The Integration of Health and Social Care in the UK
Policy and Practice
Deirdre Heenan and Derek Birrell
Interagency Working in Health and Social Care Series
Basingstoke: Palgrave Macmillan, 2018
Paperback. xi+199 p. ISBN 978-1137404428. £24.99
Reviewed by Pat Thane
King’s College London
A widely recognised problem for health and welfare services in the UK and elsewhere is poor coordination between health and social services for the growing numbers of people in simultaneous need of both. It has been increasingly recognised since the 1960s that many people suffering from mental and physical disabilities can function effectively in their own or family homes rather than in hospital if they receive adequate community support services with access to medical supervision and care when needed. The numbers in need have steadily grown as average life expectancy has grown. People with lifelong physical and mental disabilities live longer due to improved medical knowledge and living standards. Most people who are fit in earlier life live longer and are healthy longer than previous generations but more survive to acquire multiple physical and mental disabilities in their later years. In the less acute stages of dementia, following strokes, heart attacks or suffering from diabetes or other chronic conditions they can maintain their independence and lead active lives if they have social support with meals and housework, personal care when needed. Everyone gains if these services are adequate because they free hospital beds for those in acute need and they cost taxpayers less than hospital care.
As Heenan and Birrell describe, the need and the advantages have been repeated increasingly insistently in the UK since the 1960s, yet successful integration of health and social services has not been achieved except occasionally and locally. They describe aspirations to integration and the reasons for failure in each of the four countries of the UK since the 1970s. A valuable feature of the book is the comparison of policies and practice across Scotland, Wales, N. Ireland (where the authors are Professors of Social Policy at the University of Ulster) and England, something all too rare despite important differences across the countries in many respects.
The problem originates, as the authors do not describe, in 1948 when the National Health Service was established, providing free health care for all, and the National Assistance Act gave local authorities responsibility for social care – residential and in the home – but requiring means-tested payment. The two services were administratively and financially quite separate. Through the 1950s, 60s and 70s research increasingly showed the inadequacy, and occasional brutality, of institutional care for older and disabled people and that many could live independently if community services improved. Deinstitutionalisation and community care became the official policy of successive governments. The powers of local authorities to provide means-tested social work and domestic help services, either themselves or through independent providers, and free health care services – e.g., district nurses – in the home, were increased by the Labour governments of the 1970s.
Labour’s ambitions to achieve integration were undermined when they lost the 1979 election. Margaret Thatcher’s Conservative governments to 1990 and John Major’s to 1997 produced a remarkable series of proposals for restructuring both the NHS and local government and protestations of support for integration, all faithfully detailed in this book. But simultaneously NHS and, especially, local government funding were cut, private provision was encouraged, there was little effort to implement the rhetoric, and services deteriorated. Similarly Labour governments from 1997 to 2010 produced a succession of policy and strategy papers in this field including some potentially effective reforms, but again effective outcomes were few, while reorganisation of the NHS made cooperation with local government even more difficult.
The Conservative-led coalition government, 2010-15, and the Conservative government which has followed produced yet more rhetoric and proposals, including the Health and Social Care Act, 2012, while austerity policies cut local authority funding further and the NHS is underfunded. To make things worse, both the NHS and local care services depend upon immigrant workers from the EU, but, as the authors point out, as Brexit looms their numbers are shrinking. They try to assess the outcomes but find little systematic information. They find occasional local examples of successful integration and delivery of services, but they are few. Generally in England local care services are deteriorating and many older and disabled people are trapped in hospital by lack of community support.
The other countries of the UK have used such devolved powers as they have to try to do better. These powers have increased in Scotland and Wales since they gained devolved elected governments in 1999. They have long been somewhat greater in N. Ireland. All three governments have repeatedly expressed commitment to integration and improved services. Scotland provides free social, as well as health, care for all over-65s and, unlike England, it has a focussed strategy which requires and funds local collaboration. But, as in England, the NHS does not readily collaborate with non-medical services while Westminster continues to restrict local authority funding. The story is similar in Wales, where devolved powers are more limited. Ambitious policies have brought some local improvements but less than the devolved government hoped due in particular to the constraints of UK austerity policies. N. Ireland has had area health and social services boards since 1972 but coordination of services is at best patchy because, again, health services have taken priority and local care services have been underfunded and underdeveloped. The authors conclude by examining the international scene. Again, they find many expressions of support for integration of health and social care, especially in view of international population ageing, including from the World Health Organisation, but only occasional examples of success and no sign of attempts by the UK government to learn from good practice elsewhere, including within the UK.
It is a depressing, but all too convincing account. The more so for the decades of reiterated rhetoric by all UK governments of support for integration and high-quality health and welfare services, while they persistently decline. Among many other problems underfunded health services are currently delaying ‘non-essential’ surgery for joint-replacement, cataract removal, etc., which mainly affect older people. They will not die of these conditions, but they severely constrict their independence and increase their reliance upon support services which are dwindling in availability and quality, often forcing them into expensive hospital or residential care. Needs continue to grow as more people live longer and the high proportion of pensioners on low incomes are more likely than others to suffer from multiple health problems without resources to fund their own care. As the authors conclude, there are many reasons for these failures but the greatest is the unwillingness of successive Westminster governments to turn rhetoric into reality and fund implementation of effectively-led strategies for integration and delivery of urgently needed services.
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