ADASS President’s end of year reflection

ADASS President Melanie Williams reflects on the end of 2024, including giving evidence to the Health and Social Care Select Committee’s inquiry on ‘The 10 Year Plan’ for the NHS. She makes the case that adult social care plays a unique role in more than one million people’s lives, and must not be subsumed into health.

Given my job in adult social care, I seem to spend an enormous amount of time discussing the NHS and health. I do often challenge myself on whether this is the best use of my time, when social care is about supporting people to live independent, safe, and full lives.  

The role of social care in health has grown, but we can often feel this has happened without our say. Certainly, I’d argue that it isn’t at the request of our local political leaders, who largely fund social care by raising local council tax.  

Where’s the line between social care in healthcare? 

Many of my fellow Directors share a growing view that while they are picking up more of the support for people at home, it’s not a shared endeavour and there has been a rolling back of community health services as the amount of Continuing Healthcare funding getting through to social services tightens. 

For many years we’ve been on a journey of working to support people with learning disability, autism and mental health challenges to live in homes, not hospitals. This has been successful and many people that should never have been in-patients are now living at home.  

There is also work we do in rehabilitation and reablement with older people, that helps them to recover – often from a health issue or illness. This type of work has grown in many areas as we work to the NHS agenda of discharge to assess.  

However, the people we are supporting to leave hospital now are often being recommended to have very intensive and specialist support plans, which go way beyond what we would expect good social care to look like (and cost).  

Our wider social care workforce has taken on delegated healthcare tasks, and equally is taking on healthcare tasks that are less planned and supported. This was a clear part of the Skills for Care workforce strategy, published in July, and the need for colleagues to be better trained and supported given the nature of their work is shifting.  

The question I ask myself, is where is the line between health and social care, is it in the right place given our legal and regulatory framework? And where does it need to be if we are to achieve our vision of social care focussing on prevention and quality of life for people? 

What should neighbourhood health look like? 

This has been such a live topic in recent weeks – I didn’t have a day when I was not in a conversation about what neighbourhood health should be. At my ICB Board development day,  it was framed as a vehicle to develop general practice and deliver a primary care strategy. My colleagues at the Time to Act Board, had a whole range of views about what was important, including community assets, the right language, and prevention. Personally, I would love it to be about transformation and a radical approach to how we fund and support people. 

There is no doubt that the NHS and DHSC see this as being one of the key approaches to delivering the Secretary of State’s priority to shift care from the hospital to the community. I was pleased to recently present evidence to the Health and Social Care Select Committee on that element of the 10-year plan and had good challenge from Members who were concerned about the status and visibility of local government, how we have democratic accountability for health outcomes, and how we learn the lessons from the past.  

Reflecting on our three areas of policy direction for the NHS interface in the last 15 years – the Better Care Fund, Transforming Care, and Community Mental Health Transformation – the learning is clear. Understanding who we are talking about and the outcomes we want to change for them, having clear policy and using metrics that measure that shift, taking a programme budget approach and making funding flow changes stick, and accountable leadership are all key areas that have helped ensure success.  

At NCASC 2024, we heard many examples of how different places lead practice in these areas and bring together partners together to improve lives for people – by working across boundaries and making things work. When we have so many individual needs to consider, it can be challenging to chunk up our thinking and frame policy and funding levers to fit a model for social care that has been included in the NHS vision. 

Moving forwards 

We know the problems we need to tackle: the scope of social care has drifted, forcing us to focus on more intensive care for a small number of people and there is a lack of clarity on where the wavy line sits; there is a need to fund housing, social fabric and the building blocks of health; and all the while we must not lose sight of human rights and personalisation.   

We have a task of working with others to shape what a transformed system could look like in 10 years, as well as paying attention to some of the areas we know we can improve with short-term steps – an inclusive neighbourhood health model that tackles health inequality, integrated teams that are responsive and flexible to proactively meet need, and a new solution for supporting people who need a great deal of support outside of institutional care and build elements of a good life around them.  

As 2024 draws to a close we can reflect on some increased attention on the issue of adult social care. Next, we need to look ahead to 2025 and think about how best we tackle the challenges laid out, and hope that the much-anticipated new National Care Service will come to fruition – and be ambitious and well-resourced enough to help us do this.