Loose connections

The establishment of care trusts, the soon-to-be-piloted children’s
trusts, and different uses of the partnership flexibilities raise
questions about the shifting boundaries between health and social
care, and about different models of integration. The emergence of
primary care trusts also raises many issues about how commissioning
for older people is being approached with partner agencies,
particularly social services.

The personal social services research unit (PSSRU) at the London
School of Economics has looked at early developments. We carried
out interviews in two county councils, two unitary authorities and
two London boroughs in central and southern England to explore the
scale of integrated or joint commissioning services for older
people. However our findings are only a snapshot – these are
shifting sands, and change is rapid.

In the sites studied, much of the development around joint or
integrated commissioning services for older people has focused on
intermediate care. However, while progress towards more coherent
and integrated approaches is evident, it is far from complete. For
example, PCTs and social services were typically still managing and
providing their own particular models of intermediate care.

Integrating intermediate care remains an objective within health
and social services. But at the sites, discussion was under way as
to how this might be achieved.

Existing intermediate care services across the sites were funded
predominantly by either health or social services, and not through
joint funding streams. None of the sites were using the provisions
of the health act flexibilities (HAFs) for any of their integrated
older people’s services. However, plans to register services in the
near future were being discussed.

Where services were jointly funded, the distinction between health
and social care contributions remained. This highlighted some of
the practical difficulties in achieving integrated funding
alongside a need to demonstrate accountability and transparency of
spending. Typically, health and social care authorities are seeking
ways to achieve the aims of the HAFs without the accompanying
bureaucracy.

Across all the sites, strategic plans for integrating older
people’s services were frequently concerned with developing
combined health and social care facilities, housing staff from both
services and providing preventive and recuperative care.

While integration of health and social care services was at a
relatively early stage, this needs to be seen alongside the far
wider strategic integration that has developed at senior management
levels between PCTs and social services. Respondents often said
that they felt they “live out of each other’s pockets” and talked
of “parallel”, if not quite shared, agendas.

Considerable restructuring was taking place in planning,
commissioning and contracting mechanisms. These processes were
typically the focus of much joint working. Other engagement was
necessitated by the demands associated with the implementation of
free nursing care, and with reimbursement mechanisms around delayed
discharges. These developments carry a risk that strategic
commissioning for older people could become divorced from that
undertaken on behalf of other client groups – notably learning
difficulties, mental health and children’s services.

Once planning and commissioning structures bed down, the logical
next step is local integration of health and social care funding
streams. Across the sites, it was recognised that new planning and
strategic commissioning structures could neither be fully tested,
nor wholly successful, without a commitment to pooling funds.
Nonetheless, the emphasis was being placed, at least in the short
term, on getting the mechanisms right before moving further.

It could be argued that the creation of appropriate planning and
commissioning structures presents greater practical challenges to
county councils than to unitary authorities or borough councils.
County councils face the added demands of managing their
relationship with district councils, and also with multiple PCTs.

But lack of co-terminosity in itself was not generally identified
in the sites as a major obstacle to greater integration. Instead,
there was considerable insight into the need to rationalise
structures – both to take account of limited human resources and to
ensure a firm grip was maintained on overall strategy and delivery.
In one of the county council sites this was addressed by one PCT
assuming the role of lead commissioner for older people’s
services.

We also found examples of ad hoc approaches to sharing risk and
financial commitment. Such developments pointed to a degree of
trust between partners, and an appreciation of the need to build
capacity and develop innovative approaches to older people’s
services. While these examples were encouraging, they are a long
way from a comprehensive pooling of large service budgets for older
people, with the correspondingly greater risks and liability for
the respective partners.

While there may be an enthusiasm to get on with integrating health
and social care budgets, the pace of change is constrained by
concerns over issues of governance and accountability. Moreover, as
other research has also highlighted,^1,2 while sites were
grappling with these challenges, a willingness to proceed was often
constrained by the imbalance between health and social care
finances, and concerns about the risks of overspending by partners.

Most respondents described an increasing openness about finances.
One respondent said that “although complicated funding streams
continue to hinder the good progress made towards a more honest and
shared approach to financesÉincreased information sharing and
joint working to explore funding possibilities has generated some
real mutual understanding”.

A further catalyst to joint working has emerged in joint planning
groups, established to address particular Department of Health
policy imperatives. These groups have provided opportunities to
address information sharing, and demand and supply. The need to
produce three-year plans in partnership has secured a belated focus
on long-term funding strategies.

The nature of joint commissioning, and of models of health and
social care service integration, are shifting radically. The
experience of the early days of PCT and social services
partnerships indicates that this is a rollercoaster ride. To date,
much of the effort has focused on constructing the new mechanisms
and processes. These are important developments, but the real test
will be further down the track.

In all six localities, stakeholders were seeking the establishment
of genuinely integrated strategies for older people’s services. In
securing substantive rather than merely incremental change, they
acknowledged that additional hurdles lie in convincing councillors
and chief executives that the investment is essential, and that
integrated strategies offer the only sustainable means of securing
objectives.

Vanessa Davey is a research officer with the personal
social services research unit at the London School of Economics
while Melanie Henwood is a health and social care analyst and a
visiting fellow with PSSRU at LSE.

References

² B Hudson, B Hardy, R Young and C Glendinning,
National Evaluation of Notifications for the Use of the Section
31 Partnership Flexibilities of the Health Act, 1999, Final
Report, National Primary Care Research and Development Centre
and Nuffield Institute for Health, 2002