Published: 18/08/2005, Volume II5, No. 5969 Page 12 13

The merging of the primary and social care white papers into the healthcare outside hospitals document signals an unprecedented opportunity to integrate health and social care. Continuing our series on white paper themes, Daniel Martin looks at what will be asked of those on the front line

The Department of Health is about more than just health. It is also in charge of social care policy.

An obvious point, perhaps, but it appears it has only recently occurred to many civil servants. The DoH's forward plan, published last week, lists one of the priorities for the future as being to 'increase internal awareness and understanding of the social care context and implications [of policy-making]'.

It was with this in mind that social care minister Liam Byrne announced last month that the proposed primary care and social care white papers would be merged into a single document - the healthcare outside hospitals white paper.

The merger of the white papers and the acknowledgement that civil servants from the two wings of the DoH have not worked together effectively enough has been warmly welcomed by the Association of Directors of Social Services.

'This is a golden opportunity, ' says John Dixon, chair of the association's disability committee. 'What we are used to is having an initiative in the NHS then something in social services and it has not been co-ordinated. Full marks to the DoH for doing this.' It is becoming clear that ministers will soon start demanding a correspondingly greater degree of integration from the front line too.

This was heralded when NHS chief executive Sir Nigel Crisp last month urged primary care trusts to become co-terminous with social care department boundaries. This is expected to be pressed further in the white paper, but just how strongly is the subject of speculation.

Mr Dixon, who sits on the DoH's social care forum, says he has been 'absolutely assured that It is not a structural white paper but is about functions'.

But the government does not have to impose prescriptive structural solutions to get the outcomes it wants. It has a number of levers. The merged health and social care inspectorates will reward joint working, and the DoH can wield the carrot of budgetary incentives and the stick of financial penalties such as delayed discharge fines.

A less generous financial settlement after 2008 is playing its part in the government's desire for greater integration. The DoH has told PCTs to save£250m and social services are being squeezed on efficiency savings outlined in the Gershon review. Both need to cut back, and integration is a way to do it. 'From the DoH's point of view, a key driver behind this is an economic one, ' says Mr Dixon. 'It can't afford to continue investing increased funds into the acute sector. It needs to get people out into the community and provide more economical care pathways.' Choice also makes integration a priority. Empowered patients will want the best care available and will not be interested in who provides it.

Commissioners, whether from PCTs, GPs or social service departments, will have to respond to this pressure for invisible joins between elements of care pathways. This in turn will force providers to work together more effectively.

And if direct payments - already available to those accessing social care services - is extended into health, as has been mooted in the higher echelons of policy circles, there will be more pressure on commissioners to work together.

The theory is that empowered patients with long-term conditions would demand integrated care packages.

National director for social care Kathryn Hudson says the DoH is looking at direct payments - or more likely individual budgets - for health in response to feedback from March's social care green paper.

'There is no doubt [the lack of individual budgets] creates barriers between health and social care, ' she said. 'We are looking at this.' However, some have warned that the government would have to be extraordinarily brave to consider direct health payments because it would open an unwelcome debate over whether the policy would erode the founding principles of the NHS such as equal access for all. Centreleft think tank the Institute for Public Policy Research fellow Joe Farrington-Douglas says: 'There is a risk that, unlike in social care, the healthcare costs the individual will accrue are less predictable because people have flare-ups. And if people are to make choices themselves they need information: but there is even less information about primary care outcomes than hospitals.' But there are still formidable barriers to closer working. Pooling budgets and transferring funds between councils and PCTs is notoriously bureaucratic. Arcane rules mean certain local authority workers are legally not allowed to work for a healthcare organisation.

NHS and social care IT systems cannot talk to each other, and the practitioners themselves speak a different language. And Ms Hudson says she is concerned about present eligibility criteria which mean that many patients do not receive the community care the NHS says they need on being discharged because they are not eligible for free care.

The white paper will apparently suggest ways to tackle many of these concerns.

However, the barriers have not prevented some councils and PCTs appointing joint managerial posts and the white paper is expected to encourage other areas to make such appointments.

'It is absolutely critical, ' says NHS Confederation policy manager Jo Webber. 'We need to ensure we have a lot of managers who have worked in both sectors so there is a pool of people to choose from.' Greater Manchester strategic health authority chief executive Neil Goodwin says joint appointments would save on administrative costs.

'There are managers at the moment whose job is to act as a go-between between health and social care, ' he explains.

However, when PCTs were formed only six areas opted to become care trusts, where the entire primary care and social care organisations are merged, and the model has therefore not been seen as a success. Social services were hostile to a perceived NHS takeover, meaning future attempts at organisational integration will have to treat local authorities as an equal partner if they are to succeed.

However, the white paper will not stipulate the exact form of future joint working arrangements. The key to the DoH's thinking, says Ms Hudson, is that local solutions must be found to improve relationships between health and social care. She urges PCTs to look at examples of best practice outlined in the social care green paper - such as the connected care model, piloted in some areas, where GP surgeries are sited in the same location as social services and housing advice centres.

She says health managers have nothing to fear. 'Integration is not the same as making everyone do the same thing. It is about health recognising what social care can offer, and vice versa.

'When organisations look at structures they need to consider what is needed in their particular locality and what would be in the interests of local people, ' she adds.

But others say you cannot rely on goodwill alone, and pressure may need to be brought to bear. The Association of Directors of Social Services, the NHS Confederation and others on the social care forum are pushing for a duty to be placed on local authorities and PCTs to work together.

Ms Hudson says the DoH is looking closely at the idea, but she warns: 'You can't simply order people to co-operate; they will do it when they see the value of doing something. We are looking at levers to bring that about.' Children's health and social care commissioners have already had a duty imposed on them to work together through children's trusts - 'virtual' bodies on which managers from various bodies which deal with children (such as councils' education and social services departments, and PCTs) take care of a pooled budget and jointly commission services.

While the white paper is unlikely to make the establishment of an 'older people's trust' a requirement, many feel that a duty to co-operate would lead almost inevitably to the setting up of such bodies to jointly commission services for older people with long-term conditions. They would bring adult health and social services face to face with managers from housing, leisure and other council services which impinge on the well-being and independence of elderly patients.

'I think we will see a lot of people being brought together under the children's trust model, ' says Mr Dixon. 'Governments will use them as a mechanism for delivering funding so people will adopt this approach.' King's Fund health policy fellow Penny Banks says older people's trusts would ensure that social care is treated as an equal partner.

'Otherwise there is a danger that social care gets swallowed up by the priorities in the healthcare system, as we have already seen with the fines for delayed discharges.' The push towards older people's trusts should be all the stronger once PCT boundaries are aligned with social services.

However some have begun to take a more long-term look at the future of health and social care. PCTs have already been told they will in most cases lose their provider function. If practice-based commissioning is a success they will lose much of their commissioning role as well. So in the longer term, with PCTs reduced to a rump, would it not be more sensible to hand healthcare commissioning to councils? How more integrated with social care could one get? It would slash administration costs, and would bring direct local democratic accountability to the NHS, removing the need for fig leaves like the derided scrutiny committees.

One highly placed policy-maker has even put a date on the change.

'By 2020, ' she says, 'local government will be responsible for commissioning health and social care.' Who said that? Why, none other than health secretary Patricia Hewitt's special advisor Liz Kendall, when she was a research fellow at the IPPR.

Mr Dixon says it is an idea worth exploring. 'There is now a much stronger recognition from the DoH that local government has a part to play, and that local elections and local mandates are important factors, ' he says. '[Sir Nigel] Crisp has made a point of saying the NHS should look to the experience of local authorities.

'We need to be careful about saying local authorities have the expertise to commission healthcare at this stage. But I am not saying it can't be acquired.' Such a move would mean overcoming entrenched resistance within Whitehall and Westminster to giving the huge social and economic power and responsibility that comes with the multibillion-pound healthcare commissioning budget to local government - especially, as is often the case, when the opposition holds the majority of political power.

But one senior Whitehall source says giving councils control over funding might be just the type of shake-up the NHS needs. 'You could say the NHS is the biggest unofficial quango - I am all for accountability, ' he says. .