The white paper emphasises collaboration and puts forward a range of proposals. But is there a
much commitment to implementing partnership as there is to performance, asks Bob Hudson
The general response to the proposals in The New NHS has rightly been positive.1 A lot of this goodwill probably stems from the different ethos it embodies, rather than from details of how the NHS will actually work. Arguably, a white paper is the publication in which to paint a broad picture of how different the future will be. But equally, any response to it must highlight the tedious matter of delivering effective change. This is particularly so for inter-agency working.
The white paper promises a 'new start' - 'a third way' of running the NHS based upon 'partnership and performance'. But the proposals for the partnership bit of the equation - especially for partnerships outside the NHS - look less well-developed than those for performance.
The third of the six principles said to underpin the white paper is 'to get the NHS to work in partnership'. This involves strengthening partnerships within the NHS, but it also recognises the importance of inter-agency partnerships. The white paper is clear that 'by breaking down organisational barriers and forging stronger links with local authorities, the needs of the patient will be put at the centre of the care process' (paragraph 2.4). It is an emphasis which occurs elsewhere. Paragraph 4.13, for example, accepts that the current quality of co-operation between the NHS and social services authorities is too variable, and asserts that: 'health authorities will work more closely with local social services and other partners on planning care for patients'.
One way to do this would be to give local government some measure of commissioning responsibility for healthcare - a move which might also help to secure what the white paper describes as 'a simple maxim': 'the NHS as a public service for local communities should be both responsive and accountable'. But, notwithstanding any deliberations by the health select committee, the government seems to have turned against any such local reconfiguration of responsibilities. Indeed, even any merging of smaller community trusts with each other or with acute trusts has been ruled out of court. Where does this leave the desire for better inter- agency working? Five partnership approaches are contained in the white paper. These may be classified as programme, professional, administrative, governance, and performance partnership.
The main proposal for programme partnership is the health improvement programme, the means to deliver national targets in each HA area. Although the HA will have lead responsibility for drawing up a local programme, this is explicitly portrayed as a vehicle for inter-agency collaboration. Paragraph 2.11, for example, states that: 'in the new NHS, all those charged with planning and providing health and social care services for patients will work to a jointly agreed HIP', but it is not clear how far this will restrict the autonomy of non-NHS partners. The same paragraph notes only that the HIP will govern the actions of all parts of 'the local NHS'. The emphasis therefore seems to be on 'health and healthcare' rather than on health and social care. There is, for example, no reference to community care plans and how these might relate to HIPs.
Nevertheless, the new statutory duty of partnership requiring local NHS bodies 'to work together for the common good' will affect local authorities in two ways. First, the duty will extend to them, strengthening the current requirements under the 1977 NHS Act - a measure which has been widely seen as discretionary or unenforceable.
Second, a duty will be placed on local authorities to promote their areas' economic, social and environmental well-being, with powers to develop partnerships with a range of other organisations, including the NHS. With luck this may create a legislative climate in which agencies realise they need contributions from one another to fulfil their responsibilities.
The white paper identifies the problem of inter-professional, as well as inter-organisational, fragmentation. Paragraph 6.10, for example, notes: 'In an NHS based on partnership, it will be increasingly important for the staff of NHS trusts to work efficiently and effectively in teams, within and across organisational boundaries.' The white paper refers to the establishment of 'programmes of care' - partnerships between secondary and primary care clinicians, and with social services, which will allow planning and resource management. No detail is given on the nature of these programmes and of implementation, but experience suggests that inter- professionalism cannot be easily achieved.
The importance of an administrative partnership is acknowledged by the renewed recognition given to coterminosity between primary care groups and social services departments. PCGs will be expected to work closely with social services in planning and delivering services. They should 'develop around natural communities, but also take account of the benefits of coterminosity with social services' - a reconciliation which might be difficult. The suggestion that PCGs will typically serve populations of around 100,000 will mean that for smaller local authorities - particularly the new unitaries - there will be 'whole organisation coterminosity'. Larger local authorities, however, can be expected to have up to 10 PCGs within or on the borders of their area, and building relationships which are coterminous and based upon natural communities will be a complex task.
The task will be further complicated where PCGs evolve into primary care trusts, for there will be those who see the inclusion of adult social care responsibilities within such trusts as a logical way forward. The white paper says regional chairs will take the lead in ensuring NHS and local authority partnerships are developed. This could be an important way of addressing potential difficulties, but will require the chairs to have sensitive political antennae.
The new national performance framework is said to enable all management to look at what is being achieved by the NHS for the local population, and to examine the contribution of individual institutions. The regional tier is again given an important cross-agency role. The white paper notes that regional offices will drive the new approach to benchmarking, but will do so in conjunction with the regional social services inspectorate. Paragraph 7.21 states that, together, they will 'jointly lead and monitor local action to strengthen partnerships across health and social care'. This is an important measure, which harks back to the implementation of the community care elements of the 1990 NHS and Community Care Act. At that time, good co-operation between the Social Services Inspectorate and the former regional HAs led to an effective system of monitoring and implementation that will be equally needed in the new NHS.
Although the white paper offers no scope for local democratic accountability in the NHS, it does seek to make NHS bodies more representative of local communities, and this involves re-establishing a local government presence in NHS governance. Some aspects of this have preceded the white paper and include local authority representation on HAs, but there are proposals to take this a little further. Provision will be made for the local authority chief executive - rather than the director of social services - to participate in meetings of the HA, while PCGs will, more vaguely, have a governing body 'which includes social services'.
As well as the proposals contained in the white paper, other current or emerging measures can be expected to signal closer relationships between the NHS and other agencies. The white paper itself notes that: 'The government will consider further with the NHS and local government how partnership arrangements can be further strengthened, drawing upon the experience of health action zones' (paragraph 4.21). The HAZ experience can also be expected to figure prominently in the imminent green paper, Our Healthier Nation, while more generally the government intends to produce a 'Berlin wall' white paper specifically to address the problematic health-social care interface.
The government deserves at least one cheer for putting the emphasis on collaboration rather than competition, and a further cheer for putting a range of proposals - albeit at this stage a little vague - on the table. The third cheer must await evidence that there is as much commitment to the implementation and monitoring of 'partnership' as there is to 'performance'. Given the disappointing track record of both inter-organisational and inter-professional collaboration, it seems reasonable to conclude that partnership has no qualities of spontaneous growth or self-perpetuation, and that accordingly a broad and cohesive implementation strategy is required.
Part of such a strategy will involve central government structuring a collaborative environment in which joint working is a higher policy priority. The white paper recognises this to be the case for integration within the NHS, but it is less convincing in the case of inter-agency relationships. Too often there is equivocation about whether or how new duties and structures relate to social care, or indeed whether collaborative activities are discretionary or mandatory. No specific incentives or sanctions seem to be proposed to encourage joint working, and the new national performance framework does not explicitly mention inter-agency relationships.
Important lessons for the centre about structuring local collaborative environments can be learned from several recent experiences, such as implementing the community care reforms in 1993, developing arrangements for hospital discharge in 1992, requiring local agreements on continuing healthcare in 1996, and allocating 'winter pressures' money in 1997. On the last, for example, a recent survey by the Association of Directors of Social Services reports HAs' 'considerable degree of co-operation' with almost all social services departments.2 Effective joint working is not easy to secure, but for the partnership aspirations of the white paper, one message is clear: localities are far more likely to take inter-agency collaboration seriously where it is clear that central government also takes it seriously.