Distinct cooling on care trusts revealed in plan for adult services

Last week’s adult green paper made it clear that councils and
health partners would be forced to set up commissioning
partnerships for the long-term planning of social services.

Councils and their partners will be set broad outcomes and have
relative freedom, tempered by regulation and the duty of
partnership, over how to pursue them.

But this was as far as the prescription went. In particular,
care trusts received scant mention in Independence, Well-being and
Choice, and were alluded to only as one of several different ways
of joint working.

The green paper says: “We do not want to impose solutions.
Decisions about the best models to suit local circumstances should
be made locally.”

This contrasts with Ladyman’s speech to last year’s Association
of Directors of Social Services spring seminar, where he launched
the consultation on his vision for social care asking whether he
should “push everyone into a care trust”.

As late as this month, the Local Government Association’s
community well-being board warned that the green paper would put
“structural changeÉ in particular care trusts” back on the
agenda.

Such fears have now been allayed, although Ladyman believes the
green paper and this month’s national service framework on
long-term conditions will encourage more care trusts.

But how credible is this belief, given that just eight have been
set up, and none since October 2003? And why has the government
held back from “pushing everyone into care trusts”?

It was all so different when the 2000 NHS Plan proposed
establishing care trusts to “remove the outdated institutional
barriers between health and social services” and threatened to
impose them where effective partnerships did not exist.

This threat was removed during the passage of the Health and
Social Care Act 2001, which enabled the creation of care
trusts.

But in his speech to that year’s National Social Services
Conference, then health secretary Alan Milburn said: “Eventually, I
hope care trusts will be in place in all parts of the country,
because they break through bureaucratic boundaries in order to
focus on the needs of service users.”

Milburn and health minister John Hutton were the two main
architects of the policy. But Milburn resigned as health secretary
in June 2003 and Hutton was moved out of his social care portfolio
in June 2001, which appears to have reduced the government’s drive
for care trusts.

Ray Jones, director of social services at Wiltshire Council,
says: “The government itself stopped talking about care
trusts.”

This, he says, is one reason why Wiltshire, which had considered
joining forces with its three primary care trusts, decided against
it, as one of several pilots not to make it to care trust
status.

A Commission for Health Improvement report delivered perhaps the
biggest blow in Whitehall for the policy in September 2003. It
centred on Rowan ward in Manchester, a facility for older people
with mental health problems, where allegations of abuse of patients
emerged in August 2002, four months after Manchester Mental Health
and Social Care Trust was set up.

The report said: “The assessment that the partnership was fit to
become a care trust appears to have been flawed. Establishing the
care trust diverted scarce management time away from service issues
and quality of care.”

Among its recommendations was that the Department of Health
evaluate its process for considering care trust applications.

But evaluating the existing eight care trusts is a problem for
the DoH. A spokesperson says: “There’s been no formal evaluation.
Because the number is so small the costs would be disproportionate
to the population covered.” An evaluation would also not compare
like with like.

Currently, only Northumberland has responsibility for
commissioning all health and social care services in its area,
while of the rest, five purely provide services and all are client
group-specific.

The low take-up of care trusts can be explained in various
ways.

One has been the existence of alternative models, in the shape
of the Health Act 1999 flexibilities, which permit integrated
teams, pooled budgets and lead commissioning. As of last October,
414 partnerships had been set up under the act, worth more than
£3.4bn.

An October 2002 evaluation by the National Primary Care Research
and Development Centre of the first 32 agreements found evidence of
“improvements in efficiency and effectiveness” as well as cultural
change.
One of the authors, Caroline Glendinning, now professor of social
policy at York University, says the cost of setting up a care trust
has led areas to favour the looser partnership arrangements of the
flexibilities.

She says: “There are many costs in terms of senior management
time – that time may better be spent on other things, if there are
other ways of achieving the results that are perhaps a bit more
flexible.”

While the Manchester experience illustrates the extreme end of
transition costs, all care trusts have had their problems.

Chris Taylor, director of social care at Northumberland Care
Trust, says: “I think we probably lost 18 months when we set up the
care trust through organisational change.”

In most cases, social care staff have been transferred to the
care trust – an NHS body. But care trusts have been plagued by the
problem of bringing together council and health HR, pension and IT
systems.

Evidence suggests that transitional costs have been kept to a
minimum where sound partnerships were already in place, which calls
into question the ability of care trusts to build new, strong
partnerships.

Bexley Care Trust chief executive Simon Leftley, who is also the
council’s director of social services, says the care trust built on
a health partnership board set up in 1999 to plan and commission
services.

There have been others disincentives for councils to be involved
in care trusts.

Terry Butler, director of social services at Hampshire Council,
which also pulled out of a care trust pilot, says: “One of the main
reasons that adult care trusts failed was that there was a great
deal of suspicion in local government about it being a health
takeover.”

Care trusts are only performance-rated on the basis of their
health functions. The performance of the social care functions
delegated by councils to care trusts remain councils’
responsibility despite the fact that councils have no part in their
delivery. And question marks have been raised over local
authorities’ ability to monitor and scrutinise the performance of
delegated services, as councillors appointed to trust boards are
accountable to care trusts first, not councils.

Les Smith, executive member for adult services at
Northumberland, says this is not a problem in practice as the care
trust is assiduous in giving the council performance updates.

He also denies that the performance management system distorts
the care trust’s priorities in favour of health. But he adds: “I
can’t believe it makes social care staff working for the care trust
feel good when their organisation is praised or blamed solely on
the basis of its performance on NHS targets.”

This suggests that Ladyman’s wish for lots more care trusts is
unlikely to be more than a trickle, and that the model will only
ever be a minority preference.

Nevertheless, existing care trusts, despite their tribulations,
believe that they have built a platform for success.
Leftley says that despite the organisational changes, performance
has improved in social care and staff turnover has been low.

But he adds: “We are proud of what we’ve done but it’s unhelpful
to overstate the case.”