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As social services and the health service are made to co-operate more in the way they commission their care, Ruth Winchester finds out what the two professions might be able to learn from each other.

Last week, the Department of Health published a set of broad principles that should see social care moving toward a new era of partnership between statutory bodies and the independent sector.

The document, Building Capacity and Partnership in Care, is likely to prove key to the development of services in the brave new world of joint health and care.¹ It sets out a vision of statutory and independent agencies working together in harmonious, supportive partnership; consulting each other, mapping need together and jointly putting service users at the heart of their decision-making.

But while Building Capacity is undoubtedly aspirational in tone, it could be a classic example of aiming for the stars and reaching the ceiling. For if social care has any maxims, one of the most enduring is that the interests of service commissioners, service providers and service users are very rarely the same. In fact, they are often in direct conflict. Drawing some kind of harmony from these groups is going to be extremely challenging.

Social services, for their part, have some reason to feel smug about their experience and expertise as commissioners of services. Over the last 10 years or so social care has developed one of the most dynamic networks of private and voluntary sector providers in the public sector. As the Institute for Public Policy Research report, Building Better Partnerships, highlighted earlier this year, 40 per cent of publicly funded social care in 1998-9 was provided by the independent sector, including more than two thirds of all social care provision for older people.² This compares to just 16 per cent of public health spending.

As a result local authority social services often pride themselves on their ability to manage and direct the activities of the independent sector, to deliver responsive services to local people, and to keep costs down. They have learned, sometimes painfully, how to influence local markets, work in partnership with myriad small agencies and involve service users in decision-making.

Compare this to health, where commissioning experience has largely focused on massive, long-term contracts with large-scale, often monopoly providers, or contracting to itself within the internal market. Health-style commissioning is regarded with horror from the social services side of the fence, with many arguing that it is wooden, prescriptive and top-down. Monitoring of health contracts also tends towards narrowly defined performance targets, rather than the outcomes for end users. Health also has far less experience of dealing with small independent agencies, of manipulating a local market, and of involving service users and carers at the heart of the service planning process.

But if health is not a shining example of commissioning expertise, can local authorities really claim to be the experts? In the new joint commissioning teams, will social services end up leading their health counterparts by the hand, or do they still have a lot to learn? The answer depends on who you talk to.

Most commissioning authorities would argue that social services have stolen the march on other public sectors over the past 10 or 15 years. Their approach, they suggest, is sensitive, inclusive and partnership-oriented. In fact, many are fearful of losing the commissioning expertise so painstakingly built up over the past decade, as social care moves towards the health sector.

But those on the receiving end sometimes see things very differently. Independent sector providers can feel they are bossed about by local authority commissioners, bullied into untenable positions, forced to accept unreasonable terms, and treated as disposable. Many suggest that the traffic is all "one way" - that very little attention is paid to what they need to survive, and that their expertise and opinions are not valued.

Bill McClimont is chairperson of the United Kingdom Home Care Association, an umbrella body which campaigns on behalf of its home care agency members. He acknowledges that local authorities often see themselves as sophisticated purchasers and commissioners of care, but says; "It just doesn't tally with our experience. There are some very good ones out there, but they'd be a tiny minority. You could probably count them on the fingers of one hand. By comparison our experience of health has been very, very good.

"Some of the reasons for that are by no means the fault of the commissioning organisation," he adds. "But there are a couple of areas where I think there's real room for improvement. Their contracting process, for one - it's unilateral. They never, ever, consult - they will tell you they do, but in fact they come and tell you what they are going to do, and what the contract will say."

McClimont also argues the idea of local authority commissioners treating independent agencies as "respected partners" is laughable. "They treat us as functionaries. Home care agencies are never - or hardly ever - given a care plan. They are given very specific tasks to perform, and times to do it. And there are enormous transaction costs involved - for instance if someone wants to change the time they have their home care, it can take days to get it authorised - always assuming you can get hold of someone to ask."

But he admits that commissioning of other services can be exemplary, and suggests that local authorities whose current practice leaves a lot to be desired will have to change their approach with the introduction of the new minimum care standards.

The advent of Best Value may also herald a sea change in local authorities' commissioning behaviour. The new emphasis on quality and cost, rather than purely cost, has been welcomed by both commissioners and providers alike.

Providers, for their part, should be able to demonstrate why a particularly good service costs more and will no longer have to compete solely on how cheaply they can operate. Local authorities will have a clear justification and rationale to show why they have opted for someone other than the bargain-basement bidder.

Unfortunately, how Best Value will function when local authorities are having to cut budgets to the bone remains to be seen. Ray Jones is director of Wiltshire social services. He says: "The difficulty with commissioning comes when the money just doesn't stretch far enough. Times of growth, when we're asking for new things are fine - but we are often in a situation of being 'rationers'. We end up asking providers what can be done for less money."

In terms of the imminent collision between health and social care, most observers suggest that both sides will have a lot of learning to do, although there is a certain amount of gung-ho self-confidence on the part of social care.

Health will bring far larger budgets into the frame, and more clout, possibly tempered by more stringently controlled and inflexible commissioning frameworks. Social care will have to adapt to these, and learn to handle them, without losing its hard-won sensitivity to small independent agencies and commitment to service user involvement.

But both sides will have a lot to learn. Committed, trusting partnerships with independent providers will be essential if the new care set-up is to deliver. Those partnerships could mean that the existing power balance between statutory and independent sectors is going to dissolve.

And in future, commissioning will involve far more than pinning down the terms of a contract. Commissioners will have to take on board many of the issues facing independent sector partners, including the thorny issue of profit-making from public funds, and the recruitment and retention of care staff in a difficult climate. The new Social Care Institute for Excellence may make the transition easier for all concerned by disseminating the good practice there is in social care more widely, but it is undoubtedly going to be a challenge.

¹ Department of Health, Building Capacity and Partnership in Care, DoH, 2001

² Commission on Public Private Partnerships, Building Better Partnerships, Institute for Public Policy Research, 2001