Partnership pressures

The government’s emphasis on acute
health services is endangering developing partnerships between
health and social care, writes King’s Fund fellow Penny
Banks.

There will be no let up on the push from
government to solve problems with acute health services. Tony Blair
has said he will be held to account by the voters “if the NHS is
not basically fixed by the next election”.¹ The
government recognises that solving the crisis in hospitals needs
action by the whole system of services, and that joint work between
the NHS and local government is crucial. Partnerships must deliver.
But where does this leave social services and other local authority
services?

Research by the King’s Fund suggests that this
push to solve pressures in acute health services is distorting
local partnership working.² In the long term, this could
set back work between the NHS and local government and ultimately
fail to deliver better integrated services to vulnerable
people.

The King’s Fund has been reviewing
partnerships between the NHS and local government with the help of
an expert group offering a range of local and national
perspectives. The focus has been on partnership working to improve
services to vulnerable people, ranging from strategic alliances to
joint teams delivering services to individuals and families. A
distinction is made between these partnerships with some kind of
agreed rules of engagement and mergers between organisations, such
as in care trusts. One of the key questions in monitoring
partnerships is how far health and social services have been able
to develop their work together to solve the difficult problems,
particularly the issues that cut across services and systems.

There is evidence of progress over the past
year both in attitudes towards partnership working and in practical
developments. There is no longer a dispute about the importance of
working together to integrate services for individuals across
traditional organisational boundaries and to plan developments
based on the whole network of local services. Energies are now
directed towards how best to make partnerships work.

There are examples of different models of
integrated care emerging for different service users. New teams of
health and social care staff are working together offering
rehabilitation and integrated care in older people’s own homes and
in different health settings. Primary care organisations, acute and
community trusts, social services, voluntary and independent
agencies are working together with service users and carers to
develop local strategies and agree joint plans. All of these
organisations recognise that action by one will have a knock-on
effect on the others.

Despite this encouraging progress, there are
serious concerns about pressures on partnerships. While government
policy clearly promotes partnerships, there is increasing tension
between the relentless push to solve the crisis in hospitals and
the pull to address local priorities. Broader agendas to
co-ordinate housing, primary health, social care and other
community services appear to have been overtaken by the drive to
reduce emergency admissions and delayed discharges from
hospital.

In some instances, partnerships are being
presented solely as a solution to ills affecting acute health
services. Problems afflicting hospitals are blamed on the failures
of local government. All of this challenges good working
relationships and diverts attention away from other important
activities that are needed to improve outcomes for users and
carers, including more low key, but valued, preventive
services.

The drive to show rapid and visible changes in
services through tighter performance monitoring and measurable
indicators risks unintended outcomes. For example, measurable
changes such as more intermediate care beds could result in tying
up resources in institutions rather than providing rehabilitation
at home, which is most older people’s preference, and providing, at
worst, “holding” rather than rehabilitation opportunities.
Performance measures need to be more broadly based if they are to
support the goals of independent living to which local partnerships
are committed. It is important too that audit and performance
management systems are joined up, as these currently either involve
duplication or, more worryingly, undermine local partnerships.

Visible new structures, such as care trusts,
are no quick fix to bring together health and social services.
There are fears that these structures could be creating a new set
of boundaries that prevent the delivery of better integrated care
and do little to address cultural differences. Although there has
been some toning down of the original threat to create care trusts
as a solution to those failing to work in partnership, the
perceived threat, or incentives to adopt national models, risk
“shotgun marriages” rather than more locally tuned approaches to
partnership working.

These pressures from the centre are exerted on
partnerships, which are already fragile and facing a number of
familiar challenges. Organisational turbulence, resource pressures
and changing old ways of working are three key problems that
threaten progress in collaborative working between health and
social services.

Organisational changes within the NHS are
altering previous balances of power and making it more difficult
for local authorities to forge stable joint-working relationships
with health colleagues. Primary care organisations are gradually
gaining more experience in participating in wider alliances, while
acute health services are often notable by their absence. At the
same time, local government is seeing the emergence of a range of
new partners, in initiatives such as Sure Start and Connexions.
Voluntary and private partners are also affected by changing
relationships, sometimes unclear about their role within the closer
partnerships developing between health and social services. All of
these changes are disrupting relationships and the stability of
local networks that are essential to effective partnership
working.

Financial pressures on both health and social
services are causing some partners to be reluctant to engage in
joint ventures, particularly where there are fears of inheriting
the other partner’s deficit or losing financial flexibility. Local
authorities face major challenges in meeting all their
responsibilities, not least to stabilise their children’s budget.
Some primary care trusts have been wary of local authorities that
are cutting back to avoid a serious overspend. Although recent
government funding awarded to social services has acknowledged that
part of the overspend in social services is because of NHS
pressures, if the primary purpose is to save acute health services,
partnership working feels very fragile. There are indications that,
in some areas, current pressures on the NHS and local government
are tempting partners to relinquish major responsibility to the
other. Dubbed “sloping shoulder partners”, these organisations
appear content to play less than their full part in achieving
better integrated support, in particular for people with mental
health problems or learning difficulties.

Bringing together staff with different
professional and organisational allegiances presents yet another
major challenge for partnerships. New mixed teams are often
disconnected from other mainstream activity and as yet it is not
clear how far they have been able to influence the work of other
staff. It cannot be assumed that if inter-agency partnership
policies are established, joint working between a range of separate
professionals will simply fall into place. Middle managers, charged
with leading change, are having to tackle these professional issues
as well as major headaches around information systems, joint
budgets, pay and work conditions. They are often expected to
undertake the day job at the same time, caught between fulfilling a
corporate role with explicit responsibilities and working in new,
flexible ways with more apparent risks.

There is an urgent need to improve and
integrate services for people with long-term illness and disabled
people, and more evidence is needed about the impact of
partnerships and different service models on the lives of users and
carers. This picture of partnerships under pressure suggests the
need for more time and support to local initiatives rather than a
push for change in ways not yet proven and where objectives are too
circumscribed by central government.

Penny Banks is a fellow in health and
social care, King’s Fund.

References

¹ The Guardian, 28
January

² P Banks, Partnerships
under Pressure, King’s Fund, 2002 www.kingsfund.org.uk