Health and Social Care
Health and local government - a brief history
Health and social welfare functions in English local government extend back at least to Tudor times, when parishes were given responsibilities for poverty and the environment. However, the modern public health function is best traced to the early nineteenth century, when government responded to the social impacts of rapid industrialisation and urbanisation that had led to poor neighborhood and housing environments, occupational health risks, and heightened prevalence of communicable diseases, such as tuberculosis, typhoid and cholera.
Subsequent public health legislation further strengthened local public health departments, which by 1900 included drainage, sanitation, safe water supplies, street cleansing, disinfection, disease notification and isolation, food safety, smallpox vaccination and institutional care for the mentally ill and infirm older people. The following decades saw local government receive additional responsibilities for maternal and child welfare, health visiting, school medicine, managing venereal diseases, services for learning disabilities and an increased role in slum clearance.
In 1930 London County Council (LCC) took over responsibilities from the abolished Metropolitan Asylums Board for 140 hospitals and other medical institutions, and by the outbreak of the second-world war, the LCC was the largest public health service in Britain.
The establishment of the NHS in 1948 saw the size and scope of public health departments substantially reduced. Regional Hospital Boards were established to administer hospital and specialist services, and were responsible for managing local Hospital Management Committees. This period also saw the introduction of universal access to primary care and an increase in the role of GPs providing community services.
Local government retained responsibilities for maternity and child welfare clinics, health visitors, midwives, health education, vaccination and immunisation, and ambulance services together with environmental health services. Enoch Powell's 1962 Hospital Plan sought to unify the NHS from three distinct parts – hospitals, general practice and local health authorities. The Hospital Plan approved the establishment of district general hospitals for population areas greater than 125,000.
Declining morbidity and mortality from communicable diseases, a growing welfare state and increased integration of services for older people within the NHS, saw a decrease in the prominence of public health in local government environmental and housing policy. Local government did, however, continue to deliver a range of health and public health related services up until the implementation of the NHS reorganisation Act in 1974, which effectively abolished local government’s responsibilities for public health (except those for environmental health) and introduced a system of NHS-led regional and local health authorities.
Serious high-profile food poisoning outbreaks in the following decades (salmonella, BSE/CJD), the emergence of HIV/AIDS, regeneration and recognition of the impact of social exclusion on health, and the subsequent publication of the 1998 Acheson Report into health inequalities all led to a step change in attitudes towards the importance of the public health function.
The Health and Social Care Act 2012
The Health and Social Care Act 2012 brought about the largest structural overhaul of the NHS since its creation. Clinical Commissioning Groups (CCGs) and NHS England local teams were given responsibility for a £65 billion NHS budget (c.60 per cent of the overall NHS budget). Local authorities have taken over a £2.6 billion public health budget, mostly for commissioned services including: tobacco control and smoking cessation services; alcohol and drug misuse; services for children and young people; comprehensive sexual health services (including testing and treatment for sexually transmitted infections, contraception outside of the GP contract and sexual health promotion and disease prevention) amongst others.
The Act also requires each top-tier and unitary council (including London Boroughs) to establish a Health and Wellbeing Board (HWB) to act as a formal council committee. HWBs are responsible for:
- Driving local commissioning and creating a more effective and responsive local health and care system
- Having a strategic influence over commissioning decisions across health, public health and social care
- Involving councillors and patient representatives in commissioning decisions
- Bringing together CCGs and councils to develop a shared understanding of the health and wellbeing needs of the community
HWBs play a central and increasingly important role in leading on the commissioning and delivery of local health and social care services. Membership of boards must include: a councillor, a representative of the local Healthwatch, the CCG, and the local authority directors for adult social services, children’s services and public health.
The current system of social care can be traced back to the National Assistance Act of 1948. The Act required local authorities to provide some form of residential accommodation for vulnerable older people and disabled people.
While the Act set up the NHS to be free at the point of delivery, it allowed local authorities to “means test” and apply charges for residential and community social services. Local authority services at this point covered both children and adults.
Following the 1950s there was greater awareness about the effects of long term institutional care particularly on those with mental health issues. This awareness was accompanied by a shift in the type of care provided to people; from one focused on in-hospital or institutional care, to increased provision of care in the home or community. This was thought to be in the best interest of people and found to be much cheaper.
In 1962 the powers and responsibilities of local authorities in the delivery of social service were strengthened, encouraging local authorities to provide more services including more meals for vulnerable people and day centres for older and disabled people. The provision of domestic help and support for vulnerable people also became mandatory.
Social services departments
By the 1970s the provision of social services became more entrenched as a local authority service. The 1970 Local Authority Services Act established the framework for local authorities to have social services departments whose role was to provide coordinated support to families and people who need help.
In the 1970s and early 1980s local authorities were at the forefront of directly providing a range of services for vulnerable people. Provision of day centres was increasing; residential homes and meals on wheels services and other social services were all on the rise.
However by the mid-1980s funding cuts meant that services began to be more restricted such that by the early 1990s they were increasingly targeted only at those most in need of support. This trend has continued to today.
A new role as 'commissioners'
By the 1990s a new trend was taking hold with local authorities outsourcing some of their services to the private sector. The NHS and Community Care Act 1990 established councils’ central functions as assessing need for support, and funding and commissioning care rather than direct service delivery. Their new role as commissioners continued to grow through the noughties to today. In 1992 the private sector delivered 2 per cent of state funded home care, but by 2008 this had increased to 81 per cent.
Two decades of outsourcing means councils are primarily commissioners, directly delivering an increasingly small minority of services. Years of on-going budget cuts now mean that accessing support from local authorities is more restricted than it has ever been before.
The noughties saw the separation of children and adult services. The Children Act 2004, allowed local authorities more flexibility in organising their children's services, with the amalgamation of education and social services no longer mandatory.