Joint-working between health and social care can benefit service users and the public purse but an Audit Commission study, reviewed by Jill Manthorpe, found that it is under-used in the adults’ sector
Author: Audit Commission, November 2009
Formal arrangements on pooling functions and resources have eased the way for joint working in health and social care organisations. Adult social care can be tailored to local circumstances under section 75 of the NHS Act 2006, but it remains rarely used. The Audit Commission recommends that central government should do more to support this form of joint work, which it sees as providing better value for public money and better outcomes for service users. The arrangements are another way of ensuring that services are not constructed around different funding streams or thwarted by disputes over who pays for what.
This multi-method study draws on a literature review, including an analysis of a survey sent to auditors of all councils and primary care trusts in England in 2008.
Eight areas in England (covering 13 local authorities) were visited to collect local data through workshops with managers and examination of data, documents and strategies. Examples of joint financing were developed to illustrate the range of activities funded in this way. This material is set in the context of the options available to health and social care bodies.
The legalities of joint financing are complex. In essence, the NHS Act 2006 (the main legislation used in this area) allows functions to be delegated and pooled between local authorities and health bodies. Pooled budgets are likely to be the most common type. However, the incompatibility of many financial and information systems thwart many developments. This seems to explain why they account for only 3.4% of health and social care spending.
The commission found that pooled funds were used mainly for learning disability and mental health services as well as community equipment but rarely for older people’s services. It suggested that one reason for the general absence of formal joint financing arrangements for older people’s services is that social care is means-tested.
Some local authorities are guarded in their views about the costs and benefits of pooled funding, with the difficulties of the rules around reporting requirements to national government cited.
Some chose to take an approach whereby budgets were aligned rather than pooled. In this way, although information may be shared and priorities discussed, the budget is kept separate. The commission found that this had sometimes become a stepping stone to pooling of budgets. If a service was integrated, pooled budgets were more likely to be encountered. In some cases it was difficult to track down partnership agreements on joint financing in written format. Other documents or agreements were not particularly comprehensive, running the risk of difficulties in establishing agreed specific responsibilities should a disagreement arise. The commission recommended greater attention to measuring outcomes; it commented, for example, that a goal of “creating a seamless care experience” could be so broad as to be meaningless. It highlighted the idea of testing service integration once established and using vignettes or fictional case scenarios to investigate the espoused integration from a services user’s experience.
There were mixed views on whether pooled budgets enabled greater transparency on commissioning and delivery.
Their formality and reporting requirements can mean that reviews of resources are undertaken more often and that drawing up agreements is helpful in formalising responsibilities between agencies. The commission observed that, overall, managers in local authorities were more likely to be knowledgeable about the statutory arrangements of pooled budgets than their counterparts in primary care trusts. They were also better able to handle some of the complex reporting arrangements with the Department of Health and in their own organisations.
Nonetheless, pictures of uncertainty emerged and many of those participating in the study were unfamiliar with all the joint finance options. The commission was not surprised: it had found itself that many central government polices relating to integration were hard to implement and seemed to offer confused advice. It predicts that the move to a single national indicator set, the arrival of the joint regulator – the Care Quality Commission – and the development of comprehensive area assessments should help performance management more generally for local authorities and PCTs.
There are benefits and challenges in implementing joint financing arrangements. But the commission is clear that these legislative powers should result in better value and improved outcomes for service users.
However, the area is not standing still: health bodies are being affected by their own changes and local authority adult social care services are being transformed by personalisation. This may explain the continued attention to administrative processes rather than a focus on enhancing the direct impact on service users and outcomes.
The commission noted that the time spent on legal matters and on staff who administer joint financing seemed considerable, although seldom quantified. Few joint staffing posts have been established through joint financing; savings appear to be more in the area of improved use of resources and understating by health and social care staff of each others’ processes and constraints. This may be important at a time of budget freezes or reductions. It may not be long before these relationships, forged at a time of economic growth, are tested when the financial climate is less rosy.
The commission called for central government to support joint working and joint financing. This may not be a vote winner but it does point to the need for better joint working between local service delivery and commissioning bodies in health and social care with national government.
A spur for government may be the development of joint financing to help fund areas where it is already committed to improvements. The potential for joint financing might be explored, for example, on subjects and activity such as adult safeguarding and dementia services, where working together is often urged. There are lessons to share from colleagues in learning disability services and mental health services. There is also a pressing need to think about other important initiatives, such as personal budgets and individual health budgets, which are another form of combining funding.
This is a helpful report for professionals in adults’ services because it suggests that some managers have done well in addressing the problems of joint finance and that its limited use may not be attributable to reluctance or inertia.
The report is likely to be useful to other managers in confirming the wish of regulators and inspectors to support service delivery organisation in devising audit trails that take into account the outcomes for people using services.
It is also a useful reference guide for those seeking to understand the systems that are likely to be increasingly important in funding their posts and deciding priorities.
Senior managers How would your authority rate in the checklists provided by the Audit Commission? Have you embarked on the recommended review of joint financing against the advice contained in this report? Are you familiar with the legal provisions or have you confused alignment of budgets with pooled budgets? How is this subject relating to your programme of transformation of social care? What will be the impact on joint finance of any reductions in resources locally?
Local councillors Do you regard joint funding with some suspicion or cynicism? How certain are you that your views are well founded?
Voluntary and third sector groups Are you clear about joint financing and your place in discussions about its effectiveness for service users? Are partnerships between health bodies and local authorities in danger of becoming exclusive?
Social workers There will be further demands to set and monitor measurable outcomes for service users. These cover access and suitability of services, achieving independence, reducing unnecessary hospital admissions and user satisfaction. How are these being addressed in supervision, IT support and case work?
Jill Manthorpe is director of the Social Care Workforce Research Unit, King’s College London
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