The experiences of care trusts indicates that the key to integrated services does not always lie in structural change. By Natalie Valios
It would have been interesting to see health secretary Andy Burnham’s face when Blackburn with Darwen’s application to become a “care trust plus” landed on his desk. (Blackburn will be the first care trust to be responsible for children’s services’ commissioning as well as adult social care and health when it starts work on 1 April, hence the “plus”.)
So few primary care trusts and local authorities have formed care trusts responsible for health and adult care since the model was launched in 2002 that any government minister would be forgiven for forgetting about them. Currently they only exist in Northumberland, North East Lincolnshire, Solihull and Torbay (see box, below).
There are two reasons why organisations tread the care trust path, says Jo Webber, deputy policy director at the NHS Confederation: “Because one partner is seen as weak so bringing services together will get everything up to acceptable levels. Or because they have been working so closely together that it’s the logical next step.”
Will Blackburn’s decision to bite the bullet resurrect interest in light of the drive for more integration between health and social care? It’s possible, but unlikely, says Jon Glasby, professor of health and social care at Birmingham University. “Changing structures is a disruptive process that reduces staff morale and productivity for about two years,” he says. “Integration costs before it saves, and sometimes it doesn’t save. Many areas were excited by the idea initially, but then thought they could achieve similar outcomes with less disruption.”
Given the state of public finance it’s clear that social services are going to have to work more closely not just with health, but with other partners like housing, says Richard Jones, vice-president of the Association of Directors of Adult Social Services. “I’m not a big fan of structural change,” he says. “If we are not careful we change the way the organisation works which has little impact on what it delivers. My starting point is clarity about what we’re trying to achieve and what needs to change to improve outcomes.”
Care trusts are not the only option; other mechanisms include pooled funding, open-book accounting, where partners can examine each other’s accounts, joint commissioning and integrated teams. Total Place, an initiative being piloted in 13 areas in England, could also help. It involves the totality of public funding that comes into an area being put on the table to see how it can be used to ensure better services at less cost in a “whole area” approach.
Whichever government is in power after the election, the feeling is that none would impose the care trust path. A spokesperson for the Conservative Party says: “This is down to local bodies to make decisions as to what is appropriate. We won’t ride roughshod over local needs when it’s not always in their best interests.”
Glasby agrees: “Any future government would set clear outcomes but allow flexibility for achieving them and that’s right because you can’t micro-manage this from Whitehall.”
Case study 1: TORBAY CARE TRUST:
‘For clients the response and service is much quicker’
“We haven’t saved a lot of money but we have improved services,” says Steve Wallwark, director of finance and deputy chief executive of Torbay Care Trust.
Five years ago the Commission for Social Care Inspection rated adult social services at Torbay Council as “performing poorly”. After establishing a care trust in 2005, the rating from the Care Quality Commission is now “performing well”.
Five zones were set up clustered around GP practices with teams consisting of social workers, community care workers, mental health workers, district nurses, physiotherapists, occupational therapists, senior practitioners and community matrons.
Clients have a single point of entry through health and social care co-ordinators and there is one electronic records system. Integration has resulted in there being no delayed hospital discharges, while other improvements have included the proportion of care packages being in place within 28 days of an assessment rising from 67% to 97% from 2006-9.
Robin Causley, chief executive of Age Concern Torbay, says the care trust has benefited the area’s elderly population: “It’s clear who has responsibility for what, rather than people falling between health or social care. Teams are sharing information and people are able to gain the support they need more expediently.”
There were hurdles to overcome – each organisation had different VAT regimes, insurance systems and staff had different terms and conditions. Wallwark says “we could have said ‘this is just too difficult’, so I can see why for others it wouldn’t be worth the effort”. The biggest challenge was when staff formally merged. All social services staff had to go through the Agenda for Change process (the NHS’s single pay system) because in the legal framework for adult trusts the NHS is the lead body. So staff had NHS terms and conditions, and most transferred to the NHS pension scheme.
Neither the NHS nor the council have put additional investment into the care trust. It runs on a pooled budget. In 2009-10 funding was £250m from the NHS, £40m from the local authority and £10m from social services charges.
Sonja Stefanics, zone manager for Torquay north and south, says: “The old referral process when there was the PCT and social services had seven steps, this is down to two. There is one assessment form and we talk to each other so users don’t have to repeat their story. We know the different aspects of that person’s care, there is continuity of care and quicker access to services.”
Pivotal to this are the health and social care co-ordinators, such as Katie McAuley, who is also a trainee social worker: “Working together was strange at first but now it’s such a benefit that we are all sitting under the same roof because for clients the response and service is so much quicker. Now we all work as a team and it’s easier to have multi-disciplinary meetings about a case.”
Case study 2: BEXLEY CARE TRUST
From PCT to care trust and back again in six years
Bexley PCT became a care trust in June 2003 when Bexley Council delegated its adult social care functions to it, although commissioning responsibility stayed with the council. The decision was reversed in April 2009 when the council took back management of adult social care staff.
During this period the local authority built up its commissioning expertise, says Mark Charters, director of social and community services at Bexley Council. The decision was “not about pulling back from integration”, but was based on “the need to radically modernise social care in light of the personalisation agenda”. He adds: “The NHS isn’t delivering services on the basis of individual budgets yet and the care trust’s decision to outsource primary health care meant the council had to review the arrangement.”
“There’s a real risk of just creating a care trust and expecting good integrated working to follow,” Charters adds. “You have to ensure the care pathways are brought together and that can be done in a care trust or in two separate bodies with an agreement to work together.”
The spirit of the old arrangement continues with joint commissioning arrangements for mental health and learning disability services and a joint commissioning strategy for older people and adults with physical and learning disabilities.
Carl Millin, branch secretary at Bexley Unison, says: “There had always been a history of close integrated working so there was not a great jump in performance when they merged or decline in performance when they separated.”
This article appears in the 11 March issue of Community Care magazine under the heading Care trust conundrum