I'm glad we've got that sorted out |
There is a school of thought, which has its origins in some fuzzy concept of “Victorian values”, that there is something inherently wrong with the State intervening in health and social care. This reaches its apotheosis in the
Real Victorian
concepts of philanthropy encompassed the idea that doing good was not only
inherently virtuous, but was also a pragmatic and utilitarian solution to the
problems that impacted on society. When large numbers of the populace are poor
or sick, this affects everyone, even the rich. One of the factors that drove
the development of National Insurance and improvements to social housing after
the First World War was the discovery that many of the men seeking to enlist in
the Armed Services were in very poor physical health. You couldn’t fight a war
with unhealthy men.
There have been
efforts to introduce market forces into the provision of health and social care
for many years. The first Thatcher Government introduced the NHS &
Community Care Act in 1990. One of the changes it introduced was the concept of
the “purchaser/provider split”: this created an internal market, and
essentially meant that those who “purchased” social care services should not be
the same people that provided them. Until then, nearly all home care services
were provided by the local authority. After that, at least 80% of services had
to be purchased from private of voluntary providers
I was working in a
local authority social services department when these changes came into effect
in the early 1990’s.
This is how it worked
before the Act. As a generic social worker, I would receive a referral for an
elderly person living alone who wasn’t managing very well. I would go out and
assess them and establish whether or not they needed a service: a home help to
assist with cleaning or preparing meals; aids and adaptations to their home; or
residential care.
I would then consult
with our Occupational Therapist, who would assess for aids and adaptations, or
the Home Help Organiser, who could assess precisely the level of home care
services required, and then arrange for one of her Home Helps, who was employed
by the local authority, to deliver that service. Some of these home helps could
even be neighbours, who might be employed specifically to provide a service for
that individual.
This is how it worked
after the Act. The social worker would assess the person. They would then have
to decide themselves exactly how much time in a week that person required a
cleaning service, or preparation of meals, or someone to shop for them, or
someone to help them get up in the morning or go to bed at night. The social
worker would then go to the Home Care Manager, as they were suddenly called,
and tell them what was required, and the Home Care Manager would then have to
work out how to provide that service, using a combination of “in house” staff
and external agencies.
Since then, this
process has accelerated, to the point that more and more local authorities have
sold off or out sourced all of their care services, and many are actively
looking at how they might out source social workers, too.
The recent reforms in
the NHS, centring on the GP led Clinical Commissioning Groups, are creating a
culture in which it becomes imperative to provide health services via private
service providers. The premise, behind the smokescreen of the mantra of
“customer led” service, is that private providers can deliver cheaper and more
efficient services.
There is a basic
fallacy in all this: health and social services are inherently and
fundamentally different from the manufacturing or service industries. You
cannot apply models of the private market to the public sector.
This is what might
happen if it really were the case that the health or social care service user
was the “customer”.
Jeremy’s windows are
draughty and let in water. He decides he needs double-glazing. He gets several
companies to give him quotations for replacement windows, then makes a decision
based on price and quality.
A few months after his
new windows have been installed, Jeremy starts to worry about pains in his
lower back. He looks these up on the Internet and decides that he must have
problems with his kidneys. So he contacts the Renal Department of the local
hospital, sees the consultant, and insists that he needs a kidney transplant.
The second scenario is clearly absurd. It
is necessarily the role of specialist doctors to assess a patient’s health
problems, and it is ultimately their decision as to what treatment the patient
requires. Equally absurdly, if we were to apply this to the first scenario,
then Jeremy would simply be told what sort of double glazing he needed by the
expert double-glazing salesman.
Because in reality users of public services
are not “customers”: it is the GP’s, via their CCG’s, who are the real
customers. They are the ones who want specific services for their patients, and
they choose what service they will go with.
The concept of “Payment by Results” and
“clustering” currently being implemented as a means of service delivery in
national mental health services is, in the words of the Department of Health,
“a major change in the way that mental health care is currently funded, a shift
from block grants to Payment by Results currencies which are associated with
individual service users and their interactions with mental health
services.”
And there is revealed the true state of
affairs: in this brave new world, users of public services are not “customers”,
they are “currency”.
I have been aware of "payment by results" and "clustering" for around 10 months. I have approached my Care Coordinator about this and she was evasive and seemed embarassed. I wanted to try to understand and wanted to ask her what cluster I had been assigned to. Obviously, I have not been consulted as to what level and unit of cost I represent so this means that my input is irrelevent. Not only this, nobody wants to know how I feel about my interactions with my Mental Health Team. I smell a rat because if I was assigned to a cluster then it is not static and can move up and down without me being aware. This is all about smoke and mirrors which tries to hide the fact that no money is being put into the public mental health pot. So, the question is, will it even be helpful for me to know what cluster I am? or (currency). I think we all know the answer to this.
ReplyDelete