A new bill will oblige councils and primary care trusts to work together. In a joint feature with Local Government Chronicle, Kaye McIntosh asks how it will work in practice
'The government has always been clear it wants us to work together but sometimes other things get in the way,' says Graeme Betts, strategic director of adult health and community services at Warwickshire county council.
Mr Betts is talking about co-operation between councils and primary care trusts - something that should get a big boost from the Local Government and Public Involvement in Health Bill, currently going through Parliament.
The bill imposes a duty on both to work together to produce joint strategic needs assessments. 'The new guidance will help focus everyone's minds,' says Mr Betts.
Warwickshire is ahead of the game in developing strong relationships with its primary care trust. But Mr Betts is not alone in his enthusiasm. Senior managers and policy analysts agree the new bill gives councils a real chance to turn aspirations into reality.
The move is part of efforts by the government to achieve a strategic reorientation towards promoting health and well-being, investing now to reduce the future costs of ill health.
But at a time when many councils accuse PCTs of shifting costs from health to social care, will the new duty to do joint assessments of the local population be enough to make this 'reorientation' happen on the ground? The Commissioning framework for health and well being, published this month, underpins the new duty.
A Department of Health spokesperson explained that the document provides 'a stronger focus' on commissioning, with comprehensive guidance for PCTs and councils covering everything from primary and community healthcare to social care, public health and well-being for the whole population..
Find the gap
Andrew Cozens, strategic adviser for children, adults and health services at the Improvement and Development Agency for local government (IDeA), welcomes the new joint assessments.
He envisages that they will identify overlaps between and gaps in services provided by the NHS and social care. They will also focus attention more broadly across all council services: not just health and social care but housing, transport and leisure too, he says.
'It [the joint assessment] is an essential precursor to proper commissioning as it has regards to the needs of the population based on the data that is available.'
But how well collaboration works on the ground 'will depend on the quality of the data and the relationship between local public sector partners - the willingness to share information', he adds. Councils and PCTs will have to move towards joint asset management, taking decisions together about the future of community hospitals, for instance.
Although joint needs assessments should help make the debate about shifting costs from healthcare to social care - when PCTs withdraw services, for instance - more open, 'what it won't do is resolve some of the more local issues about what we do when there isn't enough money to go around in the system', Mr Cozens says.
IdeA national adviser for healthy communities Liam Hughes says there is cost shifting in both directions. While some councils accuse PCTs of cutting services and leaving social care to pick up the clients, some PCTs say their staff are having to take on work as a result of tighter eligibility criteria for social care. District nurses having to help people who are no longer assessed as top priority for social care, for instance.
What the new guidance will do is to promote 'mature disagreement', getting both sides to talk about these issues, Mr Hughes says.
It could also play a major role in supporting the Department of Health's pledge to move 5 per cent of NHS activity out of hospitals into community services and long-term interventions to improve the health of the population. NHS resources have always been drawn towards the powerful, high-profile acute sector. PCTs have struggled to redress the balance - shutting down hospital services never wins the hearts and minds of local people, even if they are replaced by alternatives in the community.
Mr Hughes says the new duty, taken together with the councils' role in scrutinising the NHS, means 'local authorities are probably going to have to get interested in how efficient their secondary care hospitals are'.
The current debate about cost shifting is an argument about 'pennies', he says: 'The big money is in getting hospitals to do what they should be doing and not what they shouldn't.'
In London alone, some estimates suggest£150m worth of services could be moved out of the acute sector. But getting councils and PCTs together to do this will be challenging. Anne Williams, vice-president of the Association of Directors of Social Services, says 'the instability in the NHS hasn't helped'. It is hard for councils to maintain relationships while PCTs have been going through wholesale restructuring.
Also, when health secretary Patricia Hewitt has put her own job on the line if the NHS does not break even, managers are not going to have much attention to spare for anything other than the bottom line.
But the new guidance could help to change that. 'It gives more incentives to the health and well-being agenda that councils have a huge part to play in.'
True partnership will depend on commitment at all levels, she adds: 'It does take more work to do things in an integrated way than to do it yourself. We have got to be motivated by the vision.'
Councils that have taken a lead in joint working provide a glimpse of what the future might look like. Graeme Betts says that in his area, joint working is already in place.
Although he is employed by Warwickshire county council, he is responsible for working with the PCT, NHS Warwickshire, to develop joint commissioning in health improvement and jointly manages the director of public health.
'I was very keen to make sure we had a joint understanding of our population's needs. We have got a needs analysis now for key client groups and hard-to-reach groups. That is informing our joint commissioning strategy.'.
Now there is a joint commissioning board and joint commissioning posts across health and social services. NHS and council-funded services include telecare to help elderly people remain in their own homes, such as an alarm service that shows if someone has fallen. Another programme offers healthy eating advice to people with learning disabilities, delivered by dieticians but with support from trading standards.
'The main determinants of ill health are socially determined? there isn't a single council area of responsibility that doesn't impact on health in some way,' Mr Betts argues.
But Ms Williams says joint commissioning will only work in the long term if councils and PCTs face the same performance assessment regime. 'There still aren't enough joint outcome targets, and the pressure in the NHS around the 18-week waiting list and some other [targets] focus them on that above everything else.'
And some local government insiders fear the struggle to balance the books of the NHS could yet stymie joint working. The strategic health authorities that performance-manage PCTs have, in many areas, cut budgets at some trusts in order to rescue others that are in deficit. So it is essential that SHAs themselves have to sign up to the new needs assessments and commissioning arrangements. Otherwise the new policy could end up creating a lot of work for little gain.
Joint working case study: 'Working for two organisations means double the procedures'
Chris King is head of strategic planning and commissioning at Dumfries and Galloway county council, a joint appointment with the NHS. She manages seven people who work across both sectors.
'Joint post-holders can put the needs of the client first, then the needs of the organisation after that,' she says. But it isn't straightforward. 'Working for two organisations means double the procedures you have to work through, and there are different organisational cultures in the NHS and council.'
The posts suit people who take a flexible approach and can respect both local democracy and the decision-making structures of the NHS, who can 'see the good
in each system and see the bad and want to change it'.
In her area, the key issue was to develop trust among both NHS board members and elected council members in a shared agenda.
The backing of the Scottish Executive for joint working at strategic policy level has been vital, together with a joint performance assessment framework.
Now in Dumfries and Galloway there are joint local health improvement targets across all community care groups. Care packages for older people can be put in place fast, with a service providing six weeks' intensive support for people coming out of hospital or those at risk of admission. There are joint health and social care teams for learning disabilities and mental health.
Ms King says: 'I would recommend joint working. I think it has benefits for those who use our services and both organisations who support them. You get better services and
the public pound is better spent.'