Once more into the breach, by Seamus Ward

1 Sep 05
It seems the 'Berlin Wall' dividing health and social care might finally be coming down, as ministers finalise a combined white paper. But will this lead to a merger of social services departments and primary care trusts? Seamus Ward reports

02 September 2005

It seems the 'Berlin Wall' dividing health and social care might finally be coming down, as ministers finalise a combined white paper. But will this lead to a merger of social services departments and primary care trusts? Seamus Ward reports

Health and social care – the phrase seems to roll off the tongue, underlining the interdependence of the two main 'wellbeing' services. Yet in England these are provided largely by separate organisations and are often disjointed, despite attempts over the past eight years to encourage greater collaboration. These efforts are due to be stepped up at the end of the year with a white paper on out-of-hospital care that will set out the future for primary and community care as well as adult social services.

Adult social care was going to have its own white paper this autumn, following on from March's green paper, Independence, wellbeing and choice. However, in July, Liam Byrne, the junior health minister responsible for care services, announced that it would now be combined with the white paper on out-of-hospital care. Although the NHS and social services are co-operating more, the seamless service patients want has not been achieved. Byrne promised that the joint white paper would deliver 'integrated health and social care systems'.

What could this mean? The white paper will also detail plans to reduce the number of primary care trusts by making most coterminous with local authority boundaries by next October – proposals first made in July's Commissioning a patient-led NHS.

Health and social services will also soon have the same regulator. The Commission for Social Care Inspection and the Healthcare Commission will be merged by 2008. Could ministers be about to grasp a nettle avoided by their predecessors since the early 1970s – and merge health and adult social services at local level? And if social services merge with primary care trusts, will this mean a further reduction in local authorities' responsibilities?

Before these questions are answered, the Department of Health will hold a series of consultative events with the public in September and October, under the banner of 'Your health, your care, your say'. The DoH says that the public's opinions will contribute to the white paper.

Kathryn Hudson, DoH national director for social care, says: 'The white paper gives us an opportunity to look at how we can integrate health, social care and other services in the community to improve the experience of those who use them. We have not developed firm ideas about policy changes, but want to shape the paper through the views and experiences of people who use services, staff and others who have a contribution to make. The consultation will offer a chance to obtain a fresh perspective from a wide audience.'

Hudson adds: 'This is an opportunity to look again at the way that health services outside hospital and social care perspectives can develop the agenda further in response to the consultation on Independence, wellbeing and choice.' In the meantime, she says, the department will be pushing ahead with the green paper's proposals that have already been warmly welcomed, including 'work on individual budgets, assistive technology, outcome measures, and assessment of risk'.

Since 1997, the Blair administration has been encouraging health authorities, then PCTs, to work closely with their local authorities – to break down the 'Berlin Wall' that has divided them. Since 1999, PCTs and councils have been allowed to pool their funds for a local initiative, for example to create a single assessment team for patients or clients or to jointly employ a member of staff. Since 2002 they have been able to formalise their collaboration by forming a new organisation – a care trust – that combines both organisations' responsibilities under a single management.

Although it would be tempting to see care trusts as the definitive future model for health and adult social services, it is important to note that the idea has not gained much support on the ground. Only a handful of such trusts exist and the Local Government Association does not support them. It believes councils should forge closer ties with PCTs by developing Local Area Agreements. These would have wider benefits as they would bring the NHS firmly into existing local strategies to improve community wellbeing. The association argues that the NHS has always been a sickness service while local authorities play a key role in the wider determinants of health, such as housing, employment and education.

David Rogers, chair of the LGA's community wellbeing board, says: 'The white paper could provide a real opportunity to explore the interface between health and social care, to build strong partnerships that have been forged between local government and health, and to bring the NHS and, in particular GPs, into the wellbeing agenda. Local government has a critical role to play in the health and wellbeing of local communities. It is welcome that Commissioning a patient-led NHS stresses the importance of engaging with local authorities. A wide range of council services contribute to promoting public health outcomes, including housing, cultural services, lifelong learning and community safety.'

So far, local authorities and PCTs have been more enthusiastic about pooling funds without creating a new organisation. The DoH says it has registered 230 such partnerships with a total value of more than £2bn. Independence, wellbeing and choice floated the idea of virtual care trusts, which would appear to be little more than most councils and PCTs are doing already – pooling funds and staff – without the upheaval of merging two organisations.

NHS Confederation policy manager Jo Webber says the joint white paper is a step in the right direction. 'We welcome the fact that the two have been brought together as a single system. One of our underlying concerns is that adult social care does not get lost in the detail of the out-of-hospital white paper. Social care is part of out-of-hospital care and there are a lot of good relationships and agreements between councils and NHS organisations. It would be a shame if we didn't build on that.'

Care trusts are a vital element in these partnerships and Webber is sure they have a future. Indeed, she adds: 'I think there is a challenge for PCTs and local authority partners to look again at the arrangements for children's trusts and at virtual care trusts in line with what was said in the adult social care green paper. They could remain virtual or think about merging the services to put children's and adult social services as well as community health services in one organisation, rather than having a virtual arrangement. This may be a stimulus for some areas to consider creating a care trust, where they had not considered it before.'

PCTs have been asked to save 15% of their budgets as part of the reorganisation. Webber says that some of this money might be saved by trusts merging with others to become coterminous with council boundaries. But further savings could be made through creating care trusts, she adds. Another option would be to contract out back-office functions to the local council.

Some observers believe that a foundation care trust, with the same financial freedoms as the current batch of foundation hospital trusts, would be a powerful vehicle to champion community care in all its forms against the burgeoning power of provider hospitals.

Local authorities might fear that the underlying agenda is to remove their responsibility for social care altogether, but the LGA insists this is not the case. It welcomes the fact that the NHS is seeking greater co-ordination with social services through improving the congruence of PCT and local government boundaries. Many PCTs have appointed councillors to their boards as non-executive directors, while local authorities also have a say in their local health service through overview and scrutiny committees.

Rogers adds: 'The changes envisaged in the way services are commissioned to develop a patient-led NHS should provide the opportunity to ensure that all organisations involved in the health and care of communities do so in partnership. Local authorities are already working in partnership with the statutory, voluntary and community sectors to fulfil their powers to promote the social, economic and environmental wellbeing of their areas.'

Sources close to the DoH say the white paper is unlikely to insist on formal mergers between social services departments and PCTs, though voluntary take-up of such an option will remain an option. However, the department will tell local authorities and PCTs that they cannot sit on their hands and do nothing.

Finance will be a major consideration for both local authorities and PCTs, whether structural reorganisation occurs or not. PCTs will be scrabbling around trying to save that 15% of their budgets, while social services have been told that the changes set out in Independence, wellbeing and choice, such as greater support for independent living, more preventative work and more individual budgets for clients, will be cost neutral. Not so, say the LGA and the Association of Directors of Social Services. They argue that adult social services are already under-funded and that these changes, combined with the need for staff training and new IT systems, will add to costs.

Webber does not believe that the current arrangements for pooling funds need to be changed, but she thinks that they could be simplified to encourage co-operation. 'It would be good if the process were not so bureaucratic – it tends to take a lot of time and effort. If it were simpler, it would encourage people to look at their service structures.'

She says local authorities and PCTs planning to co-operate more closely should pay attention to the changing face of NHS commissioning. Since April, GP practices have been able to hold budgets to commission care for their patients. Though initial take-up has been slow, the government hopes it will soon become the norm.

'A lot of the commissioning decisions will be made at GP practice level and these decisions should link into a strategic plan – in the same way as a children's trust uses its child and young person plan,' says Webber. 'A strategic plan could link up what the practices feel they need with the overall strategic plan for the area. Otherwise, you would end up with a series of commissioning decisions and a plan that does not match.'

As well as ensuring patients receive a less disjointed service, closer working between health and social services could help particular patient groups. The Sainsbury Centre for Mental Health says the move could be good news for those who suffer from mental illness. 'This has the potential to be positive if it is about making the services work together effectively, simplifying the funding streams and making social care a bigger part of the mix,' says a spokesman.

'While treatment is important to patients, they also want to make sure they get the right benefits, a decent place to live, a job and generally have a life. We would like to see the social care side developed and properly funded.'

He adds that the joint efforts of health and social care teams could improve mental health commissioning, which is still very much led by providers. The white paper and any subsequent legislation have the potential to offer better, integrated care for patients.

But Webber says all sides must work together to achieve this aim. 'There are some opportunities, challenges and the risk of throwing the baby out with the bath water, in that we might lose some partnership working. There has been a period of change and we have to hang on to what works well. This is the challenge for local partners. Patients want a system that works for them and, as long as it does, they have no interest in who provides it.'

But perhaps the main challenge in the wake of the white paper proposals will be to ensure that the reconfiguration of services raises the profile of social care – not just in terms of funding or political clout but also by enhancing its attractiveness as a career.