The boundaries between health and social care are shifting and PCT cuts are leaving local authorities with funding gaps. In a joint feature with HSJ sister title Local Government Chronicle, Nick Golding looks at the pressures they face

As every agony aunt knows, financial difficulties put relationships under pressure. So it is scarcely surprising that at a time when primary care trusts find themselves saddled with deficit, simmering tension with their council partners has occasionally spilled over into public rows.

While in some areas adversity has strengthened the bond, a survey of directors of social services published last month by the Local Government Association and the NHS Confederation revealed the extent of the pressures partnerships have been under and what the different parties involved have done to cope.

One-third of the respondents in the 55 authorities in areas that have experienced PCT budget deficits reported the loss of NHS beds, with community hospital closures, reduced district nursing and increases in waiting times also widespread.

The knock-on effects for social services departments have been huge. As many as 36 per cent said local PCT funding had been withdrawn from joint services and 20 per cent said the NHS was refusing to pay more than an additional 1 per cent to compensate for inflation in the cost of its existing contracts.

Transfer of responsibility

Perhaps the greatest impact was an increased burden on council-led services. Forty per cent of directors said they were being asked to fund cases that had previously been considered an NHS responsibility.

Social workers are unhappy with their intensified workload, as British Association of Social Workers chair Ray Jones explains: 'Where you have people with quite profound impairment, including conditions previously cared for by nurses, where they require tube feeding, they say that's no longer an NHS responsibility. Now it's social care's responsibility.'

Social care budgets are limited too - extra money spent covering what used to be the job of the health service means new restrictions have to be placed on who receives other services. An Association of Directors of Social Services survey in March revealed that more than three-quarters of councils are tightening eligibility criteria. With tighter restrictions, often only those with the most profound needs receive significant support.

'We need a clearer definition of what constitutes a health responsibility; that needs to be properly debated,' says Mr Jones. 'Social carers are finding their work skewed. They have to review the services that people are receiving as a means of trying to restrain the increasing local authority overspend.

'That's not what they came into social care for. We want to improve services, not reduce them.'

Agreements undermined

Other social care professionals say NHS cuts to community nursing and transport have forced councils to fill the void. Meanwhile, local area agreements have been undermined as PCTs pull out of section 28 and section 31 commitments to fund services jointly.

Many say community hospitals are being closed or reduced in size - despite ministers' stress on the importance of these facilities. With NHS cuts costing councils dear, some directors have even called for a specific grant to be given to councils to compensate for health cuts.

The case of Wiltshire county council, where Mr Jones previously served as director of social services, illustrates the impact. The council said a withdrawal of PCT funding left a£4m gap, forcing it to tighten social service spending and transfer resources from other areas.

But before councils start thinking they are the only ones hard done by, they might want to bear in mind the results of an NHS Confederation straw poll from May this year.

While 14 per cent of PCTs admitted pulling out of arrangements with their local council, the same percentage said their council had withdrawn from a joint scheme. Nearly one in five said their local council had raised the eligibility criteria for services, resulting in more people requiring health treatment.

Social services' finances are in a similarly parlous state to those of PCTs, with the ADSS reporting a national budget shortfall of£1.77bn. Directors of social care complain they are being forced to make cuts - and these will undoubtedly impact on the NHS. Councils are regularly being fined for their tardiness in supplying care to those leaving hospitals, which has led to beds being blocked and unnecessarily long hospital stays.

Marriage of inconvenience

Neither health nor social care has been entirely saintly in its relationship to the other. But when both sectors are under such enormous pressure, it is often hard for one side to avoid letting down the other.

NHS Confederation deputy policy director Jo Webber says: 'People need to work together to find solutions. They need to approach this as a joint health and social care community.

'We must not get into tit-for-tat arguments - it should be about people working together in partnership. We get nowhere by saying &Quot;in these areas it is this particular group of people who are pulling out from supporting a service&Quot;.'

One area which has witnessed occasionally fraught relationships is Hampshire, where Blackwater Valley and Hart and North Hampshire PCTs have respective deficits of£8.25m and£4.37m. In addition, Hampshire county council will feel the effects of an additional£47m savings planned across the county's PCTs for this year.

The irony is that both the council and the seven PCTs in the county can agree on a way forward. A number of preventative projects have been piloted to identify groups such as elderly diabetes sufferers who are at the greatest risk of ill health and offer them additional support in their own homes, reducing the risk of expensive hospital stays.

No cash for good ideas

However, when finances are stretched it can sometimes be difficult to fund innovatory schemes, as Hampshire county council director of social services Rea Mattock explains. 'What concerns me is when we don't plan together. When we face these deficits we really need to work together to ensure the whole system works well and patients and clients don't get compromised. We haven't done that well in Hampshire.'

She says greater planning is required to improve co-ordination between health and social care to ensure that hospital patients are discharged at the right time and have the most appropriate support when they arrive home or move to a care home.

With the NHS emphasising the importance of shorter hospital stays, the council finds itself dealing with people with complex conditions who would have previously been treated on the ward, in many cases requiring 24-hour support. This has increased the average annual cost of the council's care packages from£9,000 to£13,000.

Although there is a consensus that it is better to support people at home than in hospitals, which are more costly and often lead to a sense of dependency among patients, the council believes the county's PCTs are not picking up their fair share of the tab. 'We haven't yet worked well enough to ensure a shift of resources to that area,' says Ms Mattock. 'At the moment we can't do enough preventative work to stop people getting ill in the first place.'

Prevention would help

Mid Hampshire PCT chief executive Chris Evennett agrees there needs to be a greater emphasis on prevention, even if he has a more upbeat assessment of relations between PCT and council. 'I don't think the relationships we have with the council are dysfunctional. But it has been difficult to build permanent relationships with all the changes in PCT boundaries,' he says.

He denies the suggestion that the reduction in hospitals' average length of stays means costs have unfairly shifted from the health sector to councils. 'When we put people out into the community the NHS still picks up the cost of their nursing care but not their accommodation,' adds Mr Evennett. 'We don't try to put people out into the community simply to cut costs in the NHS.'

However, Hampshire's period of uncertainty is coming to an end. In October the county's PCTs will be merged into one with the same boundaries as the council. It is hoped the new PCT will be better able to take the more strategic decisions required to ensure that users benefit from more
co-ordinated services.

'If you have seven directors of older people?s services within the council's area and you're trying to get agreement, it can be very difficult. But if you've a one-on-one relationship that will make an agreement on the direction of travel much easier to reach,' says Mr Evennett.

A chance to get on better

With PCT boundaries across the country being redrawn this autumn - making them the same as councils' in many areas - hopes are high nationwide that the scope to improve relations between council and PCTs is enormous.

The situation in Hampshire shows the difficulties with implementing the Our Health, Our Care, Our Saywhite paper, which called for ever closer links between the NHS and social care.

Even in areas where relationships remain good, the two sides find it difficult to forge a way ahead. In Hertfordshire, where massive PCT deficits have contributed to a shortfall of£100m across Bedfordshire and Hertfordshire strategic health authority, director of adult social care Sarah Pickup has much sympathy for her health colleagues, even though she anticipates a loss of community hospital beds having an immense impact on social care.

'I can see the situation my health colleagues are in,' says Ms Pickup. 'They've been told to break even and have to do whatever they can. This is irritating. You could invest a smaller amount of
money in community facilities and get a good deal, but because of the speed with which this is
happening they can't do that. You don't get the transfer of finance to social care to provide the community support necessary to make up for cuts elsewhere.'

Demographic pressures

Even before its PCT's difficulties, Hertfordshire county council's costs were increasing as a result of rising numbers of people with severe disabilities surviving into adulthood and a growth in its elderly population.

With Britain's population - and its voters - ageing, the pressure is on ministers to make social care a funding priority at last. Sir Derek Wanless's report for the King's Fund this year called for a huge increase in social care funding.

And more progress was made when the Department of Health set out the principles by which health and social care should work together when it launched a consultation on its continuing care framework in June.

But although such forward thinking might make things a little clearer, it does not entirely remove the potential for conflict.

'In theory the continuing care framework should be very helpful - to some extent it should make more of an even playing field but there will always be grey areas and battlegrounds,' says King's Fund senior fellow in social care Penny Banks. 'Although they don't resolve all the issues, the Wanless proposals offer a way ahead. They make the state and personal responsibilities more upfront.'

Looking ahead

Some areas are taking more immediate measures to minimise the scope for future strife. In Brighton and Hove, for example, children's trusts are being piloted. The result is local government children's services departments and local NHS child health specialists operating with a single joint management.

And in Knowsley, social care and health specialists are working together in a single executive team, taking a holistic view of service development and reducing management costs.

'Both the council and the PCT faced enormous inequities in terms of health, so we realised the only thing to do was to work together,' says Knowsley metropolitan borough council and PCT director of health and social care Jan Coulter.

'There's nowhere to hide on our executive leadership team. The books are open so we have to take a collaborative approach to solving problems. We are both investing in the same priorities. It gives us a holistic view of our care.

'We were lucky when we set this up. We had a lot of visionary people around on both sides.'

As both NHS deficits and social care?s under-funding continue to bite across the country, many more visionaries will be required to avoid future disagreements.

With local government and the NHS united by the knowledge that only closer working can bring about the seamless working practices required to improve support for the most vulnerable, both parties know what they have to do.

However, when cash is short, real vision is require to avoid the spats that embarrass local government and PCTs and, more importantly, result in the poorly planned fluctuations in services which hit service users so hard.