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Professional boundaries and government bureaucracy are the main obstacles to further integration, practitioners told delegates.

Caroline Glendinning from the National Primary Care Research and Development Centre at Manchester University, said research on the use of the Health Act 1999 flexibilities revealed several problems at a national level.

These include staff transfers, differing VATregimes and accountability and performance management.

She said:"Local joined-up policies need to be translated into joined-up policies at a national level."

Julie Sharma, project director of the North Somerset primary care group, said a consultation exercise on the possibility of becoming a care trust had revealed problems around the notion of a single budget. "We were getting concerns, mainly about funding and that the focus was on secondary care and waiting lists," Sharma said.

"What people wanted was a categorical promise that budgets would remain the same. But that was counter to what we wanted to do. We didn't want to talk about health and social services separately anymore."