Introduction

The implementation in 1993 of the 1990 National Health Service (NHS) and Community Care Act was one of the most fundamental upheavals social services in the UK had ever experienced, introducing splits between the purchasing and direct provision of care services for adults, and implementing a ‘quasi-market’ in social care (Le Grand and Bartlett, 1993; Lewis and Glennerster, 1996). These reforms aimed to control public expenditure, facilitate joint working between health and social care and empower service users. This legacy remains a powerful driver in social services: policies designed and implemented by the New Labour government since 1997 have never strayed too far from these themes. Within the policy discourse of ‘modernisation’ efforts have been concentrated on addressing problems associated with the implementation of the legacy of the 1990s changes, rather than changing the vision or the discourse of the policy itself (Newman, 2001).

Adult social care services have always struggled with the sometimes conflicting aims of community care policy. Analyses of the implementation of the 1990 changes have shown how frontline workers have become compelled to prioritise the overarching aim of controlling expenditure, acting as gatekeepers and rationers, rather than facilitating user empowerment (Lewis and Glennerster, 1996; Rummery, 2002a). Development of the mixed market in care has resulted in an increase in the proportion of services being delivered by the independent sector, without any evidence that this has necessarily increased choice and control for service users (Hardy et al, 1999; Tanner, 2003; Clarke 2006). In some respects the gatekeeping and mixed market elements of community care policy started in the 1990s have continued unabated under New Labour, albeit under the discourse of modernisation rather than the discourse of new managerialism (Newman, 2001).

Where New Labour has differed significantly from the previous Conservative administration is in the emphasis given to joint, or partnership, working with health. This has moved from a marginal activity to the mainstream of business for both organisations, with the removal of structural barriers to integration at various levels with the 1999 Health Act, to various organisational changes, performance objectives and cross-cutting policy initiatives since. Adult social care organisations have, sometimes with good reason, been wary of increasing pressure to work in partnership with health.