Health and social care disagree over boundaries in the North East

There are fears in the North East that valuable partnerships will be lost in the wake of strategic health authority proposals, writes Mithran Samuel

The increase in the number of councils sharing boundaries with a single primary care trust (news, page 6, 20 April), under strategic health authority plans, will be welcomed by local authorities.

If the proposals are implemented, coterminosity – seen as a crucial condition of partnership working between health and social care – will rise from 44 to 78 per cent.

But shared boundaries would be lost in 25 areas, and the impact differs significantly by region. Notably, nine are in the north east.

County Durham and Tees Valley SHA and Northumberland, Tyne and Wear SHA, which are under the same management, have proposed reducing 16 existing PCTs to four, rejecting a rival option of 12 coterminous trusts. The SHAs will also merge to form a single strategic body for the North East.

Existing partnership arrangements in the nine areas include seven local area agreements, which the Department of Health, through the health and social care white paper, has lauded as a way of PCTs and councils pooling resources to work towards common goals.

There are five jointly appointed directors of public health, which reflect the health and social care white paper’s proposed role for directors, alongside adult social services directors, in carrying out strategic assessments of their populations’ health and well-being needs.

Then there is Northumberland Care Trust, which commissions both health and adult social care, but would be swallowed into a larger PCT, also covering Newcastle and North Tyneside, under the plans.

Stockton-on-Tees Council’s director for children, education and social care, Ann Baxter, says: “We are very worried. We think this is a time where close partnership is very important.”
However, the SHAs’ decisions reflect the eight criteria for restructuring set by the DH and wider NHS policy developments.

In their submissions to the DH, the SHAs said there were advantages and disadvantages with both options.

Fewer, larger PCTs would do better on three of the eight counts. Firstly, they would commission better and be more efficient than smaller trusts, by carrying greater clout with powerful providers, such as foundation trusts. This is particularly important given the roll-out of payment by results, under which providers are paid according to service volume rather than through block contracts.

The SHAs also said larger trusts would secure better services, given better commissioning, and be more financially secure given their size.

Smaller, coterminous trusts won on two criteria – better partnerships with social services and improving public engagement with services – while the SHAs said the two options were level pegging on tackling health inequalities and promoting practice-based commissioning.

They also said both fulfilled the final criterion – making 15 per cent savings in management costs. However, with four PCTs, most of the savings would come through cuts in senior management and trust boards, as a result of having far fewer organisations. With 12, they would have to make more damaging middle management cuts.

Rosemary Granger, executive director at the two SHAs, says they concluded that the weaknesses of larger trusts could be addressed by localised structures based on council boundaries. But the limitations of smaller trusts, particularly in commissioning, could not be adequately addressed by having neighbouring PCTs work together.

She says: “When you have a number of statutory organisations working together, decision-making can be very slow.”

But she admits that with larger trusts, a “huge amount of effort would have to go into ensuring that joint arrangements continue”.

This would mean the devolution of responsibility to areas coterminous with councils, and Granger suggests that the new single SHA for the North East should performance manage trusts.

This would not be sufficient for Baxter, who says councils will be lobbying the DH to turn down the SHAs’ plans.