Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, on 19 October 2001.
I want to set out today some of the improvements we have seen in the last year, some of the challenges we now face and the further progress we can now make.
There is today a shared agenda between local government and central government. A shared vision for social services and, I hope, for the wider public services. That is a vision of services designed around the needs of the user, rooted in the values of community.
In education: where pupils come first in highly performing local schools at the heart of their communities.
In health: where patients come first in hospitals and GP practices serving the needs of their communities.
And in social care: where the vulnerable adult or child come first in safe and sound community services.
In all of these areas local government is a valued and valuable partner. I strongly believe that should continue to be the case.
We have a shared agenda too, for improving quality in care. For services that offer fair access to all and which help promote opportunities for all.
I want to thank you for the contribution you make to the fairer society we want to create. People who work in social care – and those responsible for managing social care – do so under real pressure. You are on the front line of many of the major challenges which face our country today – addressing the problems of poverty and deprivation, a growing elderly population, and growing public expectations too.
And in this time of international tension, I want to place on record my gratitude for the work of local government – officers and members – in emergency planning and preparation. Your local contribution is vital to our national vigilance.
Meeting these challenges must sometimes seem like a Herculean task. Sometimes – often – there is scant thanks for what you do. And yet just a few months ago when people faced the choice in this country between short term tax cuts and long term investment in public services, the public of this country backed public services and they backed the people working in them. I think we should all take heart from that.
Today people know a fair society, where everyone in our communities and not just some get a fair chance, can only be built on the sure foundations of a strong economy and strong public services.
There can be no such thing as a fair society – or a strong economy – if the education system is geared to success for some but not for all, or if whole communities are laid waste by the ravages of drugs and crime. And we certainly cannot have a fair society if health and social services deny people help when they need it, where they need it.
We all know today we are a long way from having public services to match Britain’s position as the fourth largest economy in the world. We know too that the public are impatient for change. Some people say public services can never deliver, that private provision is the only answer for problems that are self evident.
I say that on grounds of efficiency and equity that view is wrong. But I say with equal firmness that failure to deliver reform in public services will prove the doubters right.
Delivering improvements in public services – in all aspects of our public services – is not an optional extra. In these next few years progress must be made – and be seen to be made – in all of our public services if we are to sustain progress towards the fairer society we seek.
There are good grounds for optimism. For a start the investment is going in. In health and education, with the NHS today the fastest growing health care system of any major European country.
In social services investment is growing too. I know there is real pressure on your budgets. I know that that’s true for children’s care and as well as elderly care. And that is why we responded just last week with a further £300 million of new funding for social care. It brings growth in social care budgets up to 3.7% in real terms next year compared to growth of 0.1% a year prior to this Government coming to office. I know we have not solved every funding problem. But we have made progress – and we will go on making progress.
I want to give you an example of one area of progress. Let me give you one example of progress. For years, politicians and newspapers blamed social workers for just about every ill our country faced. So, it is progress when I can come to this conference and say without equivocation: we need more social workers in this country not less.
That’s why today we are launching a three year social work recruitment campaign with a view to an extra 5000 social worker. I know that shortages of social care staff are biting hard in many parts of the country. But these shortages can be turned round. The nurse recruitment campaign we have run in the health service over the last few years has proved that. Last year at your conference I was able to provide extra cash to help students train for a career in social work. Now the recruitment campaign will set out the positive benefits of a social work career to help counteract the all too frequent negative coverage the profession receives in the media.
Expanding staff numbers and investing in frontline services then are the pre-conditions for improvements in social care. But investment alone will not deliver. The courage to invest must be matched with the courage to reform. And the courage to tell the truth about how things really are.
While I see real beacons of excellence in social services – just as there are real beacons of excellence elsewhere in public services – the best has not been available to the many: it has all too often only been available to the few. What is more, the needs of the service user have all too often come a poor second to the needs of the service provider.
In the modern world that will no longer do. To command public confidence our public services today have to offer choice as well as fairness to those who use them.
All the money in the world will not deliver these changes. Indeed, there is a danger that simply pouring more money in without linking it to reforms will ossify ways of working, embedding attitudes and structures that are long overdue for change.
Reform in social services then is as vital as reform in any other area of our public services. And just as in health or in education there are four main principles which underpin the reform programme:
First, high national standards and full accountability
Second, devolution to the front line to encourage diversity and local creativity
Third, flexibility around the needs of users in how staff are employed and how services are organised
And fourth, the promotion of alternative providers and greater choice.
So how should this programme apply to social services? Before I answer that, let me just say this: I know change is difficult – I know that there are real pressures out there – but it really must happen. Whether it is the exceptional high profile service failure or simply the day-to-day reality of unresponsive services, public confidence cries out for change.
We should be confident that we can meet the challenge of change. There is much to be proud of and much on which to build. The work we have done together in bringing in the Quality protects programme with its focus on the needs of the most vulnerable children, the General Social Care Council, the National Care Standards Commission testifies to our shared commitment to improvements in social care.
So let me begin with standards and accountability.
People have the right to know that they will get certain minimum standards wherever they live. And I am pleased to come to this conference today and report real progress. Today I am publishing the latest set of social services performance indicators. They cover performance over the last three years.
Compared to last year, 20 out of 23 indicators show either improvement or a continued high level performance.
More older people than ever before are being to helped to live in their own homes rather than in care homes.
The number of children adopted has risen again giving them the chance of a stable family life.
Compared to two years ago there are 850 more children who have found permanent adoptive families – well on the way to meeting our ambitions for a 40% increase by 2005.
I really do want to congratulate you for the progress being made. But as ever, there is much more to be done. It should concern us all that the target on delayed discharges was missed. That means people are being kept in hospital when they should be at home. There was a slight improvement this year it is true, but with the new money I announced last week for social services specifically to address the “bed blocking” issue, I expect to see significant improvements during the course of next year.
Similarly, more than 6 in 10 children are still going out into the world from care without a formal qualification. None of us would be happy with that for our own children. It is also unacceptable that only one quarter of councils reviewed all their child protection cases on time.
What is crystal clear from these tables is that there is excellence in our social services. But it is excellence spread too thinly. It is available only to some when surely our ambition as a nation must be to make it available to all.
Of course local services should be attuned to the needs of different local communities. That is why we have locally run social services. But right now, as these tables show, the variation in performance across social care is just too great.
Take London for example where there are particular problems with cash pressures and wide societal pressures. In one part of the City fewer than one in five children leaving care had a qualification. In another part almost 6 in 10 had. In one part of the North only 2% of looked-after children were adopted while in another part five times that number were. In both examples, alongside countless others, the councils concerned have similar locations, deal with similar problems of poverty and deprivation and have similar levels of funding.
These tables remove the excuses for unacceptable variations in performance. This is not primarily about money. It is about management and organisation. And that is the value of these tables. They expose those areas where performance needs to improve. I know there will always be arguments about the details in the tables and the methodology behind them but for me – and I hope for you too – there is a simple principle at stake here – the public who use our public services have a right to know how well those services are doing in comparison with others.
Public services don’t belong to me and they don’t belong you to either. They belong to the public. Accessible information for the users of public services is essential if we are to design services around the needs of users. That is what we are doing with schools and hospitals. And it is what we must now do for social services.
I know that current tables are far from perfect and are far too complicated. So I can announce today that we plan next year for a new approach which will provide more easily accessible information to the public about social services performance. From next year, we will bring together the existing performance data with information from inspections and in-year monitoring. The result will be a more rounded assessment of each council’s performance.
Just as we have recently done for hospitals this year, so from next year each council will receive a star rating for its overall social services performance. There will be separate ratings for adult and children’s services. We will work with the LGA and the ADSS on the details of the new system. I believe profoundly that it will help councils to improve their performance.
That brings me to the second part of the reform programme – devolving power and encouraging diversity.
Providing information to the public is just the first step. Being able to act on it is what counts. Action should follow assessment. Where there is good, bad and indifferent performance so different approaches are clearly needed.
Where there is good performance we should step back. Where there is poor performance we should be prepared to step in. We should offer more rewards for the best performers. And more help to turn around the poorer performers.
One of the greatest frustrations I hear expressed in the NHS and in social care too is that all too often rather than rewarding the good we simply bail out the bad. That is what we now must change if we are to provide the right incentives for improvement in all aspects of our social, and indeed all, services.
So beginning with this year’s best performers – including the top ten consistently high performing councils in Derby, South Tyneside, Sunderland, Derbyshire, Cornwall, Rotherham, York, Salford, Dudley and Leicestershire – in future all of them will get the greater local freedom they have earned.
We will invite the best performers to discuss with us how they could have greater control rather than less. We will explore with them a lighter touch inspection regime with non-children’s services being inspected, perhaps only every five years. We will consider removing the conditions attached to special grants so that top social services authorities are free to spend their money in ways they decide can best make the improvements in services for the communities they serve.
And we will give the best star rating performers their share of next year’s new £50 million performance fund to spend as they think fit. Some could go on staff bonuses. Some could go on developing new services. The point is that it will purely be a matter of local discretion.
The point is that good performance will earn the devolution of power. This new approach will not only reward success among the best it will encourage improvement among those who could be better.
The performance indicators show every council is doing well in some areas. Some authorities while not yet the best are improving and improving rapidly. Councils such as Cambridgeshire and Newcastle upon Tyne deserve special praise since they have only recently come out of special measures and they are making record improvement. We now need to make sure that every one of them do even better and that others can learn from what they have achieved. We will look to the Social Care Institute for Excellence as it develops its role, to disseminate and embed good practice.
I can announce today that we will consider using a part of the new Performance Fund to allow the fastest improvers to spread the benefits of their knowledge to others that are in most need of improvement.
For the few who are genuinely poor performers – including the bottom ten of the Isles of Scilly, Richmond on Thames, Buckinghamshire, West Berkshire, Windsor & Maidenhead, Kirklees, Torbay, Bracknell Forest, Warwickshire and Lambeth – I believe that different action is needed. We already have mechanisms to deal with poor performance including the powers to put Councils on special measures. There is evidence that performance does improve when the SSI is closely involved. But sometimes delivering improvements simply takes too long. So I can say today that I will act using Best Value and other intervention powers where the evidence suggests the pace of improvement is simply too slow.
I will also be discussing with the LGA, and with Stephen Byers at the DLTR, how we can use external expertise from the voluntary, statutory and private sector to turn round performance where local social services are persistently failing or falling behind.
We will want to explore in particular how to encourage the best performing local social services to take over responsibility for running the worst. I want to encourage in social care, as much as we are trying to do in health care, the development of a new public sector enterprise culture where we get the best people in public services to lead improvements across the rest of our public services.
So, today I am putting this year’s worst performers on notice:
First, they will be required to agree with the Chief Inspector an action programme for improvement.
Second, special measures will follow if services do not improve.
Third, by the time we award star ratings next summer, if performance and prospects for further improvement remain poor, I will consider using other intervention powers.
In some cases I know that social services management can struggle because there are problems at the corporate or even the political level. If I find evidence of corporate failures limiting social services delivery I will consider triggering corporate inspections so that we can find where the problems lie so then we can tackle them.
Where councils and the NHS are not working together effectively, I will consider asking the SSI and CHI jointly to investigate the reasons for partnership problems. If necessary I will use my powers to compel local health and social services to work more effectively together.
That brings me the third strand of the reform programme – building services that are flexible enough to meet the needs of their users. The painful truth about the way we organise care is that it is like a maze for too many of its users.
There is confusion and uncertainty about where the responsibilities of health and social care begin and end. Too often people who rely on these services – whether they are elderly or disabled or have a mental illness – find themselves faced with an endless procession of staff carrying out roughly the same assessments. And then of course there are turf wars over who funds what and who does not.
I know there is a monumental effort going into all parts of the country into improving partnership working both in health and in social services. I want to thank you again for the progress you have made. We saw the results of that last winter. I hope we can see it again this winter. Where partnership works it works brilliantly. Where it does not the needs of the user come a poor second to disputes between services.
And let me just say candidly, I know the problem lies as much on the NHS side of the fence as on your side. The answer is to take down the fence. I believe we now have the means to do so.
From next year we will be putting in place a single process for assessing the needs of elderly people for health and social care. I hope that can be accompanied by fewer demarcations between staff to build on the pioneering work in places like Wiltshire where social workers and community nurses work as a single team.
Greater flexibility between staff needs to be matched by greater flexibility between organisations. Frankly, so far I have been disappointed by the take up of the legal powers, which are now available, for health and social care to pool their budgets and work more closely in partnership. I will be looking for faster take up of these powers in the year ahead, towards our aim of having them used in every part of the country.
What the bed-blocking problem in the NHS reveals is the simple truth that social services and health services sink or swim together. Each needs the other. The older person needs both. What we have to move to then, is one care system. Not by takeovers but through partnerships.
Today, I am pleased to be able to confirm that next year the first of up to fifteen Care Trusts will come on stream, bringing together in a single organisation health and social services for older people or for people with mental health needs. Eventually, I hope Care Trusts will be in place in all parts of the country because they break through bureaucratic boundaries in order to focus on the needs of service users.
That brings me to the final part of the reform programme – promoting greater choice and diversity in provision. In social care diversity of provision has already taken hold. Over 80% of residential care and over 50% of home based care is provided by the independent sector. Some of the best learning disability services are run by voluntary organisations.
Yet for too long, in my view, there has been a stand off in the relationship between the statutory, private and voluntary care sectors. There should be no ideological barriers getting in the way of the best care for vulnerable people.
Last week, I hope we saw the beginning of the end of that stand off with the publication of the ground breaking agreement between the Government and representatives of the NHS, local councils and independent sector providers in housing, health and social care. The document we published, “Building capacity and partnership in care”, marks a decisive break from the short termism of the past. It sets out principles and practices to underpin what I hope will become a more mature long term relationship between the public and private care sectors.
The recent losses of capacity in the care home sector call for such a relationship, with longer term contracts between councils and care homes. They call for the independent sector to have a seat at the table for planning future provision. They call for public and private sectors to work together not just to shore up existing provision in care homes but to develop new services in people’s own homes: intensive home care packages; new more active intermediate care where the emphasis is firmly on rehabilitation and independence. All of this is about providing more choice for users by promoting greater diversity in provision.
The £300 million we announced last week to deal with the problem of delayed discharge will translate the Agreement into action. This is a cash-for-change programme. We want to see real change to eat into the bed blocking problem. By the end of this winter, we want to see 1,000 fewer older people stuck in hospital at any time, that way we can release 1,000 extra beds for other NHS patients. Next year we will want to see further progress still towards our aim of ending widespread bed blocking by 2004.
Together, people working in health and social services are at can bring about these improvements. They can do it providing they seize the opportunities which now exist to reform these services.
For too long, social services have been undervalued in our country. Blamed when things go wrong. Ignored when things go right. Often expected to fail. Sometimes set up to fail.
So, let us make a fair assessment of social services in our country today.
Investment is now rising and performance is improving but there is much more that must be done to put the needs of the user at the centre of the service.
To do that, the best in social services must help reform the rest of social services. The old barriers, which divided health from social care, and separated public from private provision, must now be overcome.
The poor performers must receive direct support to do better.
The big improvers must spread the lessons of improvement.
The best performers must have new freedoms to be better still.
None of this is easy. Much of it will take time. All of it requires a huge amount of effort. This is a reform programme based on our belief in public services and our belief in social services. It is based also on our belief that these services can be better – and must become better than they are today. And most of all, we believe they can be better than they are. What we must now do is demonstrate we can deliver. We’ve made substantial steps forward – we need to build on that and we need to deliver. The public expect no less.