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Northern Ireland's integrated services offer the government a model for England's health and social care but, as Terry Philpot asks, is integration actually delivering?

The government's zeal for modernisation has caused it for once to cast its eyes not across the Atlantic but to the other side of the Irish Sea. There Northern Ireland's much-trumpeted integrated health and social services are seen as a solution to the perennial problems of health and social services' failure to work together.

Last July's NHS Plan mapped a future which leaned markedly toward the province's arrangements. Initially this was greeted with relief by the Association of Directors of Social Services who, curiously, saw no reorganisation implications. Now, mature reflection and the Health and Social Care Bill giving flesh to the idea of care trusts under NHS control - by carrot or stick - the reality is starker and less agreeable. The association, some of whose members have in the past at least thought Northern Ireland worth more than a second glance, now wants more pluralist arrangements.

Only those who take textbook descriptions for organisational blueprints can overlook the complicated nature and - now - the uncertain future of the Northern Ireland system. It is a system not only sometimes questioned from within but, in the light of the coming of the Northern Ireland Assembly, its future is being debated. Only last December Bairbre de Bruin, the health secretary, was talking about the strong possibility of an all-Ireland health service. Could integrated services remain intact in the face of that? There is also the review of local administration. Should democratic local government return to the province after nearly 30 years (the present 29 local councils do not have major responsibilities)? And what would, then, be the chances of the boards and trusts being subsumed wholesale by new structures, when local government control in the rest of the NHS has never got beyond the starting post? One possibility would be to drop primary health care and social care into a new (democratic) system while acute hospitals were hived off into another quango of which Northern Ireland has now become so accustomed as a form of governance.

In 1974 the suspension of the Stormont parliament and with it the end of elected, if deeply flawed local government, left an organisational gap into which were inserted centrally accountable joint health and social services boards.

Set against the dual administrations of the rest of the UK, the boards might have looked innovative and even desirable, but internal structures included professional silos of directors of medicine, nursing, administration and social services and others. What the system suffered from was "too little collective vision and not enough shared culture", says Hugh Connor, director of social services, South and East Belfast Community Trust and a member of England and Wales community care task force in 1994. However, in 1980, the Department of Health and Social Security transplanted into the province Sir Roy Griffiths' plans for general management in the separately run NHS elsewhere in England and Wales. Despite initial protests from some, the professional silos remained but were concerned with regional strategic planning, quality monitoring and professional standards; the directors lost operational and line management and executive responsibilities. Unit management followed soon afterward with the creation of acute hospital and community trusts shifting responsibility for services and commissioning considerably downward to create more variety and local responsiveness. The community trusts have social care, district nursing and health visiting under their belts.

Significantly, what dramatically affected the management and delivery of social care stemmed from health reforms, just as the potentially enormous changes for English social services have grown from a national plan for the NHS. Roy Blair, director of social services, Southern Health and Social Services Board, points out that all reorganisations have been occasioned by health service needs. His predecessor, Terry Bamford, later executive director (social services and housing), Royal Borough of Kensington and Chelsea, in a paper for the ADSS last year, wrote: "There has been no recognition that the delivery of social care may require a different model. The needs of health care have dominated decision-making."¹ But almost everyone agrees that the structure has gone a long way to break down the traditional straitjackets of professional approaches. Multi-disciplinary working has become the norm. One offshoot of this is that inter-professional training has moved far more quickly in the trusts than in England and Wales. Unsurprisingly, training for the medical profession has kept its traditional distance.

Andrew Dougal, chief executive of the Northern Ireland Heart, Chest and Stroke Association, says that "in recent years there's been a lot more synergy and harnessing of different professional skills". He also thinks that close inter-professional working allows doctors to see the validity of social work models of caring for people. "They tend," he adds "to welcome the possibility of learning." Hugh Connor believes that integrated structures, solving problems, assist health and social services, "march to the same drumbeat".

However, Mary Wilmont, director of social services, Northern Board, believes that social work has had a secondary place: much of her energy is taken up in defending its corner. She instances one of the most dramatic signs of social services' status when two years ago the Eastern Board's social care budget was raided to make up for an overspend by the acute sector.

It is also Mary Wilmont's opinion that integrated structures are confused with inter-disciplinary working. "If you are competing with other services for scarce resources it is more difficult to co-operate with them."

A major example of the budgetary primacy of health and acute care is perhaps the fact that there are still too many acute hospitals and beds for the province's needs. Again, a higher proportion of adults in Northern Ireland are in institutional care. Long-stay hospitals still have their place. In 1999, 62 per cent of all packages of care for older people were in residential and nursing care, 10 per cent higher than 1995. The percentage of mentally ill people being supported at home has fallen in five years.²

Even Hugh Connor, an unabashed enthusiast for the present arrangements, who was also critical of the Eastern Board experience, says: "Northern Ireland is no different from England in the sense that the first thing people think of is 'Save our hospital'. GPs are just as powerful here as elsewhere. Being a community trust has, however, allowed us to keep an eye on that kind of provision. We have tried to create a common purpose and vision and a great deal of that is about social work values. People want cohesive services and in this trust we have led general practice, it hasn't led us. We have nurtured it because our GPs didn't work together and we have helped them to do so." Individual trust directors of social services carry other responsibilities - some as heads of management performance, operations or planning, one as general manager of children's services, another as deputy chief executive of a trust. This, says Hugh Connor, gives them a wider vision.

Dominic Burke, director of social services, Western Health and Social Services Board, suggests that one benefit for social services is that because they are tagged to health organisationally, their spending has kept pace with it. His Southern Board colleague Roy Blair demurs. He believes that is open to question.

Northern Ireland's experience has been heralded as a possible promised land over the years. But only now, with the Health and Social Care Bill provoking serious thought about a world without social services departments, are we learning how little, in fact, we know about the province.

The 1.6 million people of Northern Ireland are top heavy with boards, trusts, directorates and the paraphernalia of the quango - four boards, 19 trusts and one central department run health and social services. Until very recently, its public services have been governed day to day by civil servants. Lobbying has relied largely on its thriving voluntary sector. Politicians have for decades had their eyes on bigger issues than the delivery of home care or bed blocking. It still has no equivalent of Quality Protects, modernisation or joint reviews. Spending on children is £70 per head per child behind England. There are proportionally more children in care in Ireland than in England and Wales.

Curious, too, that the government has borrowed from a model one of whose most significant factors is "the democratic deficit". Health and social services are two very different entities and Northern Ireland suggests that it takes more than placing them under the same roof to weld them together for effective delivery.

And while the Department of Health is obsessed with health and social care working together, some councils have joined social services and housing, others have brought in education. No one is mentioning that in Northern Ireland housing and education - other key partners of social care - are separate and even have different boundaries. But Northern Ireland's system does take in all services - adult and children. In the UK the future of children's and family services is not even addressed as a consequence, so driven by adult services are the reforms. On paper, which is all Westminster ministers and most people know about Northern Ireland, things look hunky-dory. But are not the consequences of change for vulnerable young and old alike worth a more concentrated examination than this, the politicians' latest panacea?

¹ T Bamford, Integrated Health and Social Care in Northern Ireland - Myth and Reality, paper for ADSS seminar, August, 2000

² T Bamford, ibid