What Adult social services Directors really think about the NHS
What social services directors really think about the NHS
The conversation we don’t have—but should
Let’s start with something we don’t say out loud:
Most of us in social services don’t think NHS Trusts are particularly well led.
That’s not a comfortable thing to read. It’s even less comfortable to write. But with waiting lists still at record levels and another winter of crisis management behind us, the pressure to “fix” discharge and patient flow has never been greater. If we are serious about solutions, we need a little less diplomacy and a lot more honesty.
First, what works.
At the frontline, relationships are often good—sometimes very good. Social workers, nurses, therapists and GPs collaborate every day to solve problems the system creates faster than it can fix them. Consultants, in my experience, are often the most open to joint working: pragmatic, locally focused, and less interested in organisational boundaries than in getting a patient safely through the system.
Multidisciplinary teams do work. Not as a slogan, but as a reality where trust has been built.
But here’s the problem: good practice survives despite the system, not because of it.
Too many NHS Trusts are characterised by a hierarchical, occasionally macho management culture that talks collaboration but defaults to control. There is a heavy reliance on the goodwill and professionalism of staff—so heavy, in fact, that it has become a business model. People hold things together because they care, not because the system is well designed.
Leadership churn makes this worse. The lifespan of a hospital Trust Chief Executive can feel closer to 18 months than anything resembling stability. That isn’t leadership—it’s a visiting role with a leaving speech. You cannot build meaningful partnerships or reshape culture on that kind of timescale. What you can do is manage optics and move on.
It shows.
Many Trust leaders remain, at heart, hospital-centric. Their world is beds, flow, targets and headlines. Social care becomes visible when it blocks a bed—and invisible when it prevents one being needed.
I’ve sat in meetings where delayed discharges are discussed as if they are a social care failure—full stop. Little attention is given to internal hospital processes, risk thresholds, or how decisions made on wards directly shape what happens next. It is a one-sided narrative—and a convenient one.
There is also an unspoken hierarchy at play. Too many Trust leaders see their natural counterpart as the Local Authority Chief Executive, not the Director of Social Services. It’s a small signal, but an important one. It reveals a lack of understanding about where expertise, authority and accountability actually sit.
Attempts to create shared priorities often collapse under this imbalance. On paper, we agree. In practice, social care priorities drift to the bottom. Integration becomes assimilation—our agenda folded into theirs, rather than a genuine partnership.
If you want to understand the real-world consequences, walk into a GP surgery.
I remember a GP describing a patient who came in repeatedly with chest pain. It wasn’t cardiac—it was anxiety driven by eviction. There was nowhere to refer her. That’s not a medical failure or a social care failure. It’s a system failure.
GPs see this every day: housing problems, debt, addiction, isolation—presenting as health issues because that’s where people turn when everything else has failed.
They also understand something else: the support they need from social services is increasingly unavailable. Years of cuts have stripped services back to the point where help is reserved for the most acute cases. Early intervention—the thing everyone agrees is essential—has quietly disappeared.
Mental health tells a similar story. Unless someone is an immediate risk to themselves or others, access to support can be limited or delayed. Frontline professionals see the same gaps and the same people falling through them. This is not about blame; it is about capacity and priorities in a system that still treats mental health as a second-order concern.
Then there is dementia—the slow-burning crisis. Too often framed as a social care issue because the individual is “old first”, rather than recognised as a shared responsibility requiring a coordinated response. That framing is convenient. It is also wrong.
On equality, diversity and inclusion, the NHS has been long on ambition and short on delivery. The data on disciplinary action, representation in senior leadership, and staff experience tells a story that cannot be explained away. This is not a communications issue. It is a management issue. And poor management is the single biggest barrier to organisational performance.
Of course, there are outstanding leaders and partnerships across the NHS. But they are not yet the norm—and that’s the point.
What is most striking is how rarely success spreads. A model that works in one part of a Trust is not replicated elsewhere, let alone adopted across the wider system. We still talk about “the NHS” as if it were one organisation. It isn’t. It is a collection of organisations with different priorities, pressures and incentives. Expecting seamless collaboration without addressing that reality is wishful thinking.
So what would social services directors say, if we were being candid?
Get your act together.
And if we were being completely honest?
Your budgets have been protected in ways ours have not. Local authorities—and social services in particular—have been cut to the bone. Yet the expectation remains that we will absorb pressure, facilitate discharge, and prevent crisis with diminishing resources.
It can feel like a one-way relationship. Social services bending over backwards to maintain cooperation, while the NHS barely gives us a second thought—until something goes wrong.
That is the uncomfortable truth.
But this is not about blame. It is about leadership.
If NHS leaders are serious about partnership, start here.
Stability matters. Stop the revolving door at the top.
Broaden your field of vision. Hospital performance is only one part of system performance.
Reset relationships. Directors of Social Services are not junior partners—they are system leaders.
Turn EDI ambition into operational reality. Measure it, manage it, and hold people accountable.
And use HR properly. Workforce and culture are not back-office concerns; they are the engine of performance.
Above all, focus on management quality. Because poor management—not structure, not funding, not policy—is the biggest barrier to improvement.
Right now, too much of what works depends on goodwill.
And goodwill is not a strategy—it’s what’s left when leadership falls short.
Blair Mcpherson former Director author and blogger blairmcpherson.co.uk
