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  • Author or Editor: Jon Glasby x
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This is the concise, accessible guide for students and practitioners who want a comprehensive introduction to health and social care.

Engaging practical features, such as user-focused case studies and reflective exercises, promote understanding of theoretical and conceptual knowledge. In turn, clear explanations of social policy theory help frame the policy and practice dilemmas faced by students, front-line workers and policy makers. Chapters cover partnership working and integrated care, independent living, disability and long-term conditions, discrimination, user involvement and support for carers.

This new edition has been updated to cover key developments under the Coalition and beyond, including the 2012 Health Act, the 2014 Care Act, the Francis inquiry, the Winterbourne View abuse scandal, the integrated care agenda and the impact of austerity.

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More than any other area of the welfare state, UK health and social care are big business and are everybody’s business. Each year, they spend billions of pounds of taxpayers’ money, employ millions of staff, and work with millions of patients and service users. While this is true of other services as well, health and social care touch all our lives at so many times and in so many places. Overall, the NHS in England employs 1.4 million people and has an annual budget of some £116 billion. It deals with over one million people every 36 hours, with nearly 10 million operations carried out per year (up 45% in 10 years), nearly 23 million attendances at Accident and Emergency (A&E) (up 22% from a decade ago) and nearly 16 million people admitted to hospital (31% more than a decade ago) (NHS Confederation, 2016a). Adult social care in England has spending of around £19 billion (including £2.5 billion in user contributions), with 1.5 million workers, 5.4 million unpaid informal carers and nine per cent of adults in England limited ‘a lot’ in day-to-day activities by illness, disability or old age (National Audit Office, 2014, p 4). Unlike the NHS, which has often been dominated by public sector provision, social care staff work in a wide range of public, private and voluntary sector organisations, spread across an estimated 17,300 organisations and 39,000 individual establishments. The private sector is by far the largest employer, employing over two thirds of people working in adult social care (Skills for Care, 2015, p 3).

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In a new century and with a 24-hour news cycle, it is tempting to see every issue as new and every solution posed as a radical departure from the past. Thus, Labour, the Coalition and the Conservatives have portrayed their reforms as being about modernisation and transformation – and all governments have a tendency to emphasise the distinctive nature of their own policies. The Labour governments of 1997 to 2010 are a good example of this, with the rebadging of the party as New Labour and therefore as being fundamentally different to what went before. In practice, Hegel and George Bernard Shaw are often quoted as concluding that ‘we learn from history that we never learn from history,’ while the Bible is clear that ‘there is nothing new under the sun’ (Ecclesiastes, 1, 9–14). Against this background, this chapter reviews the origins of health and social care services, charting the development of different professions and the way in which this historical legacy continues to influence current provision. While summarising some of the chronology, this discussion does not provide a full overview but instead highlights the key implications of specific aspects of this history (while also signposting to further reading for those who wish to explore these issues further). Essentially, this account does not explain how things have developed over time, but represents a more selective attempt to explore why some things today are the way they are (and perhaps to lay the foundations for readers to reflect on where things might be headed in the future).

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By the late 1970s, health and social care in the UK were in difficulty. The NHS had initially been established on the basis that it would improve the health of the general population (and so would cost less in future once health status was generally higher). However, this neglected the fact that many people cured by the NHS (and who presumably might have died in the past) were brought back to full health and discharged from hospital, only to become ill again in the future. By improving the health of the population and by extending life expectancy, the NHS was thus a victim of its own success and its funding requirements far exceeded official assumptions. Following the devastation of the Second World War and with insufficient capital funds, proposed building programmes were limited in scope, and many former workhouses and infirmaries continued to be used in practice. Despite a national system, workforce planning seemed underdeveloped, and many of those areas that had traditionally lacked access to local services still seemed under-served. In spite of repeated attempts to develop more community-based services, the power of the institution continued to dominate and the resources to make a reality of community care never seemed to accompany the policy rhetoric (see Box 3.6 later in this chapter for an example). A series of hospital scandals also brought to light the poor quality of many long-stay services for particular community care user groups.

In social care, the National Assistance Act 1948 initially focused attention on residential forms of care, stating that ‘it shall be the duty of every local authority … to provide residential accommodation for persons who by reason of age, infirmity or any other circumstances are in need of care and attention which is not otherwise available to them.

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In most developed countries, health and social services are beset by problems of fragmentation and insufficient interagency collaboration (see, for example, Meads et al, 2005; Kodner, 2006; Glasby and Dickinson, 2009). Whatever the exact structure of local and national services, health and social care tend to work with people with complex, cross-cutting needs, typically requiring a more coherent and ‘joined-up’ response from a range of agencies. As a result of this (and due also in part to a desire to find ways of organising services that are as cost-effective as possible), there is a national and international emphasis on partnership working – both between health and social care, and with other services and sectors of the economy (public, private, voluntary and informal). Against this background, this chapter reviews the current UK emphasis on achieving more integrated care, focusing mainly on health and social care partnerships, but also acknowledging the importance of collaboration with other partners. After reviewing the policy context, a range of key concepts and theoretical frameworks are introduced to help make sense of the current partnership agenda, and a series of ‘hot topics’ are explored as case studies of the complexities surrounding the pursuit of more effective joint working.

More than many other areas of policy, the partnership agenda is justified in terms of a desire to provide better outcomes for service users and patients. While the evidence to support such aspirations can sometimes be problematic (see below for further discussion), there are very powerful examples of what can happen to people when the support they need is poorly coordinated or delayed.

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In Chapter Three, an overview of services for disabled people briefly introduced the concept of independent living, highlighting the importance of social care policies such as direct payments and NHS priorities such as the long-term conditions agenda. This chapter explores these themes in more detail, placing such issues in a broader context and developing key concepts such as a social model of disability and issues of dependence/independence. In the process, this involves an important discussion about the potential breadth of the independent living movement, and the extent to which a social model of disability can be applied to other user groups (for example, people with learning difficulties and people with mental health problems). Like each of the substantive chapters in this book (Chapters Four to Eight), however, this account begins with a real-life case study ( Box 5.1 ) in order to illustrate the significance of the subsequent discussion. While theories are important, they matter so much because of the ability they give us to understand and respond to very significant real-life issues.

Underpinning experiences such as those cited in Box 5.1 is a policy context frequently shaped by implicit and (until recently) often unchallenged assumptions about disabled people’s quality of life and about their position within society. Prior to the passage of the Care Act 2014, the former Prime Minister’s Strategy Unit (2005, p 73) argued:

Independent living initiatives are constrained by a welfare system which assumes dependency. The National Assistance Act 1948 underpins later community care legislation and provides the legal definition of a disabled person [as] … someone who is ‘blind, deaf or dumb, or who suffers from mental disorder … and persons who are substantially and permanently handicapped by illness, injury or congenital deformity…’.

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Challenging discrimination is a key element of many health and social care professions (at least in terms of their formal codes of conduct – see Box 6.2 ) and is enshrined in legislation, in government policy and in organisational policies and procedures. However, in practice, the achievements of health and social care in this area have been mixed, and much more remains to be done. Against this background, this chapter explores the current policy context, before focusing on some useful theoretical frameworks that help to explore issues of discrimination and reflect on current policy and practice dilemmas. In order to provide something of a ‘human face’ to some of the theoretical and policy issues below, Box 6.1 begins with some common examples of the issues at stake.

A core and enduring feature of the UK welfare state is its commitment to equality and to treating people on the basis of need rather than ability to pay. Nowhere is this more apparent than in the foundation of the NHS itself, with the NHS Act 1946 pronouncing that:

The NHS Act 1946 provides … a complete and medical service free of charge at the time it is required for every citizen. (Introduction to the NHS Act 1946)

These beliefs are firmly held, and have been constantly repeated throughout the history of the NHS. Thus, the trade union Unison (2002, p 3), in writing about What’s good about the NHS, emphasised that the aim of the NHS is ‘to provide to the entire population of the UK health care free at the point of delivery.

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Forty years ago most people did exactly what the doctor (and other professionals) told them, and those who can remember the pre-welfare state system tend to be very grateful for whatever support they receive. In the early 21st century, doctors still enjoy considerable professional power, but attitudes have changed, and patients and the public expect to have a greater say – around their own care and the nature of services more generally. From passive recipients of welfare services, patients and service users have increasingly been recast as ‘customers’ or ‘clients’, and even more recently as active citizens and as ‘micro-commissioners’ of their own services (see Chapter Five), with both ‘rights and responsibilities’. In several key areas of policy and practice, service user movements have developed their own alternative services and ways of working, directly challenging traditional and often very paternalistic statutory approaches.

Against this background, this chapter reviews the growth of user involvement in social care and of public and patient involvement in the NHS, highlighting underlying theoretical assumptions about people who use services as consumers, citizens, ‘expert patients’ and/or service providers in their own right. In addition to reviewing recent policy shifts, progress to date, and different types and models of involvement, the chapter also considers the role of a human rights-based approach to health and social care, moving beyond previous notions of ‘involvement’ to more recent attempts to improve the position of service users and patients via campaigning and a direct appeal to civil rights, direct action and social and political change.

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While health and social care in the community has always been based on the support provided by carers (friends, neighbours and families providing support on an unpaid basis), it is only relatively recently that official policies have been developed to support carers in this role. This chapter reviews the emergence of carers (including young carers and older carers) as a policy priority in their own right, the research evidence about the impact of caring, policies to support carers and carers’ own priorities for the future. In the process, the chapter summarises current critiques of the notion of ‘the carer’ and the relative neglect of some types of ‘carer’ (for example, of people with mental health problems). In particular, it challenges the notion that caring is necessarily a ‘burden’, while also acknowledging that caring without meaningful choice and without adequate support can most definitely be a negative experience (see Box 8.1 ).

From the 2011 Census, we know that there just under six million carers in England and Wales (just under one tenth of the population), and that since 2001 there have been increases in the overall numbers and in people caring for 50 or more hours per week (see Box 8.2 ). While caring is often perceived as a negative activity (involving a considerable physical and emotional burden on the carer), there is clearly scope for caring to be a rewarding and fulfilling relationship – at its best, being a carer for someone implies caring about them, and many carers speak passionately about the strength of the relationship they form with the person they care for.

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This chapter reviews the Conservatives’ approaches to adult social care, moving from the legacy of the Coalition government to that of the Conservative governments since 2015. During this period, there have been a series of broken promises and a tendency to kick a number of key matters into the long grass. Sometimes this has seemed a pragmatic reaction to challenging world events and to the political complexities of these issues. At other times, there have been glimpses of traditional Conservative ideology around topics such as inheritance, the role of family, the needs of business, tax cuts and so on. Despite a pessimistic national picture, there are a number of grounds for optimism in more local, bottom-up approaches and in the increased visibility of social care during and following the pandemic.

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