It’s strange isn’t it? I have devoted long periods of my career to promoting joint working but it took being on the receiving end as a carer to really understand how far we still have to go.
Joint working has been a recurring theme in health and social care for at least three decades. Its importance was reaffirmed in the recent and welcome white paper Our Health, Our Care, Our Say. But, despite this – and a formal duty of partnership for the main statutory agencies – why does it feel like we are still talking about it? Why haven’t we done it yet?
It is easy to identify the obstacles, including the fact that health services remain by and large free while a range of social care services are means-tested. Then, of course, the NHS includes more than 20 professions, each with a degree of clinical autonomy, led by people from different backgrounds. Social care is dominated by a single profession and, until recently at least, managed mainly by people from that profession. Social care is part of the range of services subject to local decision-making while the NHS is a nationally organised and delivered service.
The latest example of the impact of this difference can be seen in the top-slicing of primary care trusts to help neighbouring PCTs with financial problems.
It doesn’t help that the models of care are different. I know the NHS medical model is seen by social care colleagues as authoritarian and disempowering. What they don’t always appreciate is that nurses see it that way too.
Another obstacle is the fact that health and social care organisations are subject to separate performance management systems that generally do not measure joint performance.
The systems of delivery are different – with in-house provision dominating the NHS and with extensive use in social care of the mixed economy, including the voluntary sector.
And lest we forget: different rates of pay, pension schemes, computer systems and, especially, access to car parking!
These wide-ranging structural and cultural differences do not encourage collaborative behaviour and, at worst, work against it. Given these challenges, it is surprising that any joint working takes place at all and yet there are examples of good practice as a visit to the Integrated Care Network website confirms. But are the health and social care communities in the network exceptions that prove the rule? Are they succeeding in spite of the forces that would keep them apart?
Most health and social care colleagues just want to deliver good outcomes for people who use their services. But we tend to judge those outcomes from the perspective of our profession or organisation.
My own experience as a carer, supporting terminally ill older relatives, has confirmed for me that there are wonderful services available. It also confirmed that services are failing to talk to each other and so are not reaping the gains from joint working, either for themselves or the users at the centre of their care.
Perhaps a way to make progress on joint working is to worry less about joint structures and focus more on joint outcomes, measured from the perspective of the user. In the face of the systemic obstacles set out above, this would provide us with a common currency to judge our endeavours. This would involve change at several levels, including perhaps the most challenging: change at the personal level. We would all need to be prepared to work outside our established comfort zones, to work not just with others but for others.
The biggest single contribution we could make to joint working is to recognise that our professional and organisational differences are not the starting point.
See Health Special Taking the accent off the acute coverage of current policies and challenges facing the NHS.
Jennette Arnold is a former nurse and a member of the Greater London Assembly’s health and public services committee
“We would need to work outside our established comfort zones, to work not just with others but for others”