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In 2000, The NHS Plan stated that: "Primary care trusts have the potential to make real improvements for patients, making the health and social care system easier to understand, simpler to access and more convenient to use."

Three years down the line, that potential is starting to be turned into reality, with the development of partnership working between primary health and social care from the very top down.

As most front-line social workers and their managers would testify, not everything is working perfectly, but there seems a genuine optimism that obstacles can be overcome.

Opportunities to tackle "traditional" social care problems differently have arisen, leading to greater innovation in practice. Most importantly, clients are beginning to see the benefits.

Over the next three pages, health and social care professionals explain about the primary care-based projects they work in, what the benefits are for service users and how they have worked together to achieve this.

At the moment they are trailblazers, but it is likely that over the coming years their way of working will become the norm.

Taking off from the day centre

A pilot project on continence at a day centre for older people proved to be so effective that it formed the basis for a county-wide advice and training service, writes Sue Brown.

Incontinence is distressing and can have a huge impact on any individual, but for older people, when combined with increased dependence on care services, it can be devastating and affect their ability to stay in their own home.

Concerns expressed by a nurse working at a social services day centre for older people with mental health problems about the increase in continence problems, and reluctance by the centre to accept clients with incontinence, were the catalysts for a pilot project undertaken there in 1998.

The project entailed consulting staff on their skill needs and implementing training to enable them to change their practice - by getting advice from infection control and tissue viability nurses, and reviewing environmental audit and staff action plans.

The results were that staff could deal with incontinence more effectively, the continence status of many clients was greatly improved so residential or hospital admission was prevented, no client was refused attendance at the day centre because of incontinence, and the physical environment was improved.

The project's success meant that in January 2000 it attracted funding, from prevention grant monies, for two continence advisors to train social workers and occupational therapists at Nottingham social services in providing services to clients.

The service was devised, and staff and a mandatory training programme put in place. The training included aspects of physiology and anatomy, physical symptoms, management of incontinence, and proper use of equipment.

The service involved setting up and running continence clinics in day, residential and intermediate care centres and the Indian day centre; raising continence awareness with clients and carers through information and support sessions; partnership in assessment and care planning; close liaison with community nurses; and developing written guidelines.

So far, 1,635 people have been trained and 247 clinics held.

Clients seen in day centre clinics have key workers to support and reinforce advice. They get to know the continence advisers and feel less embarrassed about discussing their problems. An assessment tool enables staff to gather information regarding clients for either the continence adviser or the community nurse.

The benefits are manifold. Relationships with care staff and community nurses have improved, resulting in more appropriate contacts and earlier referral for tissue damage, continence problems and urinary tract infections. Problems previously attributed just to old age are now raised with community nurses for proactive management.

A continence adviser-led clinic has been run in a learning disability day centre. There has been a reduction in laundry costs in local authority residential homes. And discussion is taking place with independent sector providers about the potential for training their staff.

The scope for the development of continence services within social services is immense. The issue also has implications for older people remaining in hospital who need social services placement.

Sue Brown is a worker atcontinence support to Nottingham Social Services

Extra tool to tackle drug misuse

A GP team in a socially deprived area of Leeds was already doing work with drug and alcohol misusers, but the addition of an addictions therapist has allowed it to progress further, writes GP Dr Jez Thompson   

The Chapeltown area of Leeds is vibrant and alive, multicultural and colourful. But it also has problems. Indices of social deprivation are high, as is unemployment. There are large neighbourhoods of poor-quality housing, and the city's sex industry is centred here.

Social inequality and deprivation provide fertile conditions for a drug culture, while others whose lives have been damaged financially, socially and personally by drugs gravitate to the area's cheap housing.

We at the St Martins GP practice in Chapeltown have always recognised the links between social exclusion and drug misuse, and a philosophy of providing non-judgemental care predates any of the current practice team.

Treatment of heroin addiction with the prescribed substitute methadone began in the practice around 20 years ago, but at that time the service was isolated and unresourced, relying essentially on the goodwill of the practice team.

A milestone was the granting of funding as a secondary care service five years ago, with the subsequent appointment of a full-time addictions therapist to work alongside other members of the practice team.

This step allowed us to broaden and deepen the scope of the work we do with clients. A beacon award in 2000 gave us an important role in sharing our good practice with others, and in recent years doctors at the practice have helped train other care professionals.

Our drug service is completely integrated with our general practice work. Clients are offered full assessment and involvement in their own care planning and are offered supportive help and other "talking" therapeutic options.

Major focuses are reducing drug-related harm and promoting general health. We provide maintenance prescribing for drug problems and detoxification, and relapse prevention for both drug and alcohol problems. We liaise with, and refer clients to, other organisations for help with social, financial, educational and employment issues, and aspire to planning holistic care packages for our clients.

Problem drug use exists in the context of social, emotional and other health issues. Providing both the GP and addiction service for a client enables us to tackle problems that are directly or indirectly drug-related.

We frequently provide care for families and significant friends, and offer them support. We also support clients who are parents, and address child protection issues. The service is community-based and accessible.

Data relating to our service show low drop-out rates from treatment. We are particularly effective in engaging with women service users, who are significantly underrepresented in many other services, and maintain excellent relationships with local black and minority ethnic communities.

Our personal observations of dramatic changes in many clients' lives as they enter treatment are backed up by outcome figures, which confirm that most service users achieve the targets they have set themselves.

We continue to improve our service, and are developing close working relationships with Touchstone, a Leeds-based voluntary sector mental health organisation. We aim through this to facilitate access to treatment for those with mental health problems, and those from black and minority ethnic communities.

Dr Jez Thompson is a GP at the St Martins Practice in Chapeltown, Leeds.

An ear to the ground 

Listening to and using the expertise of volunteers from ethnic minority communities have helped to tackle mental health problems that often remain hidden, writes Pat Bracken.

There is a growing acceptance that traditional ways of thinking about mental illness and the development of services have not always served ethnic minority communities very well.  

In an effort to tackle this issue, Bradford City Primary Care Trust agreed funding last year, in conjunction with the Centre for Citizenship and Community Mental Health at the University of Bradford, for a community development project targeted at new ways of engaging ethnic minority  communities. Bradford District Care Trust, the main provider of mental health services in the city, also supports the project. 

This issue is particularly important to the PCT because it serves an inner city where more than 55 per cent of the population are from ethnic minority communities, predominantly of South Asian backgrounds.  

The project is located within a local voluntary sector organisation, the Asian Disability Network. Called the Sharing Voices initiative, it began operating last August.  

Experience so far confirms the original proposal that, when it comes to mental health, individuals, families and communities have untapped expertise and know many of the solutions.  

Two workers are already in place and a third is being recruited. They have found that successful engagement, particularly with hard-to-reach people, has been possible through an open and honest approach and one that recognises the limitations of traditional psychiatry.  

The workers have been supporting "safe spaces" where people can develop strategies for coping. Other measures involve supporting partnerships between community groups and services already doing mental health work outside traditionally defined parameters, such as supporting staff at a local place of worship to develop their capacity to deal with the social, political, religious and spiritual issues they and the regular attendants face.  

Sharing Voices has recruited volunteers from different communities. These are involved in setting up self-help initiatives and befriending others, while offering practical support in applying for jobs, completing application forms and developing interview skills. 

The team members are also building partnerships with existing statutory/voluntary organisations and commercial businesses to support people to re -engage in meaningful work.  

A community development approach to mental health is premised on the belief that poverty, racism, unemployment, loneliness, family conflict, sexual abuse and spiritual conflicts significantly affect the development and outcome of mental illness.  

Pat Bracken is a senior research fellow at the Centre for Citizenship and Community Mental Health, University of Bradford.