How effective are links between primary care groups and social services? Bob Hudson and Helen Lewis report on a national survey

Great store has been set by the link between primary care and social services, reflected in the direct representation of social services on primary care group boards. But little is yet known about this specific representation or about the wider relationship between PCGs and local government.

The Nuffield Institute for Health carried out a national postal survey of PCG chief executives, social services PCG representatives and social services directors in June and July this year.

1The response rate was high - 168 social services representatives (65 per cent); 206 PCG chief executives (43 per cent); and 90 social services directors (35 per cent).

The survey aimed to identify the nature of social services membership of PCGs, the relationships between PCGs and social services departments and gauge perceptions of the value of social services membership of PCGs.

At the time of our survey, no other research data were available on the nature of the social services role in PCGs. Respondents were asked a mixture of closed and open-ended questions.

Guidance on developing PCGs has not been prescriptive on the background and status of the social services representative.

2 Our findings indicate that many representatives are fairly senior, with more than four out of 10 having director or assistant director status. It might be expected that such people have some remit to speak on behalf of the authority and make decisions without routine referral back.

Although our report tends to focus on the social services officer nominated to the board, it is also important to look at other ways in which both social services officers, other officers of a local authority and elected members of a local authority may secure a presence. PCGs have the power to co-opt others who may be considered appropriate for dealing with specific tasks as 'associate members' of the board, without voting rights. A variant on this arrangement is where established board members share their vote with a colleague from the same organisation or profession.

The examples of co-options given in NHS Executive guidance cover pharmacists, professions allied to medicine, community paediatricians, practice managers or those with financial or public health skills, and does not seem to readily envisage additional or shared representation on the part of social services.

In fact, about 15 per cent of PCGs have additional social services representation, typically through a shared vote and remuneration rather than as a formal co-option, with a further 10 per cent of additional representation coming from local authority officers other than those in social services. This is an interesting indication of the extent to which the role of local government in the health of a locality is recognised as stretching beyond the more traditional intersection with social services.

The government's decision to ask for social services officers nominations for PCG boards was also a decision to exclude elected councillors. Supporting guidance to circular LAC(98)21 points out that councillors do have 'an enhanced opportunity to influence at a strategic level by influencing the development and implementation of health improvement programmes in their community'.

But our survey shows a small but significant elected councillor presence on PCG boards. The two possible routes of entry are appointment as lay members or as health authority non-executive members. Almost one in five PCG boards has a councillor as a member, usually from the social services authority.

The social services role We tried to gain a view of the nature and value of the contribution made by social services representatives.

Respondents were asked whether they considered the role very useful, useful, not particularly useful or not at all useful.

They were also asked about the nature of the role and the time it took up.

Most respondents rated the role very useful (81 per cent of directors of social services, 82 per cent of social services representatives on PCGs, and 73 per cent of PCG chief executives).

Almost three-quarters (74 per cent) of social services representatives spent two to four days a month on PCG business. Two-thirds felt they needed more time and support to perform the role properly.

Directors of social services and board representatives considered the representatives on the board to be of appropriate seniority. But there was less agreement over the number of social services representatives on the board.

Three-quarters of directors, but only half the representatives, considered this 'about right'.

There were also differences of opinion about the amount of time and support needed for PCG work. Some board representatives felt their time commitment was considerably higher than that perceived by social services directors. Almost half (45 per cent) of social services representatives felt they received little or no support, whereas directors put this figure at only 20 per cent.

Accountability and feedback PCGs' lines of accountability through HAs are relatively well defined, but there is less clarity about the roles and delegated authority of social services representatives. The most likely feedback route for the representatives is to colleagues in social services management, with the social services committee a less likely option - indeed, the introduction of Cabinet-style local government means the representatives will have to develop new mechanisms for reporting and account-ability. Given the pre-ponderance of managers sitting on PCG boards, it is understandable that the clearest feedback mechanisms are back into senior management forums of various kinds, with little or no emphasis on involving operational colleagues other than by items in staff bulletins. It is clear that successful partnership needs to be rooted in hard-headed deals that promise mutual gain - what some term 'win-win' situations.

The immediate message arising from this is for PCGs, social services, the wider local authority and other councils to identify areas of inter-dependency and look for 'quick wins' which will enhance credibility inside and outside PCGs.

The most obvious candidates would be problems relating to prevention, hospital admission, hospital discharge, rehabilitation and admission to residential or nursing-home care.

The fact that some PCGs may disappear in the transition to primary care trusts does not invalidate this message - or many of the other parts of our report, as current locality arrangements are likely to remain as the build-ing blocks for any future configuration.

The survey's main findings The results showed:

10 per cent of PCG boards include a director of social services.

About a third included an assistant director.

The remainder of social services representatives were mainly team leaders or third-tier managers.

Two-thirds of social services representatives had a background in adult care and commissioning.

Almost 15 per cent of PCG boards had more than one social services representative.

About 10 per cent of boards included local authority officers from departments other than social services.

Almost 20 per cent of boards had a member who had been elected.

Key points

A national survey of PCG chief executives and social services representatives on PCG boards showed that most consider the social services role 'very useful'.

Most social services representatives spent two to four days a month on PCG business.

Two-thirds felt they needed more time.

Almost half felt they had little or no support.

Better feedback mechanisms are needed for social services representatives.

REFERENCES

1 Hudson B, Lewis H. Social Services and Primary Care Groups: delivering on partnership . Nuffield Institute for Health/ Association of Directors of Social Services, October 1999. Full report available from Julie Prudhoe, community care division, Nuffield Institute for Health,£10.

2 NHS Executive. The New NHS: modern, dependable: establishing primary care groups . Health Service Circular 1998/065.

Bob Hudson is principal research fellow, and Helen Lewis is development consultant in the community care division of the Nuffield Institute for Health, Leeds University.