Care trusts were set to turn the social services world on its head back in 2002. Mark Hunter asks why things didn’t quite turn out like that
Once considered the future of social care, care trusts seemed to have disappeared off the radar until late last year when Torbay primary care trust absorbed 850 staff from adult social services and became the ninth care trust in England. Now two more areas – North East Lincolnshire and Solihull – are poised to go the same way. Could it be that the “break up of old monolithic social services” promised in 2002 by then health secretary Alan Milburn is finally coming to fruition? If so, it has been a long time coming.
Of the 16 care trust demonstrator sites that were due to go live on 1 April 2002, only four actually made it on time. Another four trickled through over the next year. But as both social services and the NHS began to reel from their respective reorganisations, local authorities and PCTs seemed to lose interest in the concept of a single organisation that could offer integrated health and social care. By the beginning of this year, care trusts had dropped so far down the agenda that the white paper devoted to integrating health and social care (Our Health, Our Care, Our Say) didn’t even mention them.
So why the sudden re-emergence? One reason could be the white paper itself. Its vision of “joint health and social care teams” could have come straight out of a care trust mission statement, and it is difficult to see how many of the proposals for greater integration could be achieved without some form of joint management.
But there may also be a more pragmatic reason. Reorganisation has left many health and social care agencies feeling vulnerable.
Those on the adult side of the social services divide could now be regarded as the poor relations of social care, while many of the smaller PCTs face being merged or absorbed into larger organisations. Joining forces to become a care trust could raise the profile of adult care while allowing the PCT to protect its local identity.
“It’s about gaining the critical mass necessary to fight off any external threat,” says Jon Glasby, senior lecturer at the Health Services Management Centre. “Within social care, the splitting away of child services has led to a debate about what to do with what’s left. At the same time, there are questions over the viability of some of the smaller PCTs. Some are merging but others feel it’s better to merge with social services. That way they can retain a local focus.”
A good example of this local approach can be seen in Solihull’s bid for care trust status. With a management team already in place and a provisional launch date of 1 October, the local authority and PCT are awaiting government approval to merge the PCT with the council’s adult social services team. The new organisation will employ 2,000 people and have a budget of £280m.
According to Crispin Atkinson, director of partnerships at Solihull PCT, care trust status will allow health and social care staff to tackle the root causes of problems that are very specific to the local area.
“Solihull has a very particular identity when compared with surrounding areas,” he says. “It is the health area with the greatest variation in health inequalities in the UK. We felt that becoming a care trust would allow us to tackle those problems at a deeper level and retain a Solihull focus. It will bring us closer to the council, not just in social care but in areas such as housing, benefits and employment, which is where the root of these health inequalities lie.”
Atkinson admits to being reassured by the content of January’s white paper but emphasises that the Solihull proposals are not a kneejerk response to it. “We’ve been working on it for two years and there were scoping reports before that. So, having got a long way down the track, when the white paper came out it was gratifying to read what we have been saying all along.”
In many ways the move to become a care trust is simply a logical progression of joint working arrangements between health and social services that have been under way in Solihull for several years. Indeed, Atkinson emphasises that an existing good relationship between the council and PCT is essential before a care trust can be considered.
“We’ve always had a good relationship with the local authority and we’ve been doing joined-up working for several years.
Another important factor has been local political support. The care trust has cross-party support on the local authority and that really does make a difference.”
Solihull’s vision of a single organisation that incorporates a PCT and the whole of adult social services is just one of several models now available for care trusts. Indeed the diverse nature of the services makes it difficult to judge whether the concept has been a success or not. When Community Care reviewed the pioneer trusts one year after their inception (“Pioneers together,” 3 April, 2003) it found that most front-line staff and care users had hardly noticed the difference. Age Concern says it has no evidence as to whether health and social services are better integrated in care trusts or elsewhere.
Certainly, some have faced their problems. A £1.9m budget deficit at Northumberland care trust led to the rationing of some services and Bexley care trust (south east London) was recently on the wrong end of the landmark “Grogan judgement” after refusing to fully fund the care of a wheelchair-bound 65-year-old suffering from deteriorating multiple sclerosis.
Nevertheless, seven out of the nine care trusts have achieved star ratings of two or more. An independent assessment of Torbay care trust, which has yet to receive its star rating, recently found that care trust status had led to “some dramatic reductions in waits for assessments”. Staff reported much improved communication, teamwork, face-to-face contact, sharing of information and decision-making.
Despite the white paper’s promotion of more integrated services, it remains unclear how many more areas will pursue care trust status. Mistrust between health and social services management undoubtedly remains and many areas are opting for other models of integrated care.
“One of the reasons that care trusts haven’t had the uptake that the government would have liked is that people have realised that it’s not the only mechanism by which social care and health can work together,” says Jennifer Rankin, a research fellow at the Institute for Public Policy Research. “For instance some areas are setting up ‘virtual trusts’ along the same lines as children’s trusts. So, there are a lot of different models out there.
“A lot of people are unconvinced that full integration is necessary,” agrees Jon Glasby, who points out that those areas that have opted for care trust status are “fairly unique”.
“They tend to have very longstanding relationships between health and social services anyway, so becoming a care trust was seen as a logical next step. They also tended to have very stable and coterminous boundaries.”
Glasby believes that a variety of different models of integrated working will emerge, each based on local circumstances. This would be preferable to a one-size-fits-all approach, he says. And each model should be judged, not on its management structure, but on the service it provides.
“Service users don’t care who provides the services as long as they are of high quality and delivered with dignity.”