The strategic joint working envisaged in the The New NHS white paper requires a partnership approach at the front line, argues Bob Hudson

The Labour government's concept of partnership distinguishes it from the Conservatives' approach. All The New NHS white paper recommendations and many of the green paper recommendations on public health hinge on joint working, as do health action zones.

But the emphasis tends to be on strategic working between agencies, sometimes with many organisational alliances, which may not much affect relationships between professionals. However, if the relationships of professionals and other staff who have to deliver integrated care are not clear and constructive, broad inter-agency strategies may fail.

What are the prospects of a partnership approach at the front line?

The idea of teamworking as the best way to deliver products and services has become favoured in many manufacturing, service, private and public sector organisations.

1There seems to be a general view that primary healthcare is best delivered by a team of professionals working in the community, and that social care should be part of this arrangement.

The view was put forward as long ago as 1920 in the Dawson report on medical and allied services. It has not been easy to achieve, and to move ahead we need to appreciate why past progress has been so patchy and limited.

Usherwood and colleagues suggest the key problem with inter-professional relationships is that: 'On the one hand the team contains workers with a range of potentially conflicting professional allegiances, values and contractual responsibilities. On the other hand, these workers are responsible for the care of substantially overlapping groups of patients and for working together in providing that care.'

2There are several possible barriers to effective joint working (see box 1).

Members (or potential members) of an extended primary care team usually have different patterns of employment and accountability, which can hinder joint working. In particular, GPs tend not to work under hierarchical management, and may consider themselves the natural leaders of any extended team. Although the primary care trusts and some Primary Care Act pilot schemes have the potential to overcome this barrier, it won't happen quickly.

There are important differences between the commissioning roles of local authorities and NHS commissioners. For social services commissioners, the formal assessment of individuals is increasingly seen as a part of the care management process. In the NHS, individual assessment lies almost entirely with the providers, and is seen as a process of clinical diagnosis. Where assessment is linked to purchasing in the NHS it tends to involve priority- setting for populations and client groups at health authority level. The shift towards more decentralised purchasing at primary care group level will still leave a difference in approach between health- care and social care commissioning.

Time and work put into improving joint working takes up effort and resources that could go elsewhere. And perceptions of cost and benefit differ. Social services departments may feel that GPs benefit more than themselves from having social care staff in practices.

3There is a similar problem with the way scarce resources are used across a locality. Even where social services are willing to align to a degree with general practice, typically there will be too few social workers to go round.

Across welfare systems, medical care is recognised as being justly free at the point of use. Social care isn't seen in the same way, and as eligibility criteria become more often used for rationing services, staff have got used to prioritisation and charging. This lies uneasily with the view NHS colleagues have of themselves as advocates of universal patient welfare.

The question of cultural barriers concerns ideas professions may hold about how people should be supported and how services should be configured. Such understanding can bolster a sense of professional identity and worth, yet hinder co-operative working across professional boundaries. Much of this comes out of formal and separate training and education, and the rest through less formal processes of professional life. It may not benefit patients. The recent Health Advisory Service report on elderly people, for example, reported that social services care managers were too often unaware of the medical illness that can lie behind functional failure, while primary healthcare team (PHCT) members were slow to accept that some disability in older people may be improved by multi-disciplinary packages of therapy.

4It is useful to look at different models of joint working, from lower to higher levels of collaboration (see box 2).

In its least structured form, communication simply involves giving information with little or no personal contact.

More structured communication can lead to formal agreements between practices and social services - an arrangement which has become known as PASS (practice agreements with social services). It usually means adapting a general framework to a practice's needs, and although it involves formalities and signatories the documents do not have legal or financial status.

Co-ordination covers many forms of shared assessment and joint provision. Official reports often say shared assessment is desirable, but it has not been easy to achieve. Noting this, the Audit Commission has recently praised the development in Australia of geriatric assessment teams. Assessment by such teams is mandatory before someone can be admitted to a nursing home, and this is reported to have reduced the use of such beds.

5Joint provision is often specific, such as joint provision of aids and equipment stores, and funded by employing or commissioning agencies.

Co-location normally means having social services staff in GP practices - an option long favoured by GPs. The joint working is seen as beneficial, as is having a more co-ordinated approach to meeting individual needs and providing a single access point to a range of health and social care services.

Evaluations of such arrangements are usually favourable.

Less thought has been given to other forms of co-location, such as attaching a community nurse to a social services team or co-locating a wide range of professionals in community hospitals.

Commissioning is a more complete form of collaboration.

It may include not only the three elements already discussed, but also some explicit form of aligned or joint commissioning. In the case of joint working, this may take place at the level of the practice or the level of the individual.

6With practice-based commissioning, the PHCT and social services department will jointly commission services for a practice population - something which might have been expected to develop with social services care managers working alongside GP fundholders, but rarely did.

The position with commissioning for individuals is similar. Many people who need support from a variety of sources for a long time could remain in the community if more complex packages of care could be put together and readily managed. But the absence of a commissioning role for community health services professionals has been a hindrance. A challenge for primary care trusts will be to align with social services by delegating budgets to community nurses working in self-managed teams.

Teamworking across the primary healthcare/social care boundary is typically inadequate. What is needed is a strategy of planning for joint working where health and social care needs meet.

For example, with elderly people, this would mean going beyond discharge planning to take in admission to hospital, residential or nursing home care, discharge from hospital, and planning the movement between them. It means recognising that secondary healthcare, primary healthcare and social care are bound together.

Box 2. Models of inter-professional collaboration

Communication: interactions are confined to the exchange of information.

Co-ordination: individuals remain in separate organisations and locations but develop formal ways of working across boundaries.

Co-location: members of different professions are physically located alongside each other.

Commissioning: professionals with a commissioning remit develop a shared approach to the activity.

Box 1. Barriers to effective inter-professional relationships

Different patterns of employment and accountability.

Differences in where decision-making lies.

Different perceptions of cost and benefit.

Different models of resource distribution.

Different professional cultures.

Key Points

Joint working between organisations and professions is a key part of many of this government's initiatives, including health action zones.

To work effectively together, professionals must overcome the problems of different cultures and different patterns of accountability.

Teamworking across the boundaries of health and social care is generally inadequate.

REFERENCES

1 West M, Poulton B. A Failure of Function: teamwork in primary health care. J Interprofessional Care 1997; 11(2): 205-12.

2 Usherwood T, Long S, Josebury H. The Changing Composition of Primary Health Care Teams. In Pearson P, Spencer J (eds), Promoting Teamwork in Primary Care: a research-based approach . London: Arnold, 1997.

3 Hudson B, Hardy B, Henwood M, Wistow G. Inter-Agency Collaboration: primary healthcare sub-study . Final report. Leeds University, Nuffield Institute for Health, 1997.

4 Health Advisory Service. Services for People Who Are Elderly: addressing the balance . Stationery Office, 1997.

5 Audit Commission. The Coming of Age: improving care services for older people . 1997.

6 Rummery K, Glendinning C. Working Together: primary care involvement in commissioning social care services. Manchester; national primary care research and development centre, 1997.

Bob Hudson is senior research fellow, community care division, Nuffield Institute for Health, Leeds University.