Building a united front

The Labour government came to power in 1997 committed to
breaking down the “Berlin Wall” between health and social services.
Since then, there has been a stream of legislation and policy
guidance – often backed by substantial ring-fenced, known as
“badged”, funding – to support this objective. The partnership
grant, joint investment plans and national service frameworks all
encourage closer collaboration. The “flexibilities” in section 31
of health act flexibilitiesthe Health Act 1999 are among these
measures. They relax some of the statutory obligations that were
seen to create barriers to closer collaborative working. The
flexibilities, which were implemented in England in April 2000,
allow the NHS and local authorities to:

• Pool budgets for specific services. Contributions to the pool
  lose their original organisational identity.
• Delegate commissioning responsibilities to a single
  organisation.
• Employ health and social service staff within a single
  organisation.

One, two or all three flexibilities can be used simultaneously
or in succession.

NHS and local authority partners planning to use the flexibilities
must notify the joint unit at the Department of Health. By late
2000, 32 partnerships in England had been notified and their
experiences formed the basis of an 18-month study carried out by
the National Primary Care Research and Development Centre at the
University of Manchester, together with the Nuffield Institute for
Health, University of Leeds, published last month.¹

The most common combination of partners was a health authority, an
NHS trust and a local authority social services department.
Overall, pooled budgets were the most popular flexibility, either
alone or in combination with another flexibility.

The services involved in the new partnerships were predominantly
adult learning difficulties, adult mental health and older people’s
services. Given the priority attached to partnerships in older
people’s services, the early notifications tended towards
short-term “winter pressures” schemes rather than longer-term
solutions. Only a minority of partnerships involved other services,
such as child and adolescent mental health services, services for
disabled children or for people with sensory impairments.

Although a range of local authority services can be included within
section 31 partnerships, local authority partners were exclusively
social services (apart from the involvement of education in child
and adolescent mental health services).

Most partnerships were funded from a combination of mainstream
budgets and specific badged or non-recurrent resources, such as the
partnership grant or winter pressures funding.

One or two localities used the flexibilities to kick-start
faltering local collaborations, but most partnerships built on
strong histories of collaboration.

The section 31 flexibilities were used to achieve several aims.
First, localities wanted to create integrated health and social
care teams or bring together services that had been fragmented
between different statutory provider organisations. Second, they
aimed to create new services, such as assertive outreach teams,
small group homes, day care and advocacy services. And third, they
wanted to shift existing services away from hospital, residential
and other institutional provision towards more extensive local
community provision. These changes were expected to reduce
duplication and overlap of services to create flexible, seamless
services distributed more equitably across a locality and to
enhance the experiences of service users and carers.

Within 18 months of implementing the flexibilities, some areas
reported significant changes in ways of working together as they
shifted from a blame culture to a whole-system approach,
underpinned by shared visions and objectives. One interviewee said:
“What we are now not doing is saying, ‘That’s not my problem, it’s
your problem’. Whatever the client’s needs, it has to be solved.”
Another interviewee described how “there’s less energy spent on
blaming partners for not delivering and a much greater investment
in maximising the use of shared resources”.

Given the long, problematic history of NHS and local government
relations, this is a major achievement on its own. But section 31
partnerships also had to establish legal and financial frameworks
covering matters such as governance and risk management. These
agreements were visible and provided a template for other services
in the area. They therefore had the potential to move partnership
working from the margins to the mainstream of local activities.
Moreover, some partnerships reorganised their commissioning or
provider arrangements to incorporate high levels of user
consultation and involvement.

Early improvements in efficiency were reported. The transparency
required to put together a pooled budget – particularly if
resources were scarce – prompted partner organisations to review
existing spending patterns and identify areas of duplication and
overlap. Delegating commissioning to a single lead organisation cut
out duplication in commissioning and contracting. Another source of
efficiency arose when services such as community equipment, which
had previously been marginal to the core business of social and
health services, were integrated into a single service. This
enabled dedicated assessment and service delivery systems to be
devised. Waiting times for assessment and receiving equipment were
slashed; and the recycling and repair of equipment improved.

Other resource gains included increased opportunities to apply for
additional grant funding, for example from the European Social
Fund; and new opportunities to construct local service packages for
people with complex needs.

Partnerships created by the flexibilities also reported new synergy
or added value through bringing together Cinderella services such
as those for learning difficulties or community equipment, which
previously had low priority. Integrating these services improved
staff morale, recruitment and retention. Improved funding leverage
at local and national levels was also reported; in turn,
commissioners found it easier working with one provider rather than
several, such as in developing protocols for referrals.

All the partnerships had experienced challenges in implementing the
flexibilities; indeed, the process of working more closely together
in itself often revealed new barriers. Legal agreements had to be
drawn up between the partner organisations, setting out
arrangements for governance, accountability, financial probity and
risk management. These were crucially important, but had to be
negotiated in a way that underpinned, rather than displaced, the
trust and commitment of the partners.

Deciding on contributions to a pooled budget could be problematic
if one partner was thought to be transferring a deficit to the
partnership. As one respondent asked: “Would you get married to
someone knowing they had a huge overdraft?” On the other hand,
equal levels of poverty were less problematic and provided a strong
motivation to reduce duplication and improve efficiency. Problems
arose in managing national funding increases within a pooled budget
if one partner’s increase was larger than the other’s. One person
said: “The local authority has just had their third year of a
standstill budgetÉthe health contribution to the pool is going
up.” Initial problems caused by different VAT regimes in the NHS
and local government were eventually resolved by central government
guidance.

The second most widely used flexibility, integrating health and
social services staff within a single provider organisation,
created some difficulties. “Hard” human resource issues, such as
aligning pay scales and pension arrangements, required government
intervention. “Soft” personnel issues – professional territories
and boundaries, attitudes and resistance to change – were tackled
through joint training and “awaydays”. New appointments to the
partnership could contribute to changes in attitudes and culture,
as these new staff were “buying into the partnership”. But full
transfers of employment to a new, integrated provider were rare and
most partnerships were seconding their staff for the time being.
One respondent said: “We are saying do the job, get into the work,
meet your new managers, get into your new structures and then we’ll
look at who is employed by whom at a later date.”

Incompatibilities between NHS and local government information
management and technology systems were widespread. National
priorities focus on integrating these systems within sectors,
rather than creating linkages between sectors. Even where technical
barriers were being addressed, confidentiality and professional
access issues remained. Finally, partnerships still had to cope
with major differences in financial planning cycles and audit
systems between the two sectors; and differences in performance
management systems required them to separate activities and return
separate health and social care data.

Caroline Glendinning is professor of social policy,
National Primary Care Research and Development Centre, University
of Manchester; Ruth Young is fellow in healthcare and public sector
management, Manchester Centre for Healthcare Management; Bob Hudson
and Brian Hardy are principal research fellows, Nuffield Institute
for Health, University of Leeds. 

References  

¹ C Glendinning, B Hudson, B
Hardy and R Young,  National Evaluation of Notifications for
Use of the Section 31 Flexibilities in the Health Act 1999; Final
Project Report, 2002. It is available free of charge from
Communications Unit, NPCRDC, Williamson Building, University of
Manchester, Manchester M13 9PL. Tel 0161 275 7634. e-mail:
communit@fs1.cpcr.man.ac.uk

How the partners shape up 

Across the first 32 partnerships that were studied, the range of
partner organisations involved widened during the 18-month
evaluation. Primary care trusts and other NHS trusts replaced
health authorities; and local authority education, transport and
leisure departments, police and probation services, voluntary
sector organisations, user and carer organisations and private
sector providers joined some existing partnerships.   By the end of
the evaluation, three partnerships were using all three
flexibilities and seven more were planning to do so. However, there
was no evidence that section 31 constituted an automatic
stepping-stone to care trust status; future plans were dependent on
local contexts.   Three factors shaped plans to extend the
flexibilities or consider care trust status.  

First, this was considerably easier where organisational
boundaries and service networks were coterminous. Second,
newly-established primary care trusts could be reluctant to lose
some of their services, such as the newly acquired community
nursing service, to a separate partnership. Third, some local
authorities were anxious about the “salami slicing” of social
services into several partnerships and the ultimate viability of
the department.   These anxieties are likely to have been increased
by the recent proposals for children’s trusts. 

Overall, the flexibilities made a significant difference to
local partnerships. Tangible changes include closer co-ordination
in processes, protocols and structures and early improvements in
efficiency and effectiveness.

The intangible changes are even more significant – the removal
of “hiding places” and the transformation of thinking from a
preoccupation with narrow organisational “silos” to a whole-system
approach. However, implementation has not always been easy and some
barriers remain; some of these can only be addressed by central
government, others need to be addressed locally.  

Underpinning the implementation of the flexibilities are high
levels of local commitment, trust and leadership. Organisational
and professional cultures that confront fragmentation and promote a
holistic approach are the necessary foundations on which policy
instruments like the flexibilities can be built and made to work.  
The national policy imperative to collaborate has undoubtedly been
helpful in changing the attitudes of reluctant local partners.
However, attention now needs to turn to building and supporting the
local partnership relationships from which changes for service
users will ultimately emerge.