Can health and social care really work together?

A financial dispute seems to have killed off health and social care partnerships in Glasgow, but in next door East Renfrewshire integration is working well, finds Gordon Carson

The end of Glasgow’s community health and care partnerships (CHCPs) looks more likely by the day, with no sign of a reconciliation between Glasgow Council and NHS Greater Glasgow and Clyde in keeping the integrated health and social care bodies going.

However, the neighbouring authority of East Renfrewshire has shown how solid partnership structures can be created, and with NHS Greater Glasgow and Clyde too.

East Renfrewshire CHCP is responsible for services such as community nursing and older people’s teams, holds budgets for residential care and home care, and has strong links with local GPs, though there are no hospitals within the authority’s boundaries.

As a relatively affluent suburban area, East Renfrewshire, with a population of around 90,000, faces largely different demands from Glasgow. One key challenge is keeping its increasing number of older people at home and out of hospital, which means creating strong links between services and with hospitals in Glasgow and Renfrewshire.

Anne Marie Kennedy, who represents East Renfrewshire’s older people’s network on the CHCP’s public partnership forum (PPF), says the integrated working structure has brought major benefits to the area since it was introduced in 2006. She tells of how co-ordination between health and social care helped to maintain the quality of life for one older lady by moving her from her own home into sheltered housing rather than residential care. “That was great for her,” says Kennedy.

As in England, joint working between health and adult social care has long been championed in Scotland.

The 2003 Partnership for Care white paper said NHS boards should set up community health partnerships (CHPs) in localities, to manage primary care while also working closely with councils in integrating services.

These were subsequently set up across Scotland. In Glasgow and East Renfrewshire, partners went further by bringing social work services within the same organisation as health, creating CHCPs, a route that is also being pursued elsewhere.

While the national policy framework explicitly supports integration, the cultural, organisational and financial challenges of doing so are manifold.

But the example of East Renfrewshire shows they are not insurmountable, particularly with decisive leadership from senior staff and elected members, and clear accountability and governance.

Single director

Julie Murray, director of the East Renfrewshire CHCP, says a key to its success is the fact that she is the single director for health and social care, and there is no separate social work director post. The CHCP covers all social work services for children and adults, plus health visiting, community nursing, school nursing and community mental health, among others. It has 1,000 staff – 800 employed by the council and 200 by the NHS.

Murray reports directly to the chief executives of the council and of the health board, and is a member of both organisations’ executive teams.

She is also accountable for £40m of funding from the council and £40m from the health board, devolved to the CHCP.

Though the budgets are aligned, not pooled, individual heads of service and their management teams are responsible for both, giving them flexibility to use resources. For example, the manager of the CHCP’s addictions service has used council money to fund a part-time health visitor to work with parents with addiction problems, while NHS funding has helped to improve the council-owned building used for counselling sessions.

Glasgow Council has cited feedback from the Social Work Inspection Agency as contributing to its unwillingness to fully devolve control to CHCPs (see box), but East Renfrewshire has not encountered similar problems with the inspection framework.

Although there are currently no special inspection arrangements for CHCPs, Audit Scotland will soon undertake an in-depth study of their governance and financial arrangements, which could bring changes.

While accountability for the CHCP is vested in its senior management structure, staff and service users also have significant input through two main vehicles: the professional advisory group, which includes representatives from clinical and social work services; and the public partnership forum (PPF), a network of local individuals and organisations.

Of the PPF, Murray says: “We are keen to use them as a sounding board and ask them to challenge us over things like the use of jargon in publications.”

Kennedy says consultation with the public has greatly improved under the new structures.

She cites the example of a new health and care centre being built in Barrhead. “We were able to do a lot of public consultation through the PPF and when the plans were put in place there were no objections because people had had their say before then,” says Kennedy.

She also says the CHCP structure has helped to protect resources for East Renfrewshire, particularly as it is only a small part of the Greater Glasgow and Clyde health board. “They say East Renfrewshire is very affluent but it also has small areas that are very poor,” she adds. “Because the CHCP has more control it can work more specifically to local needs.”

At the forefront

Glasgow has been at the forefront of integrated working in Scotland. The first joint care service between the council and NHS, the Glasgow Learning Disability Partnership, was founded in 2001, followed by partnerships for homelessness (2003) and addictions services (2004).

Then, in 2006, the council and NHS Greater Glasgow and Clyde set up five CHCPs, operating with aligned budgets – where different organisations’ finances are targeted towards the same objectives – to bring together management and delivery of local health and social care services.

The relationship was set to be cemented further this April with the full devolution of the council’s management responsibilities and budgets, increasing its contribution from £190m to £400m a year to the CHCPs (the NHS had already devolved almost £500m of funding). However, at the last minute the council said this would pose too great a financial risk and instead wanted to devolve funding and responsibilities incrementally, starting with £75m for adults’ residential care.

“We are not talking about tiny little steps,” says David Crawford, Glasgow’s executive director of social care services. “That’s a huge amount of risk and money.”

Central to the council’s reluctance to proceed as planned is a comment in a 2007 Social Work Inspection Agency report of the city’s social care, which said the move to CHCPs should not result in “unacceptable differences in the level and quality of provision across the city”, and that social care should retain “a strong strategic core”.

“People are concerned about the potential for postcode lotteries,” says Crawford.

However, the health board has said the council’s focus on this issue has “underlined our concern about their commitment to move from a highly centralised approach”. In addition, it said there had been “no financial management issues” relating to the near-£500m of health budgets held by CHCPs.

Brian Smith, secretary of Unison’s Glasgow branch, says he has some sympathy with the council’s position, particularly regarding its strategic oversight of children’s services, which were also due to be fully integrated into CHCPs.

In an attempt to find a way forward, the council has approached John Arbuthnott, who led a review last year of joint working plans for eight local authorities in the central belt of Scotland, and is a former chair of NHS Greater Glasgow. However, as Community Care went to press a resolution did not look likely, with both organisations developing plans to disentangle their own services from current partnership arrangements before final executive meetings later this month.