What is it?
The Health Act 1999 came into force in April 2000. It includes the latest attempt to pull down the "Berlin Wall" that divides health services funded and provided by the NHS from social services run by local councils.
What is the point of the Act?
The distinction between health and social care is often unclear to service users, who complain of being pushed from pillar to post in sorting out different parts of their care package. There is confusion over who does what. If a client is given a bath is it a "health" bath or a "social" bath? (If a health care assistant is giving it, then it is probably a health bath; a social care assistant, then it is a social bath. But as far as the bathed client is concerned, it is still a bath, although they may have to pay a means-related fee for a social bath while a bath provided by the NHS is free.) These types of artificial boundaries can lead to a lack of continuity of care and funding disparities. Another classic problem arises where NHS beds are "blocked" by people who no longer need hospital care but whose social care packages have yet to be organised because of social service funding problems.
What exactly does the legislation change?
Joint working is not new. But new "flexibilities" have been introduced to remove perceived obstacles. These include allowing health bodies and local authorities to:
• set up pooled budgets;
• delegate functions, by nominating a lead commissioner or integrating provision; and
• transfer funds between bodies.
Which services are involved?
There are very few restrictions. But the focus has so far been on older people, people with learning difficulties (or learning disabilities), children or mental health.
What will it change?
Services should become far more co-ordinated and designed around users. There will also be cost savings. For instance, keeping an elderly person in hospital can cost more money than the more appropriate package of social care needed to allow the patient to be discharged. With pooled budgets, funds will no longer be tagged as belonging to health or social services, and managers will be able to take more sensible, holistic decisions. One partnership in the pipeline could see health funds used to support the development of cycle paths to meet accident and heart disease prevention objectives.
How are things going?
By October 2000, only 26 projects had been registered with the Department of Health's joint health and social care unit. The word is that the partnerships are proving difficult to get off the ground.
What are the problems?
According to the health department, there are no outstanding legal obstacles to joint working arrangements, but there are still reports of council lawyers turning down proposals. Suspicions remain between health and social care organisations. Health service non-executives and local councillors are concerned about losing control over major parts of their budgets and, in particular, about audit and governance arrangements.
How are these problems being dealt with?
The health department accepts that joining major strategic services was never going to be easy but it is adamant the concerns are a by-product of risk-averse solicitors' vivid imaginations and conservative attitudes to change. It points to the Manchester mental health partnership, the country's largest example of joint provision with a budget of £50m, as proof the issues can be worked through. According to Carole Bell, a member of the department's joint unit: "No further major statutory changes are needed to make joint working a reality." On the governance side, the solution seems to be meticulous attention to detail up front. In North Yorkshire, the health authority and county council have produced an accountability framework document that could be applied to most projects. It lays out procedures that will apply to auditing and accounting and tackles the partners' major concerns, such as how underspending and overspending will be dealt with.
Are health and social care budgetary timetables compatible?
No. Councils must finish drawing up their budgets by the end of March, while health authorities and trusts have no such duty to complete their service agreements by a set date. But the health department says the budgets should not be seen as ringfenced and, as long as mechanisms are agreed for dealing with pressures during a single financial year, there should be no problems.
Aren't there problems with "coterminosity"?
Actually, it is the lack of shared geographical boundaries (coterminosity) that is the problem. Local authority and health authority boundaries are frequently different. The problem is even more acute at the primary care trust level. But it is unlikely to lead to boundaries being redrawn. Instead, local agreements should be drawn up, perhaps involving the transfer of funds between neighbouring authorities to cover the population involved.
How long before these partnerships become widespread?
Councils and health bodies will not be allowed to drag their feet. The government has already indicated in its NHS plan that use of the new powers will become compulsory.
