opinion: OVER THE WALL

The NHS is under the cosh of structural reform yet again. This tends to be a time when developing external relationships takes a back seat. Not so now. Indeed, the new NHS's main potential partner is not simply social services but local government as a whole.

Yet the pace and scale of reform is immense here too, and may not be widely understood in the NHS. A prerequisite to effective joint working is understanding respective roles and responsibilities, but this is no longer straightforward in local government.

It all seemed simple in the old days. Local authorities delivered services as required by national legislation, in a structure focusing on committees and departments with specific service responsibilities. Authorities were assumed to be self-sufficient in discharging these responsibilities, while services were uniformly provided and directly controlled. Accountability was upwards to officers and councillors rather than outwards to service users, whose role was to exercise periodic judgement at the ballot box.

This world has long since changed and looks set to change even more, with important implications for the NHS. Local government's role as direct service provider has continued to diminish over the past decade, gradually moving away in turn from manual work, leisure and housing management, then from a wide range of professional services - a dismantling of in- house activity which the NHS has been spared. The Blair government has brought no relief - quite the opposite, with new requirements on best value and, for social services, financial penalties for directly providing residential care.

But while it may have been good enough under the Conservatives for a local authority to get arm's-length agencies, especially the private sector, to provide what had traditionally been directly provided, there is now an additional requirement: to engage with the agenda of local governance.

This is taken to mean a vision of local authorities beyond mere service organisation and delivery, embracing a concern with the locality's well- being - a remit which by implication involves a whole complex of organisations, not least those in the NHS. The proposals in the white paper, Modern Local Government: in touch with the people, to provide councils with clear discretionary powers to engage in partnership with any other local bodies, and to impose a statutory duty to promote an area's economic, social and environmental well-being, are part of this new focus.

The traditional system simply cannot meet these demands, so talk of a 'Berlin wall' between the NHS and social services is the language of a disappearing era. In a recent poll, almost half the 1,000 social services professionals asked thought social services departments would disappear in less than five years, and a further 30 per cent gave them less than 10 years. But if localised departmentalism is yesterday's system, what will tomorrow's look like? Two imperatives will dominate - corporatism and regionalism.

Any system of government has to be divided into parts, but an effective system has to recognise the need for integration as well as differentiation. A range of strategic and planning activities - community care plans, children's services plans, early years plans, joint investment plans, health improvement programmes - now require a multi-agency response, and some see the need for corresponding structures, such as the inclusion of social services in primary care trust arrangements.

Many councils are combining various functions in new super-directorates which cut across traditional boundaries - for example, children's services with education or social services with housing and environmental issues. These arrangements will be catalysed by the government's push for either a directly elected mayor or sleek cabinets of leading councillors instead of the unwieldy committee system. At a stroke, social services departments will become part of the new-look corporate approach to council services, with priority setting across departments. After a mere 30 years, the Seebohm settlement is dead.

As councils adapt or not to the new agenda, a final shift is waiting in the wings - towards regional governance. The trend began in 1994 when the Conservatives established the government offices for the regions, drawing together environment, transport, education, employment and industry functions under a single senior civil servant.

In England this has been followed by the recent creation of regional development agencies, with budgets of more than£1bn, and by regional chambers - two bodies with an uneasy relationship. The former are mainly business-led, while the latter are largely staffed by councillors. While the RDA has to take account of the chamber's views, it does not necessarily have to act on them.

The real issue with regional chambers is the extent to which they are a stepping stone to devolution, particularly the more powerful Scottish model.

If existing local authorities are to work effectively in this milieu, they will need to speak with a single voice, if only to avoid the new regional institutions threatening to take over roles and responsibilities better left to more local bodies.

One lesson from joint working between health and social services is that budgets need to be aligned or pooled before partnership is taken seriously. This remains the Achilles' heel of the new local governance, for while recent moves have locked councils, the NHS, housing agencies, the police and the private and voluntary sectors into locally based initiatives, flexible funding is still elusive. Meanwhile, NHS agencies are being urged to take their partners for the collaboration waltz. But which partners? And which waltz?

Bob Hudson is a senior research fellow at Leeds University's Nuffield Institute for Health.