Can you see the join?

There can be little doubt that PCTs have been the catalyst for
change in health and social care in recent years, breaking down
organisational and professional barriers and reshaping service
delivery. But much of their perceived success at doing this has
been down to timing and funding.

The network of 304 PCTs has evolved as the NHS and social
services are being forced to work together in order to meet a host
of government targets. Care standards laid down in the national
service frameworks for older people and children will be impossible
to meet without good quality partnership across health and social
care.

Inevitably, the biggest factor in PCTs’ success came last
December when health secretary Alan Milburn announced a 30 per cent
increase in funding over three years so that by this April they
will be responsible for spending 75 per cent of the NHS’s
total budget. The minister’s message to health and social
care could not have been starker – PCTs are where the money is and
they represent the future.

Social services directors, who have been at the forefront of the
development of PCTs, report some spectacular success stories. They
are hopeful, if still a little cautious, that the extra funding,
guaranteed for three years (see panel, facing page), will bring new
ways of partnership working.

Last year, some PCTs were forced to clear budget deficits
inherited from the health authorities they took over from. The size
of the total deficit was estimated to be in the region of
£1bn.

Dr John Beer, director of social services at Southampton and
chairperson of the health and social inclusion committee of the
Association of Directors of Social Services (ADSS), admits that a
lack of money hampered developments in some PCTs last year.

“There were a number of PCTs which had significant financial
pressures and were therefore cautious about commitments such as
pooling budgets and shared care arrangements until they had sorted
out their own finances.

“After this first year there is generally more confidence that,
once they have sorted out their budgets, they will be clearer about
what money they have for growth,” he says.

Over the next three years, every PCT budget will go up by at
least 28 per cent, Milburn has promised. A three-year funding
programme was deliberate to encourage PCTs to plan ahead, he
said.

Dr Barbara Hakin, who leads the government’s National
Primary and Care Trust Development Programme, emphasises the
importance of guaranteed long-term funding. “The fact that we have
this money for three years is incredibly welcome because it allows
us to be more committed to the work that we know is innovative and
will reap rewards,” she adds.

Even before the extra money was put on the table social services
directors were already noticing the difference PCTs were
making.

Julia Ross, joint director of social services for London’s
Barking and Dagenham Council and chief executive of the
borough’s PCT, says she applied for the dual post because she
wanted to create a merged social care and health organisation.

“I wanted to pull things together. I recognised that as a small
local authority, with high levels of deprivation and regeneration,
we couldn’t afford to have any duplication of staff or to be
pulling in different directions.”

Ross has also created joint appointments at PCT board level to
promote partnership working involving joint teams working across
health and social care.

Two years into the post, she can see significant changes. “We
can now do things in a way which was quite difficult for me to do
just as director of social services,” she says.

“We have created seamless services and integrated care pathways.
And our intermediate care programme is happening much quicker
because our head of older people’s services has a nursing
background and is familiar with how clinical, district, as well as
social service, care works.”

A key advantage of joint appointments is the insight into the
culture of the NHS that health staff can bring to social
services.

“There is something about the hierarchical conditions and
controls in health that social services might struggle with,” Ross
says.

“The culture of health thinking – that there is another level of
hierarchy up there which will hold you to account and tell you to
do something – goes against the normal social care approach of
‘what does this community need, and what and how am I
accountable to them?’.”

Dr Andrew Dearden, chairperson of the British Medical
Association’s community care committee, and Dr Beer from the
ADSS agree that success is blossoming where partnership working is
already well established.

Dearden, a GP in Cardiff, says: “Where it has worked well they
have worked to a single budget and commissioning system where they
have agreed the outcomes they both want, put money into the pot and
got on with it.

“It’s worked badly where people from both sides have
brought a lot of baggage with them and have different working
priorities – if you cannot agree priorities then you are unlikely
to put money into it.”

Michael Sobanja, chief officer at the NHS Alliance which
represents primary care bodies, says PCTs have brought “more
rounded” solutions to health and social care problems because both
sides are working together.

But he adds: “There have been some areas where partnership has
been led by mistrust and misunderstanding – there is turf
protection.

“PCTs are all about tackling this and understanding the needs
and objectives of different organisations.”

And Dr Hakin believes that PCTs are the beginning of a
fundamental reshaping of how primary health and social care is
delivered.

“I think we are in the middle of a sea change – not just the
organisational change of PCTs but a climate across health and
social care to stop working in separate silos. PCTs have
facilitated something which was already happening,” she adds.

Evolution to care trusts

First mooted in the NHS Plan three years ago, primary care
trusts have quickly become the main health commissioning
organisation for a locality, developing primary care and building,
it is hoped, seamless services across social care.

In April 2002, five care trusts – which take the concept of PCTs
a step further by establishing a new organisation responsible for
both health and social care – were also launched.

David Parkin, social care director for Northumberland Care
Trust, admits there have been teething problems with the trust
model, but is optimistic about the future and the benefits his
trust can bring to services.

“What we are starting to see is, when we talk about access to
primary care, we do that in the context of taking into account
social care. I believe this is the way forward, but it’s not
the only option. The government says there is a range of different
partnership ways of working to achieve the outcomes, and you should
choose the best to suit your location,” he says.

However, Dr Barbara Hakin doubts whether most PCTs will be keen
to go down the care trust route. She thinks they will rely instead
on existing mechanisms such as Health Act flexibilities – where
budgets, staff and commissioning responsibilities can move between
social services and health – to achieve joint working.

Only a further two care trusts have been established since the
five pilots started operating last year, and it seems the
government’s focus has now turned towards developing
children’s trusts, bringing more joint working across
agencies devoted to children’s services.