Will the government be able to avoid a politically disastrous 'crisis' this winter - the last before the election? Alison Moore reports that it is putting its hopes on joint initiatives at local level by health and social services

Patients on trolleys and cancelled operations have become as much a part of the NHS's winter as Father Christmas visiting the children's ward.

But the determination of ministers and managers to avert the seasonal sideshow looks stronger than ever, in what is bound to be the last winter before a general election.

In his final week as NHS acting chief executive, Neil McKay warned managers that he was 'concerned that the proposed expansion in intermediate care is not yet in place'.

He ordered them to increase spending on social services and buy capacity from the private sector. The concordat with the independent sector fleshes out that suggestion - but NHS services without a history of collaboration with their private colleagues may find that the 52 days left until Christmas leave them little time to plan capacity changes.

In the past month a survey by the Association of Directors of Social Services found that English social services were facing an average 2.1 per cent mid-year overspend - an average of£1.45m.

Two weeks ago, representatives of nursing and care homes warned health minister John Hutton that unless they receive the equivalent of an extra£50 per patient per week, the NHS would face blocked beds and trolley waits.

Last winter was the first time health and social services planned their response together, with variable results. This winter even more is expected to be done at a local level.

The seriousness with which the government is approaching the problem is clear: more than£60m is available for pooled budgets to facilitate step-down care, there is a long list of national criteria for winter planners to meet, and intensive monitoring of each area's efforts.

Part of the reason for this is the perception that the NHS 'failed' last year, even though some joint working was in place.

The official report on how the NHS coped over the millennium, published in May, argues that staff did not generally share the view of a system in crisis. But it does highlight numerous areas in which improvements could be made.

Some - such as more critical care beds - will take years to achieve.

But many could be tackled this winter, including areas in which better planning with social services could 'free up'NHS beds.

One problem last winter was admissions from nursing and residential homes where only nursing care was needed. This care could be provided through community nursing teams with input from GPs - rather than by hospital admissions.

Some trusts are now hoping to use private beds for patients needing rehabilitation - and to send NHS therapists into nursing homes to provide the appropriate therapy. Spare capacity in social services' residential homes is also being targeted.

But some inappropriate admissions to acute care can be avoided if there is adequate support for people to remain in their own homes. Rapid - or emergency - response teams have been set up round the country to provide packages of home-based care as an alternative to hospital admission. This has been adopted on a year-round basis by Rotherham (see panel, top).

Other initiatives tried across the country have included placing social workers in accident and emergency departments so that they can be involved in planning care from the beginning. In Blackpool this has been so successful that it is now being done throughout the year, and the borough council is evaluating whether social workers with different skills - such as dealing with mental health issues - should be used at certain times of the day and week. Funding for much of the scheme has come through cash transferred from the health authority.

The North Mersey emergency services action team set up a control centre staffed by managers from both health and social services. Once a potential problem was spotted, the team could call in extra help for the affected hospital - such as a GP to divert some inappropriate admissions or social workers to sort out bedblocking.

'In effect, we were actively managing the emergency admissions to hospital across the area, ' says David Woods, chief executive of Aintree Hospitals trust, who headed the team.

So will this winter be any better?

Many health authorities and local authorities will have greater experience of working together. In some areas the team-working and structures used to cope with winter pressures have already been called into play to handle September's fuel crisis.

There is also a greater realisation that joint working goes beyond the basics of sorting out bed blocking. It can range from multiprofessional teams designed to prevent hospital admissions in the first place, to packages of intermediate care provided in private nursing homes but with input from NHS and social services staff.

It can draw in other local authority departments - housing, for example, or even the registrars' office or crematoria to avoid a repeat of last year's distressing delays before bodies could be disposed of.

Money may not be as tight as it has been in the past for the NHS - but the impact of financial problems in many social services departments may be more problematic. And ever-evolving structures in the NHS will mean the arrival of new players in the shape of primary care trusts.

Keith Murray, director of social services at Leeds city council, says: 'The process has been so very different this year. We have had to increase consultation to take on PCTs and at the same time we are trying to get on with the modernisation agenda.'

Hospitals have already endured a year when demand for acute beds has increased significantly. If there is a 'winter crisis', hospitals may be starting from a higher bed occupancy rate - and may face problems earlier. And some of the key factors likely to put pressure on services are hard to plot: a bad outbreak of flu could still stretch services.

Both the Christmas and new year holidays are long, with weekends followed by bank holidays, which may limit patients' access to normal primary care and pharmacy services.

GPs are already unhappy with some of the ideas touted by the Department of Health about extended opening and emergency services over the holiday period, yet their co-operation may be crucial to keep people out of hospital.

With politicians' minds already turning to the election, few health or social care managers would relish being the first to be caught failing to deliver.

A jab in the dark

The government's decision to introduce flu vaccination for all people over 65 and target health and social care workers may ease winter pressures. But the level of uptake will be critical.

Newcastle and North Tyneside health authority is one of the few areas already to pay GP incentive payments for vaccinating specific groups. Last year it targeted people over 70, but uptake was only 47.5 per cent.

Even if targets are met, it is still uncertain how much effect it will have on hospital admissions. Many elderly admissions are likely to be those with chronic health problems - such as lung disease and diabetes - who have been targeted for flu jabs for several years.