Health care and social care: the great divide

In confronting a problem which has existed since the creation of the NHS in the 1940s, Professor Mike Oliver comes up with a radical solution for dealing with resultant inequity.

Recently I switched my support package from the local social services department to the local health authority and succeeded in crossing the great divide from social care to healthcare. As my needs are now seen as predominantly health needs that means I no longer have to go through the demeaning yearly financial assessment nor do I have to make a financial contribution from my ever diminishing pension pot.

This problem exists not just for the small numbers of direct payments users but for many more elderly people who go into residential or nursing homes. It has been estimated that there are at least 100,000 people or families who have fallen foul of this divide between health and social care and have been wrongly assessed, some of whom have been forced to sell their homes to pay for care that should have been provided free.

The confusion at the heart of this goes right back to 1948 and the implementation of both the National Health Service Act and the National Assistance Act. Under that legislation, health needs were to be met free at the point of delivery and social needs were to be met by assessing the ability of individuals to make a financial contribution. Unfortunately however it has never proved possible to accurately distinguish between them, and this confusion between health and social needs has bedevilled health and social care provision ever since.

I have seen this confusion first hand over the years. Many years ago I was friendly with two young men from the local Cheshire home which had joint registration, both as a residential and a nursing home. Both men had the same impairment and hence the same needs for support but because they came from different parts of the country, their respective local authorities assessed their needs differently, which meant one of my friends was financially assessed for his care and the other had it provided free.

Some years later I saw how the system worked from the other side when I worked for a social services department. We regularly financially assessed people for community and residential care and even occasionally resorted to the courts to ensure people paid for their care occasionally forcing them to sell their homes.

What has changed in recent years is the sheer number of people and families who fall foul of this confusion and this has resulted in considerable interest from legal firms who are beginning to recognise that this situation will not be able to withstand the scrutiny of the courts. Hence in the next few years we are likely to see the already overstretched health and social care systems diverting scarce resources away from direct care provision and into fighting court cases driven by lawyers offering a ‘no win no fee’ service.

There are, however, two possible options for dealing with this problem: we can either try yet again to produce adequate guidelines to distinguish between health and social needs which will stand up to legal scrutiny or we can abolish the distinction between them and meet all health and social care needs free at the point of delivery.

The first option is unlikely to succeed. After all if it were possible to distinguish between health and social needs then someone would have discovered how to do it in the last 60 years. The second option has already been implemented in Scotland, and the Scottish economy hasn’t collapsed nor has the British taxpayer had to bail Scotland out.

My crossing of the great divide was not without difficulty and necessitated me going to appeal as I was originally turned down. When I attended the appeal panel the Chair greeted me with the comment that they had never had a patient represent themselves before. Perhaps if those responsible for maintaining the boundaries between health and social care were to listen more to users we would see less injustice in their decision-making processes.

4 thoughts on “Health care and social care: the great divide

  1. There is, I fear, a fundamental issue which doesn’t just go back to 1948 but was never resolved with the early theories around ‘the social model’ – Distinguishing between impairment and disability and the degree of overlap between the two is, admittedly, very challenging but it has never really been clearly agreed upon by any of the stakeholders from individual citizens through to the institutions of politics and government. Indeed when I look back at the disability movement in the UK, which Mike, you were important part, when I realise we never quite convinced the bulk of disabled people of their unique social identity and what it was that it meant in practice.

    I warned that the subversive and seductive renaming of Disability Living Allowance or DLA to the Personal Independence Payment or PIP was a way of removing disability per se as an identity as it had become too wide a term in terms of funding, opening up the flood gates to a bottomless pit. The trick of calling it a Personal Payment, rather than an acknowledgement of the real and lifetime costs of being disabled, thus allowed the focus to shift. The fact that, in order to define us as a disabled person the DLA used indicators that focussed upon impairments, was more a function of finding something that vaguely worked. It should not have meant that the key to defining us as disabled people was level of impairment in relation to a cost to the state. Therefore removing disability became almost logical and what has happened since was inevitable.

    We need a 21st century version of the social model of disability and to educate and identify what being disabled is and means as an identity. We need to avoid infighting and not rejecting social support for all disadvantaged groups but being a disabled person is not being ill or old or something that could be resolved by treatment and support, important as those are to be dealt with in a modern democratic society. Disability is not, and should not be a catch-all. I worry that we have been seduced into a rhetoric around how we are just people with impairments, that awful phrase ‘we all have impairments of one sort or another’ and therefore with aids and support all of us could climb mountains, win gold medals, work 60 hours a week and yes be brave and admirable tabloid heroes, those that don’t are just not trying! This is of course rubbish and until we try to reclaim our distinct identity as disabled people we will always fail to achieve equality of choice and independence.


  2. Please can you let me know how and where I would apply for continue health care my dr said ask social services and social services keep saying there is social needs more which is not the case


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