Joint working: health and local government

Primary care trusts often boast of achieving joint working between health and social care or health and local authorities. But poor relationships, organisational culture and poorly joined structures can make such claims seem hollow.

Now Herefordshire is aiming to be the first place in England to do away with structural barriers completely, by establishing a public service trust - a partnership of the local council and primary care trust, under a single chief executive. And there are hopes that a more efficient use of resources and a desire to work across traditional boundaries will keep the focus on the needs of the area's population.

'There's a very strong sense of place in Herefordshire, which I find quite powerful,' says Chris Bull, who has been appointed chief executive of the fledgling organisation.

As it is the first time such a post has existed, Mr Bull knows people across the country will be watching, but is determined to proceed at a pace 'which is right for Herefordshire'.

Currently deputy chief executive of the London borough of Southwark, Mr Bull is set to take up the new post by the end of the year. He says he will spend the first few weeks getting to know the people and the place and getting Herefordshire's issues clear in his mind before moving on to looking at where performance needs to improve and at efficiency.

Mr Bull is no stranger to this type of joint arrangement. Previously he was joint chief executive of Southwark PCT and strategic director of social services at Southwark council and is accustomed to reporting to two masters, the council's elected members and the PCT board.

'I need to work with and respect the governance structures of both organisations,' he says.

Construction work

Earlier plans to create a public service trust in Herefordshire had been shelved because of the lack of a legal framework to create such a body. As it is, the trust will use existing mechanisms and operate under a 'section 75' pooled budget arrangement.

'There are governance and finance issues which just rule it [a legally unified trust] out and I think actually hamper the proper work,' says Herefordshire county council leader Roger Phillips. But he is determined not to get caught in a trap of waxing lyrical about structures when there is real work to be done.

'The term public service trust sounds very sexy, but if you are not careful you spend all your time talking through the construction of it and not getting on with the day job.'

The arrangement is perhaps not as revolutionary as it may first appear.

For the moment then the two organisations will focus on achieving a greater degree of integrated working and getting the section 75 arrangement working smoothly.

'We can address these other issues further down the line when maybe the government is a little more co-operative,' adds Mr Phillips.

Now is a good time for a joint appointment, he says, with a bad settlement for local government in the comprehensive spending review coupled with the sizeable pressures of an ageing population and public health issues.

'What we recognise is that it's only by working more closely together that we can actually deal with some of those challenges,' he says.

But he adds: 'I think the key issue is that we must make sure that national government does not play us off against each other. They send mixed messages with the degree of funding that is allocated. They fund the NHS yet they don't fund social care, where some of the biggest pressures are. You have this terrible settlement in the comprehensive spending review and yet a lot of the non-statutory work that we do is in the preventive health agenda.'

A number of details remain sketchy. But Mr Phillips says so far the county's pioneering structure has not attracted much interest from central government. 'They have not taken a great deal of interest in us at all. We haven't had any pump-priming money, so have had to struggle with it on our own.'

Herefordshire PCT's budget is£233m and the council's is£230m, but after education is removed, the combined partnership budget will be around£300m.

'Risk sharing arrangements are yet to be determined,' says PCT chair Joanna Newton.

And although Mr Bull will be chief executive of both organisations and therefore responsible for all the combined services, not everything will be integrated. The PCT's provider services, for example, will still report directly to the PCT board.

'The aim is to bring together commissioning functions across the council and PCT, so that we plan what we do together and we decide how services are going to be delivered,' says Mr Bull. 'There are areas where it will make sense to integrate and areas where it won't make sense to integrate.'

Because there will not be a new legal entity, staff will continue to be employed by either the council or the PCT. There will be some joint posts, including the director of public health and director of integrated commissioning, with others still to be determined.

'One of the first tasks of the new chief executive will be to look at his management structure,' says Ms Newton.

Mr Bull says that it would be wrong to think of the move in terms of 'being about significant changes in terms of staffing'. He says rather the focus should be around structuring services in ways that create the greatest benefit for local people.

Likewise the PCT will retain its board and the council will retain its cabinet and each will keep responsibility for its statutory roles. This is a 'comfort blanket', says Ms Newton, since it will provide the assurance that the PCT can justify to the strategic health authority how it is spending its money.

The strengths of the partnership will be in combining the non-executives, who are appointed on a competency-based framework, with the democratic representation councillors provide.

Ms Newton says: 'What we're very much about is recognising the strengths of both cultures.'

She acknowledges that people talk about a democratic deficit in health. But while councils' health scrutiny committees and local area agreements are both powerful tools for giving local government more say in what health does, she says Herefordshire is taking it 'a slight step further'. In future, members will potentially be involved at a more strategic level, rather than simply having a scrutiny role.

Mr Bull believes the council's health scrutiny function will become more effective, 'in the sense that its level of influence might be enhanced through the new arrangements'.

He adds: 'Councillors will gain greater influence over health services and things for which they are not directly accountable.' But he stresses that councillors and non-executives will still be accountable to the council and PCT as they are now.'

Cultural differences

'The two statutory bodies remain two statutory bodies [and] remain the accountable bodies. What we are doing through this process is that the council and PCT are agreeing to work together in partnership and to plan and commission together. By doing so, both the PCT and the council gain influence over decisions which would normally have been taken just by the other organisation.'

The advantages are around joining things up and being able to take decisions which cut across traditional agency boundaries, such as improving public health.

'If you talk about those things together and decide those things together, then you can do those things in a much more joined-up way.'

But what about the different cultures of health and local government, which often lead to squabbles over local services provision and funding?

'The issue is in trying to break down the barriers and cultures of these two organisations so that they do start to work more collaboratively for the benefit of the user and the taxpayer,' says Mr Phillips.

Mr Bull prefers to concentrate on the similarities, rather than the differences. While he acknowledges the differences in history and culture between the two sectors, he says 'there are also powerful things which bind public services together.

'They are both public services with people working within them that have a strong commitment to public service.'

In cases where cultures do differ, Mr Bull's strategy will be to have 'straightforward discussions about how that team is going to work together and how professional cultures can be respected in the new structure'.

Ms Newton says Herefordshire is the ideal place to try the new arrangement. The area is unique in that the PCT has been coterminous with the council since 2000, when the PCT was created. The council was also one of the first of the new wave of unitary authorities, which means there are fewer political layers.

'People are well aware now that the agenda is trying to bring places together in terms of local government and health,' she says, adding that in some places this process has been 'incredibly difficult' because of the political or organisational culture. 'One of our arguments last year when we had the reconfiguration process was to justify why that was of value to Herefordshire and why we should remain coterminous,' she says.

Local answers

The county has examples of where it has been able to work together in the past. Herefordshire was one of the first parts of the country where the PCT opened a unit in a community hospital where the PCT and the council were able to commission beds for both health and social care. The county population is small and dispersed, creating challenges for both the council and PCT. Because they face the same issues and both operate in rural areas, it is often efficient to join up and work together. For example, whereas an urban area might require six district nurses, Herefordshire would need eight.

Mr Phillips says: 'I think there was a recognition that in a county which is as small as ours but which is geographically and resource challenged, we need to make the best use of the public pound where we can.'

Mr Bull says that when he saw the job advertised it looked 'really exciting'.

'It's the prospect of bringing public services together and achieving a vision for public services across the county. I thought that was a brilliant opportunity'.

He stresses that while he does bring a lot of experience to the role, he also brings 'the humility' to know that local solutions are needed.

'It's very important to remember that the solutions that we build in Herefordshire will be the solutions which suit Herefordshire and not necessarily things which have been done before somewhere else.

'I come into this job with a very strong commitment to making it work, with a commitment to listening to and working with local people. And a commitment to ensuring that both organisations, both separately and together, deliver high performance for local people.'

He adds that there is clearly a commitment in Herefordshire to the new arrangements because otherwise the council and PCT would not have agreed to advertise the post of a joint chief executive, or to proceed with their roadmap towards joint-working arrangements (see box).

'Obviously there will be people who have doubts and it would be odd if there weren't,' he says. 'Part of my job is to understand those doubts and to work with them.'

Does he envisage the PCT and council completely merging in years to come?

'We have to demonstrate the benefits of the level of integration that we're talking about,' he says. 'And I think until we've demonstrated those benefits then the argument for a new legal structure is not the point.'

Once the trust has shown that the new arrangements can produce greater efficiency and better outcomes for local people, 'there may well be some discussion about changes to legal structures'.

'This isn't a race,' he insists. 'We're not motivated by being first, we're motivated by doing what's right for Herefordshire. And it is clearly right for Herefordshire that we commission and plan together and that we integrate services on the ground where that makes sense. And that's what we'll do.'

Fine sentiments. But the trust may have to be prepared to make tough decisions if others are to be persuaded such changes can produce real differences to their local people.

Herefordshire public services trust: how will it work?

Arrangements for the public services trust have been ironed out by a steering group consisting of the chair and chief executive of the PCT; the leader, deputy leader and chief executive of the council; the chair of the PCT's professional executive committee; a PCT non-executive director; and a representative from the Government Office for the West Midlands.

PCT chair Joanna Newton says its role was to identify how to make the plans feasible. Its work was fed by eight working groups: change management, human resources, finance, communication, service users, planning and commissioning, public health and environmental services.

The idea was to look at things in 'big blocks in terms of answering certain questions' for the board and cabinet.

A public consultation in June and July resulted in 57 per cent of responses in favour of the new arrangement. In September the council and PCT approved a 'roadmap', and working framework to integrate the planning and purchasing of the county's public services.

It was agreed a single chief executive would be appointed and an interim joint board set up by January, with governance arrangements formalised by September 2008. Ms Newton says the board will have both non-executive and member representation.

'Having a single chief executive is a defining moment for our vision. This is about delivering better outcomes for our users, to try to provide them with a seamless service that makes sense to them.

'We see the value of having a single person leading at the top to develop not just a new organisational arrangement but a new culture, taking the best practice from the local government arena and health.'