Alan Milburn – 2002 Speech on Reforming Social Services

Below is the text of the speech made by Alan Milburn, the then Secretary of State for Health, to the Annual Social Services Conference, Cardiff, Wales on 16 October 2002.

This is the fourth year I have addressed your conference as Secretary of State for health and social services. Each year I have been able to report on real progress in the delivery of social care. I am pleased to say that this year is no exception. You have delivered more intensive support to help more older people live independently at home. Your co-operation with the health service has reduced delayed discharges from hospital. You have helped 10% more looked after children to be adopted.

Social services – local authorities, voluntary organisations, private sector providers – make a difference – every single day.

You make a difference when the foster parent, the teacher and the social worker help a child who has been in care all their lives get through school and then on to college.

You make a difference when the therapist and the advocate help a young man with a learning disability get training and then a job.

You make a difference when the home help and the social worker help an old lady return home after hospital to regain her confidence, her dignity and then her independence.

So, I want to thank you for what you have done and for the vital role you play in delivering care and offering hope to millions of people in our country. Good social services – and social workers – are valued. They do not deserve to be vilified.

Yet, today I believe social services are at a crossroads.

You are under scrutiny as never before. For all the millions of successes, it is the lapses in social services that still corrode public confidence. All of us here know that if social services fail, the consequences fall on the most vulnerable people in our society.

It would be comforting to believe the problems confronting social services stem purely from a hostile media. I do not believe they do. They stem in my view from a much deeper failure – a failure, which we all share, that has allowed the way we deliver social services to get out of step with the society we serve.

In the half century since the Welfare State was founded, and in particular, in the thirty years since Seebohm formulated the modern concept of social services, British society has undergone profound changes.

Fifty years ago, if you got a job, it was for life. Today, while the new global economy has brought more opportunities for prosperity than ever before, there is more insecurity and uncertainty. While unemployment has fallen sharply in recent years social exclusion has found new expression. Prosperity has widened but poverty has become more entrenched. Joblessness has become more concentrated in certain communities and amongst certain families. New social problems – particularly the link between drugs and crime – have emerged.

Family structure has undergone profound change. Family breakdown is more common. Teenage pregnancies are still too high. For the first time older people outnumber children in our society.

Public expectations have changed too. Thirty years ago the one size fits all approach of the 1940s was still in the ascendant. Public services were monolithic. The public were supposed to be truly grateful for what they were about to receive. People had little say and precious little choice.

Today we live in a quite different world. We live in a consumer age. People demand services tailor made to their individual needs. Ours is the informed and inquiring society. People expect choice and demand quality.

These changes challenge all our public services. For some, these changes call into question the very values on which health and social services are based. They say, public services must inevitably fail because they always put the needs of the institution above the needs of the individual. For them the only solution is a free market solution.

Nothing could be more mistaken. Think about it. A privatised health care system based on ability to pay not the depth of need would leave those needing health care most able to afford it least. Delivering up youngsters in care to the whim of the free market would only mean more lives paid for in drugs, delinquency and despair. We have lived through the decades when there was apparently “no such thing as society”. Society was poorer as a result. We all ended up paying the price. I believe that we must not pay that price again.

The values that underpin our social services – the recognition that we do achieve more together than we ever can alone – are more relevant today than they have ever been. The problems society faces today call for modern active social services.

It is the means of delivery – not the values of social services – that need to change.

Delivery requires investment. It is a fact that for too long social services have been the poor relation in the public services. Investment in social care has failed to keep pace with today’s challenges. You can see the impact of decades of neglect in high staff vacancy rates and staff who work under real pressure. I believe that we now have the opportunity to put that right.

A year ago I said at your conference that social services needed more resources. In the lead up to the Budget I fought for those extra resources. The Budget secured them. From April 2003, for the next three years, real growth in social services investment will double compared to the last three years. Whereas just six years ago real terms spending on social services was rising by just 0.1% a year it is now set to rise by 6% a year.

The extra resources will help get the extra staff we need. A year into the national social work recruitment campaign which I launched at last year’s conference we have already reversed the trend in falling applications. Over the next three years we can look forward to 50,000 more social care staff.

New challenges call for new skills. I think you all know the complexity of modern social problems requires more specialised skills not just the traditional general mix of social work skills. So I am today, asking the General Social Care Council, training organisations and local government to work with us to develop new types of social care professional.

People who can work in the community, combining the skills of the therapist and the home help to provide rehabilitation alongside home care. Family care workers combining the skills of the health visitor and the social worker to provide family support in times of trouble.

The extra resources give us the opportunity to make these reforms.

Of course, extra resources can not solve every problem but having made the case for extra investment in social services local government now has to spend those resources on social services.

Here I think that there is a tension: different communities have quite different needs – and that calls for a greater local say. And yet it must be right that an older person in one part of the country is able to enjoy similar standards of care to an older person in another part of the country – and that calls for proper national standards. Better services are not a choice between national standards and local control. Raising standards requires both. Getting the right balance holds the key to securing these improvements.

There was a time when there were no national standards. When care was a local lottery. I do not believe anyone who is serious about ensuring fairness in social care wants to go back to those days. Equally with national standards, tough inspections and performance ratings all now in place I believe the time is now right to shift the balance of power – to greater local autonomy. So I can tell this conference whilst there will be more resources for social services, there will be less earmarking of those resources for local government by central government. Today 17% of social services spending is ring-fenced. That will now fall to 15% next year, 11% the year after and 9% the year after that.

The Local Government White Paper sets out the basis for a new partnership between Whitehall and the town hall as a means of rejuvenating local democracy. Where councils have greater financial freedoms. Where inspection is more proportionate. Where local councils have powers to scrutinise local health services and ensure the well-being of local communities.

And we can go further. The new governance arrangements we will shortly bring forward for the first generation of NHS Foundation Hospitals will mean local government can represent the local community in the running of the local health service too.

We are moving into a whole new ball game with brand new rules: where flexibility and freedom come in return for delivery and reform. As performance improves – as I am confident it will – greater autonomy for social services and local councils will be earned. Those that are doing best will get more freedom. Those that are doing less well will get more help. Where there are persistent problems central government will step in. Where there is progress we will step back.

Those councils that enjoy the highest star ratings will get significant freedoms: reduced inspection; the right to carry over resources between one financial year and the next; the freedom to spend social services grant on any aspect of social care free from ring-fencing altogether. And I can tell this conference that, together with the Deputy Prime Minister John Prescott, I am examining further freedoms still for the best performers.

The better you do the more you get. That is a discipline that needs to apply just as much in the public sector as in the private sector. Both to provide a reward for those already the best – and to provide an incentive for those who can to do better.

At the other end of the spectrum there are a small minority of councils where social services are persistently in trouble and, frankly, failing to deliver. Here a different approach is needed. Here, central government can not stand idly by. We have a duty to act to uphold standards in care. And when we do it works.

Of the 21 councils put on special measures in the last few years, 18 have improved their performance. Since August, where there have been more entrenched problems still Performance Action Teams – put together by the private sector but involving the best of the public sector – have gone in to social services departments to strengthen management structures and improve service delivery.

And in extremis where there is endemic failure and where this form of external support also fails, I will use powers under the Local Government Act to appoint a nominee to take over the running of the local service. The nominee will be able to make radical recommendations about how the service is delivered and crucially how more effective local partnerships can be developed.

Today over half of all councils have broken away from the old monolithic, single social services departmental structures towards greater specialisation and more integration with other service providers. I want to set out now how I believe we can help you take this process further.

The old style, public service monoliths can not meet modern challenges. They need to be broken up. In their place we can forge new local partnerships that specialise in tackling the particular problems local communities face.

Combating social exclusion, breaking the link between drugs and crime, securing for elderly people dignity in old age is beyond the remit of any one organisation.

Dealing with these new challenges demands new forms of organisation: that enlist support in the community as well as of statutory agencies; that harness the expertise of the private and voluntary sectors alongside the public sector; that recognise that in the modern world people will no longer tolerate inflexible services from competing systems but demand instead flexible services from a single care system.

In recent years social services who have led the effort to break down boundaries and build up new partnerships. Two thirds of social services today are provided by the private and voluntary sectors. The 600,000 social care staff who work in those sectors provide the majority of home care and residential care. Most looked after children rely on foster carers. The voluntary sector today is the mainstay of learning disability services. New initiatives like Sure Start have put community and charitable organisations centre stage in delivering what are mainstream public services.

I believe that the voluntary and community sector has an even greater role to play. If we are to activate local communities to help deal with the problems they face – rather than simply complain about them – now is the time to bring those organisations in from the cold.

So I can tell the Conference I have asked the Strategic Commissioning Group – chaired by my colleague Jacqui Smith – to report to me on how local voluntary and community organisations could play a bigger part still in the delivery of social services.

Government, central or local, no longer needs to provide every public service. Gone are the days when Whitehall or indeed the town hall always knew best. What counts today is the quality of the service, not the origin of the provider. And today the sheer complexity of the social problems facing us call for services that are less homogenous and more specialist.

The job of providing services to children in need is a very different job from services to the elderly person. The one size fits all approach embodied in the traditional social services department may have been OK in the 1970s, but as more and more councils are recognising, it does not belong to today.

Let’s take children’s services. Every child deserves the best start in life. They need services that lift them up and keep them from harm. Mostly that is what social services deliver. Sadly, sometimes they do not.

Two years ago Victoria Climbie died in the most appalling circumstances. No one who has heard the evidence to the independent inquiry I established under Lord Laming could fail to be shocked by what occurred. Quite simply services which should have protected a vulnerable child failed that child.

When Lord Laming delivers his report it will consider what changes are needed to the whole system of child protection in our country – and we will consider his findings carefully.

We will also be considering the conclusions of this week’s report from the SSI and other Inspectors into safeguards for children. And later this year we will publish the first strand of the new children’s national service framework which will set out for the first time clear standards for all of our children’s services.

There is much that remains to be done despite the achievements of Quality Protects. Our goal surely has to be to give the children in care the same opportunities as every other child: to be part of a family; to do well at school; to get a job; to have a home; to live a life free from drugs and crime. But progress towards this goal is still too slow.

Today I can outline extra resources to help us do better. To reduce the number of children in care. To bring about improvements in life prospects when children leave care. Growing up in a stable family provides the best environment for children to develop. So over the next three years over £180 million will be made available to expand and strengthen fostering services and to provide extra support for adoption so that more children get the chance of growing up as part of stable and loving families.

Some children of course need further help still. Around one in ten aged between 5-15 years old have a mental health disorder. Tackling poor educational achievement, dealing with youth offending and other behavioural problems calls for a major expansion in child and adolescent mental health services. So I can announce today increased investment of £140 million over the next three years, to build capacity, improve access and, together with new NHS investment, to help deliver for the first time a comprehensive CAMHS service in each and every area.

To get the best from these resources, there will need to be reforms. All too often traditional service boundaries get in the way of good care for children. The local education service can be pulling in one direction with health going in the other and social services going another way still. That brings failures of communication as well as organisation. Children and parents get passed around the system. Confusion means that services intervene later when they should be involved sooner.

Fragmented decision-making is not delivering the best for anyone. I believe it is now time to develop more specialised local organisations which pool the knowledge, skills and resources that exist in our education, health and social services to provide a more seamless service for children.

So I intend to create specialist Children’s Trusts to jointly plan, commission, finance and – where it makes sense – deliver children’s services. Children’s Trusts which commission services will be based firmly in local councils with the power for the first time to commission health as well as social care. And for those Children’s Trusts that want to specialise in providing services we will want to explore a range of models in different parts of the country. These could potentially include local, not for profit, public interest companies that could enlist the involvement of the community, voluntary and private sectors alongside the public sector.

We want to pilot this new approach so in December this year my department alongside Estelle Morris’ will ask for expressions of interest from local organisations keen to test how Children’s Trusts could improve local services.

Children’s Trusts can help you dramatically reshape how social services are organised and delivered. Many of you have already taken advantage of the NHS Act flexibilities we introduced two years ago . They have allowed health and social services to work more closely together through at least 160 local partnerships delivering services now worth £2 billion a year. These services are breaking down barriers between services so that people who are elderly or have a mental health problem do not have to deal with two different – sometimes competing– systems. You know as well as I do that health and social care sink or swim together. They both need each other. The older person needs both.

Care Trusts provide another means to this end. Some are already in place. More will follow next year. Later this month we will launch a new national Integrated Care Network to provide more support and encourage wider take up. In the next two years I expect to see health and social services in every part of the country pooling resources and skills to deliver a seamless service for older people – either through a Care Trust or through use of the existing Health Act flexibilities. In time this should become the norm for how elderly care services are provided and commissioned.

In the meantime we intend to legislate to ensure that conflict between health and social services does not get in the way of older people receiving the care they need. I am continually struck when I visit health and social care around the country by the power of partnership when it works. But when it does not, it is the older person who suffers.

Delayed discharge from hospital is a particular problem affecting 5,000 older people at any one time. Thanks to your help and the resources we have made available, delayed discharges from hospitals have fallen but this has been achieved only through a short term fix of ringfenced money, top down targets and intensive monitoring. I do not believe this approach is sensible or sustainable for the long term.

In any partnership people have to know who is accountable and who is responsible for making things happen. So where people are needlessly waiting in hospital for social services to become available, we will shortly legislate so that councils reimburse the hospital for the cost of the bed the person occupies. This will provide an incentive – which does not currently exist – to end the misery of what is sometimes pejoratively called bed-blocking but is in fact thousands of older people needlessly trapped in hospital when they are well enough to be cared for in the community.

Councils that enjoy positive partnerships with the NHS – and those that are prepared to invest extra resources to build up capacity – have nothing to fear from this policy. Indeed the policy should help social services get the money spent on social services. It is not about punishing councils, still less about forcing them to fund people who wait for services that are not their responsibility. The policy will guarantee more seamless services for older people. I hope what ever your reservations might be, you will now work with us to deliver this reform.

It is all about putting the users of services centre stage. You can already teach the health service a thing or two about that. But today I want you to go further. If social services are going to genuinely put users first then those users have got to have more power. And that means more choice.

Choice is not just a question of consulting users or promising to take their views into account. Nor is it just about making advocacy services more widely available. It is all these things – and I believe that it is more.

Choice means opening up a broader span of services so that care can be tailored to fit the needs of the individual rather than assuming the individual will simply fit the off-the peg service.

In elderly care for example local councils will want to use some of the extra £1 billion we will provide over the next three years to stabilise the care home market and to buy extra care home places. But different forms of care are needed for older people too, in order to widen choice and promote independence. More intermediate care and better rehabilitation services through partnership with the health service. More extra-care housing in partnership with housing associations. More intensive home-based support. Free community equipment for the first time. And greater backing for our country’s carers. So more older people get what they say they want – help to live more independently for more of the time at home.

It is right that the generation which created our great public services should have more direct choice over those services. So I can confirm today that I will shortly be laying regulations in Parliament to ensure that all older people assessed as being in need of care – whether for rehab after a hip operation or for a bit of help with household chores – have, as of right, for the first time, the choice of receiving a direct service or instead receiving a direct cash payment to purchase care that better suits their individual needs. Direct payments will give older people direct choices over the services they receive.

And to ensure these are informed choices, I can also announce today that we will make available £9 million to help older people’s and other voluntary organisations make a reality of direct payments not just for tens of thousands of older people but for thousands of adults and the parents and carers of disabled children too.

It is local government that has called for devolution and decentralisation: to make services more responsive; to make social services more effective. Today, devolution and decentralisation are at the heart of the Government’s programme of investment and reform in public services.

But devolution does not start in the corridors of Whitehall and end at the doors of the Town Hall.

True devolution sees power flow from central government, through regional government and into local government and then out into communities and neighbourhoods. True decentralisation empowers the individual at the expense of the institution.

And social services are nothing if they are not about empowering the powerless: giving older people the power to stay in their own home; giving young people in care the chance of a stable family life; protecting the most vulnerable children from abuse and neglect; promoting independence and self-reliance; bringing hope to families where hope has almost gone.

Our task – together – is to reform social services so they are better able to empower the individual; better resourced to support the vulnerable; better structured in the interests of the user.

Having had the courage to invest in social services. Now is the time to make these big reforms. I look forward to working with the LGA, ADSS, private sector, voluntary sector and councils in making these changes happen.