So, the secretary of state didn't really mean it. Social care is ostensibly reprieved from an NHS takeover, even though the Health Act flexibilities are to become compulsory and the threat of care trust status looms for poorly performing social care partners.

The sigh of relief in the social care world is audible. But oddly, everyone assumes that where a local partnership is floundering, it must be social care that is weak.

The debate on partnership- working has created the impression that the only seam in the garment of patient-centred care is that represented by social care. In reality many structural divisions within the NHS create fragmented services for patients and carers.

The recent Audit Commission report on rehabilitation offers a stark example of the ways in which divisions within the NHS, as well as between the NHS and social care, can impact on patient care.

1It notes: 'The need for better joint planning between health and social services has long been recognised. However, what is less well recognised is that many of the difficulties occur because of discontinuities between different parts of the NHS. The barriers between acute and community health services, and between acute and primary care services, can be every bit as high as those between health and social care. '

The commission refers to health and social services being 'locked in a vicious circle'. Rising hospital admissions and falling lengths of stay have reduced the time for recovery and rehabilitation, leading to increasing (and unsustainable) demands on social services, especially for residential and nursing home placements, thereby reducing resources that could have helped to contain rising hospital admissions.

NHS organisational structures may also impede partnership- working when the scale and pace of intra-organisational change is so great that little time and energy can be harnessed for partnership working.

Several aspects of this turbulence can be identified: Primary care groups' internal preoccupations: When they were set up, PCGs were understandably preoccupied with internal development, such as the legacy of fundholding, developing rules and procedures and exploring sub-groups and their relationship to the PCG board. This had to be done with the flimsiest of infrastructures. Evidence suggests that decisionmaking has often become the preserve of a triumvirate of the chief executive, chair and GP representatives. For example, the national tracker survey found that the vast majority of nurse, social services and lay representatives felt they had little or no influence on decision-making.

2 Developing a comprehensive PCG commissioning role: The PCG commissioning remit has tended to be weakest in areas of greatest direct intersection with social care. The Audit Commission survey of PCGs carried out just before April 1999 revealed that responsibility for around three-quarters of the total hospital and community health services budget was to rest with PCGs, but only 11 per cent would have full commissioning responsibility for learning difficulties and 20 per cent for mental health services - both areas which might be expected to be prime candidates for joint locality commissioning with social services.

3The tracker survey reported little change on this position by April 2000. This does not necessarily suggest that primary care is the best place for commissioning social care.

Transitory status: The national tracker survey refers to the 'distraction'for PCGs of the drive for primary care trust status, noting that 'no sooner had they established themselves as PCGs than they were involved in negotiating mergers or preparing bids for trust status'. Two-thirds of PCGs were reported to be considering merging with neighbouring PCGs, but the most common reason for doing so was the desire for independence from the health authority. Indeed, partnership with social services or the local authority was the least-cited reason for becoming a PCT. With all PCGs effectively required to become PCTs by 2004, it is doubtful whether partnership-working will be a priority for some time.

Turbulence elsewhere in the NHS: Although the prime focus tends to be on the emergence of PCTs, this will have destabilising effects throughout the NHS likely to impact on established partnership arrangements.

Existing NHS community trusts are most obviously at risk. Many are metamorphosing into mental health and learning disabilities providers, with their remaining services transferred to PCTs; others face complete disestablishment following the decision to include mental health in the PCT remit rather than in specialist mental health trusts as stated in The New NHS.

Significant grey areas remain which may involve local authorities and the voluntary sector, such as learning difficulties, rehabilitation and palliative care. HAs will become smaller and more strategy-oriented, rendering them incapable of continuing the joint commissioning partnerships often established with local government.

All of this makes it unlikely that the evolving NHS is in any state of preparedness to take on social care responsibilities other than through stable and consensual local negotiation. And even in these circumstances it is not obvious why the care trust route is preferable to using the flexibilities in the 1999 Health Act.


1 Audit Commission. The WayTo Go Home: rehabilitation and remedial services for older people. Stationery Office,2000.

2 Wilkin D et al. The National Tracker Survey of Primary Care Groups and Trusts: progress and challenges 1999/2000. National Primary Care Research and Development Centre/King's Fund,2000.

3 Audit Commission. Primary Care Groups: an early view of PCGs in England. Stationery Office,1999.