Care trusts were vaunted as central to modernisation. So why is there so much uncertainty surrounding the pilot process, asks Lauren Revans.

Despite being hailed as key to the government's modernisation agenda, the care trust pilot process is beginning to resemble a badly organised party. Early guests claim they hadn't realised it was a party at all, while later arrivals speculate about lost invitations. No one seems entirely sure what the party is about, and several have already made their excuses to leave early or turn up late.

Care trusts came about when MPs and peers pushed the Health and Social Care Bill through parliament before the General Election in June. Outlined in the NHS Plan in July 2000, the new bodies were cited as pivotal to the reform process, bringing together health and social services "for the first time" with new agreements to pool resources. The NHS Plan describes "new care trusts to commission health and social care in a single organisation".

One year on, health minister Jacqui Smith announced the first nine care trust "demonstrator sites" (News, page 3, 26 July). At the time, Smith said: "I am very clear that it is going ahead, as far as the nine demonstrator sites are concerned, from April 2002. We also have another 29 expressions of interest. The fact that we have that level of enthusiasm and interest at a stage when the legislative basis is relatively new, and there are still issues that we're working through, I think is very encouraging."

Not all those involved were prepared for the announcement, though, and the April 2002 deadline saw some take a step back. Partners in north-west Surrey, originally proposing to establish a care trust for mental health services, have now disappeared from the official list of demonstrator sites while they carry out more local consultation and consider a more manageable deadline.

"It was felt that we couldn't, in the time we had, establish the voluntary agreement to go for pilot status by April 2002," Surrey's acting director of social services Sue Fiennes explains. In particular, health partners saw their priority as getting the local primary care trusts right first. Plans to establish a north west Surrey mental health partnership trust by next year will go ahead, however, with a view to developing these "building blocks" in the future.

Several other pilots that are still on the official list were also concerned about the April 2002 deadline, and the government has now issued a revised deadline of "between April 2002 and April 2003".

Brighton and Hove social services director Allan Bowman admits he was among those taken by surprise when the list was announced in July, given the "low-key approach" from the Department of Health prior to the event. He agrees an April 2002 start date is "too soon", and that October 2002 or April 2003 are more realistic targets.

Bowman is also calling for "clarification of all implications" for transferring or seconding staff, as well as an evaluation of the impact of any change on employees' terms and conditions. "It seems for some posts, NHS conditions are better and, for others, local authority conditions," he explains. "There are, in particular, superannuation issues to be resolved."

For other areas, the announcement of the first nine sites was something of a wake-up call, and the initial list has now increased to 16. The eight new care trusts - including two in Birmingham, three in Wiltshire, one in Northumberland, one in the New Forest, and one in south east Hertfordshire - will also widen the range of client groups covered (see box).

Hampshire's director of social services Terry Butler says there is no definite commitment to the late proposal for a care trust in the New Forest, but that he has a "personal commitment" to seeing the development of more integrated services. "This is one of about five models that we are exploring," he says. "But because we came along late, we have obviously got a lot of catching up to do."

Partnership manager for south west Hampshire Pauline Owen says the New Forest partnership needs, by April 2002, to have achieved "joint teams with pooled resources that can be the fore-runner for the establishment of the care trust" before looking to an application for April 2003.

Wiltshire's director of social services Ray Jones says the county was late onto the scene because of demonstrator sites being initially identified as only those that would be ready to become care trusts by April 2002. "The Department of Health has since then invited us into the process," Jones says. "We are targeting integrating our operational structures by April 2002. We then hope to move to care trust status by April 2003."

Jones says care trusts are the "natural progression" in Wiltshire after 10 years of integrated working, but that extra time is needed to establish the primary care trusts involved and to reflect on care trusts' governance arrangements. He also proposes that staff transferring to the new organisations could take their terms and conditions with them, and that in time these would be "equalised".

"This usually means a levelling up," he explains. "We would not want to place social care staff in a new organisation where they would be disadvantaged by it."

In Northumberland, divisional director of community care David Parkin warns that public consultation on care trusts cannot be carried out and formal proposals to councillors cannot be presented until the government explains the details of care trusts' governance arrangements.

The Association of Directors of Social Services, participating councils, and the Local Government Association have long argued for local authorities and health bodies to have equal representation in governance arrangements, with councillors forming a significant part of care trust board membership. Government guidance on this issue is expected in the near future.

Parkin also believes it would be a mistake to jump immediately into combined budgets. "We would not want to rush forward for the hell of it. We would spend the first year understanding how things fit together."

The mood in Camden and Islington, home to the only care trust to span two local authorities, is more upbeat. Islington's director of social services Paul Curran describes the proposed care trust for mental health services as "an important step along a journey on which we have already gone a long way".

Bradford's social services director Liam Hughes is also "optimistic" about the plans, confirming that partners is his area are still working towards an April 2002 deadline. "The crucial thing, I think, is that care trusts are seen as new organisations that bring benefits to users and treat staff fairly in the process," he says.

In North Somerset Council, the care trust model is being hailed as "suitable for all client groups" and will cover children's services too, leaving the traditional social services department virtually redundant save for a monitoring and scrutinising role.

Sandwell, too, is keen to progress along the care trust path. Acting director of social services Angela Saganowska explains that community mental health team staff reviews have shown that partnership work really works and that "current dual structures are now getting in the way".

"If it is done properly, it's a wonderful opportunity to have an organisation based on models of care we want for mental health services," Saganowska says. Nonetheless, she predicts a care trust in only shadow form by April 2002.

People do seem keen to come to the care trust party after all then - even if some are late to RSVP and others cannot turn up on time. Despite confusion and a desperate need for central guidance on staffing issues and accountability arrangements, an underlying enthusiasm remains about the potential benefits to services users of care trusts. Let the party begin.

Care trust pilots

Bexley: older people
Birmingham: one care trust for mental health and one for learning difficulties
Brighton & Hove: range of vulnerable client groups
Bradford: mental health
Camden and Islington: mental health
Essex: housing and older people
Manchester: mental health
New Forest: older people and physical disabilities
North Somerset:: all services except mental health
Northumberland: working age adults (except mental health)
Sandwell: mental health
South east Hertfordshire: to be confirmed
Wiltshire: three trusts covering services for older people, physical disabilities, learning difficulties, children’s health