Older People and the Health–Social Care Boundary in the UK: Half a Century of Hidden Policy Conflict

Abstract

The boundary between health and social care services has been an important focus of both social research and policy reform in many western and northern European countries. In the UK there is a history of particularly sharp divisions between the centrally funded NHS and locally run social services. A consequence for older people, especially those with less acute or "intermediate" needs, is that they may be rationed out, ignored, or treated inappropriately on either side of the boundary. This paper seeks to go beyond explanations in terms of financial, administrative and professional divisions by using now-available public records to show how the boundary between health and social care was set in stone in the immediate postwar years and resulted in a constant battle between the two services over the needs they would meet. The first part of the paper examines a largely hidden history of health and social care policy. The second part examines the new NHS Plan and the extent to which it is likely to resolve the problem of the boundary.

Direct Payments in England: Factors Linked to Variations in Local Provision

“…Direct payments policy can additionally present itself as a way to offer care and support to people whose needs are situated in the 'grey' area between social and health care (Lewis, 2001). Empowering users cuts through at least some of the supply-side boundary disputes and role conflicts that have traditionally dogged this area (Glendinning et al, 2000a(Glendinning et al, , 2000b.…”

Professional perceptions of joint working in primary care and social care services for older people in Scotland

“…The organisation of the National Health Service has traditionally been divided in acute and primary care services. The boundaries between health and social care have also existed at least since the origins of the modern welfare state (Lewis, 2001). Over the last 50 years, these divisions were repeatedly re-structured and have at times been more or less marked.…”

“…What is known, however, is that joint working is fraught with difficulties. Since the early 1990s the majority of research in England has explored organisational barriers and facilitators to the development of partnerships from the perspectives of professionals (Abbott & Lewis, 2002;Asthana, Richardson, & Halliday, 2002;Banks, 2002;Glendinning, Abbott, & Coleman, 2001;Lewis, 2001;Rowbottom, 1992;Wistow, 1994). Whilst this evidence base is still relatively small, it has highlighted a number of barriers, including: little experience of collaborating across services; financial pressures; changing government priorities and agendas; and professional cultures.…”

Joint Planning across the Health/Social Services Boundary since 1946

“…The last five years have seen the acceptance -and almost immediate extension -of greater financial flexibilities at the boundary, including pooled budgets; the introduction of a new duty of partnership on health and local authorities; and a renewed commitment to joint planning, in the shape of health improvement plans (HiMPs) -and, with respect to the development of services for older people and other particularly vulnerable groups, joint investment plans (JIPs). These initiatives have been backed up by the threat that central government might impose an integrated 'care trust7 on local areas where collaboration does not occur (Lewis, 2001). 'O But are these new initiatives likely to be any more successful in encouraging joint planning than those of the previous 40 years?…”