What do the planned health changes mean for adult care departments, for partnership arrangements, public health and funding? Phil Cooper reports on a recent debate among top council directors organised by The MJ and Civica.

The capacity of GPs to take on the role mapped out for them in the public health white paper, the crucial importance of relationships between the various partners, the impact of welfare benefit changes and where the £2 billion ‘extra’ funding for social care has gone were all issues that surfaced during The MJ and Civica round table on the impact of health reforms on local government.

There was what could be described as a ‘conditional optimism’ among the assembled senior officers from mainly London borough and county councils. whose responsibilities variously encompassed adult social care, older people, young adults, health and commissioning.

People expressed themselves to be generally quite optimistic with the opportunities offered by the government’s proposed reforms, although, in the light of the current ‘pause’ in the legislative process, one senior officer remarked: ‘I’m a bit less positive on the direction of the bill now that it seems to be meandering around.’

There emerged a feeling of excitement on behalf of GPs and the new powers that were being proposed for them as this should encourage creativity in care and provision and should free up thinking which had become somewhat stilted under SHAs and PCTs.

But this ‘excitement’ was tempered by a concern expressed around the table that GPs were not yet necessarily up to the challenge of governance required by the NHS reforms.

‘There are a lot a risks in this move and I worry about the loss of the SHA capacity in governance,’ said one director. ‘Will GPs really be able to influence and shape of the future?’

Another director agreed: ‘ We have huge foundation hospital trusts in my area with huge purchasing power and what we as local authorities want and what GP practices want are seen very much as of secondary concern,’ she said.

A colleague whose area had a long-established GP consortium echoed this worry in respect of the GPs’ ability to manage the quite different relationships that would now need to exist with the hospital trusts.

The issue of relationships was one that figured predominantly in the first half of the discussion with a consensus that local authorities and their respective GP consortia had worked well. The white paper proposal did however offer the chance for councils to take on a new leadership role in the field of health and, said one strategic director, her elected members had shown a great appetite for this. Another referred to the fact that local government brought to the table a particular style of engaged leadership that could only be advantageous to the NHS.

But there was a caveat, applying both to GPs and councillors. ‘It is trying to keep them focussed strategically and not get lost in the small detail,’ said one director. Said another of her elected members: ‘They are ok collectively when setting a strategic budget but then they alter focus when talking to people at ward surgeries.’

The changing nature of relationships was a feature of the Commission on Funding of Care and Support chaired by Andrew Dilnot. ‘As Dilnot brings in recommendations about the role of national assessment what does this mean for integration and how we work with GPs in the future?’ asked a director with responsibility for commissioning services. ‘And,’ she added’ ‘ how does this affect commissioners and providers working together with each other in the future as commissioning is all about relationships?’

This sparked a further consideration. An adult social care director commented: ‘ People who were previously working very collaboratively are now going to be bidding against each other in competition. This is not only time-consuming, it also risks damaging relationships.’

Taking part... Zena Deayton, Operational director of adult social care, Westminster City Council Charlie MacNally, Corporate director of health and adult social services ,Northamptonshire CC Adi Cooper, Strategic director of adult social services and housing, Sutton LBC Jenny Owen, Deputy chief executive and commissioning director of adult social services, Essex CC Kim Wright ,Corporate director of community services, Hackney LBC Kate Kennally, Director of adult social care and health, Barnet LBC Sarah Mitchell, Strategic director for adult social care, Surrey CC Earl Dutton, Strategic director, older people and physically disabled people, Hertfordshire CC Sarah Creamer, Surrey health and social care Bill lead, Surrey CC Helen Charlesworth–May, Executive director of integrated commissioning, Lambeth LBC Pauline French, Divisional director (older people/physically disabled),Croydon LBC Dawn Warwick, Director of adult social services, Wandsworth LBC Debbie Ward, Director for adult and community services, Dorset CC Elizabeth Raikes, Chief executive, Torbay Council Brenda Scanlan, Director of support and young adults, Croydon LBC Michael Burton, Editor, The MJ David Roots, Director of health and social care, Civica Phil Cooper, The MJ

In answer to the broad question on their reaction to the provisions in the White Paper one participant commented: ‘Well the bill was not expected because it was not in anyone’s manifesto.’ Another said: ‘ There is an ideology that goes through all this and we would be foolish not to recognise this.’ She continued: ‘Prior to the election we weren’t talking about NHS in crisis. This is a manufactured crisis to shift the NHS into an American model. There is a lack of real political analysis of this issue and that is sad.’

The question of how councils’ budgets had been affected by the government’s announcement of an additional £2 billion for social care was posed.

A senior officer said: ‘We had to use it for our base budget. I was under the impression that everyone else was using it for additional funding.’ This was greeted with ironic laughter. ‘The money has bought us time because of the scale of the transformation we face is so huge,’ she said to widespread agreement. Another commented: ‘All this £2 billion has done is almost re-instate the budget to where it was two years ago because of cuts.’ And another described it as ‘ No new money. Just a sleight of hand.’

A couple of the participants raised concerns about the effect of welfare benefit changes which would certainly have imminent short-term consequences, especially in housing, which would impact on adult social care. This sparked consideration of the prevention agenda and the impact of squeezed budgets on the voluntary sector. ‘We have relied so much on them and some of these organisations will now cease to be there,’ said a London borough director.

A participant felt that a solution for voluntary sector involvement could be the evolution of personal care budgets with individuals able to choose their own care providers. It was felt that the Bill missed out this topic. Another agreed: ‘There is much said about patients’ rights but I haven’t seen anything said about people taking responsibility for their own health.’ This led to thoughts being expressed on the future need to adjust people’s expectations of health and care services and to manage them downwards.

Time and again around the table participants raised concerns about the need for the reformed NHS to give proper consideration to adult safeguarding and the children’s agenda, to mental health and to those minority groups with less of a voice to articulate their specific needs. ‘These issues are not at the top of GPs’ or hospitals’ agendas,’ said one director.

‘Are we having a conversation about Total Place or social care and health integration? Not yet. I don’t think GPs have got their head round this. They need an awful lot of development on this,’ commented one participant. Another added: ‘Long-term funding is the issue. We need to consider the impact of investment on prevention looking at 20, 30, or 50-year outcomes. If you do get in at the right time with the right support you can make a critical difference.’

Whereas hospitals emphasised discharge of patients rather than aftercare the reforms would need to refocus them on care outside of the hospital as well. Local authorities were much better at demand management.

A senior director from Civica said that the future shape of health and social care would seem to suggest foundations trusts firmly in place looking after a range of services with social enterprises taking some share of responsibility for service provision. He added: ‘There is a re-emergence of the debate on integrated health and social care coming to the fore. I can see more partnerships taking place but it’s all about where the money goes.’