The NHS plan promises that powers to create new care trusts will be made available to primary care trusts and to local authorities with social services responsibilities.

The new trusts will bring together in one legal entity the commissioning and provision of health and social care services, especially for older people.

The government also intends to take power to establish a care trust in areas where little progress is being made in developing greater integration between health and social services. This includes powers to jointly commission, to lead purchase and to pool budgets.

The opportunity is to drive forward the integration of health and social services by creating local care trusts, building on the progress which has already been made in many areas, and tackling organisational and territorial boundary disputes which lead to inefficiency and 'stranded' service users.

The threat is that if local health and social services organisations continue to fight and pass blame across their organisational boundaries the government will intervene and sort it out by creating a local care trust.

Either way, care trusts seem to be the future.

The government has still to describe the constitution, governance, powers and accountabilities of care trusts, but by April 2001 their legal framework will be established.

Indeed there may already be PCTs, or PCGs moving to become PCTs, who see the opportunity, with their local authority colleagues, to become care trusts, reducing future uncertainty and tackling organisational change in one step rather than through a lengthier phased change.

In some areas, developments during the 1990s bringing together health and social care within primary care may mean that the move to care trusts would now be timely, and would resolve at least some of the issues that are best tackled by moving into one organisational structure.

In whose interest?

There are several factors a care trust will have to build on, especially while the government is leaving their establishment as a local option rather than a requirement:

The establishment of a care trust will need to be seen as attractive and acceptable to key players in the local NHS and social services.

Care trusts must not be perceived as a takeover of one organisation by another.

While statutory responsibilities and funding are separately allocated to the NHS and local government there will need to be dual accountability and audit trails for care trusts.

Recognising vested interests Beyond the altruistic ambitions to create more responsive, coherent, efficient and effective services, care trusts might serve a number of vested interests and ambitions:

NHS care trusts would provide the opportunity to bring together, in one NHS organisation and management structure, health and social care staff and budgets. There would be opportunities for better strategic shaping of combined services, with health board members, managers and practitioners being able to influence and indeed have some control of social care services, as well as healthcare.

Social services would have the opportunity to participate in shaping, and also in delivering, health as well as social care services.

For local government elected councillors there would be the opportunity to have direct influence over the shaping of local health services, as well as a continuing (but not controlling) role in shaping local social care services. Giving up some control with regard to social care would, in effect, be offset by greater participation in influencing the NHS spend locally.

In essence, for local politicians, board members and managers there are opportunities for greater influence and control across health and social care, but these require some trade-off in giving space and opportunities to others. There are opportunities here for reputations and careers to be enhanced.

For staff currently working separately in the NHS and in local government there are opportunities, which might be experienced by some as threats, to:

Come together in multi-disciplinary teams, with the skills and perspectives of all the professionals in the team valued and appropriately deployed, and with careers in professional practice and in general management opening up for all team members.

Bring staff currently separately employed in the NHS and in local government into one organisation, with potentially one set of terms and conditions of employment. This could help dispel some of the current resentments at disparities in salaries and employment terms between the NHS and local government.

Create bottom-up organisations where practitioners and local teams have the opportunity to contribute to the shaping of services and local practices.

Reduce some of the restrictions staff may experience from working within, at present, two or three bureaucratic organisations each with different rules and procedures.

For the government, care trusts provide an opportunity to remove the barriers which currently might be seen to thwart central government ambitions and commitments on issues such as waiting times, bed blocking, and the independence and prevention agenda for disabled and older people.

Bring social care and healthcare together in the centrally accountable structures and processes of the NHS rather than the potentially weaker and less direct mechanisms of specific grants, national targets and public reporting which the government increasingly uses with local government.

What about the opportunities for consumers?

Services which are better co-ordinated, with fewer gaps and boundary disputes between health and social care; less duplication and less delay in services, with the most appropriate professional co-ordinating and managing the services required; greater reassurance that relevant information will be shared within the local care trust team so that the assessment and assistance required by the service user is kept relevant.

Establishing a care trust also requires that the partner authorities do not wrong-foot each other by taking unilateral actions which so undermine the interest of the other partners that the commitment to move forward together is destroyed.

These might include appointments being made into new structures without the new posts being opened up to (ring-fenced) competition for relevant staff in each of the partner agencies.This is a very real danger as PCGs move to become PCTs with arrangements being made with NHS trusts but excluding social services.

For their part, local authorities might take the view that they would only look to the establishment of care trusts in their area if they were controlled within local government as part of an agenda that is defined as bringing back local democratic control of the NHS.

Steps to becoming a care trust These might involve:

Recognising that current services are not working well together;

Building integrated front-line teams of health and social care professionals where each team has one manager, and with this manager being accountable to middle managers in each of the 'parent' NHS and social services authorities;

Creating integrated general management structures with services commissioned by a joint commissioning board with a membership representing the NHS and the local authority.

These stages have often been followed in developing integrated mental health services.

But moving through these stages has sometimes taken about 10 years and this is not likely to be an acceptable timetable for the creation of new care trusts. So it would seem sensible to agree a critical path of action to move through the stages in the next four years, by which time the government expects that level four PCTs will be established throughout England: it is quite possible that this becomes a level five/care trust expectation.

What might a care trust look like?

A care trust is likely to require dual accountability through NHS and through local authority structures. This might be achieved by having both NHS and local authority membership of the care trust board and with the board reporting back to the NHS through the health authority and NHS regional office and back to the relevant local authority (with social services responsibilities).

The NHS board members might be approved by the secretary of state for health, the local authority board members might be elected councillors and be determined by the local authority, and the board might also have practitioner members, as in the current PCG/PCT structures. It may be that these interests should be in numerical balance within the board, but the government is likely to take a view on this. There are already joint boards such as police, fire and probation authorities. School governing bodies are, in effect, joint boards, so there is nothing overly radical or novel here. Joint commissioning boards are already being established in some areas to jointly commission integrated health and social care mental health services provided by specialist NHS trusts.

The introduction of general management would bring together staff from different professions and organisations to work within multi-disciplinary teams. The development of integrated services requires integrated general management as well as integrated boards and organisations.

Investment in multi-professional training and staff development, partly as a means of creating new cultures for the new organisations.