news analysis of pioneering care trust experience in Somerset

An evaluation of Somerset’s “blueprint” for integrated
working offers food for thought for the new care trusts. Lauren
Revans reports on the implications for staff.

Last week, the Institute for Applied Health and Social Policy at
King’s College London described progress in Somerset’s mental
health services since the establishment of the Somerset Partnership
NHS and Social Care Trust in April 1999 as “a cause for cautious
celebration”.

However, weighing up the benefits of integration for service
users against the impact on staff, the institute’s report concludes
that Somerset’s introduction of joint commissioning and combined
provision has led to “some reduction in certain aspects of staff
morale”.

Published just days after the official launch of the first four
care trust “demonstrator sites”, the report holds many lessons for
these new integrated health and social care organisations –
particularly at a time when the social work profession is already
suffering from low morale.

Judging by Somerset’s experiences, it appears that to succeed as
integrated bodies the care trusts – based in Bradford, Manchester,
Northumberland, and a joint site in Camden and Islington – must
address key issues including staff workload levels, cultural
differences, the fear of “the diminution of the social model of
care”, clarity of professional roles and responsibilities, and
clarity of the organisation’s direction and purpose.

Chief executive of the Somerset trust, Paddy Cooney, is the
first to admit that his trust did not originally have a clear
identity and that, in the early years, he focused on the
integration of social services staff into health at the expense of
wider organisational development.

Responding to suggestions that social workers in the trust feel
cut off from colleagues still based in the social services
department, Cooney questions whether this is more to do with “a
function of specialisation rather than of integration”.

He says there is no direct evidence that the social model of
care has been eroded by integration, although he admits there have
been some difficulties in meetings where social workers have felt
dominated by health colleagues. “But in terms of individual care
plans, they feel their voice is still heard,” he adds. “The issue
isn’t about the structure. It’s about whether the body you work for
reflects the values you hold.”

Cooney predicts that the cultural differences between health and
social services professionals highlighted in the report would – and
should – “never disappear”.

He says his previous job working with dysfunctional mental
health teams as a consultant with the Centre for Mental Health
Services Development taught him that the teams that struggle are
those whose members are unclear about what their profession brings
to the team.

Cooney says he does not disagree with the report about the
issues of low staff morale and high workloads, but adds that it is
important to look at “what’s cause and what’s effect”.

“Was this lack of morale the result of integration or the result
of working in the public sector at this time?” he asks. “Every
public organisation has had this feeling of overwork. However,
added to this you have the stresses of a period of change.”

Cooney says the pay and conditions of staff transferred to the
trust from the council have remained “a constant issue” since
integration, but that the trust is not in a position to change or
resolve this as pay increases are agreed nationally between the
government and the professions’ representative bodies.

“What we have seen over the past four years is health
professionals getting above-inflation pay increases while social
workers have been getting inflation-only increases. We have lived
with the difference in the past. But that difference is getting
polarised, and is growing and growing. And I see it in an
integrated trust much more.”

The fledgling Bradford care trust, which covers mental health
and learning difficulties, is already well aware of these issues.
Kevin Mitchell, who was a director at the former Bradford Community
Health NHS Trust, is now responsible for the care trust’s
organisational development. He says resolving the issues around pay
and conditions of staff transferred to the trust from the council
is a “huge task” that will take time.

Mitchell says a human resources forum has been established
between the employers and the various professions’ union bodies to
tackle the issues, and standing orders were previously placed
before parliament to achieve the necessary legislative change to
allow transferred council staff to make their own choice about
whether they wanted to remain with the local authority’s pension
scheme or switch to the NHS one.

He insists working for the care trust will have a positive
rather than a negative impact on morale, referring to the sense of
pride he expects staff to feel from being part of a pilot
organisation breaking new ground.

The care trust’s size will also allow it to establish new
methods of working and to be focused on the needs of mental health
and learning difficulty staff delivering the services, rather than
having to work with the one-size fits all approach of the past,
Mitchell adds. Staff can also expect benefits in terms of joint
training programmes and a broader range of career
opportunities.

Annie Ralph, chairperson of the steering group for the Essex
care trust which is due to go live in October, says the group has
already been doing a great deal of work with the staff to prepare
for integration, including holding a series of joint staff
workshops to identify staff needs.

“It’s as much about culture as about structure,” Ralph says.
“The preparation we are doing is setting up a very clear culture
and involving staff in what sort of organisation it should be.”

One thing Ralph, Mitchell, Cooney and the report’s authors agree
on is that integration should not even be considered unless there
is already a long-standing, good relationship between partners. The
report lists nine points that can be used to assess the extent to
which a locality is in a position to pursue partnerships in
commissioning and providing health and social care (see panel,
above).

“Partners wanting to create a care trust must have a good
relationship,” Cooney says. “Otherwise it’s like saying, ‘this
marriage is crap, I’ll tell you what we’ll do, we’ll have a
baby’.”

‘Modernising Partnerships: An Evaluation of Somerset’s
Innovations’ from 020 7848 3740.

The Somerset experience

In 1997, Somerset social services department, Somerset Health
Authority, the Bath Mental Health Trust and the Avalon Trust
proposed the creation of a joint commissioning board and the UK’s
first ever integrated mental health and social care provider in an
attempt to tackle problems identified in an earlier review of
Somerset’s mental health services.

In April 1999, a joint commissioning board was established with
devolved responsibility for all spend on mental health services by
health and social services.

At the same time, all council staff involved in the delivery of
mental health services – except approved social workers – were
transferred to the new Somerset Partnership NHS and Social Care
Trust on NHS contracts. The management of the ASWs was devolved to
the trust but, under the Mental Health Act 1983, it was not – and
is still not – possible to transfer their employment. The trust
provides secondary mental health services for children,
adolescents, adults and older adults within Somerset.

The combined outcome of the JCB and the trust was effectively a
blueprint for the four new care trusts brought in two weeks ago
under the Health and Social Care Act 2000.

Ready for metamorphosis?

The Somerset care trust report puts forward criteria to gauge
whether services are ready to be incorporated in a care trust,
including the following points:

– Agreeing shared values and principles with a vision of how
life should be for service users.

– Agreeing specific policy shifts that the partnership
arrangements are designed to achieve.

– Being prepared to explore new services or providers.

– Being clear about what aspects of service and activity are
inside and outside the partnership arrangements.

– Being clear about organisational roles in terms of
responsibilities for, and relationships between, commissioning,
purchasing and providing.

– Ensuring effective leadership, including political and other
senior-level commitment to the partnership agenda.

– Identifying agreed resource pools, including pooled
budgets.

– Providing sufficient dedicated partnership development
capacity.

– Developing and sustaining good personal relationships.