In whom we trust

Primary care trusts bring out mixed emotions
in social care professionals: some fear it will mean a health
service takeover, others believe they offer a new era of joint
working. Terry Philpot talks to some of the social care chiefs put
in charge of trusts and how they see the future of social work.

When Liam Hughes left his post as strategic
director of Bradford social services department in January, some
people were surprised at his move to his new job as chief executive
of the East Leeds Primary Care Trust. But not Hughes, as there is a
thread running through his career that makes this new job an
obvious culmination of what has gone before.

A qualified psychiatric social worker, Hughes’
experience of working with mentally ill and older people had
brought him into close contact with health professionals almost
from the start of his career. He also worked in the resettlement
programmes set up to move people with learning difficulties from
long-stay hospitals, which brought him experience of housing as
well as health. In 1980, when most social services departments were
still giving grants to the voluntary and private sectors for
services, he was working at Barnet – an authority that was using
contracts.

Hughes is unsentimental about modern social
services departments, which were created by the Seebohm report in
1968. He sees them as a by-product of the failings of the NHS and
education, and thought the report itself was flawed. He makes no
predictions about the future. The most he will say is that it is
“probable” that care trusts will be the structure of the future.
But in response to what is now becoming the social care
question: “Will social services departments be here in five years’
time?” he says no. He qualifies that by saying that it is difficult
to see where all social services departments’ functions will be in
five years’ time.

Social work, he says, would have to be
invented if it didn’t exist. Social services departments do not
correspond with natural synergies – their mental health work has
more in common with that of the NHS than, say, their work with
children in care. But if care trusts do come, Hughes says, “there’s
a paradox in that they will work best where least needed and worst
where they are needed the most – because in some places it will be
the end of a process of working together. They are less likely to
be successful where they are imposed.”

Partnership, he says, is as much about what
you are willing to give up as about what you take. Many of the GPs
and nurses he knows are not antipathetic to the holistic model that
social work promotes.

He sees the vast responsibilities of a really
responsive primary care trust as being to ensure social well-being
as well as good health care, being involved with social care,
neighbourhood renewal, preventive work, local strategic
partnerships, the voluntary sector and regeneration. They will be
responsible, too, for integrating services with social services and
for tackling health inequalities. Primary care trusts have
“incredible potential” says Hughes. Boil this down and you have
PCTs in the vanguard of creating consistent standards across the
country, underpinned by National Service Frameworks.

Hughes came to Bradford in 1995 and, as he
puts it, “I didn’t want to spend my last years making an orderly
retreat from Seebohm to whatever else was coming along.”

But the opposite has happened: he’s now in the
advance guard.

After our initial conversation, Julia Ross,
with her unique portfolio as director of social services at London
Borough of Barking and Dagenham, and chief executive of the local
PCT, telephones me. “I am not doing two jobs – I am doing one and
that’s improving health and social care, and I don’t think you can
do one without the other,” she says.

Ross has reason to feel at home where she is.
She qualified as a general nurse before switching to social work
and then chose psychiatric social work – she had worked briefly as
a psychiatric nurse – and, later, hospital social work. These two
jobs were, and in many ways still are, closer to working in health
care.

In Scotland, she became deputy director of
social services of the former Lothian region and then moved to
London as director of social services for Hillingdon. She did a
two-year stint as an independent consultant working on family law
reform in the Lord Chancellor’s Office, and then came to Barking
and Dagenham in 1998 as director to get the department off special
measures. She took the PCT job in April 2001.

Barking and Dagenham has its virtues. It is a
comparatively small and compact area and the PCT and the local
authority have coterminous boundaries. It is also an area in need
of regeneration. This, thinks Ross, makes her dual responsibilities
well matched.

She believes that social services departments
have probably reached the end of their usefulness (with some solid
achievements, she stresses, behind them) but she’s not dogmatic
about the future. Indeed, perhaps it is a sign of the flux in which
health and social care find themselves that, prompted to say what
the future looks like, she’s hard put to do so.

What she comes out with is an organisational
spectrum that runs from all-embracing care trusts – “the health
takeover” – at one end, and still extant but far fewer social
services departments at the other. In the middle is the Barking and
Dagenham model. Her ultimate hope is that her two job titles will
merge into one, with all posts being joint.

Ross says she always thinks of social services
as a service and not as a department. It is possible that in some
areas, she says, the function will remain separate, evolving and
coexisting with education, housing and health by “very good liaison
and a lot of working together at the interface”.

And as if to prove her belief that having two
titles to manage two agencies is really one job, she insists that
if she hadn’t persuaded those who appointed her to the PCT that she
should also be director of social services, she would have taken
the trust job and tried to persuade them by other means. And if she
hadn’t taken the job? Then, eventually, she says, she would have
gone elsewhere where her ideal could have been realised.

Perhaps it is a sign of how much joint working
between health and social services exists already that Graeme Betts
says that it didn’t seem strange to “step over”. In fact, that was
one reason why he took the job as chief executive at Hillingdon PCT
in October 2001.

Betts had worked in joint commissioning,
developed joint planning structures and had been involved with the
modernising programmes for mental health and learning difficulties
at Hillingdon social services department. The other reason for
applying for the Hillingdon post was, as he puts it, that “although
there is a lot of joint working, the feeling is that health is
where it’s at and it is where the innovative work is taking
place”.

He spent three years at the top in Hillingdon
as well as spells as a manager and a researcher elsewhere in London
boroughs and as a joint planning officer for Lewisham and Lambeth
Health Authority.

The situation into which we are now moving,
says Betts, begs questions about the local authority as a provider
of services. He is certain that, in five years’ time, social
services departments will have ceased to exist.

But in a future without the departments,
social services will bring to the new arrangements an attachment to
user involvement, and experience of performance management,
commissioning and Best Value. In fact, Betts goes on to say that he
notices even now that the language of the PCT is now very often the
language of social services. He points out that the now oft-scorned
Seebohm report was talking about working with the community more
than 30 years ago.

Betts counts the solid achievements to date as
being an even split of PCT and local authority funding; radically
reformed accommodation services for people with learning
difficulties; the integration of speech, language and occupational
therapy services; and the integration from this April of what are
currently three locally based community mental health teams.

Betts says:”Social care is not just a social
services issue, it is a council issue and if people don’t grasp
that, then they do not understand the situation. People need to
think in terms of health and social care provision and not the
social services department or the PCT. If you think in those terms
it therefore makes sense to think of creating strategic jobs.”

If there is a discernible trend in the way
things are going in social care, Sue Ross expresses it most
concisely: “I have never been committed to the maintenance of
social services departments. But I am committed to the role of
social work.”

Ross says this from the perspective of having
moved in June 2001 from director of social work, East Renfrewshire,
where she had been for six years, to become chief executive of the
York PCT after a career in social services.

She also thinks that health needs social
care’s skills and insights but, as she puts it, health is not
begging social care to join it. What social care needs, she says,
is self-confidence – more so in England than Scotland. And it must
demonstrate its value.

She also says:”Social work ought to be able to
exist in any organisation. Whether it is, say, a health or housing
setting isn’t important – what is important is that social work
should be there. The question is if you put social work alongside
professions that are seen to be more powerful (like medicine), will
they lose out? It is not inevitable – it depends on the quality of
what they offer.

“If you go to the other end of the spectrum,
people who receive services do not care who delivers them but
rather whether the services meet their needs. If we were in
Northern Ireland [where there are joint health and social care
trusts], we wouldn’t be discussing the future of social services
departments. We wouldn’t regard what we had as offering
difficulties.”

Ross is anxious for social work to demonstrate
its valuable role in multidisciplinary teams, its “unique”
perspectives on community and the family and skills in assessment.
Unfortunately, she says, underspending on the standard spending
assessment means that some other professionals never have contact
with a social worker.

Ross applied for her job out of curiosity –
the PCT post was advertised in Community Care, so she reasoned that
the trust must be interested in someone other than a health
professional. She saw, too, that it would offer a vast range of
services by a wide variety of professionals.

She also remains uncertain about whether
social services departments will survive. At one point she thinks
not; at others she thinks they may exist in some form in some
places, in others not at all. Of East Renfrewshire, she says: “I
didn’t join health by leaving a sinking ship. I left a
high-performing department that will continue for many years to
come.” But she doesn’t look back on the creation of social services
and social work departments as some ideal organisational era.

She also doesn’t foresee too many problems
with the move from democratic control by local government to
unelected trusts. Councillors, she says, never had the control over
social services that they did over some services, and she thinks
that the new role of local representative, advocate and scrutineer
is one which suits the new world of health and social care.