Obstacle course

If health and social care are to develop in the way that policy-makers hope, then strong partnership working between the NHS and local authorities remains essential. Yet the drive for better partnership working is nothing new, so why isn’t it happening to the extent that it should be?

Health and social care have been undergoing radical and rapid change. Perhaps of most significance was the Health Act 1999. This placed a statutory duty on NHS bodies to work in partnership with local authority colleagues “to maintain and improve the health and welfare of the people of England and Wales”, and sanctions have been available to punish those who do not.

The Act also made it easier for the NHS and local government to pool their budgets, and as a result, good examples of joint-working have sprung up. But only in some places and in some services.

Without doubt, a major challenge, and one that cannot be ignored, relates to the differing cultures and make up of the NHS and local authorities. NHS boards are appointed, not elected, and are accountable to central government. By contrast, in local authorities, elected local councillors are in charge, with council staff then accountable to the community through them. This inherent structural difference has a fundamental impact on front- line staff in both sectors. While social services directors and senior managers accept public political scrutiny by councillors on a regular basis, NHS chief executive officers and senior managers have nothing like this level of scrutiny and accountability to the local community.

The result is that decision-making processes in the NHS and local authorities continue to be profoundly different. It stands to reason that a local authority committee of elected politicians overseeing large budgets will always need to consider the direct political implications of its decisions whereas an NHS board, relatively free of such constraints, can make decisions behind closed doors.

An attempt to rectify this  came in 2003 with the formation of overview and scrutiny committees in England and Wales. Through these, local authorities were given new powers to subject the NHS to local and public scrutiny. An OSC is formed of elected local politicians who focus on the planning and delivery of health services.

They have powers to call local NHS chief executive officers and others to appear before them in public and account for their stewardship of NHS resources. They also must be consulted on service developments, including service configuration issues in the local NHS.

Over the past two years many OSCs have  appointed full-time officers with health expertise to advise  them.

It is early days for OSC structures, but it is clear that NHS boards that work well with their OSC colleagues and share plans and ideas are likely to experience smoother working relationships.

But those in the NHS who are less open and proactive in working with OSC colleagues have found that the OSC can make life difficult. For many in NHS management such direct local and public political scrutiny has been something of a revelation.

Another barrier to successful partnership working at a practical level relates to pay and conditions for front-line staff. In so many areas of care, joint NHS and social care teams make total sense and much has been done to integrate staff from different professional backgrounds. But increasingly, we are asking health and social work staff to take on broadly similar responsibilities – for different amounts of money.

How can it be reasonable for a social worker to earn 20 per cent less than a NHS colleague undertaking a similar role? There also continues to be discrepancies between NHS and local authority annual leave and study leave provision. There is a need to look at new payscales that allow for greater harmonisation in joint teams, and in the current climate of the NHS
pay modernisation programme, Agenda for Change, perhaps now is the time to do that.

Information systems also continue to pose real problems to good partnerships. If NHS patient information IT systems cannot “talk” to social services IT systems, the ability to share information effectively is compromised.

Equally, data that a centralised system such as the NHS wants to collect can be very different from the data a local authority needs. This poses real issues for front-line staff working in joint teams. Add to this the complexities of the Data Protection Act 1998 and the Freedom of Information Act 2000 and it is easy to see that this issue needs tackling at a strategic level to deliver effective partnerships.

Even after all this time, many of the barriers to joint-working flow from misperceptions. In 2002 Baroness Cumberledge, a former Conservative health minister, undertook a survey of London boroughs and their NHS counterparts, exploring how each perceived the other. They described each other in almost the same terms – distant, out of touch, bureaucratic, lacking real accountability, and slow to respond. Three years may have gone by but all too often the same perceptions remain. NHS and local authority leaders really do need to take time to uncover the myths and find common ground – it is the only way to ensure partnerships have real meaning and benefits for clients.

In many respects it may prove to be the merger of the Healthcare Commission and the Commission for Social Care Inspection which provides the impetus that partnership working so desperately needs. In so many areas of hospital and community-based provision, including housing, leisure, education and employment, it has seemed bizarre that inspection arrangements have remained so separate.

By bringing together into a single body the inspection of NHS and local authority services we at last have a real opportunity to share best practice across agencies more systematically and wisely. It will take time for stable joint arrangements to become embedded, but the potential benefits, including a reduction in multiple inspections could be real.

In addition, there is no denying that a significant stimulus for good partnerships lies in the quality of local leadership. As a reviewer for the Commission for Health Improvement (CHI) I spent a good deal of my time examining clinical governance across the NHS. I found that where there was passion and commitment from NHS and local authority leaders, joint-working seemed hugely successful. It is when such leadership is weak or absent that problems become apparent.

The demand for better partnership working is not going to diminish. With the NHS pushing choice for individual patients up the agenda and the focus on increased independence for disabled people, the pressures on NHS and local authority services to deliver are immense.

This agenda will surely be pushed even further by the forthcoming joint health and social care white paper, which will, in all likelihood, lead to yet further legislation compelling health and social care agencies to work more effectively together.

Ray Rowden is a health policy analyst and an associate with the Healthcare Commission