Ten years on from the establishment of the first care trusts, the Health Services Management Centre carried out a series of interviews with care trust leaders to see what could be learnt about integration.
According to the Health Select Committee report at the start of this year, Care Trusts are able to deliver more integrated care and significant benefits for patients. This contrasts with the care services minister Paul Burstow who, in the same report, described care trusts as “an experiment that … did not really make it out of the lab.”
In many ways this is similar to a quote from a chief executive at one of the early care trust development events which the Health Services Management Centre (HSMC) ran in the early 2000s: asking whether care trusts were at “the vanguard of integration” or something of “a lost tribe.”
Behind this remark was a sense that the early care trusts felt they might be at the forefront of attempts to integrate health and social care. This sense of optimism for the future was boosted by ministerial comments that in five years time all services for older people would be provided by care trusts – and HSMC was subsequently asked by a previous minister to explore the impact of care trusts and whether all areas should be asked to form one.
In practice, the emerging evidence seemed to suggest that areas forming care trusts had a number of locally-specific factors that made this an attractive model for them – but meant that this might not be the case elsewhere. Often, they had co-terminus boundaries, with senior leaders in post over time and relationships of trust. Many were also building on many years of joint working, and saw care trust status not as an end in itself but as a natural next step.
Slightly more ambiguously, several were in very small health communities that may have lost their PCT or mental health provider in a previous reorganization had they not sought economies of scale locally by integrating health and social care. While many had a positive history of joint work, therefore, some were also motivated at least in part by fear of external threat. All this was summed up by another early care trust leader, who concluded that “care trusts work where they work” (but might not, by the same logic, work elsewhere).
Initially proposed in The NHS Plan of 2000, care trusts are integrated health and social care organisations that either deliver or both commission and deliver integrated health and social care. Based primarily on a PCT or NHS trust, they were NHS organisations that had social care powers, staff and budgets delegated to them.
Ten years on from the first care trusts, HSMC carried out a series of interviews with care trust leaders to see what we could learn about integration. Like the select committee, it seemed to us that this was a significant innovation and that such organisations could have important lessons for the system more generally. While we would not describe the model as ‘not making it out of the lab’, the fact remains that there have only ever been 12 care trusts, and that their impact overall seems to have been less than initially hoped for.
Seven of the 11 care trusts then in existence agreed to take part and answered a series of questions about why their organisation had been set up, what it had achieved, what had helped and what had hindered. While the full results are available from the HSMC website, six key issues seem important in light of current changes and the debate raised by the select committee:
- Participants confirmed the importance of local context and history in shaping their decision to explore care trust status – and care trusts seemed to work best where they were a natural next step on a longer-term journey and built on longstanding relationships. Care trusts formed primarily as a response to external threat could sometimes feel more like ‘marriages of convenience’ and subsequent tensions could arise.
- In seeking to deliver something genuinely new, care trusts needed to devote significant time and attention to thinking through what outcomes they were trying to achieve and why this organizational form was the best way forward (in spite of the short-term upheaval that it would create). Meaningful staff and patient engagement was crucial, and organizations needed a strong sense of what success would like as care trusts.
- Many care trusts found themselves trying to function as integrated organizations in a silo-based system. This could cause friction when policies such as Agenda for Change, Transforming Community Services, Foundation Trust status or indeed clinical commissioning affected the health care part of their remit but had not necessarily been designed with integrated organizations in mind. Many also continued to struggle with issues such as separate IT systems or different terms and conditions.
- More important than integrated structures was the detailed organizational development needed to create more integrated working on the ground. Thus, the task was cultural rather than structural, and there was a risk that creating a new organization could become an end in itself rather than a means to an end.
- While care trusts helped to develop a closer relationship between health and social care, creating a new organizational entity could sometimes distance the new agency from broader local government – and this could be a key limitation in terms of promoting broader health and well-being.
- Participants could identify improvements in terms of more integrated ways of working locally, but often struggled to demonstrate that these had subsequently led to improved performance (as measured by national inspection agencies) or improved outcomes for patients. This is not necessarily to say that outcomes did not improve – but more that it is difficult to tell with so much else happening in the broader policy context. With hindsight, four of our seven interviewees would still have formed a care trust – but three would not have gone down this route (citing the time and effort required to set up a new organization and a reduced connection to the broader local authority as key limitations).
In terms of the future, PCT-based care trusts have had to separate their commissioning and provision like other PCTs. They are also trying to explore what the future might look like in an era of clinical commissioning – and the danger is that a number of integrated structures that took a long time to establish could be dismantled in response to current changes. For provider care trusts, the future seems more positive, and a number have sought to expand their remit by taking on additional community services.
Overall, some care trusts feel that they have been able to secure advantages for local people through an integrated structure, but others would choose a different route if they could. Rather than asking “is a care trust the best way forward”, perhaps the question should be “what can services in our area do to deliver the best outcomes for local people”. While some areas might still answer this question with a care trust, others would choose a different approach – and this seems entirely appropriate in an era of localism and of ‘liberation’.