Glen Garrod, President, Association of Directors of Adult Social Services

What is the best vehicle (highly centralised or local) for good governance? The organisation of public services is not a new topic of conversation, indeed any cursory search on Google will provide multiple sources of opinion, academic studies and political discourse. Polarised debates abound and resonate far wider than whether social care alone should be run as a national enterprise or – presumably – remain within local government on a dispersed model. Of course this is not an academic study where we can envisage ourselves as aliens visiting earth for the first time with wisdom to impart. There are vested interests in professional, political and public groups and much at stake when one considers the what-if question?

The question is, of course, loaded because it is posed in the context of a significant policy agenda towards 'integration' between adult social care (with much less said about children's social care) and health. As such, this is a moment in history when such a debate requires a level of profile and wide public discourse as it is one that may have significant ramifications whatever ultimately happens – in this context a simple narrative will simply not suffice.

Why do I think this: well, at this point in time adult social care increasingly  appears to be operating between two departments of government: the Department of Health and Social Care and the Ministry of Housing, Communities and Local Government (MHCLG). Both provide funding and national political leadership and, in the case of MHCLG, have wider responsibilities towards other areas of public service that directly interface with adult social care such as public health and housing (such as supported housing), children's services (particularly the transition between youth and adulthood) and the fire brigade (such as home safety checks). It is also clear that adult social care has a significant role to play in supporting the NHS, most notably seen in the context of delayed transfers of care and Transforming Care where, in order to provide greater community based options in supporting profoundly disabled adults, local government has a significant contribution to make (think housing and social care support) that, without which the NHS 'offer' would remain inadequate in reducing the use of in-patient facilities.

Does the experience of working with both Departments appear cogent or coherent; is there a national programme designed to pursue integration? At present we have two national programmes in pursuit of integration: the Better Care Fund and Sustainability and Transformation Partnerships. I think it fair to say that one probably resonates better with local government than the other; one question will illustrate the point – which programme recognises the importance of Health and Wellbeing Boards and which is almost completely silent on their role?  

This introduces another dynamic into the debate – are we discussing integrated care (what the patient or service user experiences) or integration (between the organisations, processes and presumably funding of these)? If the former then localised agreements may deliver the desired outcomes but if the latter then it seems more likely that a central/local discourse will follow. Of course, strictly speaking these options are not mutually exclusive but the scenarios drawn serve to illustrate that different options may apply. If we look at the lives of profoundly disabled and/or vulnerable adults in our communities we will see that the role of housing, public health, the fire service  and other locally driven activities (for example, adult safeguarding and children's services) are prominent in better supporting and meeting their needs.      

In returning to the central/local dichotomy, perhaps it is best seen as a broad spectrum with mid-way points such as regional or sub-regional structures and whether these are highly formalised (for instance Greater Manchester) or rather more informal such as the collaboration between Leicestershire, Leicester and Rutland. But where on that spectrum should social care sit?  Perhaps a historical perspective would prove instructive. Both the NHS and National Assistance Act are 70 years old in 2018 and it seems clear that the population, needs and expectations are vastly different now. There seems little doubt that the post-second world war government had little conception that social care would become a major plank in how the state might better support people with a range of complex needs, wishes and aspirations. However, what if they had and health and social care were born as a single creation? An intriguing thought and it is probably fair to say that local government in consequence would now be materially different – perhaps we might be having the integration debate in reverse!

What is clear to me is that local government in general and social care in particular have the advantage of being close to communities, being of those communities and able to take decisions where the consequences are clear to us because of our perspective and our roots.

We have the ability to 'shape place', to coordinate and lead in our communities to deliver bespoke solutions that best reflect local needs. If we are to build community capacity and enhance the resilience of individuals within their families and communities the skills of social care come to the fore and a degree of localisation is necessary.

So, in summary central or local? Well in a world where complexity is the norm and our ability to collaborate a more critical attribute, perhaps it isn't the right question. Perhaps we should instead be considering what the best blend might be.

Glen Garrod

President of the Association of Directors of Adult Social Services (ADASS)