England's first joint health and social care trust still has to convince users it works, reports Pat Healy

Mental health service user Phil Cracknell was appointed recently to the joint commissioning board which spends the£28m budget available to health and social services for mental health in Somerset.

But he is not impressed. He points out that he has no vote and says the power continues to reside where it always has - with the paid senior professionals who run the services and who are, in his experience, generally impervious to the views of users.

He describes himself as having 31 years' personal experience of psychiatry during which, through local support organisations, he has fought for better services, including an after-hours crisis service.

'If you have a mental health problem on a Friday evening, the only options were either to self-harm in order to get emergency admission, or wait until a GP was available the following Monday, ' he says. 'For some people, that could be too late.'

A partial after-hours service was introduced last year - after six years of campaigning. So it is not surprising that Mr Cracknell thinks users can influence the provision of services only after sufficient noise has been created to make it politically impossible not to.

His scepticism supports one finding of an evaluation by the centre for mental health services development at King's College, London, into how the new Somerset Partnership trust, which began in April, is succeeding in integrating health and social care.

The researchers, who are due to present their findings at a conference in Taunton next month, found that while many service users and carers were told about the changes, the information was neither clear enough nor regularly updated.

'Communication and involvement should not just exist, but be meaningful to those on the receiving end, ' the evaluation report says.

Trust chief executive Paddy Cooney takes the point seriously. 'I spend a lot of time with users, ' he says.

Each locality has a reference group, and training policies are being developed for service users, who will then train others. Users are engaged in a review of day services to define the range of meaningful daytime activities that should be available to them.

The report will say what the balance should be, and at that point Mr Cooney would expect the joint commissioning board to say who will best provide it. He doesn't think it will be Somerset Partnership because 'user groups and voluntary groups are so much better at it'.

The review is being scrutinised by Simon Heyes, a former service user and editor of Speak Up Somerset , a local newsletter whose title is usually abbreviated to SUS News , with support from Somerset Partnership.

Mr Cooney also says that the joint commissioning board's decision to spend£100,000 on a county-wide advocacy service will counter fears that the new regime means less choice for users, because they can no longer choose between social services or health.

Mr Heyes believes that is a 'pretty real fear' because 'distinct social services and health' have been replaced by joint services.

'Social services are always a good counterbalance with health, ' he says.

'I would worry that working together and drinking cups of tea in the same office mean they will be able to form tighter bonds with each other, rather than with the service user.'

The evaluation report says one of the major challenges for the new trust 'is to demonstrate that integration better enables professional boundaries to be renegotiated in the interests of service users'.

That follows the researchers' finding that there is enthusiasm for closer working between health and social services clinicians and practitioners, but that this is balanced by concerns about integration, in particular in relation to roles, responsibilities and culture.

Mr Cooney attempted to forestall such problems by visiting local teams before 'integration day' to urge mutual tolerance. There were bound to be mistakes, he says, but he is relieved that the groundwork done before he arrived on the scene has paid off.

'All the problems that have arisen are ones we had anticipated, ' he says.

He also welcomes the national service framework for mental health as giving the trust an opportunity to show what integration can achieve.

One of Somerset Partnership trust's prime aims is to develop community based services, which could bring more conflict with users and their carers.

Mr Cooney believes there are 'far too many buildings', some of which could be sold to finance alternative services.

Dene Barnet, a rehabilitation unit, has been targeted. Selling it could release£400,000 to pay for more staff in the community or to refurbish other units. This will be put to public consultation.

Somerset community health council, which has observer status on both the trust board and the joint commissioning board and supports the integrated service, is waiting for details before pronouncing.

CHC chief officer Sue Rhys-Davies says: 'We need to be sure that what is being planned is not going to leave a gap in services. We are not opposed to bed closures provided there is a proper service that will replace them.'

She says integration appears to be working well, citing a CHC visit of a local day hospital where staff and patients appeared to be happy with the new regime.

But feedback from service users suggests mixed views.

Mr Cracknell says that from the users' perspective, the changes have mainly affected management rather than the services themselves.

'Managerial chess games are no concern of theirs, ' he says.

And for all the willingness to engage service users more, neither Mr Cracknell nor Mr Heyes has been invited to the November conference on the evaluation report - which will have two workshops on involving service users and carers.

Enquiries about evaluation report to joint commissioning board manager Ralph Hayward on 01823-355 455.

Findings from the evaluation report

A major issue for staff is the development of clear roles and responsibilities - a collaborative culture.

The joint commissioning board and the trust seem to be struggling with the development of service user involvement.

The emergence of primary care groups will have an impact on joint commissioning and provision in Somerset.

Joint commissioning board membership Chair Jane Lock, deputy leader, Somerset county council.

Vice-chair Jane Barrie, chair, Somerset health authority.

Three more voting members each from the HA and county council.

Four primary care group representatives.

At its last meeting the joint commissioning board agreed to add two service users and two carers.