium to make up for the inadequate levels of public funding and the consequences of a decade of brutal austerity.

    A reformed social care sector must be about more than structures and organisational boundaries. This is where the consultation document is weakest. The present market model of provision, linked to a decade of austerity, shapes what type of care is provided. Fewer people are being deemed eligible for more complex packages of care. Those who do not reach the threshold are obliged to fall back on their own resources and the resilience of their families, friends, and their communities where the root of the problem often lies in the first place. This is often falsely described as reducing unnecessary dependency and promoting the resilience of the care seeker.

    As social care is only fully accessed by people with increased complexities of care this place greater demands on service providers who are invariably operating on stand-still levels of resources.

    The service needs to be more citizen and user directed where co-production of provision is the heart of the assessment and delivery process. However, SHA Cymru has serious concerns about initiatives such as “direct payments” which have their own add-on costs, and which often operate on the fringes of poorly or self-regulated market.

    SHA Cymru strongly believes that obtaining any advantages and benefits of user directed care are entirely consistent with a public sector or mutual/social enterprise model of care. However, it will require resources and a culture in which the service user is the key architect of the service provided. In this new approach the work of social workers and other Allied Health Care professionals will be to facilitate and empower citizens rather than being constrained by eligibility and financial barriers on what can be provided. We need to move beyond a service in which the citizen receives what is defined by a range of eligibility criteria and means testing to one that is based on a holistic assessment of their needs.

    Response to individual Questions.

    Summary of the consultation questions The Welsh Government welcome comments on all aspects of the proposals. We are particularly interested in responses to the questions. A summary of the questions is provided below.

    Question 1: Do you agree that complexity in the social care sector inhibits service improvement?

    The complexity and inefficiencies of the market exists at many levels.

    Service users.
    1. Services users are subject to a needs assessment which is often predicated on seeking ways to delegate caring duties to the applicant, their family, or friends.
    2. Financial constraints may curtail the delivery of a fully holistic care package.
    3. Applicants are subject to a financial assessment which can be difficult and obtrusive.
    4. The lack of staff continuity means that service users must deal with a series of different carers.

    Commissioning Process.
    1. There is a multiplicity of providers of social care, usually in the for-profit sector. This involves additional and unnecessary transactional costs. This is further complicated by additional costs when a “self-funder” must be reassessed having dropped below the various capital thresholds.
    2. There is continuing confusion between paying for “social care” and “continuing NHS care (which is free).

    Cross Organisation Boundaries.
    1. We welcome efforts to promote integrated joint working via Regional Partnership Boards and through funding streams such the Integrated Care and Transformation Funds. However, all these arrangements are not without their problems though they have made an important contribution to joint working.

    The lack of clear mechanisms to identify, allocate and share budgets is a significant obstacle to joint working.

    Joint working on the front line is facilitated by putting a “face to a name” and building trust. The relationships built during the present Covid-19 crisis bears this out. In “normal times” it unusual for front line workers in social care, housing, education, and the NHS to build up a relationship based on joint working – they do not know each other, they work for different organisations with different priorities, and they do not share a common workspace.

    Question 2: Do you agree that commissioning practices are disproportionately focussed on procurement?

    Yes. Except that the extremes, price will always trump quality.

    SHA Cymru strongly believes that the number of people who obtain services and what services are provided are curtailed by financial constraints rather than by full needs assessments. This also applies to unpaid carers.

    We accept that austerity is a major obstacle to commissioning for quality when resources are extremely limited, and need is increasing.

    Also, it is difficult to measure quality as opposed to measuring a failure of compliance which is set out in rules, standards, and regulations. There needs to be better ways of capturing the lived experience of the service-user, their carers, their parents, and their advocates.

    Question 3: Do you agree that the ability of RPBs to deliver on their responsibilities is limited by their design and structure?

    Regional Partnership Boards are a step in the right direction. The Welsh Government must do more to promote their importance and profile.

    However, most of the organisations that are involved still have a limited commitment and retain a strong territorial loyalty to their parent bodies. Competition for funding and resources is a major obstacle to joint working.

    The governance arrangements for the RPBs are totally opaque and SHA Cymru suspects that their existence is only known to a small number of people in the NHS, local government, Third Sector, and public bodies such as NRW.

    The RPB needs assessments and the strategic responses that they generate are not major priorities for most of the constituent bodies. They are more exercises in compliance that an engine for change and delivery.

    We believe that RPBs could enhance their role and effectiveness by being a catalyst and conduit of best practice within their region and elsewhere.

    Question 4: Do you agree a national framework that includes fee methodologies and standardised commissioning practices will reduce complexity and enable a greater focus on service quality?

    Question 4a: – What parts of the commissioning cycle should be reflected in the national framework?

    SHA Cymru supports a National Care Service in Wales in which citizens have a reasonable understanding of what they can expect from their social care service. However, this national service must reflect the diversity of need and culture in the various parts of the country.

    We support the creation of a national social care workforce for Wales rather than the infinite variety of current employment practices and standards. This will ensure a uniformly trained workforce with national terms of service. As staff pay is the single biggest cost in the sector this will remove a lot of the fog that surrounds fee setting now. This will simplify the commissioning process and reduce its inefficiencies.

    We also welcome the Welsh Government’s proposals for regular sector viability assessments. This will be an important mechanism to align capacity with need. However, we are disappointed that these proposals are not linked with policies to promote direct public sector provision where local needs are not being met.

    The commissioning process must seek to identify unmet and unfunded need. This will provide important information for future planning cycles.

    Question 5: Do you agree that all commissioned services provided or arranged through a care and support plan, or support plan for carers, should be based on the national framework?

    Yes. However, this does not mean a one size fits all provision delivered in any colour providing it is a bland white!

    In health and education people have a reasonable understanding of what to expect across Wales. There is no reason why the same should not apply in social care. Indeed, the co-payment element in social care makes this more important. We welcome the Welsh Government cap on the cost of domiciliary care and the increased thresholds for residential care.

    Care plans must be co-produced with the service user and their carers rather than provided within constraints and obfuscations of means testing and eligibility barriers.

    Question 5a- Proposals include NHS provision of funded nursing care, but do not include continuing health care; do you agree with this?

    Without understanding the historical context, the present system is totally incomprehensible to the average citizen. There is no sense that one person gets a “free NHS bath” while someone else has to pay for a “social care bath”. Equally there is no logic that a person with a chronic illness such as cancer gets a free service on the NHS while those with dementia must pay for most of their care via social services.

    These arrangements fly in the face of the Welsh Government’s commitment to user centred and integrated care.

    Question 5b- Are there other services which should be included in the national framework?

    As mentioned in our introduction we believe that in a National Care Service there should be national standards of care, national eligibility criteria for services, national means to promote co-production and citizen led services and national terms of service for staff.
    Question 6: Do you agree that the activities of some existing national groups should be consolidated through a national office?

    A National Care Service needs a strong sense of national purpose for social care. The concept of a “national office” fails to capture this vision. SHA Cymru believes that we need a national executive or directorate to drive forward many of the objectives outlined in the consultation document. The executive / directorate should have a clear mission to develop a quality, coherent service across all of Wales.

    In a National Care Service in Wales many of the present “bolt-ons” should be integrated into a single cohesive organisation. However, the specific specialisms of the individual services need to be recognised and provided for.

    Question 6a- If so, which ones?

    While we support an overall National Care Service, the regulatory and inspection roles should be independent and seen to be independent. We welcome the integration of NHS and Social Care complaints processes on an independent basis from the NHS and local government.

    Question 7: Do you agree that establishing RPBs as corporate legal entities capable of directly employing staff and holding budgets would strengthen their ability to fulfil their responsibilities?

    Yes. SHA Cymru would welcome the establishment of the RPBs as corporate legal entities. Now they exist as a gift provision by their component bodies. This deprives them of the status or capacity to plan the delivery of integrated services across organisation boundaries.

    There must be mechanisms to allocate resources to the RPBs for both their own administrative / management purposes and to have the means to fund integrated cross boundary services. We note the references in the consultation document to experiences in the other parts of the UK in relation to integrated working.

    We believe that there are valuable positive lessons from the Scottish experiences. On the other hand, we would advise caution about replicating the main English direction of travel – which is deeply contaminated by serious under-funding and commercialisation of services.

    Question 8: Do you agree that real-time population, outcome measures and market information should be used more frequently to analyse needs and service provision?

    Question 8a- Within the 5-year cycle, how can this best be achieved?

    The Financial Crisis of 2008, Brexit and the Covid Pandemic of 2020 show how vulnerable long-term planning is to unforeseen events. Any planning cycle must be flexible enough to adjust to such shocks.

    However, we also realise that strategic change cannot be delivered on short time scales. The NHS process of in-built short- and medium-term reviews within a long planning cycle has a lot to commend it.

    Question 9: Do you consider that further change is needed to address the challenges highlighted in the case for change?
    Question 9a- what should these be?

    The consultation document has presented itself with a range of almost irreconcilable ambitions.

    For the immediate future we are likely to face continuing austerity. We welcome the Welsh Government’s commitment to continue to lobby and use its good offices to urge the UK Government to deliver on its decade old, and much delayed, pledge of addressing the challenges of social care. If these efforts are not successful, many of the consultation paper’s objectives will not be achievable.

    A shift toward “commissioning for quality” is highly commendable, but the road to achieving this is littered with obstacles and potholes. The sector itself is in a highly fragile state bordering on unsustainably. At a very minimum, a quality service requires a valued, stable, and well-trained workforce. All these requisites are at the mercy of the variability that is inherent in a multi-provider for-profit model for care delivery.

    Unless there is a way of addressing current financial pressures then the present trend of ever higher eligibility criteria will mean fewer and fewer people will be in receipt of care. As need is inevitably going to increase it will mean that more and more of people will be left to live deal with their problems by whatever means they can muster.

    Question 10: What do you consider are the costs, and cost savings, of the proposals to introduce a national office and establish RPBs as corporate entities?

    See the answers to Q6 and Q7 above.

    Question 10a- Are there any particular or additional costs associated with the proposals you wish to raise?

    We accept that a quality social care service will cost money.

    We note the work that is being done on a social care levy and we wait to see its outcome. However, any market-based funding system will be subject to major shocks – we have seen three since 2008 – and we wonder how resilient they will be in the long run. Very few insurance based public services have been sufficiently resilient to survive without state interventions and guarantees.

    Welsh language

    Question 11: We would like to know your views on the effects that a national framework for commissioning social care with regionally organised services, delivered locally would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    It is essential that social care services should be delivered bi-lingually. This is crucial across all age groups from children’s services to services for vulnerable older adults. Equally the right for people with learning and physical disability to live their lives thought either Welsh or English must be fully recognised.

    The local needs assessments must take full account of the cultural values and diversity of the population it is assessing. Service providers must not regard responding to this diversity as an optional extra.
    Welsh and English have a particular standing in Wales. However, many other vulnerable people e.g., asylum seekers, refugees, migrant workers, and minority ethnic groups will have needs which a holistic service must strive to address.

    Question 12: Please also explain how you believe the proposed policy to develop a national framework for commissioning social care with regionally organised services, delivered locally could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    If “quality” is to be the key barometer of performance, then a citizen focused service that is planned and delivered in line with local needs can only promote Wales as a bi-lingual country. Most social care providers are heavily dependent on local people for service provision. This workforce will be familiar with local cultural values and norms. A secure, valued, and well-trained workforce can only enhance the quality of life of the citizens under their care.

    Comments Off on REBALANCING SOCIAL CARE IN WALES — Response to Welsh Government White Paper on Social Care.


    Joint authors:  Colin Slasberg and Peter Beresford

    We have previously set out why we believe the Feeley review of Adult Social Care in Scotland has the potential to be truly ground breaking. Its first and primary recommendation is that social care should be established on a human rights basis. Whilst it also makes recommendations about structural change, the report recognises that structural change without cultural change is no change at all.

    While the rhetoric of human rights has littered social care policy for at least two decades, Feeley is not the first to recognise it simply hasn’t happened. Whilst there are examples of excellence, they are not the norm. However, what makes the Feeley report different is that it goes further. It pinpoints the practical changes required. These focus on the process of assessment, support planning and resource allocation. Three recommendations are of particular importance;

    1. ‘People should understand better what their rights are to social care and support and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    2. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    3. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

    Delivery of these three recommendations alone would have far reaching consequences. They would amount to the abolition of eligibility criteria to identify ‘need’ and control spending. This would lead to the re-purposing of the entire system from its current protection of public resources to one that serves to promote the human rights of older and disabled people, whatever level of funding the democratic system happens to make available to it.

    The early responses

    The Feeley report was warmly welcomed by all parties in a debate in Holyrood on February 16. The Scottish Government committed to working toward a way forward ahead of the May elections.

    However, there remains deep scepticism amongst activists and academics. For some it is born of many years of national and local government talking the talk of rights whilst walking a very different walk. For others there is disappointment Feeley did not demand funding to meet all need as the precondition of a system based on human rights, or to the structural changes they favour, or to renationalisation of social care as the solution its ills.

    The following sets out nine key tests by which to judge the authenticity of the Government’s intentions in how they respond to Feeley. They set out the practical steps required if Scotland is to deliver the Feeley recommendations.

    Nine key tests

    1. Government will establish the principle that in social care, as in the NHS, need will precede resources. A founding principle of the NHS was that clinicians must be free to identify clinical need and the resource consequences must follow. People generally trust that NHS clinicians will indeed identify to the best of their knowledge what modern medicine can do to give them the best possible health. This is not the case in social care where decisions about ‘eligibility’ are made ‘above people’s heads’. If Government declares that social care will join health care in putting need before resource, social workers will be free in line with their professional ethic to identify what will give people the best quality of life their circumstances allow. This, in itself, is arguably the single most transformative change that will deliver for social care the ‘1948 moment’ Nicola Sturgeon says she is seeking. The following eight all rise from and are a consequence of this one change.
    1. Government will declare the end of the eligibility system. The eligibility system, whereby ‘need’ is defined against so-called ‘national’ criteria, ostensibly exists to deliver equity. The scale of the inequity in levels of provision between councils identified by the Feeley report is testament to its failure. What ‘critical and substantial’ means varies from council to council according to their resources. The durability of the eligibility system is owed therefore, not to the pursuit of equity, but to control of spending. Success in controlling spending in this way comes at the expense of the resource-led and controlling practices the Feeley report so roundly condemns.
    2. Government will declare a commitment to fund all needs for people to have a dignified quality of life to the best of its ability. The Feeley report does not recommend Government commits to funding all needs. No public service is guaranteed the funds to meet all its responsibilities, not even the NHS. However, the necessary process of prioritisation should not and need not lead to loss of vision and moral purpose. Government should lead the way in ensuring the needs of older and disabled people compete on a level playing field with all other public services, currently denied by the eligibility system.
    3. Government will require systems are established that aggregate and report unmet need. Unmet need is the inevitable consequence of adopting the principle of need preceding resources. The NHS equivalent is waiting times. At the operational level waiting times provide the safety valve when need exceeds resources. At the strategic level, they tell political leaders the level of funding they need to make available. In social care the eligibility system denies them such information. Unmet need must be seen as the social care equivalent of waiting times in the NHS. Information about unmet need must be in the public domain, easily accessible and able to hold political leaders to account.

    Councils have sometimes in the past experimented with boxes on assessment forms for social workers to record unmet need. The information languishes in filing systems, goes nowhere and quickly falls into disuse. Government must avoid repeating such a mistake.

    1. Government must acknowledge that regional equity depends on the level of resources available to local authorities and is a national responsibility. Whatever else a National Care Service may comprise, national government must accept responsibility both to ensure that resource levels minimise unmet need, and are fairly allocated regionally.
    2. Government must require councils to establish systems that control spending without compromising assessments. No matter how large or small the gap between needs and resources, it is a fact of life than spending will have to be contained within budgets. Case by case decisions to determine eligibility as the means to do so must be replaced with case by case decisions that determine This will require a complete re-engineering of the decision making infrastructure, including financial and IT supports. Whilst equitable allocation of resources at individual budget holder level will continue to be important, it will be joined by value for money as no less important a challenge. A budget holder’s task will be to achieve the greatest quality of life for the greatest number of people within their budgets. This will require significant re-skilling of budget holders
    3. Government must require councils to democratise their assessment process. Assessing for eligibility spawns a bureaucratic, obscure and professional-centric process. Such processes must be swept away. New processes will be required that are accessible to all service users to support them to think through and declare their own assessment of their needs and support requirements. The council only has to be concerned that such self-assessments make the best use of resources so the person can have the best quality of life their circumstances allows. The social work role will be to support people to achieve such a self-assessment, working to whatever depth is required. An open, democratised assessment process is key realising the Feeley recommendation that assessments must be ‘co-produced’ and for people to have authentic choice and control over their support.
    4. With the system fundamentally re-purposed, Government will need to ensure there is a workforce development strategy. The social work role will be transformed from the current ‘piggy in the middle’ role to being able to work in authentic partnership with service users. It should come naturally to those whose value base is person-centred and also to social workers who are professionally qualified.

    Re-skilling will also be needed at the most senior levels too. Directors of Social Work will no longer have the task of managing a system that makes ‘need’ fit within whatever resource their political masters give them. Their task will be firstly to get the best from the given resource, and then to inform their political leaders of the shortfall. Their relationships will change. They can truly become the champions of the community.

    1. A transition strategy for existing service users. Resource-led assessments for ‘eligibility’ and person centred assessments are as chalk and cheese. Whilst the former is a negative exchange to see how bad life can be, the latter is a positive one to see how good life can be. However, there will be overlap. Some needs previously deemed ‘eligible’ will continue to be needs within a human rights based approach. There is a clear moral argument that existing service users should not be penalised by the change. All needs previously considered ‘eligible’ that also meet needs within the reformed system should be subject to a guarantee of being met as long as the need remains.


    For the above reasons, Feeley puts Scotland on the brink of becoming a world leading country in the delivery of social care. It would be one built upon the lived experience of each and every older and disabled person in need of state support. However, in the absence of pressure on Government to deliver the radicalism of the above agenda, the greater fear is that it won’t happen. Feeley’s plea for a system driven by human rights runs the real risk of being reduced to a pre-amble to the Government’s response that will amount to yet another reiteration of warm words and good intentions.

    Implications for England

    Whether or not Scotland does move forward, the lessons England could pick up are clear. England, whilst using different words, operates the same eligibility system as Scotland. England, too, has regional inequity of enormous proportions. Most service user groups will recognise the Feeley report’s description of the assessment and support planning process. It is bureaucratic, damaging and alienating.

    Debates in England are dominated by the funding issue. That takes the form either of focusing on the balance of public and private funding, sources of taxation or funding levels. There is, however, little debate about the vision for social care. Isolated Members of Parliament sometime raise the issue of a vision for social care, but those debates are not entering the mainstream. Yet without vision, how can the service know it is getting the best it can from the resources it has? And without vision, how can the public know what they are being asked to support, and how can political leaders know what they are being asked to fund?

    The issues Feeley is inviting Scotland to grapple with are issues England should grapple with too.



    Joint Authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.

    With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.

    Cultural change must precede structural change.

    The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.

    Facing up to the resource consequences

    It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.

    The review makes the following three recommendations;

    1. ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    1. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    1. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

     The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.

    The transformation process – from what to what?

    The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.

    These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.

    If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible.  Patients are aware, however, they may subsequently have a wait depending on availability of resources.

    Managing the resource consequence

    For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.

    The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.

    The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.

    The political consequence

    The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.

    That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.

    Implications for England

    We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.

    The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.

    The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.

    Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.

    Comments Off on Realistic hope for a Social Care system driven by Human Rights from Scotland

    In September 2020 the Welsh Government invited comments on the draft regulations, code of practice and statutory guidance from local authorities, local health boards, and other organisations or sectors which are represented on Regional Partnership Boards (RPBs) or have an interest in the provision of care and support to the local population. RPBs are the main Welsh platforms of collaboration between health, social care, the Third Sector and a range of other key stakeholders.

    The Socialist Health Association – Cymru agreed its repose to the consultation questions as follows:-

    Question 1 Do you agree that market stability reports should be prepared on a regional basis, by local authorities and local health boards through the regional partnership boards? If not, please give your reasons.

    The Socialist Health Association Cymru believes that the business model underpinning our social care service in Wales is no longer sustainable and we need to be planning for a National Care Service.

    The independent sector continues to express concern about its marginal viability with residential care providers requiring levels of bed occupancy that go against the Welsh Government’s policy of more care in a domestic and homely community environment.

    There is a recruitment and retention crisis which is worse in the independent sector due to poorer pay and conditions, less training and fewer opportunities for career progression.

    Within this context we believe there is an urgent need to undertake regular assessments of the continuing viability of the current model of provision.

    While the consultation document proposes reports on a regional basis, it important that the geographical spread of provision in mapped at a more local level.

    Question 2 Do you agree that market stability reports should be produced on a five yearly cycle alongside the population needs assessments? If not, what alternative arrangements would you propose, and why?

    We note that the proposals recommend that a five year assessment cycle with at least a mid-cycle interim review.

    We believe that the overall fragility of the sector requires a three yearly overall assessment with a yearly review.

    Question 3 Have we specified all the key matters that need to be included in market stability reports? If there are other matters you think should be included, please specify.
    While we are fully aware of the sector’s legacy of being heavily dependent on for-profit providers, we are surprised at the failure of the consultation document to consider what role public bodies might play in service provision. This is only briefly mentioned in the context of a sudden closure of an established private sector provider.

    The omission is all the more surprising as it recommended that the assessments should be linked the to Regional Partnership Board needs assessment.

    The implicit assumption is that local authorities will have no role in the management or shaping of the market beyond its present contract compliance assessments. This means that it will be for others to address gaps in service provision.

    The variation in local authority fees across is Wales in considerable. It is far from clear why this is the case though these fees are at the heart of any assessment of the viability of the sector.

    Question 4 Do you agree that market stability reports should be kept under regular review and revised as necessary, but at least at the mid-way point of the five year cycle? If not, what other monitoring and review arrangements would you propose, and why?

    See reply to Q2

    Question 5 In your opinion, does the draft code of practice strike the right balance between what is required of local authorities and what is left to their discretion? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    The document urges “reasonable” efforts for community engagement. This is a rather elastic requirement which could result in a minimum level of engagement. It would be useful to be more specific that efforts should be made to engage with organisations such as the CarersUK, Stroke Association, Alzheimer’s Society, Mind as well as any successor organisation to Community Health Councils.

    There should be a specific reference made to any community councils in the Regional Partnership Board area.

    There only the most fleeting reference to engagement with care staff and other support / partnership professional groups. There should be a clear requirement to engage with local trade unions involved in the Education, Health & Care Sectors e.g. Unison, GMB Unite the Union, RCN, NEU and Local Medical Committee. In some areas, where there may be low levels of trade union membership, the local trades union council ( if it exists) should be consulted.

    Local groups of faith should also be specifically included in any engagement. They provide comfort and support to many of our citizens in times of difficulty and they can have important insights into the needs for particular communities.

    Question 6 In your opinion, does the draft statutory guidance set out clearly the partnership approach that local authorities and local health boards should take in preparing their market stability reports? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    See replies already given.
    The document mentions the need to anticipate trends but is rather limited in the scope of the horizon scanning it envisages. This is a vulnerable sector underpinned by a fragile business model. It follows that more vision is required in looking at delivery models of care e.g. more in-house provision by public bodies, the NHS or the Third Sector.

    Question 7 What impacts do you think our proposals will have on the duties of public bodies under the Equality Act 2010, or upon a local authority’s duty under the 2014 Act to have due regard to the United Nations Convention on the Rights of the Child, the United Nations Convention on the Rights of People with Disabilities, or the United Nations Principles for Older People?

    This is a timely document and Welsh Government is to be commended in initiating this legislation. Not withstanding the attitude of the Westminster Government to international agreements the Welsh Government has always used best international standards to drive policy.

    A citizen focused, responsive, stable and caring service needs to be in place to meet international standards. This must include provision that is based on the needs and wishes of its users. The workforce must be well trained and valued.

    None of this will be possible if overall business model of care is not longer fit for purpose for the challenges of the 21 Century.

    Question 8 We would like to know your views on the effects that our proposals with regard to market stability reports would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    This is particularly important. Bigger, footloose corporate bodies have a smaller footprint in Wales which is generally a good thing. Smaller, local providers with a local workforce are more likely to be culturally sensitive to their needs of citizens.

    In many parts of Wales the local population will include people who have spent most of their lives in an area and others who have moved in at various stages of their life cycle. Our providers must respond to this diversity.

    Many vulnerable users would wish to engage with services in their first language. The planning and service delivery process must be responsive to this need.

    The Welsh language is an important part of Welsh life. As well, individual communities have other cultural attributes which can provide support and comfort to local service users which should also be factored into a citizen centred service.

    Question 9 Please also explain how you believe the proposed policy around market stability reports could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    See Q8.

    Market stability reports should include a specific section demonstrating how the needs of Welsh speakers and other sensitive cultural dimensions are taken into account.

    Question 10 Under the Well-being of Future Generations (Wales) Act 2015, public bodies have a duty to consider the long-term impact of their decisions. We would like to know to what extent you think our proposals will support the principle of sustainable development set out in that Act. Further information on the Well-being of Future Generations (Wales) Act 2015 may be found here:

    Our health and care service is still too illness and crisis orientated. It needs to be more pro-active and enabling for all our citizens.

    Beyond the immediate pressures of Covid-19 and the longer term legacy we have inherited, the Welsh Government needs actively to promote a policy of prevention and early intervention to create a more equal and socially just society that is at ease with itself.

    This includes providing our young people with the best start in life, providing all citizens with the opportunity to live full and enjoyable lives and providing a healthy ageing strategy including tacking loneliness and social isolation for citizens as they progress through life.

    Question 11 We have asked a number of specific questions. If you have any related issues which we have not specifically addressed, please use this space to report them. Please enter here.

    SHA Cymru welcomes this proposal to assess the inputs into service provision other than in crude quantitative ways. This approach could be extended to other field of policy e.g. to assess the scope and scale of service provision in different communities and localities.

    Our Chief Medical Officer has often pointed out that “one size does not fit all”. Different communities have different needs. If we are to address these varying needs at a community level we need to develop processes which could be informed by the lessons learned from implementing this legislation.

    October 2020

    Comments Off on Social Market Stability in Wales — Consultation Response SHA-Cymru

    Cllr Barry Rawlings, Leader of the Barnet Labour Group

    Particularly since the pandemic, public attention to social care has focussed on the fragility and impoverishment of the major services, residential and domiciliary care, that provide the direct care and support to older and disabled people. However, less visible is the beating heart of social care, which is the way councils identify need, plan support and allocate resources. This is the process that determines the fate of each individual.

    Over the past 18 months, as the Labour opposition to a Tory controlled Council, we have been forensically testing how that system works. We have found its nothing like the claims being made for it. We have been giving a great deal of thought to what is wrong and how it can be put right. We have come to a number of key conclusions.

    The first conclusion is that the UN definition of Independent Living is beyond question the right vision for social care. We believe all Barnet residents who rely on social care, whether in their own home or living communally, should have control over their lives with ‘choices equal to others’ with ‘full inclusion and participation in the community’.

    We have to make this a practical reality, not just a pipe dream and not just yet more rhetoric. This means addressing the resource question. So, our second key conclusion is that the UN approach to the resource consequences is also the right one. States are not expected to have all the resources immediately available but are expected to take ‘concrete steps’ to embark on a process of ‘progressive realisation’ of the resources required.

    So, instead we are looking at the feasibility of a new model of working. That model is:

      • First: To empower our social workers to work in real partnership with our service users to identify and cost all their needs for Independent Living.
      • Second: To put a stop to the miserable, minimalist ‘eligibility’ practices.
      • Third: To ask budget holders to be transparent about what their budgets can afford and what they cannot.
      • Fourth: To expect the Director to explain what is needed for all to have Independent Living, not to reduce ‘need’ to whatever budget is provided.
      • And then to do everything in our power to secure the resources required by using the evidence we have gathered to ask Government for the funds Barnet needs.


    That brings me to our third key conclusion. The Care Act already provides the primary legislation to make this happen. Its central concept of wellbeing has 9 dimensions. They include dignity, respect and control over one’s life and services. You couldn’t put a cigarette paper between this and the UN definition of Independent Living. The Act also has provisions that enable councils to be honest about what they can and cannot afford. It also requires councils to  actively find out what resources are required to meet all needs in the communities they serve.

    Our fourth key conclusion is that none of these transformative provisions are being enacted by Barnet Council. Barnet like all Councils, maintain they deliver the national template. All the Care Act has done is provide new language for the same old practices that demean service users by telling them what their needs are, and then defining ‘need’ to suit their budgets.

    Our fifth conclusion is that the problem lies with the secondary legislation – the Statutory Guidance and Regulations. These are the responsibility of Government, not Parliament. They have been constructed in a way that allows councils to by-pass  key provisions of the Care Act   and focus on eligibility rather than wellbeing. These practices serve the political expedients of controlling spend to budget while delivering the political convenience of denying the existence of any unmet need.

    None of this is the fault of local authorities or their social care staff.  Social workers do their best to squeeze as much out of the system as they can for individuals, but it’s a zero-sum game and there are always winners and losers. This is the inbuilt inequity of the system.

    This is an issue that affects all councils, as all will be applying the Statutory Guidance and Regulations. If there is a party-political criticism of the Barnet administration, it is in the enthusiasm with which they embrace the status quo. They have used it to drive spending down in Barnet to the point where they boast about being one of the lowest spending councils in the country, and by a long way.

    The Guidance and Regulations must change. They must make Independent Living the standard of wellbeing for all, require councils to deliver the spirit and letter of the Care Act, to report on unmet needs and require central and local Government to do all in their power to secure the resources required to minimise, if not eliminate, unmet need.  Local authority social care practices will need to be re-purposed  top to bottom. I believe these changes would comprise the ‘concrete steps’ toward ‘progressive realisation’ the UN expects. The UN gave a damning verdict of the UK’s delivery of Independent Living in 2017.

    With real co-production at the heart of needs assessments, as proposed in this new model, we might achieve better health and wellbeing outcomes which will actually save money in the long-term.

    And in the process the narrative will cease to be the dead end of how much money ‘social care’ requires. It attracts little enduring public sympathy. We should promote equivalence in the public mind between best possible wellbeing, which social care delivers, and best possible health of mind and body, which the NHS delivers.

    So, given that ‘adopting into English Law Articles from the UN Convention’ potentially includes changes to the secondary legislation to bring the Care Act to life, I fervently hope the SHA/KONP campaign has the greatest possible impact.



    by Esther Giles, Former Director of Finance (Specialised Services) South Region of England, SHA member”

    This article tracks the extent and nature of marketisation and privatisation in the NHS up to the current proposed move to Integrated care systems (ICSs) and argues that the current ICS proposals are the logical conclusion of the marketisation reforms implemented progressively from Thatcher onwards.


    Some of David Cameron’s many famous last words were his pre-election pledge in 2010 that there would be no more “top-down reorganisations” of the NHS[1]. He then presided, in 2012, over the most chaotic and unlegislated top-down upheaval of the NHS that can be imagined or remembered. The resulting fragmentation and damage were never resolved, and so the NHS goes limping in the logical conclusion of the relentless drive away from a universal national service, and towards the current proposals for Integrated Care Systems (ICSs) modelled on the US Kaiser Permanente system of Accountable Care Systems.

    The 2012 Health and Social Care Act and Marketisation

    The internal market was given a fundamental boost by the Health and Social Care Act 2012. Under this Act, all NHS services above a stated value had to be put out to competitive tender, turning the provision of healthcare into an economic activity and, as such, subject to EU competition Law.

    Thus, private providers such as Capita and Virgin have been seen bidding to provide NHS services, mainly in community services. Sometimes they win and sometimes they don’t. And if they don’t, they look for opportunity to sue. In the South West, we saw Virgin win contracts for Community Services in Devon[2] and Bath and North-East Somerset (BANES). Richard Branson’s Virgin HealthCare won £1bn worth of contracts in 2016/17. It won these services from the NHS and from non-profit making services such as community interest companies.

    NHS acute hospitals have all stayed within the NHS so far, except for a short flirtation between Hinchingbrooke Hospital and the Circle Group, which ended in disaster, with the provider being put into “special measures” in 2015. The picture is very different for mental health care, where the private sector has had continued domination of parts of the market, in 2012/13, 22% (£1.7bn) of NHS mental health spend was with the independent sector, compared with 4% (£1.8bn) of acute spend. Providers include St. Andrew’s Healthcare, Partnerships in Care, and the Priory Group. For secure MH services, they are all building ‘private’ because the NHS cannot afford the capital funding to do so, Typically, these independent sectors beds cost the NHS 20% more than NHS beds[3].

    There is no evidence that the Internal Market has been any sort of success. No evidence that competition has improved outcomes in any but a few limited examples where causality is neither clear nor proven. The costs of the internal market are huge. Administrative costs in the NHS were estimated at 14% in 2005 compared with 5% before the 1980s; costs of the internal market alone are estimated in the range of £5bn per annum.  To quote Professor Paton in his 2015 study:

    “The ‘market’ in the NHS is a major source of waste. Creating and maintaining markets has incurred huge direct costs and significant ‘opportunity costs’ – money which could have spent upon patient care and clinical redesign.”

    The Private Finance Initiative

    The Private Finance Initiative (PFI) was introduced by John Major’s Government from 1992 and was embraced by the subsequent Blair government as a means of removing spending from Government balance sheets and thus reducing public spending in the short term. Most authorities would accept that the PFI has failed, and at material cost to the taxpayer.

    The promulgation of the Neoliberal Ethos in the NHS

    Progressive neoliberal reforms have reinforced the ideology of the market. All have fragmented the provision of healthcare and siphoned public money off into private sector balance sheets, shareholder dividends and profit margins. At the same time, pressures on NHS budgets require NHS management to reduce costs. It seems that the NHS has been presented with an imperative to cut costs and handed privatisation as an alleged means to this end.

    The NHS is one of the most efficient and trusted healthcare systems in the World. One of the reasons for its efficacy and efficiency is that people are given care according to their needs and irrespective of their means. This ethos belongs to its workers as well as to the organisation; for many people who work for the NHS, it is a vocation, and they care deeply about what they do. They have the intrinsic motivation that drew me to a career in the NHS. But, over the past thirty-five years, this ethos has been progressively undermined by the neoliberal ideology that delivery and innovation must be driven by competition and the profit motive, and that input costs must be minimised. This ideology appears to have been accepted, without challenge, by every government since and by the top management of the NHS, despite many public campaigns against privatisation. The consequence of this, combined with a political austerity consensus – that the deficit must and will be reduced by cutting public spending and selling off public assets, means that cost-cutting is accepted as part of the “solution” for the NHS. In a ‘business’ where more than 70% of costs are staff related, the next leap of logic is that staff costs must be cut.[4] This is interpreted and delivered in a number of ways, all of which serve to undermine the quality and energy of the NHS workforce and which include pay freezes, dilution of skill mix, reducing “management costs “, and the outsourcing and privatisation of individual components of the NHS.

    Many people- and not just socialists- have been dismayed over the years at the continuing and relentless reorganisation, marketisation, privatisation and fragmentation of the NHS. The market, with its endless and costly hand-offs between one commercial entity and another, cripples the best efforts of professional staff and those that support them.  Not only are these hand-offs costly to procure, but they also require constant and detailed policing. Furthermore, continuous reorganisation and market testing destroy morale and organisational memory. All these results of the market take focus away from patient care. I believe that the NHS works best with a collaborative rather than a competitive ethos. Where decisions about care are driven by the needs of the patient, not by the scope for profit. Where quality is a prerogative always, not just when it helps to win a contract. Where the entire NHS budget is used to provide and support patient care.

    NHS workers bear the brunt of the rhetoric and dogma at the heart of current policy, being presented as a cost rather than a benefit, a “burden” on the state, the costs of whom must be minimised. They must” tighten their belts” like everyone else – apart from the wealthiest. Now, the biggest crisis in the NHS is the lack of qualified staff, exacerbated by the removal by the current government of bursaries for nurses and by its disastrous instrumentalisation of migrants’ rights in Brexit negotiations. ​ It is a crisis brought on by what appears to be deliberate incompetence by the Government, mitigated only by the continued introduction of qualified staff from third world countries.

    The Extent of Privatisation

    A simple measure is the proportion of NHS spend on private sector providers as reported in the Department of Health Accounts. In 2004, this was 2.8%. and in 2018/19, it was reported as 7.3%. with privatisation accelerating after the Health and Social Care Act 2012. However, these figures mask the extent of private provision within NHS providers, where many ancillary services- such as cleaning, catering, portering and pharmacy- have been outsourced since Thatcher’s 1983 initiative. There is also spending on private providers of primary care (including GPs) to take into account. After adding these into the figures, the total spend of NHS England in the private sector in 2018/19  is estimated by David Rowland, Director of the Centre for Public Health and Interest as £29bn, or 26% of NHS England spending. So, there’s little doubt that privatisation is increasing in the NHS, and that “market reforms”, compulsory tendering under EU Law (until now), and a lack of ready cash are important drivers of this. It is of huge credit to NHS workers that, despite these onslaughts and years of pay freezes and cuts to services, they soldier on.

    Consultation on Integrated Care Systems

    The fragmentation forced by the disastrous 2012 Health and Social Care Act exposed the gross dysfunction of the internal market. It set commissioners against providers in an endless spiral of tactics to gain at the expense of the other, at huge administrative and organisational cost. The concept of the ICS could, in theory, see a return to the local system approach adopted in District Health Authorities (DHAs) prior to NHS marketisation, with funding being based on populations adjusted for cross boundary flows, with no internal market, and with local systems agreeing plans and setting budgets and quality standards for local services. This would provide the opportunity to remove layers of bureaucracy and unnecessary accounting and contracting and enable savings to move out to fund the front line. But it is clear from the consultation document that this is not the intended approach. And neither was this ever intended.


    The very core purpose of ICSs is to drive down care based on demanding cost savings targets imposed by the Government, in a service that is already one of the most efficient in the world. The ethos, even the language[5]  is that of the American accountable care system, where being seen to be cutting costs (and creating an industry out of that) is a key organisational driver and measure of success. And it is crystal clear that the policy march started by Thatcher and continued through Major, Blair, Brown, Cameron and May was to implement the Kaiser Permanente model first introduced by Alain Enthoven, and whose thinking was adopted by the Central Policy Think Tank when the internal market was first introduced into the NHS

    Specific Areas to address in the consultation document (and for Labour to develop) are suggested as follows:

    • the document retains the language and structure of the internal market in that it refers to provider organisations and provider collaboratives, and commissioners. The inference is that fragmentation can be addressed by provider collaboration (and, presumably, ultimately merger). Thus, it intends to retain the most pernicious and inefficient components of the internal market. A socialist radical approach (and which is Labour Policy) would be to remove the internal market altogether, and focus on quality assured service provision, supported by rigorous benchmarking of quality and cost and an overarching strategic and operational planning function. Undoubtedly there are extraordinarily strong vested interests in retaining the status quo, with “providers” having developed as big businesses in their own right.
    • The consultation document refers to “digital and data” to drive system working, and yet there appears to be no single NHS solution for this. Instead, there is a “Framework” calling on a wide range of “providers”, and the suggestion that there should be “shared contracts and platforms to increase resiliency”. An alternative to this would be an NHS-wide and provided digital data and information service.
    • Each System/Geographic area will have its own pot of money covering the whole of local spending on healthcare. Transactional costs are intended to be reduced through the “blended payment” model. An alternative approach would be to remove tariffs and set budgets based on the costs of the services required by the system. These costs could be budgeted on a variable basis using agreed parameters (such as variable capacity requirements).
    • Specialised Services need to be planned on a larger geographical footprint than other general services. This will require collaboration and planning between ICSs so that the needs of each ICS population are met in an equitable and efficient way. The funding for the relevant services should sit with the local ICS (managed on the same principles as RAWP with DHAs) so that they have the funding required to budget for all their locally provided services. Whatever mechanism is put in place should minimise transaction costs.

    [1] In a speech at the Royal College of Pathologists on 2 November 2009, Cameron said: “With the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS.”


    [3] Based on tariff data collected internally by NHS England in 2018/19

    [4] “‘Since it takes time to train skilled staff, (for example, up to 13 years to consult), the risk is that the NHS will lock itself into outdated models of delivery unless we radically alter the way in which we plan and train our workforce. HEE will therefore work with its statutory partners to commission and expand new health and care roles, ensuring we have a more flexible workforce […]” [5 Year Forward View, page 30.]

    [5] Along with the structures, the purpose, and the key role of US healthcare corporations in importing it to the UK, even phrases like “Right care, right time, right place” to advertise the NHS Long Term Plan’s service closures programmes, are lifted straight from the language of accountable care in the US. It is not a coincidence that the Healthcare Financial Management Association (the professional organisation representing finance professionals in the NHS) has, for many years, operated an exchange programme with the US, and with many conferences featuring US healthcare models. The HFMA offers courses based on the US model.


    This is SHA’s response to NHSE’s consultation on putting ICSs on a statutory footing. It is a curation of the generous and thoughtful comments of many members. Please forward to as many of your groups and networks as possible.


    Next steps to building strong and effective integrated care systems across England”


    A cooperative and democratic health and care system, fully funded through general taxation, free at the point of use, that eliminates the privatisation of clinical services.

     SHA cannot support these proposals.


    Q. Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?
    SHA does not agree. Our many reasons are explained below.

    Q. Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients?
    SHA does not have a view on this.

    Q. Do you agree that, other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?
    There need to be national standards, locally delivered, matched to the needs of an area. Please see SHA’s thinking on NHS democracy.

    Q.Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies?

    NHSE, if it continues to exist, should plan for those requirements that are best planned at national level. These could include rare diseases and specialist services.


    Based around place

    SHA supports the idea of services based on an area, reflecting the needs of that place. However, this document leaves place ill-defined.

    Relationships with Local Authorities

    There is poor legislative alignment of responsibilities of Local Authorities (LAs) and ICSs.  This is an issue particularly with reference to Public Contract Regulations 2015, which will still apply to Local Authorities and could increase the regulatory burden on local government, create barriers to joint planning arrangements, or result in inappropriate planning via an NHS channel as discussed elsewhere.[i]

    Interactions with local government are alluded to but only vaguely described.  For example, the document states ‘[the proposals] will in many areas provide an opportunity to align decision-making with local government’ [our emphasis]. This is very weak. How will ICS’s that do not align geographically with local authorities function in this respect?  There is a clear risk that such multi-authority ICSs will drive a ‘one-size-fits-all’ approach across diverse communities and geographies in direct opposition to the stated aims of ‘decisions taken closer to the communities’ [para 1.9].

    Overall, it looks as though this is not a collaboration of equals. An ICS as described would be led by the NHS and the LA would be very much a secondary partner. The SHA would like to see a bigger and more equitable role for LAs.


    The statements on devolution such as at 1.11 can be applauded but the reality we know is that since 2011 the NHS has become more centralised. There needs to be more concrete proposals on how this devolution will occur. The mandatory nature of the proposals is a concern and there should be more local discretion within National Care Frameworks and oversight.


    Clauses 1.12 and 1.15 are good clear summaries of what the ICS should do and provide. However, 1.16 on page 7 states that primary care, community health and mental health services, social care and support, community diagnostics, urgent and emergency care will be working together with other public or voluntary services Including those providing skills training, assistance into employment, and housing. But no consistent mechanism, structure, governance, regulatory, or accountability framework is defined for this.

    Strategic commissioning/planning (P2, third bullet point) requires the resources of a CCG and of a CSU, but the proposal appears to leave the CSU as a separate organisation (see P24, 2.68) outside of the ICS. No explanation is given for why this is better. Our view is that the CSUs were created outside of the NHS to provide a first landing place in the UK for US insurers who failed to take up the challenge. The most cost-effective route to back office services and business intelligence would be to bring them back into the NHS as shared services operations.

    These clauses do nothing to strengthen the requirement for probity in contracting and appointment procedures made scandalously apparent through court actions presently being pursued in the wake of inappropriate commissioning during Covid.

    There are poorly delineated internal and external accountability processes. As others have noted[ii], [iii] this is a consequence of a lack of precision regarding the function, roles and relationships of ICS. These issues should be clarified.

    There is insufficient detail regarding the openness and transparency of appointments, decision-making and data sharing by ICS and the role of independent sector (IS) organisations in ICSs. While we note that the Government considered ‘it likely that statutory organisations will hold the ICP Contracts’. [iv] Our understanding is that ‘accredited’ companies can be brought in to draw up policies and make service decisions within ICSs. These services could include:

      • Enterprise-wide Electronic Patient Records Systems – for Acute & Community and for Mental Health Hospitals
      • Local health and care record strategy and implementation support and infrastructure
      • ICT infrastructure support and strategic ICT services
      • Informatics, analytics, digital tools to support system planning, assurance and evaluation
      • Informatics, analytics, digital tools to support care coordination, risk stratification and decision support
      • Transformation and change support
      • Patient empowerment and activation
      • Demand management and capacity planning support
      • System assurance support
      • Medicines optimisation

    The role of independent sector organizations in this context must be more clearly defined and regulated, and subject to governance appropriate to a public body. Where possible the NHS should provide such services and/or be empowered to provide any such expertise. We do not agree with private companies being brought in as decision makers. They are bound by law to maximise shareholder profit, not to provide a public service.

    In addition, the document does not address the potential difficulties arising from the requirement on ICS organisations to comply with various competition rules, such as not sharing commercial sensitive information or fixing prices.  For multi-site ICS providers, this presents a system risk in terms of having to share patient and staff data or information with other organisations.  In general, insufficient attention is given to issues around sharing personal health information by ICSs.

    Guidance should be also clearer on the overriding importance of transparency in ICSs decision making. Efforts should be made to limit the use of ‘commercially sensitivity’ as a spurious justification for subverting transparency.

    There is insufficient consideration of potential conflicts of interest within the proposed ICS (e.g. between providers and commissioners, or between public, voluntary, and commercial partners) and how these can be prevented or mitigated. Notably it has been suggested that providers will be able to influence allocations via the ICS partnership board, and there is a credible concern that ‘bigger players’ will skew funding decisions.[v]

    Governance and PCNs

    1.17 mentions PCNs but the regulatory framework through OfSted for children’s services, CQC, NHSE/I, is currently not fit for purpose because it is overlapping and contradictory. There is no governance framework at the moment for PCN collaborations with community and mental health Trusts, and accountability is difficult to pin down.


    The paper promises to invest in the infrastructure needed to deliver on the transformation plan. This will include shared contracts and platforms to increase resiliency, digitise operational services and create efficiencies, from shared data centres to common EPRs.

    Digital is essential to the current and future NHS. SHA warns against the vaunted flexibility of the transformation plan allowing personal data to be misused by commercial interests even more than it is now. SHA also warns against services rushing into digital solutions without adequate evaluation and without enabling non-digital solutions for those who still require them.

    Health Creation is not mentioned in this paper.

    SHA supports the concept of Health Creation. That is the process of bringing people in contact with each other, building confidence and thereby enabling communities to take more control of their area and their health and care.

    An option we would like to see would be mandating 1% of a PCN’s budget to community strengthening – population Health Creation

    Population health, but almost no mention of Health Inequalities

    There needs to be a clear vision of the metrics of “population health” especially if this it to be the main outcome or “productivity” upon which the NHS and its partners is being judged. The consultation  paper seems silent both  on what these metrics are and on what role the NHS is to play in delivering that outcome. For example, is the metric of population health a pre-determined blend of longevity and the quality of life delivered?  To what extent is managing the ” social determinants of health” to be allied with the NHS as opposed to being the task of wider government and indeed others?

    “Integrating Care” does not really explain “population health”, but the HSSF is more explicit:

    “Population Health Management is an approach aimed at improving the health of an

    entire population and improves population health by data driven planning and delivery

    of care to achieve maximum impact for the population.”

    Any concept of patients and staff planning and evaluating the service, which will involve decisions on what to prioritise, is absent. Instead, the HSSF accredits corporations to support an ICS in taking such decisions. We should propose a 5th principle on the necessary need to involve patients in these arrangements. There is good evidence that such effective engagements lead to better services.

    In practice the emphasis on the role of Foundation Trusts and clinician-leadership is likely to prioritise clinical service provision, whether primary or secondary care, with limited focus on prevention and population health. This is an inherent structural weakness of the ICS model as currently specified.

    SHA cannot support ICSs without a far clearer commitment to tackling health inequalities through tackling the wider determinants of health and working closely with LAs, housing and other key partners. The document states that greater co-ordination between providers at scale can support… ‘reduction of health inequalities, with fair and equal access across sites;’. It is not clear how this follows as no mechanism linking these two is articulated. Vague commitments as outlined in the document are inadequate to address this persistent and worsening problem. Specific goals and mechanisms for reducing health inequalities should be explicit in the proposals.

    Single pot for finance and the legislative proposals
    On the face of it, a single pot (2.40), linked with reducing the importance of competition seems like a significant step forward and a more equitable and efficient approach to funding. SHA is supportive to the extent that these proposals reduce the contract negotiation and monitoring which is so wasteful of time and effort in the NHS, with savings in overhead costs and improvement in services designed by providers aiming at better outcomes, not by commissioners principally aiming to reduce expenditure. There must be appropriate risk sharing because of the danger that an individual ICS could be destabilised by unforeseen and one off events.

    It is not clear how this single pot will be spent, assuring fairness, value for money, quality.

    At 2.47 there is a limited mention of capital. There is no mention in the document of NHS Property Services or Community Health Partnerships or the NHS Estate. This is a major weaknesses in the proposals.

    Taken together with “Integrating Care”, this makes clear that fixed payment to secondary care providers must conform to the ICS system plan. Initially , the fixed payment would be based on the current block payments under the heading of COVID-19, which make up the majority of current CCG budgets. Fixed payments will be determined locally. While national tariffs will no longer apply in general, they may be retained for diagnostic imaging, a highly privatised sector. Some elective activity, again involving the private sector, will also be exempt from blended payment. In other words, private sector suppliers of clinical services will be protected from any local cost reductions.

    However, we also see impossible control totals which will make investing and innovation extremely difficult and constrain ICSs for the future. In effect, this continues austerity. We want to see comprehensive funding for an expanding, publicly funded NHS.

    Allusion is frequently made to anticipated cost savings and efficiency improvements [paras 1.8, 1.9, 2.22, 2.46, 2.51] but it is unlikely that these will be realised in the short-term and short-term costs may even increase.[vi] Evidence from similar interventions in the UK and other countries provides at best equivocal evidence for longer-term improvements in efficiency.[vii], [viii], [ix] Quality rather than cost-savings should be the primary driver of any reorganisation.

    There are other concerns SHA has in respect of the apparent relaxation of privatisation.

    All clinical services should be retained in house and fall under a re-instated duty of the Secretary of State for Health to PROVIDE such services.

    Providers will still be able to use the private sector. There are contracts now through NHS Shared Business Services which appear to require no formal tendering.

    Beware of cementing existing privatisation. This can happen through sub-contracting as above and by current private sector providers expanding through what ever contracting process there may be. The most likely beneficiary is likely to be the privatisation of mental health services through the Priory and similar organisations.

    Backroom functions will continue to be privatised.

    “Integrating Care” never mentions “private”, “independent sector” or “third sector”. The document

    uses a new codeword, namely ‘others’. This suggests that NHSE fully expects the private sector to play a most important part in the future, including for clinical services. (NHSE/I “Integrating Care” KONP)

    Covid has shown us, if we needed showing, that a truly nationalised health and social care service is needed and vital, with the advantages of national estate agility, workforce planning, driven by a national public health strategy to invest in the social care infrastructure of the national economy, whilst local partnerships freed of wasteful market practices are responsible for local delivery and can be locally accountable.


    Whilst the fixed payment would be determined locally, neither “Integrating Care” nor

    “Developing the payment system” refer to national agreements on wages, terms and conditions.

    The SHA is very concerned that, despite papers on responding to the staffing problems, we have not seen any recommendations for comprehensive staffing programmes that support pay justice and adequately protect workers.

    Despite discussion emphasizing the key role of the workforce in effecting these changes, mechanisms to allow direct representation of workers or their trade union spokespersons on ICS are entirely lacking in the proposals.

    Any proposal for ICSs should make explicit commitments to ensuring that all workers receive the National Living Wage (and preferably the real Living Wage) whether they are employed by the NHS or by subcontractors to ICSs. ICSs should commit to abolition of zero hours contracts in all its activities.


    Despite frequent criticism of ICSs as being distant from communities and undemocratic (as indeed is the NHS as a whole), this paper gives little confidence for any significant democratic change. Healthwatch is not sufficient, too health focused and with too few teeth.

    SHA would like to see financial transparency, accountable to communities. SHA would like to see ICSs exploring the opportunities for participatory democracy – such as community development, citizens forums, coproduction networks.

    “Current ICS arrangements are outrageously disconnected not only from real democratic structures but also from real centres of identity and community. They are administratively defined and they are under the control of officers who are not accountable to local people.

    What I would like to see is NHS Sheffield accountable to the local people of Sheffield (and likewise for other communities). It is totally inappropriate to leave accountability and governance of supposedly statutory bodies open to development and interpretation by officers of the ICS. All the assets of the ICS should be treated as public assets, especially all the capital assets and these must all be put under local (not national) control.” Duffy, SHA member

    With many thanks to all those SHA members who generously contributed to this response.

    We have also drawn on documents from Keep Our NHS Public and the Local Government Association.

    [i] Integrating care: Next steps to building strong and effective integrated care systems. Local Government Association ( accessed 23/12/20)

    [ii] Delivering together: Developing effective accountability in integrated care systems. NHS Confederation/Solace ( accessed 22/12/20)

    [iii] Integrated care systems (ICSs) ( accessed 24/23/20)

    [iv] Government response to the recommendations of the Health and Social Care Committee’s inquiry into ‘Integrated care: organisations, partnerships and systems’ Cm 9695 ( accessed 26/12/20)

    [v] On the day briefing: Integrating care, NHS England and NHS Improvement. NHSProviders 26 November 2020 ( accessed 26/12/20)

    [vi] House of Commons Health and Social Care Committee Integrated care: organisations, partnerships and systems Seventh Report of Session 2017–19 ( accessed 26/12/20)

    [vii] John Lister, How Keep Our NHS Public should be campaigning on Integrated Care Systems. November 24 2020. ( accessed 26/12 20)

    [viii] Government response to the recommendations of the Health and Social Care Committee’s inquiry into ‘Integrated care: organisations, partnerships and systems’ Cm 9695 ( accessed 26/12/20)

    [ix] Scobie S (2019) ‘Are patients benefitting from better integrated care?’, QualityWatch blog. Nuffield Trust and Health Foundation. ( accessed 26/12/20)



    Joint authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    In September, while the Health and Care Select Committee Inquiry into funding for social care was still sitting, we wrote an article highlighting the case of Anna Severight. The Committee played a clip of Anna’s testimony to Matt Hancock, Secretary of State. Anna is a 34 year old disabled woman who receives enough support to be ‘fed and watered’, but not enough to have a life ‘worth living’. Hancock noted this was a sad example of people not getting ‘all they would like’.  He thus failed to recognise that having a life worth living is something very much more than what people ‘would like’, a mere wish or want. Characterised by dignity, control over life and services and being able to engage in society a life worth living is a need recognised in the law by the Care Act.

    We had prepared a submission to the Inquiry to give them advanced notice of the issues and how councils, encouraged by central government, are ignoring what the Care Act requires. We wondered in September whether the Committee when it finally reported would correct Hancock and identify what needs to happen to address Anna’s plight.

    What the Select Committee says

    We now know. The Committee’s final report, encouragingly, opened with Anna’s story as powerful testimony of the system’s failings. It then proceeded to do nothing about it. The Committee concluded the system needed £7BN more to meet demand from demography and to pay care workers what they should; £5BN more to make personal care free; £3.1BN to introduce a care cap.

    Although not much more than government has recently found to fund its failing track and trace system, such increases would represent more than doubling of current spending on social care. Even so, the Committee’s proposals would not give a single penny toward giving Anna the support she needs. Indeed, if a care cap and free personal care are introduced and not fully funded – which on past precedent is a high risk – Anna’s chances of a normal life would reduce even further. The increased gap in funding would be made up through yet further restriction of eligibility.

    Here is the nub of the issue. The eligibility regime has long allowed councils to adjust ‘need’ to their budget. When NHS clinicians make their diagnoses, the essential ingredients are the patient and the clinician’s knowledge and judgement. If not always working perfectly, the founding NHS principle that need must precede resources provides the policy context. As need outstrips resources, so waiting times go up. Not so in social care, where the equivalent of the clinical diagnosis is assessment of need. Whilst social workers gather information about the person, it is managers with responsibility for budgets, often working through ‘panels’, who make the decision as to whether a need is ‘eligible’ and therefore will be met. This enables councils to control the flow of demand to ensure spend matches budget. Councils, unlike the NHS, are permitted neither overspends nor to leave any need unmet.

    In an almost absurd denial of the empirical evidence of this reality councils hotly deny it. They claim the eligibility decisions are the social worker’s, are entirely based on need and resources never come into it. That they are able to get away with this is due in no small part to political leaders having no interest in challenging them. It is a system that keeps the lid very firmly on demand, whilst silencing the voices of the older and disabled people within. It’s a system that suits those political leaders indifferent or even hostile to the needs of older and disabled people who want to keep the pot as small as they possibly can get away with. It also suits more liberal or more generous leaders who want to make the pot a little larger, but who don’t want the true limitations of their generosity exposed. They are able to secure virtue from comparison against the worst of their kind, not comparison with the best of what older and disabled people hope for.

    Can there be a different future?

    One view that is strongly pressed is for Independent Living to become a legal right. Independent Living as defined by the United Nations is indistinguishable from the Care Act’s vision of control, dignity and participation. At the moment, making independent living a legal right can seem a utopian ideal that no-one with the interests of older and disabled people at heart will disagree with. However, under our present politics, its prospects of happening in any foreseeable future are remote. The huge variability in individual costs will mean the service would have to be delivered on an ‘open cheque’ basis if councils will be under a legal obligation to meet every need for independent living. Given that service users’ quality of life doesn’t even make it into the top political priorities if the cross Party Select Committee report is anything to go by, the prospect of Parliament giving councils blank cheques to make independent living happen is very distant.

    We will continue to make the case for an end to the eligibility regime as the source of much that is rotten in the social care system. But we do so having accepted that spending will still have to be controlled given it must take place within budgets which have been democratically determined.

    Spending should be controlled in a very different way. Councils should assess and cost all needs as the Care Act requires – in effect all needs for independent living. Councils must be honest about which needs they can and which needs they cannot afford to meet. Political leaders should know how much funding they need to make available so that Anna and the many thousands like her have the life right for them. Political leaders should no longer be allowed hide behind their officers disappearing needs that the budget they have given officers is insufficient to meet. Political leaders must be held publicly and transparently accountable for the quality of the lives of their older and disabled citizens.


    This is a very good leader in the Guardian on the need for change in social care and some of the issues that need to be addressed.