The controversy raging around care trusts highlights the divide between health and social care. A proposal intended to put the seal on joint working has provided colourful examples of mutual suspicion.
As recently as April, Local Government Association leaders were railing against the government for planning to hand social services to NHS-dominated 'unelected quangos'. On the NHS side, there have been mutterings that care trusts are an organisation too far, at best involving unnecessary structural upheaval for fledgling primary care trusts.
Since then, the controversy has cooled. Health ministers have conceded that local authorities will be able to select members to serve on care trust boards. The proposal that the secretary of state should have the power to force local health and social care bodies to form a care trust was also dropped from the Health and Social Care Act in the dying days of the last parliament.
Yet concerns remain. David Behan, junior vicepresident of the Association of Directors of Social Services, says that many of the powers needed to deliver integrated services are already available, thanks to the 1999 Health Act flexibilities. They include pooled budgets and lead commissioning arrangements spanning both health and social care.
Against this background, care trusts are only one option for delivering integration, not a universal solution. 'Where people are satisfactorily delivering the agenda on integration they may not feel care trusts will add anything, ' he says. 'The issue is not about how we develop organisations, it is about how we develop delivery of services. There may be a variety of models of service structure to support that. '
The NHS Confederation also appears reluctant to embrace care trusts as the next big thing, despite being at least partly responsible for planting the idea in ministers'minds. 'We did suggest as part of our input to the NHS plan that there needed to be clearer integration, particularly around older people, and that this might lead to single organisations, ' says policy manager Janice Miles.
The zeal with which ministers nurtured the idea appears to have come as a surprise. The confederation was quite relieved when the compulsory element was dropped from the bill.
NHS Alliance chief executive Michael Sobanja worries that care trusts will add 'another layer of complication to a change agenda that is already pretty crowded'. The belief that health services can run social services (which, he says, is what care trusts are really about, despite all the talk of partnership) is 'naive'. Mr Sobanja dares to suggest boundaries are not necessarily a bad thing: tear down too many walls and health services may get flattened.
Ms Miles is concerned that care trusts should be created only when they are wanted - and needed.
'We really have to look to see what it is about a care trust that will make a difference to services and users locally. There is so much we can do using 1999 Health Act flexibilities that there has to be a clear difference. '
Enthusiasm for care trusts is most pronounced in areas with well-developed integrated services - where, it could be argued, there is less need for structural change. Wiltshire health authority has agreed to form three care trusts by April 2003 from three PCTs. (A fourth, a mental health trust, will continue in its current form. It is the newly formed Avon and Wiltshire Partnership NHS Trust Project, the result of a merger between three NHS trusts and two social services departments. ) Why do so much, so soon? Preliminary discussions are occurring around the country, but most areas see little reason to embark on such a course, especially while the government is still working on detailed guidelines. In Wiltshire, however, the national debate has been muffled by local consensus. 'The reason we are doing this is because it is in the blood of Wiltshire to be working together and in an integrated way. We do not see it as a merger, we see it as a natural progression, ' says Wiltshire HA chief executive Jeremy Hallett. The initial focus of the care trusts will be on adult social services - older people and people with physical disabilities - but Mr Hallett hopes this will be extended to accommodate a wide range of responsibilities, including housing. This sends a chill down the spine of many health managers.
Wiltshire county council assistant director of social services Jeanette Longhurst insists the benefits outweigh the effort involved. PCTs will not have to be dismantled and rebuilt as care trusts, she says.
They are new organisations, shaping themselves from the start to fit the care trust model.
Many of the social services department's operational teams are already based in GP practices, so the move to care trusts should run smoothly for frontline staff as well as managers. Service users will no longer fall into the gaps that inevitably exist when two organisations share responsibility for care.
Ms Longhurst says single multidisciplinary assessments, and improved discharge arrangements to domiciliary or residential care, will make a big difference to users. Vulnerable people will benefit from having a single organisation to turn to for help.
Another pioneering part of the country, Bexley, is convinced one is better than two. Much can be done under the 1999 Health Act flexibilities to achieve integration, but Bexley PCT chief executive Alwyn Williams says that 'to have staff in one organisation rather than two will probably be a better end point'.
Bexley, like Wiltshire, has a tradition of successful joint working, but wants to take it further. Bexley PCT (coterminous with the borough) is, in effect, a shadow care trust. The PCT has avoided creating some management posts to allow room for managers from social services to move across when the care trust goes live in April 2003.
There is no fear that governance arrangements will prove a sticking point. The PCT board already includes the local authority chief executive and two councillors among its non-executive directors.
Ms Williams believes there is no need to wait for guidance on governance or thrash out structural issues before embarking on the care trust route. She says the debate must be about more than structures.
'We are putting our energies into defining what the added value will be in care trusts. We will then look at how we need to configure ourselves best [to achieve improvement for service users]. '
Not every area can claim to be a model of consensus. In North Somerset, where a care trust is planned for next April, housing and social services are coterminous with a potential primary care trust, and care staff in adult services are already primary-care based. But while the building blocks are in place, some staff would rather not link up.
Housing and social services assistant director of social care Graham Pearson admits some GPs are worried about 'a social services takeover' and social services staff worried about a 'health takeover'.
But North Somerset has a large elderly population, putting pressure on hospital beds, and a united care trust is viewed as the best chance of getting the most from limited resources. 'We see this as a logical step, ' says Mr Pearson.
Care trusts - a new level of primary care trust
In the NHS plan, the government proposes to establish 'a new level of primary care trust'to build on joint working arrangements and provide 'even closer integration of health and social services'. The new bodies are to be known as care trusts to reflect a broader role.
Legislation to enable their creation was included in the Health and Social Care Bill, which became an act before the general election.
Negotiations with relevant organisations are still under way, particularly on controversial areas such as governance arrangements.
Detailed guidelines are expected by late summer or autumn. Local councils will remain ultimately accountable for services delegated to care trusts, and will have significant influence on their supervision and management.
Charging arrangements for local authority services that are delegated to the care trust will remain unchanged.
The government's Emerging Framework on care trusts can be read or downloaded from www. doh. gov. uk/caretrusts/index. htm