Back in 1997, when thrusting young health secretary Alan Milburn was only a thrusting young health minister, he rejected the idea that the NHS should run social services.
'Instinctively I feel uncomfortable about that, ' he told HSJ. 'If the debate is posited in that way, far from barriers coming down, barriers will go up.' The challenge was to 'get greater co-operation without the takeover mentality'.
Less than a year ago, the government restated its position - this time in its response to the Commons health select committee's report on longterm care. 'We do not intend to integrate health and social services, ' ministers declared, pointing out that they had said as much in response to the committee's first report in 1998-99.
The government suggested that to overload the NHS with further change at th is time 'would be counter-productive'. It added that the Royal Commission on Long-Term Care had also wished to 'avoid the upheaval and disruption of a wholesale change'.
Strange, then, that Mr Milburn should do a turn-around in his speech to the New Labour-friendly New Health Network last week.
'We need to examine the advantages an integrated health and social care organisation might bring for patients, ' he said. 'In just the same way as primary care trusts at level 4 are. . . combining primary and community health services within a single organisation.'
He added: 'I therefore expect the national plan to take a hard look at how we make the best use of the new powers contained in the 1999 Health Act, which for the first time allows integrated provision, pooled budgets and lead commissioning arrangements spanning both health and social care.
'The national plan is likely to contain proposals to encourage and develop the use of these powers by PCTs, creating, if you like, a new level of PCT which would provide the whole range of health and social care for older people.'
Mr Milburn sent local government and social services representatives into a fury. 'Organisational change makes it more difficult to deliver services, ' says Local Government Association head of social affairs, health and housing John Ransford. 'If integrating health and social services through primary care teams means organisational change, that will blight the delivery of partnership arrangements and services for years.'
It is the suggestion of crossing the fine line between joint working and partnership arrangements - which the LGA supports - and a structural move - 'taking social care away from local government' and giving it to the NHS - that has caused the problem. Different funding mechanisms, with charges for social care, and different accountability measures, would make a merger 'very complex'.
The timing didn't help. The fact that Mr Milburn had seemingly endorsed NHS Confederation proposals - for a 'level 5' PCT commissioning social care and a 'level 6' providing it - the day before at a meeting of the modernisation action team on partnership provoked further ire and a dash of cynicism.
'If he's already decided what's going to be in the plan, what's the point of having consultations?' asks Mr Ransford.
Michael Hake, chair of the Association of Directors of Social Services' organisation and development committee, points out that the national public consultation exercise had ended only the day before Mr Milburn's remarks. 'It seems the government can move quickly to analyse the response, ' he says. It is unfortunate the issue has arisen at this stage, he feels.' It doesn't do a lot for confidence.'
Primary care organisations seemed less surprised. 'I don't think anyone ever thought PCT level 4 was the final level, ' says Dr Peter Smith, chair of the National Association of Primary Care and a board member of Kingston primary care group. 'Social care was always going to feature there at some point.' He points to a model in Northern Ireland's integrated health and social services boards and trusts (see box, overleaf ). He says closer integration should be an Continued from page 13 evolutionary process.
NHS Alliance chief executive Michael Sobanja says the idea has been floating about for a while. 'Since the white paper, people have been talking about level 5 and beyond, integrating social care.'
He sees a need to 'beware structural answers where actually what we want to do is integrate professional working'.
Most PCGs and PCTs have enough on their plates 'without taking on the employment, let alone the commissioning responsibilities, of social work'.
The debate had cooled by the time the partnership action team met. The meeting was 'not looking at massive organisational structural change', says team member Dianne Jeffrey, chair of North Derbyshire Community Healthcare Services trust and NHS Confederation Trent regional lead.
It was 'still definitely going down the partnership route'. The team members had been 'exploring the meaning of integration right through to its conclusion', agreeing the Health Act was just a starter.
ADSS president Jo Williams says: 'A conclusion of the debate - whether it'll be the conclusion, we'll see - was we should work towards integrating services at the frontline.' It was a case of 'working on the boundaries' between health and social care and 'pulling together the best of both cultures, rather than diverting huge energy into major structural change'.
David Panter, chief executive of Hillingdon health authority and another action team member, says the meeting was 'very consensual'.
Few people are exploiting the flexibilities of the Health Act to the maximum, says Mr Panter, who himself sits on the management team of Hillingdon social services depart Home truths: a district nurse (top) and a hairdresser (below) visit elderly clients.
Will they soon be working for the same joint employer?
Employment, in a reciprocal arrangement with the director.
A Department of Health spokesman confirms that it has had only 22 notifications of joint schemes under the pooled budget arrangements in the Act, but is aware of many others in the offing.
So which way will Mr Milburn step over the fine line between partnership and organisational shake-up?
'The partnership provisions in the Health Act require health and local authorities (not just social services) to work together and make it easier for them to do so, ' said the government in July 1999. This would bring about closer co-operation 'without the need for extensive and expensive restructuring'. But that was then.
Tried but not tested: the Northern Ireland experience
Northern Ireland's integrated health and social services boards and trusts are often held up as a model. But ADSS Northern Ireland branch secretary Roy Blair says: 'When you're part of the system, perhaps the grass is greener. . .'
He feels the more integrated approach has good examples of joint commissioning. But the downside is when organisations are under financial pressure social services come in for a 'difficult time'. Health services under pressure demand more cash. 'You can be raided, 'he says. Social services will 'always lose out to the politics of the health agenda'.
He also points out that 'no-one has evaluated integrated health and social services.
Everyone assumes it's better'.