Shaping the Future of Care Together: Green Paper Consultation

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the 48,000 chartered physiotherapists, physiotherapy assistants and students in the UK. Our members work in the NHS, in private practice and in the independent sector.

Physiotherapists assess, treat and rehabilitate people with physical problems caused by accident, ageing, mental illness, disease, or disability, using physical approaches in the alleviation of all aspects of the person's condition. Physiotherapists are involved in the improvement of the health of the public at every stage from prevention, to diagnosis and treatment and on to development of sustainable programmes for individuals to maintain and improve general good health.

The CSP is a member of the TUC. The TUC has submitted a comprehensive and useful response to the consultation which the CSP would support. This response from the CSP seeks to add comment to the points raised by the TUC submission.

The CSP strongly supports the creation of a National Care Service and encourages the Government to maintain its commitment to a national assessment criteria for England as a whole. Whilst recognising the significant funding implications, exacerbated by a decreasing proportion of the population working and paying tax, there is merit in adopting a 'NHS model' to fund the Service ie social care services available free of charge on the basis of need and funded from general taxation. The CSP is concerned that any of the three models proposed in the Green Paper ("Partnership; Insurance or Comprehensive") could lead to gaps in the coverage with less well off people not included or opting out. A system for care that sounds like the NHS should be funded in the same way through general taxation.

The model of care of provided by physiotherapists and other Allied Health Professionals (AHPs) is a bio-psychosocial model underpinned by enabling service users, patients and carers to learn how to manage their own situations more effectively. Necessarily, the NHS and local government are increasingly focussed around individual responsibility for personal health and well-being. AHPs are ideally suited to deliver within this context as their therapeutic interventions are embedded in an empowerment model, supporting service users to develop an internal locus of control with regard to their own health and well-being. Acknowledged as 'integrators of care' AHPs frequently design, lead and work in multi-agency services to support or 'sign-post' an individual or a population to other services rather than merely acting as a gate-keeper, whereby they can facilitate, engage with and empower the service user and enhancing their overall experience, for instance through a 'one-stop shop' arrangement of both health and social care services.

Government has recognised the benefits of 'joined-up working' and that the new patterns of service provision increasingly seek to address the health and well-being needs of an individual or population extend both 'upstream' and 'downstream from the point at which the condition has been given a label and the treatment selected. Upstream, to address the wide range of determinants of health and inequalities, downstream to ensure that the needs of the individual, for example activities of daily life are facilitated. Whilst there has been some change to recognise the advantages of a joined-up or pathway approach, this does not address the failure of the current systems to take a holistic approach to the expenditure of public monies on health and wealth-being.

Although Beveridge in 1942 with his plan to tackle the 'Five Giants' identified social inequalities and inadequate access to health care, it was not until the Black Report in 1980 that government sought to identify the relationship between policies to address ill health (as well as promote good health) and health inequalities. However, it was Acheson in 1998 who presented a socioeconomic model for health inequalities with the determinants of health set out in layers of influence.

In 2006, the Department of Health White Paper Our health, our care, our say set out the direction for improving the health and wellbeing of the population in order to achieve:

•     better prevention and early intervention for improved health, independence and wellbeing
•     more choice and a stronger voice for individuals and communities
•     tackling inequalities and improving access to services
•     more support for people with long term needs.

Similarly, Strong and Prosperous Communities, the Local Government White Paper (2006) stated, 'We want to improve the health and well-being of every local community and ensure that health and social care services reflect the needs and priorities of patients and their families. This White Paper will enhance local leadership on health and well-being, and will make it easier for local authorities and NHS bodies to work together to tackle health inequalities and to deliver better services for their local area.'

The DH Commissioning Framework for Health and Wellbeing (2007) set out to secure a:

•   shift towards services that are personal and maintain independence and dignity
•   strategic reorientation towards promoting health and wellbeing, investing now to reduce future ill-health costs
•  stronger focus on commissioning the services and interventions that will achieve better health, across health services and local government, with everyone working together to promote inclusion and tackle health inequalities.

The CSP would broadly agree with the Vision for the Future of a National Care Service laid out in the Green Paper. However, the CSP sees the need for more emphasis on what the 2006 White Paper quoted above called for "better prevention and early intervention for improved health independence and well being." This is still far from the case today for adults with a disability or older people.

Preventative work and early intervention has both a very positive impact on the lives of these adults and is very cost efficient because it saves substantial and unnecessary expenditure at a later stage. It should be part of the Vision for the New National Care Service. Two examples are:

•  Falls prevention services for older people, provided by AHPs and nurses, have a very strong evidence base which show that they significantly reduce the number of falls experienced by older people, reduce hospital admissions, and enable older people to more independently cope with any falls. Yet falls prevention services do not exist in many places in England and they are vulnerable to budget reductions even if they can save the NHS and Social Services large amounts of additional expenditure.

•  The lack of community rehabilitation services for stroke survivors of whatever age are a large obstacle to their ability to become more independent and therefore to require less expenditure in support. These adults may have received some rehabilitation in hospital but very frequently on discharge into the community there are few, if any, community rehabilitation or physiotherapy services available in many parts of England, resulting in longer term costs and consequences for the individual, their families, social services and the NHS.

The Government is to be commended in bringing forward the proposals for a National Care Service. The CSP would support the idea of National Standards for the NCS to be established together with local decisions about ensuring that these are applied consistently to suit the needs of individual adults.

The Government should be bold and consider a truly joined-up National Health and Care Service.

Phil Gray, chief executive

Chartered Society of Physiotherapy

November 2009