Border raid

There is still a long way to go to achieve joined up working across health and social care. Successful partnerships do exist but only in some areas and often because key individuals have been the driving force in getting them off the ground. In this special focus we explore the barriers to joined up working and analyse the implications of the government’s proposal for primary care trusts and local authorities to align their boundaries so that they cover the same areas.

The mismatch of NHS and local authority borders has for a long time hampered the government’s goal of integrating health and social services. But things are set to change. Within a year, primary care trusts are to be reconfigured to have a “clear relationship with local authority social services boundaries”, according to the Department of Health guidance Commissioning a Patient-led NHS.(1)

No one doubts there is a problem that needs sorting out: some social services departments currently have to deal with several PCTs, while some PCTs have to deal with several local authorities. Where borders overlap some of the population falls within one organisation’s patch and some in that of another. 

“It’s about how many people you have to deal with,” says Jo Webber, deputy director of policy at the NHS Confederation. She adds: “If you are trying to design new services then the fewer partners you have to discuss with the easier it is.”

The more partners an organisation has, the more time it will have to spend on developing relationships. Webber says that it is these relationships that make partnerships work at a strategic level. She adds: “For instance, to get integrated partnerships that keep people with long-term conditions in their own home for longer, then you only want to be in discussions with one social services department at a time.

“And if you are looking at housing-based solutions for people, such as extra care housing, it’s easier to sort out if you are only dealing with one housing authority.”

Webber’s former PCT  in Nottinghamshire had to work in conjunction with three district councils and two county councils. One of the county councils had seven PCTs in it, while the other had six.

However, the proposals to match PCT and local authority areas more closely have caused consternation, and the expectation is that the current number of PCTs will be halved. But it does not automatically follow that England’s 303 PCTs will be cut down to match the 150 top-tier authorities, as the document makes it clear that one-to-one coterminosity is not strictly necessary: “Big local authorities might have more than one PCT whereas a number of small unitary authorities might fit into one PCT,” it states.

The main motivation for the restructuring appears to be the 15 per cent efficiency savings that will come out of merging so many PCTs. The haste with which it is being carried out – strategic health authorities were given less than two months to submit their new PCT maps – suggests that the huge NHS deficit is the real reason for such dramatic structural changes.

In both health and social care there are fears of a loss of existing coterminosity between PCTs and second-tier councils within counties, and between PCTs and unitary authorities in other areas.

Tony Hunter, outgoing president of the Association of Directors of Social Services says the announcement did come as a surprise, but adds: “We do support in broad terms the will behind this to look for further coterminosity between local authority and health boundaries.

He admits to concerns that cost reductions are the drivers behind the changes, adding: “There’s a real risk that joined up arrangements which are working well – especially between unitary authorities and coterminus PCTs – could actually be lost.”

And he has good reason to worry. A survey of 47 unitary authorities by David White, chief executive of Thurrock Council, confirms Hunter’s fear that existing joint-working arrangements for social care could be undermined.

“It’s crucial to have coterminosity but these proposals don’t do it,” White says. “They may look to improve joint-working between health, social care and children’s services, but there’s a nasty unintended consequence. There’s a danger that current coterminosity and joint commissioning between unitary councils and PCTs will be lost.”

White is particularly concerned about the unitary authorities that were created in the mid-1990s out of larger county councils.

“If you get larger PCTs that span unitary authorities, there’s a danger that the influence of unitaries as all-purpose authorities could be marginalised. That’s contrary to other government policies such as local area agreements, where you bring funding streams together.”

Bob Hudson, professor of social policy at Durham University, thinks that because of the need to make these efficiency savings, there will be a temptation to go for larger agglomerations of PCTs.

He says: “The problem arises in shire counties which are already too big, so they have devolved their social service divisions down to localities, to the divisional commissioning manager for that PCT area.

“This has produced a lot of interesting and good results. What these reforms could do is abolish all the small PCTs that are coterminus with second-tier councils.

“So you have a real drive for provider fragmentation, when we are told we should be going for provider integration.

Hudson concludes: “The trend since this government came to power was to get more local, through primary care groups and trusts. Now we are seeing a huge swing back to health authorities – a more centralised command and control structure.”

Many in social care will note that NHS finances once again seem to be dominating the shape of services, and that social care is being tagged on as an afterthought to health.

In addition to halving their numbers, PCTs are also to be stripped of their provider function, so will no longer employ the community nurses who collaborate most closely with social care, although there appears to be some flexibility in the timeframe for this. 

Overall, however, it is the haste and lack of consultation in these cost-driven proposals that have caused the most consternation. “We do regret the way it was announced,” says Hunter. “We are concerned that we are involved in the implementation, or some very good working arrangements could well be derailed.”

(1) Commissioning a Patient-led NHS, Department of Health, 2005