Can we work together?

When people from two different cultures meet for the first time and
then try to work together there are often communication problems,
writes David Callaghan.

The same is true of health and social care with many differences
to be overcome.

This challenge is central to the government’s agenda for
care trusts to be formed for the delivery of adult services, and
children’s trusts, which both require staff to come together
and form a single body.

Recent events in Barking and Dagenham have shown that even a new
arrangement held up as a model for the future can easily be
buffeted by events. It shows that closer integration, which is
short of being a care trust, can still be a rocky road.

In this case the cold winds of a zero star rating for one of the
partners, the primary care trust, led to a fall out over how to
respond.

The PCT and strategic health authority wanted to make the holder
of the joint leadership role responsible for the poor inspection
outcome by dismissing her.

But Julia Ross’ employers were still the council and it
made a unilateral decision to withdraw her from the role, leaving
the PCT to find a new chief executive.

Graham Farrant, chief executive of Barking and Dagenham Council,
said structural change in the NHS led to misunderstandings between
both sides of the partnership. The arrangements were drawn up with
the former Barking, Dagenham and Havering Health Authority, which
was superceded by North East London Strategic Health Authority and
a primary care trust.

“It was set up with the previous health authority with a
clear understanding of what the advantages were, but the current
strategic health authority does not have the same view of
it,” he says.

The primary care trust has also evolved quickly in three years
since it was formed, taking on more services and powers from the
time when the arrangement was drawn up, which also changed the
dynamics of the relationship and placed extra responsibility on
Ross’ shoulders.

Farrant is eager to stress that the relationship will still
flourish, pointing to many examples of how this is benefiting
service delivery especially in older people’s services.

New lines of accountability have been drawn up though with staff
who were reporting to Ross in her joint role, now either answerable
to her as social services director or to the new PCT
leadership.

One point of contact

In Barnsley a different approach has been taken, with a
sophisticated commissioner/provider relationship developed to
ensure joined up services and one point of contact for the service
user.

Six boards have been formed by the council and Barnsley Primary
Care Trust, and each one commissions services. A lead provider,
either the council or the PCT, is then contracted to deliver those
services.

Social services is the lead provider in learning difficulties
and children’s services, with the PCT controlling services
for older people, disabled people and mental health sufferers.

This set up is overseen by a ‘joint agency group’
made of councillors, chief executives and treasurers of the two
organisations, and the JAG allocates the budget to each board.

Staff are ‘seconded’ from social services to the PCT
and vice versa, and they are given the option of retaining the same
pay and conditions or of taking on the terms of the lead
provider.

The lead provider only manages the staff member in their day to
day job, but their contract remains with their employer and they
can go to their ‘original’ manager to discuss personal
or professional issues. So, for example, nurses seconded to the
council retain a manager from a medical setting.

Graham Gatehouse, Barnsley Council’s social services
director, says it is vital staff can keep their professional
background. It gives them the confidence to know they have support
behind them as they go into a joint team environment.

Cross the boundaries

Mark Feinmann, who is joint general manager of learning
disabilities, working across the boundaries of three organisations,
agrees that you have to keep staff onboard all the time.

“That’s the job – negotiating with people and
engineering compromises. It’s bringing people to water and
getting them to drink together rather than forcing change on
them,” he says.

Some people actively resist closer working arrangements, he
admits, and that is because they fear a take over by the other
side.

He brings together services and 250 staff from Glasgow Council,
Greater Glasgow NHS Board and Greater Glasgow Primary Care NHS
Trust. He has an enormous workload and the job is very stressful,
but he believes in what he is doing: “I am convinced it is
the only way to go, and there is a fairly strong view in Glasgow
that this is the only show in town.”

The key element in the equation is support from the top:
“It is when you haven’t got support upstairs then
that’s when you struggle,” he says.

Feinmann is accountable to a joint board, similar to the JAG in
Barnsley, which is made up of the chief executive of the PCT, the
deputy director of social work, the deputy commissioner of the
health board, senior councillors and non-executive members of the
trust and the health board.

Any disagreements between the organisations are thrashed out in
meetings of the joint board. There are other officers with dual
roles such as joint general managers for homelessness and drug
addiction, who also report to the board.

So there are other models of how to run a joint arrangement
successfully. Barking and Dagenham was certainly the most high
profile example, which was examined by other authorities such as
Barnsley, but for areas starting out on this road there are some
interesting innovations which could be copied.

If a closer working deal is too complicated for some then there
is always the option to go the whole way and create care trusts,
which are being piloted in eight areas.

Will Barking and Dagenham’s experience put off some
potential partners?

“Must have an impact”

John Ransford, who is director of education and social policy,
at the Local Government Association, said: “It must have an
impact simply because it is so high profile. The Department of
Health used and pointed to it.”

He believes service users rarely differentiate between
providers, and just want flexible and adaptable services. He
doesn’t believe anyone should be prescriptive about how
service providers are structured.

“The LGA has always wanted to think of care trusts and
children’s trusts conceptually,” he says. Local
solutions based on a theme of much closer working is the best way
forward.

“We have to remember that we are dealing with
fundamentally different cultures. The NHS is obsessed with avoiding
a postcode lottery of services, whereas local government is about
postcode difference,” he says.

But Ransford does not want too much caution to seep into
people’s minds, or barriers will not be broken down.

“When you have a pioneering thing risk taking is very
important,” he says.

Perhaps others areas will have to suffer setbacks like Barking
and Dagenham has experienced before progress can be made towards
the cultural harmony needed if closer integration is going to
work.

The government obviously needs to be patient if partnerships are
to be allowed to work through the problems they encounter. But with
only three years given in the green paper on children for
children’s trusts to be established, will ministers be
prepared to wait?