Should health and social care join?

After more than a decade of Labour, plans for closer links with social care are back on the NHS agenda. Nick Bostock reports.

Lord Warner: The DoH should legislate to force joint health and social care commissioning
Lord Warner: The DoH should legislate to force joint health and social care commissioning

Nowhere is the cyclical nature of the debate around health policy more evident than in the toing and froing over how exactly health and social care should interact.

The first health secretary when Labour took office in 1997, Frank Dobson, promised to break down the 'Berlin Wall' between the two sectors.

The NHS Plan then envisioned 'care trust' status - a joint model straddling health and social care - as the natural next step in the evolution of PCTs.

But a decade later, just 10 PCTs have ever held care trust status, and two of these have fallen off the wagon, reverting to their former state.

Backing for integration
However, one of the trusts that did make this policy stick - Torbay Care Trust, is now reportedly seen as 'the future' by none other than NHS chief executive David Nicholson.

The latest burst of enthusiasm comes because as the financial squeeze starts to bite, the health service is desperately looking at how to find the £15 billion to £20 billion of savings Mr Nicholson has called for between 2011 and 2014.

Inefficiencies around boundaries between health and social care, as well as those between primary and acute care, are seen as prime targets.

Former health minister Lord Warner last week told a King's Fund briefing that the financial outlook left the NHS 'not much choice but to come back to the issue' of joining up health and social care.

What had 'bedevilled' integration to date was that while NHS services are free at the point of delivery, access to social care is means-tested, he argued.

'That is the fundamental difficulty that has stopped further integration,' he said.

Implementation
An Audit Commission report this month called on the government to publish 'a model document for legal arrangements' for health and social care partnerships.

Many managers on both sides simply did not understand the options open to them for pooling budgets and working together, it said.

This may explain why joint funding arrangements currently account for just 3.4 per cent of total NHS and social services spending.

Lord Warner urged the government to legislate to force health and social care organisations to set up joint commissioning. 'Exhortation and encouragement' alone were useless, he said.

Providers that can offer integrated health and social care services should be given priority over competitors, Lord Warner added.

He said care should be pulled together on a condition-by-condition basis, with care pathways spanning organisational boundaries. He also called for joint assessments of patients' health and social care needs, and managers to guide patients through the maze of services.

Dementia care was top of the list of services he said would benefit from this system.

Potential gains
Dr Phil Green, until last week the PEC chairman at Torbay Care Trust, says that cultural change has been the toughest hurdle in integrating health and social care staff and services.

The model he outlines - 'You bring everyone into a room and work out what the right pathway is' - sounds broadly like Lord Warner's plans.

Saving cash, Dr Green says is a 'happy outcome' that comes as a bonus on top of improvements in services for patients.

There have been savings from cutting duplication of services: 'You stop two people going to do the same job - you do not need a health occupational therapist and a social services one going to visit the patient.'

But major savings have been made in the coordination of back-office staff, with single finance and communications teams, for example.

From a GP's perspective, the system has improved referrals, he says: 'You make a single call to a health and social care coordinator, and they sort it.'

Obstacles to collaboration
GPC member Dr Fay Wilson backs the principle of joining health and social care because it means 'fewer silos'.

But she warns: 'Local authorities are elected and accountable to local people, whereas PCTs are accountable to the DoH, with nationally set targets. It is very difficult to bring those together.'

There are other tensions too. In Torbay, the former PCT covered the same patch as the local council, and there is only a single hospital to work with.

But in major cities the picture is more complex. Joint working may not come easily to managers schooled in a competitive, market-based NHS, either.

The reasons why collaboration fails can be even more spurious - one speaker at the King's Fund event suggested joint working often happened simply because chief executives 'got on well'.

There are clearly advantages to be had from closer working between parts of the public sector, but finding a single NHS-wide solution is a tall order.

Dr Wilson points out: 'It is not happening any time soon anyway - there is a general paralysis before the next general election. No one knows what will happen after it.'

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