John Thornberry and colleagues on making joint working and pooled budgets work

Published: 14/10/2004, Volume II4, No. 5927 Page 33

According to the rhetoric, the world and his wife are engaged in 'multi-agency working'. But scratch the surface and many of these claims appear to have little depth.

That is because while there is no doubt that many primary care trusts and councils would like to take advantage of the flexibilities introduced by the Health Act 1999 - including the option of a pooled budget - until now noone has been able to say how it would work in practice.

What if the pooled budget were overspent? Who would pick up the tab? How would you know if the joint working arrangements put in place were legal? What would happen in the event of a conflict or major disagreement?

As a two-tier local authority that has to work with five PCTs, one acute trust and seven district councils, Durham county council had been tossing these questions around for a few months when, in autumn 2003, it decided to find some answers.

PricewaterhouseCoopers (PwC) was brought in to develop a framework that would initially be used in learning disabilities and later rolled out to other services.

The local authority already had a good working relationship with its colleagues in health.

But before any decisions about spending a pooled budget could be made, it had to pin down what joint working would mean in practice.

The three biggest challenges were building trust about how the partnership arrangements would work, improving confidence about how services would be delivered and managing disputes. There were also some issues that needed to be untangled in relation to section 28a of the former Health Act, which had tied the hands of health organisations wanting to transfer funds.

PwC produced a pooled budget protocol that set out how the budget would operate and how the lead commissioning arrangements would work.

Contributions were based on partners' existing financial commitments and formed the basis of a mutual intention to share risk between and across partners.

The pool would not be divided equally between partners or split on a pro-rata basis; rather, funds would be targeted to areas in most need.

The protocol also specified up front what partners expected in terms of performance information, what they would get and how regularly they would get it. The importance of having an open, rigorous and regular flow of performance information between partners cannot be overstated. It is critical to build confidence and trust helps to identify potential problems in time to prevent them derailing budgets and services.

For any agency considering a pooled budget, overspend is one of the biggest concerns. The protocol overcame this by enshrining the principle that all partners should be involved in decision-making from the start through the development of a joint business plan.Monthly reports kept everyone informed.

So if forecasts showed an overspend was looming in six months' time, there would be enough time to decide jointly what should be done.

It also set out the options for dealing with an overspend.

Partners could agree to suspend commissioning services until they were back on track, or transfer cash from other budgets.

These are simple measures, but having them down in black and white gave everyone the reassurance they needed.

With the pooled budget in place and spending decisions made in good time for each agency to feed the information through to their own budgets, the next stage was to make the protocol an operational reality.

A pooled budget manager was appointed and made responsible for implementing the business plan. As long as an expenditure fulfilled the objectives of the business plan, the pooled budget manager was free to spend up to a given threshold without having to get the decision approved.

Above this sum, the decision was made with other staff.

The pooled budget manager was also given devolved authority to resolve disputes. This was again common sense as disputes only escalate if you have to wait for boards to meet to settle them.

Since these arrangements were put in place in September 2003, the spirit of greater co-operation between health and social services in Durham has already led to marked improvements for patients and staff.

'Pooled budgets have enabled us to have nurses working alongside social workers, ' says Durham's county-wide commissioning manager for learning disabilities services Lesley Tickell.

'People with learning disabilities are now visited by a single care co-ordinator, which can be a nurse or a social worker. This has reduced the number of people coming in and out of their home, keeping intrusion to a minimum and helping to provide a seamless service.'

While it is still early days, the pooled budget protocol has already led to better budgetmanagement arrangements and is now being adapted to work at district-council level.

Elsewhere, the PCTs and county council are in the process of applying the protocol framework to mental health services.

Joint funding has become more formalised and open as funds are agreed at the outset and their operation is more transparent. There is less confusion over access to services, reduced conflict between organisations and agencies, and better support for the movement of long-term care and the provision of independent living.

The pooled budget protocol worked because it was impartial, took into account the concerns and views of all parties and spelled out in detail how auditing requirements would be met, risks managed and decisions made.

An ethical and practical arrangement that reassures auditors and regulators the money is being spent wisely while enabling staff to invest more funds in areas that need them most, it has played an invaluable part in helping to turn the partnership rhetoric into a reality in Durham.

John Thornberry is head of service, adult commissioning, Durham county council; Nigel Porter is chief executive officer, Sedgefield PCT; Dean Oliver is manager, government and public sector practice, PwC.