News

Since the election of New Labour in 1997 there has been an increasing emphasis on delivering "joined-up solutions to joined-up problems" particularly in health and social care.

Whether they have a mental health problem, learning difficulties or physical impairment, or are a child in need, people frequently have complex needs that cut across traditional service boundaries. Put simply, people do not live their lives according to the categories in welfare services, and a joined-up response is essential if needs are to be met in full and a potential future crisis avoided.

At a local level, the partnership agenda is leading to a lot of interagency working and a range of new service models. The Sandwell Mental Health and Social Care Trust in the Midlands is one of only eight care trusts in the country that integrate health and social care.

The Midlands is setting up partnerships to tackle delayed hospital discharge and to deliver intermediate care services, integrated mental health and learning difficulty services, and joined-up services to children and young people through new children’s trusts.

The government’s five-year plan for the health service, the NHS Improvement Plan, has added an extra challenge to already complex relationships. In future, the NHS in particular is going to focus on chronic disease management.

Under this agenda, there is increasing recognition that a relatively small number of people, often older people, with very complex needs use a large proportion of health care and account for the bulk of GP consultations, hospital admissions and delayed discharges.

As a result, a number of health communities are piloting new case management systems where a lead professional - often a nurse or community matron - will work proactively to support people with the most complex needs in the community. Walsall is piloting the scheme in the West Midlands.

While the NHS Improvement Plan highlights a key role for social care in meeting the needs of people with long-term conditions, there are concerns, regionally as well as nationally, that the NHS could come to dominate the agenda and that partnerships between health and social care will exist separately from this crucial arena.

At the same time, many people in social care are starting to recognise that the most effective way to support people with long-term conditions might be to draw on wider services - not just health and social care, but also leisure, housing, transport, safety and education.

There would also be plenty of scope to learn from social care in the process. If the NHS wants to have patient choice, expert patients and case managers, then surely some of the care should be based on social models such as direct payments and the care management and co-ordination work undertaken in adult mental health and learning difficulty services.

One Midlands health and social care community is trying to take forward the long-term conditions agenda in conjunction with current health and care partnerships. Here, local services are developing a new way of working on three levels:

• Promotion of health and well-being.
• Fast response, including admission avoidance and swift discharge.
• Ongoing care for long-term conditions; complex, ongoing cases, and social care reviews.

While the first level would include much stronger links with wider partners such as regeneration and the voluntary sector, the second and third levels would involve the full integration of health and social care teams. Over time, there is a desire to shift the emphasis towards prevention - working with older people while they are still healthy and maintaining their independence.

This kind of joined-up action seems a sensible way of balancing competing policy priorities, and similar approaches will be needed elsewhere to ensure the long-term conditions agenda does not develop apart from existing partnerships, further fragmenting the system.

Jon Glasby is senior lecturer and head of health and social care partnerships at the Health Services Management Centre, University of Birmingham