Better or worse?

And the prime minister had examined the Northern Ireland experience of integration.

The absence of such proposals in the published version of the plan was a source of comment and, in some local authority circles, relief. Perhaps in consequence, there has been relatively little consideration of what the plan does propose for social care. Also, relatively little attention appears to have been given to its fit with the regeneration and social inclusion agendas.

The plan does not propose levels 5 and 6 PCTs covering social care but it expects all primary care groups to become trusts by 2004 and adds that 'they also provide a suitable means for the commissioning of social care services, using the Health Act flexibilities, for older people and those with mental health problems'(para 7.8).

In addition, it suggests establishing 'a new level of PCT' to provide 'even closer integration of health and social services'(para 7.9).These 'care trusts' would require changes in PCT governance arrangements, not least because they would deliver social services 'under delegated authority from local councils'(para 7.10).This provision has attracted little comment in the NHS but appears to imply that, for the purposes of social care, the trusts would be jointly managed bodies, accountable to councils as well as the secretary of state. Responsibilities for social care would not be transferred to PCTs but exercised by care trusts on behalf of local authorities.

This provision may explain why local government and social services have been less vocal than when the confederation's proposals emerged.

Nonetheless, a number of major issues remain to be clarified. Do PCTs operating under the Health Act flexibilities provide a route to health and social care integration additional to the care trust model? If so, might local authorities still exercise lead commissioning responsibilities for older people and those with mental health problems under the terms of that act?

The conception of social services as mechanisms for unblocking beds, increasing throughputs and reducing waits for admission is another issue.

While such contributions are essential, they beg questions about how far a system centred on rapid throughput meets the needs of older people for time and support to make appropriate decisions about their futures.

1Such considerations lead directly to the issue about the balance between the priority given to health services improvement on the one hand and health improvement on the other. The relative attention devoted to each appears uneven.

The first phase of New Labour policy-making included a white paper to abolish the internal market and ensure that health services were 'modern and dependable'; and green and white papers elaborating the new emphasis on the structural causes of ill health and inequalities in health.

This new agenda for public health was consistent with the evidence about health improvement and the tenets of New Labour's modernisation philosophy. Health services, however modern and however dependable, are only one of many determinants of health at individual and collective levels. The 1979 royal commission concluded that 'on the basis of past experience, a substantial improvement in national and community health is more likely to be achieved by preventive measures'.

2A more recent estimate is that 'less than 10 per cent of the overall determinants are to be found within the sphere of NHS activities. The remaining 90 per cent are dependent on decisions made elsewhere in the economy'.

3The wider modernisation agenda supported this understanding of public health. It advocated 'joined-up'government to tackle 'the causes of poverty and social exclusion, not just the symptoms'. While previous funding had 'focused on short-term piecemeal solutions. . . to immediate problems, very little (was spent) on preventing problems occurring in the 4Accordingly, the incoming government had commissioned an independent review of health inequalities from Sir Donald Acheson and, in Saving Lives, accepted his conclusions that both 'the poorer you are the more likely you are to die younger' and that 'inequality has generally worsened. . . especially the 1980s and early 1990s'.The white paper highlighted a number of causal factors: 'Poverty, low wages and occupational stress, unemployment, poor housing, environmental pollution, poor education, limited access to transport and shops, crime and disorder and a lack of recreational facilities.'

It proposed 'working across government to attack the breeding ground of poor health - poverty and social exclusion - and (to create) strong local partnerships with local authorities, health authorities and other agencies to tackle the root causes of ill-health in places where people live'.

5By contrast, the NHS plan is less detailed and, therefore, potentially more ambiguous in its coverage of health improvement.

The plan includes commitments to 'work with other agencies to tackle the underlying causes of ill health' and 'help tackle health inequalities' (para 1.5 and 1.6).But its analysis of 'underlying problems' gives little apparent weight to socio-economic causes of ill health.

Nonetheless, the plan recognises that the 'NHS has done too little to prevent ill-health in the first place (and that) the health gap. . . has widened. . .'(para 2.25).

At the same time, specific developments are identified, including a taskforce on inequalities and public health (one of 10 listed) and a healthy communities collaborative.

Other, more modest, proposals include screening programmes, smoking cessation services and free fruit for infant children. Finally, chapter 14 on clinical priorities includes sections on prevention for cancer and coronary heart disease but, disappointingly, none for mental health. On social, economic and environmental determinants the chapter is silent.

The commitment to community planning is also muted: 'The NHS will help develop LSPs (local strategic partnership) with which, in the medium term, health action zones and other action zones could be integrated to strengthen the links between health, education, employment and other causes of social exclusion'(para 13.24, emphasis added).

Similarly, the Department for the Environment, Transport and the Regions draft guidance on community strategies is somewhat ambiguous. Health is not one of the services specifically identified and the document refers to the community strategy existing 'together with other key strategic plans, such as health improvement programmes'. Thus, HImPs appear to remain outside the umbrella of community planning.

The lack of confidence in local government is well known. Yet local government scrutiny committees are to be given powers to review NHS plans and proposals for major service reconfigurations. In addition, by 2002, there are to be integrated, public heath groups across NHS regional offices and government offices of the regions. Their purpose is to enable regional regeneration to embrace health as well as environment, transport and inward investment. Thus the public health function is to work with local authorities.

These various aspects of the plan suggest a continuing commitment to reducing ill-health and inequalities but less certainty, detail and conviction about how it is to be accomplished across sectors at either national or local level.One explanation for these failings is the more immediate imperative to achieve rapid and visible improvements to the level, accessibility and quality of health services and the environments in which they are delivered.

Another may be scepticism about allowing local authorities, which are yet to be fully modernised, too great an influence on the modernisation of health services.Yet, if local authority scrutiny of plans is to be anything but tokenistic, it would provide them with strong leverage.

The risk remains that, in comparison with Saving Lives, eradicating the underlying causes of ill-health and inequality is securing less prominence.

The downgrading of the public health ministerial post and of HAZs are also consistent with this interpretation. Electorally, rapid improvements in health services are essential. Yet, in the longer term, the NHS will continue to face the unsupportable burdens of unnecessary hospitalisation not because of social services' perceived failure to 'unblock' beds but because of weaknesses in the integrated attack on the causes of ill health and inequalities, promised by Saving Lives.

REFERENCES

1 Godfrey M.Developing a framework for conceptualising and evaluating outcomes of preventive services for older people. Nuffield Institute for Health, forthcoming.

2 Report of the Royal commission on the National Health Service, cmnd7615. HMSO,1979, para 5.3.

3 School of Public Policy.Future Prospects for Public Health: local authority and healthy authority collaboration. Occasional Paper 14, University of Birmingham,1998, pg41.

4 Secretary of State for Social Security. Opportunity for All, Cm4445.The Stationery Office,1999, pg3.

5 Secretary of State for Health, Saving Lives, Cm43. The Stationery Office,1999, para 4.40.

6 Wistow G.The Modernised Personal Social Services: NHS Handmaidens or partners in citizenship? ADSS and Nuffield Institute for Health,2000.