Pioneers together

What’s in a name? When it comes to care trusts, the answer
varies considerably depending who you ask.

For many front-line staff and most of their clients, being told
that the organisation they worked for or received services from
would be called an NHS care trust from 1 April 2002 meant little
more to them than a change of letterhead. But, for those more
involved in developing the new integrated health and social
services bodies, the change was – and still is – far more
significant.

While some fears about the loss of the social model of care
persist, there are early signs that in some places the social model
may be able to infiltrate and influence the medical model to
greater effect from within.

And, although progress may have been slow in filtering its way to
the front line since the first four “demonstrator” care trusts were
set up, they do not appear to have caused any deterioration of
services either.

However, the blurring of professional boundaries and the impact of
that on professional autonomy and identity is still worrying some
front-line staff, and incompatible computer systems are proving an
annoyance to all.

Twelve months after Bradford, Northumberland, Manchester, and
Camden and Islington took the plunge, no one is denying that there
is still a long way to go.

But one thing is certain: almost everyone can see the care trusts’
potential for staff and service users alike.

Whether that potential is realised now depends on the
organisations’ development over the next few years – and on
government policy standing still long enough to give them a chance
to succeed.

Bradford
From outside, it is difficult to see Bradford Care Trust
as one large organisation rather than the separate four
directorates within it. Certainly, the picture of the care trust
painted by those working in learning difficulty services is very
different from that painted by those based in adult mental health.
And relationships between the two do not seem to have been improved
by being brought together.

Meanwhile, the child and adolescent mental health services and
older people’s mental health directorates appear disadvantaged from
the outset by the exclusion of the relevant council services from
care trust membership. The benefits of the two breaking off and
forming separate organisations is, unsurprisingly, already becoming
the subject of staff room discussions.

Despite fears among social services staff working in the learning
difficulties field about an NHS takeover, the mood across that
directorate one year on appears to be one of optimism, enthusiasm
and opportunity – for staff and service users alike. Rather than
the care trust being dominated by the medical model of care, there
is a feeling the social model of care may have more influence over
services from within the NHS body than it did from outside.

“I think there’s more emphasis now on social care,” says Lydia
Sharp, patient advice and liaison services officer at the
Waddiloves Health Centre in Manningham. “Issues keep coming up such
as improving people’s access to mainstream leisure activities.
There’s much more of a momentum on that than there was
before.”

The biggest improvements in the care trust’s first year, according
to staff working in learning difficulties services, include greater
financial security for services and posts, more career and training
opportunities, a stronger commitment to implementing Valuing People
and a belief that things will get done.

As Andrew Horner, unit manager of Shipley Resource Centre in West
Yorkshire, says: “Previously we were part of the council with all
its different strands. Now we’ve become part of an organisation
that is much more focused.”

Glen Stocks, social worker and manager of Green Hill centre for
people with learning difficulties, agrees that the care trust has
provided the sector with clarity and focus. “Certainly one of the
criticisms of old social services was that we were jack of all
trades and master of none. We were trying to be everything to
everybody, but not doing a very good job really.”

Staff also believe that the care trust has resulted in greater
access to a wider range of services for users.

Waddiloves’ health centre general manager and former NHS manager,
Gerry Baker, highlights progress on supported housing as another
development to result from the merger. “Social services were well
down the road with looking at that. We’ve been able to benefit, and
many of our people who had been in registered accommodation have
now become tenants.”

Closer working between professionals has dramatically improved
understanding of the health needs of people with learning
difficulties, leading to an increase in the uptake of
services.

Those working in the mental health directorate agree with their
learning difficulty colleagues that the social services’ financial
contribution to services is safer under the care trust now that it
can no longer be “raided by children’s services”.

But, according to front-line staff and managers of the community
mental health team based at Somerset House in Shipley, the care
trust has resulted in no additional career opportunities for staff
and no increase in choice for users.

However, they do acknowledge that former social services staff
might benefit from better access to training, and that access to
services may improve under the new integrated duty system due to
start soon.

But there are concerns this new system, which itself has
highlighted the cultural differences of the team’s members, will
not be sufficiently funded. “We don’t always see the money at the
front line because at the moment it’s being spent on new service
developments,” says locality manager John Keaveny. “Established
services like this sometimes feel left out.”

Concerns about social work being taken away from its traditional
home in local government and losing some of its independence have
also persisted, although all team members insist that clear
professional lines have so far been maintained.

“The role of the approved social worker is to provide a balance to
the medical model and look at alternative options, alternative to
medical care,” says ASW and team manager Cath Gormally. “The fear
is that if you’re employed by the same organisation, you haven’t
got that power.”

Although the care trust does appear to have cut bureaucracy in
terms of decision-making, it has also increased paperwork and
exacerbated feelings of “initiativitis”.

ASW Sandra Inskip has felt her job satisfaction decline since the
care trust was set up. “It’s all the change,” she says. “It just
seems to be one thing after another and it’s taking away time spent
with the people you’re working with. And I have this idea that the
government might change its mind again – it’s not unheard of, is
it?

“We don’t seem to have any breathing space either – no time to take
a step back and say ‘is it working, can we do it better, can we
evaluate this little bit?’. My experience is that morale is going
down. It feels as if we’re sleepwalking our way through and we’re
not totally in charge of what’s happening or where we’re
going.”

Camden and Islington
As director of strategic development at Camden and
Islington Mental Health and Social Care Trust, Dave Lee is the
first to admit that front-line staff and service users may have
noticed little difference between life under the care trust and
life under the former mental health trust over the past year. But
he is adamant that this does not mean things have not
changed.

For Lee, the most significant part of becoming a care trust is the
change in governance arrangements. Although social care represents
only 15 per cent of the NHS organisation, four of the seven
non-executive board posts were set aside for elected councillors to
ensure their voice was heard.

“This is seen as one of the most positive advantages of the care
trust,” Lee says. “The local authority members are bringing a new
and different perspective which we would not have got from
traditional NHS non-executive directors.”

Lee says the addition of the social care dimension has also led to
another significant change: the shift towards a user-centred
operation. Service users are now involved at all levels of the
organisation, from recruitment panels to board meetings.

Joint training is another area Lee is keen to make progress on in
the next couple of years, to build on the work already started
since the mental health teams became fully integrated in the late
1990s. However, he insists that this must not be at the expense of
specialist training and knowledge.

“We need to be careful about that,” he warns. “I do not think
people should see a care trust as a catastrophe of generalisms
waiting to happen. I would like to think we haven’t fallen into
that trap at this stage.”

But community psychiatric nurse Richard Hutchinson has some bad
news for Lee. He believes that specialisms are already being lost
and the professional identities of the team members being
eroded.

Although he attributes the “blurring of boundaries” and “more
homogeneous jobs” to joint working in general rather than care
trusts in particular, he believes the creation of the care trust
will definitely contribute to the decline of the social model of
care as social workers’ independence diminishes.

“Social workers have lost their autonomy really by being heavily
involved with the medical approach, which decides the way in which
we talk and think about clients and the way we approach their care.
It is bound to be harder to state an opinion in conflict to a
psychiatrist and a team with which you have to work very
closely.”

The line management structure that results in nurses being managed
by social workers and vice versa exacerbates this loss of
professional identities, Hutchinson adds.

On a day-to-day basis, he says the care trust has made no
difference to workloads or services. However, he acknowledges that
the inclusion of social workers on the teams “does put an emphasis
on the social dimension of client care and softens our general
approach”.

But in order for the care trust to really prove its worth to
Hutchinson, it needs to become more political. He wants it to use
its size to influence policy nationally and locally to improve
housing, employment and other mainstream services for people with
mental health problems and to tackle stigma. “This work potentially
could be championed by the care trust in a way that it hasn’t been
before,” Hutchinson says.

Northumberland
Northumberland Care Trust’s strong community ties appear
to have vanquished many of the fears about the loss of the social
model of care typically expressed by social services staff moving
to the NHS.

And basing the care trust’s four localities on those of the former
primary care group has helped ensure GPs and practice-based staff
are on board.

Although putting the structure in place has been slow and there has
been little noticeable change for the majority of front-line staff
and service users in the first year, the general feeling is that it
has been worth taking the time to get things right.

John Jennison, care trust staff development manager and former
social services staff development manager, acknowledges that the
relatively smooth transition has left some “anomalies” in terms of
different pay structures, but promises that “harmonisation” is top
of the agenda for next year.

Under the care trust, Jennison sees scope for more joint training
and the possibility for hybrid health and social care worker roles
in a few years.

However, he insists that rather than social work being lost in the
new organisation, the creation of the care trust has enhanced the
profession by forcing social workers to think carefully about what
is special about the service they provide. A county-wide social
work forum is also being set up to enhance professional
links.

Improved relationships between the various agencies has been one of
the care trust’s clear successes, achieved in part through the
multi-agency professional executive committee (PEC) and the four
locality management boards.

Marie McAndrew, practice manager at South Broomhill Health Centre
in Morpeth, believes that the new networks being created as a
result of the care trust have already had a direct impact, with
staff who previously did not know each other tackling issues
together instead of referring them to their managers to
resolve.

McAndrew believes that, although there was already a history of
joint working, integration would never have been able to develop as
far without the creation of the care trust.

She says: “We could have gone so far, but there would always have
been that organisational block. It was always going to be difficult
because we were two separate organisations, and not even two health
bodies.”

Ian Leigh, lead care manager for Blythe learning difficulty team
and one of four social work representatives on the PEC, believes
the inclusion on the committee of GPs and allied health
professionals who are not officially employed by the care trust has
been useful. The working relationships between health and social
care have definitely improved under the care trust.

He also welcomes the availability of funds to pay for cover for
care trust staff who attend PEC and care stream meetings, something
he claims would never have happened under social services.

But not everybody has been won over. Practice nurse Kate Appleby,
one of 600 community staff transferred to the care trust from the
Northumbria Healthcare NHS Trust, has seen no change in working
relationships, no new career opportunities, no change for patients
and no reduction in bureaucracy or red tape. And she is tired of
change. She says: “We have been through this many times previously
and I have no reason to believe it is any more permanent this
time.”

Budget and responsibilities    

Northumberland Care Trust has a £370m budget and is
responsible for adult social services and health services for all
age groups. Its four areas cover a population of 310,000 spread
over 50,000 square miles and it employs up to 1,400 staff and has
operational responsibilities for a further 1,600.  As well as
Northumberland Council’s adult social services, the care trust
includes services from the area’s four former primary care groups,
the former Northumberland Health Authority, Northumbria Healthcare
NHS Trust and Northgate and Prudhoe NHS Trust. The care trust’s
work will be developed via 12 “care streams” covering key issues in
health and social care.

Care trust origins   

In April 2001, the mental health services element of the Camden
and Islington Community Health Services NHS Trust joined forces
with north Camden mental health services. The new body became the
Camden and Islington Mental Health Trust. One year later, the
mental health services of Camden and Islington social services
departments came on board too, and the Camden and Islington Mental
Health and Social Care Trust was born. The care trust now delivers
and commissions all adult mental health services across the two
London boroughs. All local authority mental health staff (except
approved social workers) have been formally transferred and a
single budget is due to start from April 2003.   

Services mergers

Bradford Care Trust came about in April 2002. It was the result
of a merger between Bradford Council’s adult mental health and
learning difficulty services and the adult learning difficulty and
mental health services for all age groups at Airedale NHS Trust and
Bradford Community Health NHS Trust. The new NHS organisation has a
single budget of £70m a year and more than 2,000 staff. It
serves 550,000 people living in the Bradford and Craven district of
Yorkshire. It is split into four directorates: adult mental health,
learning difficulties, older people’s mental health, and child and
adolescent mental health services.