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The familiar refrain of "breaking down barriers between health and social care" echoes throughout the government's recently published NHS and social care model to support people with long-term conditions.(1)

In the document's foreword, national clinical director for primary care David Colin-ThomŽ declares that the strategy will encourage health and social care communities to "work across boundaries" and to "adopt case management approaches... as a means of ensuring these patients get fully joined-up health and social care".

But you only have to look at Dr Colin-Thome's job title and his use of the word "patient" to figure out on which side of the health and social care fence the report sits.

Its five chapters, three annexes and 48 pages contain no mention of direct payments and no reference to transport, housing, benefits or employment. None of its good practice examples focus on social work, and people with long-term conditions are referred to as patients throughout. There is only one specific target in the whole document - to reduce the use of hospital emergency bed days by 5 per cent by March 2008.

But the most obvious snub to social workers is the report's most radical proposal - the introduction of 3,000 community matrons by March 2007.

Community matrons will be a "new type of health professional" who will take on caseloads of around 50 to 80 people whose long-term conditions require clinical intervention as well as care co-ordination.

"They will work across health and social care services and the voluntary sector, so that this group of patients receives services that are integrated and complementary," says the report.

They will, however, be nurses.

Despite the wealth of experience among social workers who have similar case management roles, only those with a nursing qualification will be eligible for the new community matron role.

It is an exclusion that rankles with Ray Jones, director of adult and community services at Wiltshire Council.

"It totally ignores the skills and experience that social workers have as care managers, working and engaging with disabled people," he says.

"And at a time when nurses are considered to be a scarce resource, you have to question whether this is the best use of their skills. Do nurses have the knowledge to advise people within the broader social context, on their housing options for instance, on transport or how to claim benefits?"

Jones believes that, despite the inclusion of the term social care in the subtitle of the government's report, it is essentially a medical strategy, targeted at the high-risk end of the long-term disability spectrum. Its principal aim is to keep potentially expensive patients out of hospital, he says.

"This is not a social care model," says Jones. "It's a clinical model, it's disease focused and it doesn't take into account the social model of disease. Social care is an afterthought. It's all to do with resources."

The Long-Term Medical Conditions Alliance, which last year published a manifesto for improving long-term care, has also sounded a note of caution. It says that the approach laid out in the government's new model could "result in attention and resources being disproportionately focused on the small minority of people with the most complex conditions".

A warning echoed by the King's Fund, whose chief executive Niall Dickson has stressed the need for a wide range of services "not least to ensure that those with less severe needs are not left out".

In fact, the government's new model outlines three levels of care that should be made available to people with long-term conditions. Level three is aimed at the most vulnerable and at those with highly complex multiple long-term conditions. For these people, community matrons are to use a case management approach to "anticipate, co-ordinate and join up health and social care". Level two is aimed at those with a complex single need or multiple conditions, and involves disease-specific care management by multidisciplinary teams.

Level one is based around supported self-care, in which individuals and their carers are helped to develop the knowledge, skills and confidence to look after themselves.

But this pyramid of care could be used to "focus resources only on people with complex conditions", warns LMCA chair Elizabeth Wincott.

"People shouldn't be put into rigid categories, and co-ordinated care plans should be the right of everyone diagnosed with a long-term condition," she says. "Long-term conditions impact on every area of life - it's not just about keeping people out of hospital."

Nevertheless, Wincott welcomes the recognition of the value of self-care.

"We are pleased that the role of patients as partners in their treatment and care has been acknowledged, along with the importance of self-management as a means of helping people live with their condition."

Patient groups have, by and large, welcomed the report, which many see as a taster of what may be included in the National Service Framework for Long-Term Conditions, which is due to be published later this year.

Diabetes UK has applauded the proposal for community matrons although, like the LMCA, the charity has warned "against the temptation of just focusing on keeping people out of hospital rather than tackling the problems which have made some people so vulnerable". Its director of care, Simon O'Neill, adds: "The new model of care is a well overdue and much welcomed initiative. We must look at the most vulnerable people and do all we can to avoid them having to end up in hospital.

"But the most effective way to do that in the long term is to prevent them from becoming so vulnerable in the first place. It is about effective education and support."

The Parkinson's Disease Society has also welcomed the idea of community matrons and the recognition of self-management.

However, the society has stressed that the model must retain enough flexibility to respond to the particular individual needs of people with Parkinson's and their carers. It says that while it is a good objective to keep more people out of hospital, those affected by Parkinson's disease need to be able to move between services and have access to a variety of health and social care services at all times.

There are 17.5 million people in the UK estimated to have long-term incurable conditions, such as diabetes, asthma and arthritis. Although the forthcoming NSF on long-term conditions is expected to focus primarily on neurological conditions, health secretary John Reid has already made it clear that this recently published model will provide the blueprint for how long-term conditions are dealt with in the future. As to whether the desired levels of integrated care can be achieved without significant input from social care professionals, many have their doubts.

(1) Supporting People with Long Term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration available at DoH website: www.dh.gov.uk/assetRoot/04/09/98/68/04099868.pdf