Happy couples

It took 28 years and the collapse of the Soviet Union for the Berlin Wall between East and West Germany to come down. Here, the government is hoping to bring down the so-called Berlin Wall between health and social services in a much shorter time - and, it hopes, without the political fallout.

But will the latest proposals work in practice? Years of joint finance have done little to break down the barriers between two very different cultures. Add to that the recent attacks on social services' management of child care and an imminent social services white paper and it hardly inspires the confidence of NHS managers.

But there must be no more boundary disputes, Frank Dobson declared, as he flagged up the need for closer working back in July, when he presented The New NHS white paper to Parliament.

'There are two basic alternative attitudes to boundaries,' he said. 'Some people like to cross them. Some people like to patrol them. I want an end to the border patrols. If anybody in the NHS or social services feels that their real job is checking passports, I sugggest they make a career move to the immigration service.'

Before any sceptical NHS managers had a chance to send off for the application forms for a new job, health ministers Alan Milburn and Paul

Boateng fleshed out the plan in Partnership in Action, a green paper published last month with an incredibly tight deadline: the end of this month. If accepted and included in the Queen's speech this November, the new arrangements could become law by 2000.

The overhaul is long overdue. Many people have been getting a rough deal for years - endless hours have been spent arguing over whether someone living at home who needs assistance with bathing is a 'health' or a 'social' bath case. All the person cares about is that they get a hot bath.

Similarly, in mental health services, co-ordination between the two authorities is notoriously poor, as highlighted by one inquiry after another. Day centres seem, by some whim, to have been set up by either the NHS or social services, with no real reason why it should be one rather than the other.

For most people, it is completely confusing. In Somerset, where health and social services budgets for mental health are being pooled from next April, service users were surveyed first. 'The message came back quite clearly that they didn't understand the difference between what health and social services do,' says Chris Davies, director of Somerset social services.

Bed-blocking has brought joint working to the fore. As social services departments struggled on limited budgets to implement the new community care arrangements, hospital managers watched with dismay while hospital beds became filled with elderly patients who no longer needed medical care, but were not well enough to go home and look after themselves.

Around the country, health and social services were forced to talk to each other in a way that in many cases, they had never done before. And it often was not an amicable discussion.

Although the government's plans for joint budgets stole the headlines, the proposals are far more complex than that (see box 1). Some proposals refer to health authorities, but most joint working is likely to take place between social services and the new primary care groups, rather than hospital trusts.

It is a massive agenda, but, most commentators agree, an impressive first step. However, given the history of difficult relationships between the two authorties, could this at last be the answer?

Chris Vellenoweth, former special projects manager at the NHS Confederation is dubious. 'The question is whether the government is going to be really tough on local authorities,' he says. 'I don't think it is sufficient. There is still an ability for the local authority to switch money around within its services. If the priority on the NHS is to put in place services for frail elderly people and within social services it is to manage child abuse, one wonders how the two will fit together.'

The voice of realism? Or cynicism? Either way, some would argue that there really is no disparity between health and social services:

'I don't think there ever was a Berlin Wall,' says Terry Butler, director of Hampshire social services. 'If anything, the issue has been that social services and health have been despeartely trying to collaborate for so long.

'They send a disproportionate amount of time on it. It is a bit like trying to dock an American and Russian spaceship together in space. It only happens because there is lots of good will.'

David Hinchliffe, chair of the Commons select committee on health, which is currently examining joint working, thinks the government could have gone one step further. As a former social worker, he harks back to the days when public health departments were in local authorities.

'I'm sorry to be so boring and elderly,' he says, 'but Frank Dobson knows I favour a much bigger role for local authorities. I would favour a return to the local authority public health department. It would make health action zones and health improvement programmes much easier.'

Meanwhile, he believes having joint budgets will overcome many of the pitfalls of joint working. 'We have seen some excellent examples of joint working in primary care which had been hindered by the difficulties in terms of budgets. I personally feel unless you get one budget, you are going to have continuing difficulties.'

But he admits the cultures of the two organisations are very different - not helped by the introduction of the internal market and cuts in social services spending:

'We've a long way to go to repair the damage done by the market ethos. And if social services had had the security of budgets that has been around in health, they would have had an easier time. You can't plan anything when you can't plan your budgets.'

Against all these odds, though, there are pockets of joint working. But it hasn't been easy. In Somerset, where health and social services are pooling mental health budgets in one purchaser and provider trust, the two commissioning budgets have to be kept in separate budget heads and the new trust has to report back to the health and social services authorities.

'You need enormous local persistance and commitment to get through this,' says social services director Chris Davies. 'Most people would just say 'Oh God, no''

Andrew Webster, project manager for the joint Social Services Inspectorate and Audit Commission review of social services departments, will vouch for that. His team has been examining joint working with health. Joint working must be at strategic and commissioning levels, not just operational, he argues.

'If you only work closely at an operational level, then staff have to take lots of risks.

'There has been a culture that if only something technical would be put right, all our problems could be solved. But removing those problems isn't the whole story. You have to change the culture of the way you work; to take time to understand other people's culture.

'As an example, when we first started our visits and asked how many people in hospital beds who could be somewhere else, they couldn't tell us immediately. Now they are usually able to do so.'

Gerald Wistow, director of the Nuffield Institute at Leeds University and an expert on joint working, feels happier that joint funds will be an improvement on joint finance. 'Joint finance has been at the margins and it was too often about pump-priming social services activity.

'The most important element in this package is probably that there are going to be some joint performance indicators, that the SSI and regional offices are going to work more closely together and that there is going to be monitoring and support.

'Health and social services are certainly going to need support in bringing this agenda forward.'