Wales slays the critics

Welsh social services departments have been severely criticised
recently for the quality of their care provision, the way it is
managed and the lack of prospects for innovation and speedy
improvement.¹

One way to capitalise on the momentum for change that this
criticism has generated is for social services to work with other
local organisations that have a stake in care provision –
especially the NHS, but also housing, education and the private and
voluntary sectors. In England new ways of working in partnership –
namely the section 31 flexibilities of pooled budgets, lead
commissioning and integrated provision introduced in the Health Act
1999 – are helping to reduce service fragmentation, free up
resources, improve financial management and increase user
consultation and involvement.²

To this end, the Welsh assembly is encouraging partnership – and in
some cases supporting it with special grant funding – in everything
from strategic planning to front-line services. In fact, new
research suggests that partnerships between local authorities and
the NHS in Wales are developing well: a recent study for the
assembly by Manchester Centre for Healthcare Management, The
Nuffield Institute for Health and policy consultant Newidiem found
encouraging developments in Wales.

At the most general level of local strategy development, it was
found that nearly 90 per cent of respondents were part of, or were
discussing joining, a formal partnership. The proportion was
similar for formal strategic-level partnerships dealing
specifically with health and social care.

These partnerships included not only traditional partners, such as
social services, NHS trusts and the voluntary sector, but also
wider interests. Partnerships were developing with other council
departments including education, housing, and transport, other
statutory agencies such as police and probation, local education
and business sectors and representatives of users and
patients.

Joint working was also a significant feature of health and social
care commissioning, purchasing and provision – particularly in
high-profile areas such as delayed transfers of care, emergency
pressures and intermediate care. Joint working also existed in up
to 90 per cent of services for older people, adults with mental
health problems, learning difficulties or physical disabilities,
and for children. In addition, 80 per cent of respondents said
health and social care activities were an important part of other
formal partnerships (everything from Communities First and local
health alliances to schemes for particular client groups and
service areas), and 50 per cent were engaged in informal joint
working. These arrangements were felt to be improving service
outputs and outcomes as well as fostering partnership
working.

Less than a year after their introduction in April 2001, the Health
Act flexibilities:

• Covered, or were planned for, clients and services including:
  older people; adults and children with mental health problems,
  learning difficulties or physical disabilities; rehabilitation;
  rapid or crisis response teams; home care and supported living;
  joint equipment stores; residential, nursing and respite care; day
  care; outreach and prevention services; and hospital care.
• Were focusing primarily on integrated provision (in 97 per cent
  of cases), although pooled budgets and lead commissioning were
  reported by 80 per cent and 66 per cent of partner organisations
  respectively.

Again, more partners were becoming involved and arrangements
were reinforcing wider consultation and involvement.

Although the intention to work in partnership was clear, in terms
of more practical developments and linkages it was still early
days. Promoting the case for “joined-up” government is in itself
relatively easy, but partnership creation is only a first step. The
steepness of the learning curve and the length of time needed to go
from partnership formation to effective delivery cannot be
underestimated. In this respect, it is vital neither to claim too
much for early partnership working nor to bail out too soon if
improved delivery does not immediately follow.

Where organisations were already part of a formal partnership to
develop general local strategy or a health and social care
strategy, most were still at the preliminary drafting stage. Only a
few were formally consulting on an existing draft, or had already
adopted a strategy. When asked how effectively health and social
care related to broader local strategies only a quarter said it was
already fully integrated and nested within wider partnerships.
Three quarters said health and social care remained separate
although there were plans for eventual integration.

Moving from partnership formation to delivery also demands adequate
resourcing. However, the size of organisational budgets devoted,
for example, to the Health Act flexibilities suggests they were
being used essentially as a “bolt-on”. Special grant monies were
the largest source of finance rather than mainstream budgets. In
addition, partners were focusing primarily on process measures and
indicators of success, rather than clearly defined service targets.
The list of perceived constraints and challenges was long. It
included: a lack of money, staff and time; developing
inter-organisational and inter-professional relationships; and
clarifying financial, business planning, information, performance
and risk management systems.

There was concern that change needed to happen at a manageable
pace, particularly given the “crowded platform” of initiatives
facing local authorities and the NHS in Wales. Hence, partners had
stayed close to known areas of joint experience and expertise in
order to achieve some success relatively quickly. This caution is
certainly sensible, but it did mean that difficult issues had yet
to be tackled. These included:

• Ceding control over finance to implement pooled budgets.
• Integrating whole services and organisations rather than simply
  front-line teams.
• Addressing human resource implications of integrated provision
  which requires negotiation with trade unions.
• Measuring and evaluating the impact of new arrangements.

Despite the difficulties partners knew they were facing, there
was a willingness to learn and to progress. Both outside support
(such as the assembly) and opportunities to share best practice
with other areas were welcomed. Overall, the symbolic shifts were
significant. The Health Act flexibilities in particular had
introduced a helpful “nowhere to hide” attitude. Such partnerships
were described as much harder-edged, often replacing previous
informal arrangements based on one-off opportunities and particular
personalities. Another essential difference was the need for local
politicians to take a clearer view of the merits or otherwise of
sharing some budgetary power in order to deliver more coherent
services.

Even if concrete results from partnerships were not yet visible,
firm foundations were felt to be in place for real improvements in
health and social care delivery. The severe criticisms to which so
many social services departments in Wales have recently been
subject are being addressed. What is needed to build on these
foundations is time, resources and support. A key question is
whether the present policy environment will permit enough
concentration of attention and effort to reap the benefits before
yet more new initiatives are introduced.

About the study

The Welsh assembly commissioned the study to provide a baseline
for continuing evaluation of partnership developments between the
NHS and local authorities in Wales. The study consisted of postal
surveys, a second more detailed survey and a round of case
studies.

Ruth Young is fellow in health care and public sector
management at Manchester Centre for Healthcare Management; Brian
Hardy is principal research fellow and Eileen Waddington and Nigel
Jones senior development consultants at the Nuffield Institute for
Health, University of Leeds.

References

A copy of the project report is available from Steph Mullen at
Manchester Centre for Healthcare Management, tel: 0161 275 2910 or
e-mail,
steph.mullen@man.ac.uk