House of Commons - Health

Select Committee on Health First Report

Barriers to Working Together

32. The organisational divide between agencies creates structural, legal, and financial barriers which prevent professionals from working well together and from developing services which are as flexible as they would want. Witnesses called for a "fluidity of boundaries"[67] which would enable agencies to establish multi-disciplinary and cross-agency teams able to provide appropriate care, such as "a social worker leading a team including district nursing staff and vice versa."[68] These barriers, which we describe more fully below, are not unique to the boundary between health and social services. Within the NHS there are similar difficulties between different sectors, such as primary and secondary care, there can also be problems between the NHS and other local authority departments or even within the local authority between departments. In its recent discussion paper, Partnership in Action, the DoH suggests some ways in which these boundary problems might be tackled; we comment on these suggestions in the paragraphs that follow.

Lack of Clarity of Role and Responsibilities

33. None of our witnesses was able to provide an agreed definition of the boundary between health and social services. When asked the Secretary of State said:

"I do not think there can be a definitive definition, personally, because I think that the two things merge into one another."[

34. We agree that no hard-and-fast distinction between health and social care is possible. There is a spectrum of care ranging from medical interventions in hospital to home-based social care, with a considerable grey area in the middle, for example in the provision of rehabilitation and recuperation services; bathing services; respite care; personal care services; night sittingin services; and the provision and maintenance of equipment in the community.[70] Duplication of services, gaps in services and disputes between service providers can and do easily arise in these areas of overlap and they also impact on the setting of fees and charges.

35. The lack of a clear definition of the boundary between health and social services points to the illogicality of structuring the entire care system around such a definition. DoH's proposal in Partnership in Action to allow a lead commissioner for some services is one way of clarifying responsibilities by removing the boundary; we discuss the possibility of abolishing the boundary altogether in paragraph 68 below. However, even without major revision of the service, action should be taken to clarify roles and responsibilities.

36. In 1995 the DoH issued detailed guidance on the roles and responsibilities of health and local authorities in relation to continuing health care. Our predecessors welcomed the fact that the DoH had recognised the need for such guidance, but commented that further clarification was needed.[71] We recommend that the DoH review the 1995 initiative with a view to extending it into other areas where there may be overlap between the two agencies.

37. Some witnesses argued that creating a role for a generic health and social care worker, combining basic social care and basic nursing skills, would help alleviate many of the problems arising from interaction in this grey area.[72] We recommend that professional roles be reviewed to consider their continuing appropriateness and whether new professional or occupational roles are needed. We welcome the steps being taken by the Government to regulate social care and we consider there is a strong case for the regulation and registration of all care workers.

Financial Barriers

38. Possibly the most important barriers between health and social services are those caused by the current financial arrangements. Particular problems were caused by the inability to vire between the NHS budget and the social services budget although, as we have seen, under Section 28A of the National Health Service Act 1977, health authorities can transfer resources to local authorities in limited circumstances. Much of the good practice that we came across was established using funding either from one body alone or as an agreed joint package. The initial costs occasionally resulted in savings for one side with there being no way for the other investor to take advantage of these savings. We saw an example of this at the Beaufort Road practice in Southborne (see paragraph 57). We consider this to be a serious barrier to effective joint working. The ability to pool budgets proposed in Partnership in Action will help to remove this disincentive to co-operation—although our witnesses emphasised that pooled budgets are a means not an end, and that they will only facilitate successful joint working where trust and understanding has previously been built up between the respective agencies.

39. Another barrier to co-operation is the different financial systems and timetables operated by the NHS and local authorities. Health authorities know their allocations before local authorities do and can have more confidence in advance about the level of provision they are likely to receive in future years. This has hindered the wider development of joint commissioning. We heard how the differences between health and local authorities financial arrangements and "the competitive environment in the NHS and the emphasis on the length of an episode of care"[73] can create perverse incentives to 'costshunt', that is to shift responsibility for service provision to other agencies and authorities, particularly in continuing care and mental health. Pooled budgets may help to prevent this, but it is also important to review anomalies within the benefits system and to explore new types of incentives, such as those based on prevention of hospital admission. Funding mechanisms need to be reviewed to ensure that they do not discourage agencies from collaborating.

40. Lack of resources can also be a major barrier to joint working.[74] MENCAP typified witnesses' concerns in their written evidence:

41. 'Winter pressures money' was welcomed by those in the field and has helped to kick start some joint working projects, but there is an urgent need to replace this type of ad hoc temporary collaboration with proper, mainstream long-term funding. We discuss winter pressures projects further in paragraph 60 below.

42. Another difficulty is created by the split between policy and funding within central government. The DoH is responsible for social care policy and inspection while local authority SSDs are responsible for the delivery of social care services. However, it is the Department of the Environment, Transport and the Regions (DETR) which is responsible for allocating funds to the local authorities which provide social services through the revenue support grant and standard spending assessments. The DoH told us that they had some influence on the formula used to calculate SSAs but not on the overall amount allocated to social services expenditure by DETR.[76] We consider this split between policy and funding at the Cabinet level problematic and likely to lead to conflicts of priorities. DoH appears to agree as it has increasingly used specific grants to fund local authority SSDs. The fact that many local authorities are spending over their SSAs on social services is a further indication that the balance between policy and funding is wrong. We recommend that the NHS makes targeted, more long term investments in complementary local authority services, similar to the winter pressures model.

Different Charging Policies

43. It was widely acknowledged by witnesses that one of the greatest barriers to joint working is the different charging regimes used by the NHS and SSDs.[77] Health care is largely free at the point of delivery, whereas social care services are charged for, usually on a means-tested basis. This distinction has become blurred for two main reasons. Firstly, the NHS's progressive withdrawal from providing long-term care for the elderly has resulted in many people entering local authority or privately run residential and nursing homes when previously they would have been cared for without charge in NHS wards. In their 1996 report on long-term care, our predecessors called for the Government to consider the restoration of free nursing care to patients in private nursing homes in order to remove some of the unfairness and confusion caused by these changes; the then Government's response was that it "will keep this proposal under review but does not believe that it currently represents the highest priority for extra NHS expenditure."[78] Secondly, the lack of a clear definition as to where health care ends and social care begins and changes in social care provision, for instance home care services incorporating some traditional district nursing functions, have added to the confusion. Charging anomalies are compounded by the wide variation of local authority charging policies across the country and by a lack of guidance on domiciliary care charging. These circumstances have led to much confusion and resentment on the part of users and carers.

44. The variation in charging policies also acts as a disincentive to pooled budgets and joint provision.[79] Research by the SPRU has shown that such variation creates "barriers to more integrated working and the development of common 'seamless' services."[80] Current charging policies create perverse incentives, including 'cost-shunting' between agencies.[81] It is arguable that charging, particularly for domiciliary care services, is having a detrimental effect on potential collaboration between agencies which more than outweighs the benefits of the revenue which accrues from it. The Standard Spending Assessment assumes that local authorities will raise 9% of the cost of domiciliary care through charges to users (although the actual figure varies widely across the country from 0% to 23%).[82] The operational difficulties and public resentment caused by this charging system seem a heavy price to pay for revenue which amounts on average to less than a tenth of what is needed.

45. The lack of a common charging regime between health and social services clearly creates a major barrier to joint working. The Royal Commission on Long Term Care of the Elderly is currently looking in detail at this matter—we have held informal discussions with the Chairman of the Royal Commission, Sir Stewart Sutherland, and we look forward to seeing his report in due course. However we do not consider that the DoH has fully addressed this issue in Partnership In Action, which simply calls for greater transparency in local arrangements[83] and we were dismayed to find that DoH has not conducted any in depth analysis of the impact of social care charges on the NHS for about a decade.[84] We believe the charging regime will always be a barrier to some people accessing services. We recommend that a survey is carried out urgently to establish the impact of domiciliary care charges on the NHS, including the effect of charges on service users take up of health and social care services. We also recommend a review of domiciliary care charges where they are an impediment to collaboration, including an investigation of the implications of abolishing them altogether.

Legal Barriers

46. Legal barriers cause major problems for organisations that want to work well together. There are at present two main legal barriers: the inability to pool budgets and the inability of NHS organisations to delegate functions to local authorities and vice versa. A report on the legal aspects of joint working in mental health, commissioned by the Sainsbury Centre, found that there were a series of specific legal restrictions on joint working.[85] These were that:

health and local authorities must show they have used their resources in accordance with their powers and duties; it is difficult to do this with pooled budgets.

health and local authorities may only carry out functions if they are empowered to do so by statutory provision; it is thus illegal for local authorities to devolve social care responsibility to other agencies.

under Section 28A of the National Health Service Act 1977, health authorities may transfer funds to local authorities to purchase social care, but local authorities cannot do the same for health care.

NHS staff working for a local authority under Section113 of the Local Government Act 1972 can commit local authority resources, but local authority staff working for the NHS cannot commit NHS resources.

there are restrictions on what functions staff can be employed to carry out.

Section 47 of the National Health Service and Community Care Act 1990 states that SSDs must inform health authorities if they "think anyone might need their services", but there is no corresponding obligation on health authorities to take appropriate action.

We are pleased to see that the DoH now intends to address some of these issues by introducing amending legislation and in particular by allowing health and social services to pool budgets.[86] We recommend that action is also taken to deal with the anomalies which arise under Section 113 of the Local Government Act 1972 and Section 47 of the National Health Service Act 1977.

47. We welcome the proposals in the Social Services White Paper on the registration of residential care homes and nursing homes, in particular the intention that "in due course it may be sensible to move to a single registration category for all care homes".[87] This will prevent the current anomaly whereby qualified nurses in nursing homes are prevented from carrying out their duties.

Different Priorities

48. Health and local authorities have different sets of objectives, with local authority priorities varying from area to area. The Secretary of State acknowledged that this was the case. He told us that he had been careful to channel the recent "winter pressures monies" through the NHS rather than risk local authorities diverting them to other priorities:

"Putting [winter pressures money] through the National Health Service meant the National Health Service locally could then come to a joint agreement which required the local council to do what we wanted with that money. Had I not been able to do that, I do not think I would have been able to convince the Chancellor of the Exchequer and the Prime Minister that the money was going to be properly spent."[

49. The potential for a clash of priorities between the NHS and local authorities creates difficulties for joint working, especially when it comes to jointly funded provision.[89] The DoH has issued national guidance on joint priorities for the NHS and social services.[90] We welcome this, although we were disappointed to hear that there had been no formal consultation with users and carers on its contents.[91]

50. In order to establish shared priorities and working arrangements such as needs assessment teams, it is vital that proper joint planning arrangements are in place. Evidence suggests there has been an increase in recent years in the number of joint planning arrangements which have been locally established; this is a trend which should be encouraged by the DoH with appropriate monitoring and incentives. We recommend that DoH includes in its performance management mechanisms a check on the quality and effectiveness of joint planning arrangements, and that it should report back to us in due course on further progress in this area.

Lack of Coterminosity

51. Where health authority and social services authority boundaries do not match with each other, it can be difficult to agree joint plans and priorities because the two organisations are dealing with different populations.[92] Several witnesses stressed the usefulness of coterminous boundaries, and noted that these were not necessarily just "one-on-one" but may, for example, consist of one social services authority to two health authorities. Mr Stephen Thornton of the NHS Confederation told us:

52. Possible future mergers of health authorities and the development of primary care groups (PCGs), which we discuss in more detail in paragraph 68, could undermine coterminosity further. PCGs pose particular problems for coterminosity for two reasons. Firstly, the average size of the new PCGs is around 100,000, which is much smaller than the size of population covered by most SSDs. Secondly, a GP's patient list is only loosely geographically defined; even PCGs which are coterminous with social services will always have patients who nevertheless live in a different social services area. The DoH has confirmed that it was not its policy to ensure that PCGs were coterminous with SSDs.[94] We advocate coterminosity wherever beneficial and practicable, although clearly a lack of coterminosity should not be used as an excuse for a lack of co-operation. We recommend that social services teams reflect PCG boundaries and that in any future review, PCG boundaries are kept as far as possible consistent with the provision of social care in the area.

Different Cultures

53. We heard time and again that the NHS and social services have very different cultures and that this impedes the development of close links and integrated care.[95] One significant example of this 'clash of cultures' arises in relation to the use of language. We were told that the term "urgent" was interpreted differently; to a health care worker "urgent" cases must be dealt with immediately, but to social services "urgent" usually means "within the next few days."[96] Likewise, we were told that "a social worker opens a case and closes a case. In general practice a patient is a patient long term. There is no notion of a patient being processed in the out box."[97] GPs clearly have a long-term responsibility for a patient which differs from the case culture of social services, although we recognise that GPs are in actual contact with patients through a series of often very short, time limited episodes. Cultural differences can manifest themselves as a lack of understanding or even suspicion between the agencies and between professions. This is compounded by professional stereotyping and differences in perception of status, which can arise from a lack of contact and separate training regimes.[98] It is vital that there is parity of esteem between professionals, particularly given the changes occurring in primary care. We believe that joint training could engender greater mutual trust and respect between different professional groups and would have major benefits for joint working. We recommend that common pre and post-qualifying training modules be established for health and social care workers. In addition secondments between the organisations should be encouraged.

Differences in Democratic Accountability

54. A fundamental tension between the NHS and social services arises from their differing forms of accountability to the local population and to national government. The NHS is ultimately accountable to Parliament via central government, whereas social services are provided by local government which is accountable to a local electorate and only indirectly to central government. The fact that the NHS is not directly accountably to the local electorate was acknowledged by the Secretary of State as creating a "democratic deficit" at local level.[99] This was considered by some witnesses to act as a barrier to further joint working and funding. The Local Government Association told us that local authorities "have got to revisit the electorate in metropolitan authorities every four years, and so there is a very direct relationship that does not apply with the health authorities" and they argued that as a result local government was more responsive to local needs than were health authorities.[100]

55. The ADSS stressed the need for some form of common local accountability and proposed the following options: strengthening Joint Consultative Committees (JCCs); enabling local authorities to act as providers of community health services, in partnership with the NHS, by integrated commissioning; developing direct partnerships with GPs, embracing both the commissioning and providing roles for care; and establishing joint inspection arrangements.[101] Partnership In Action considers some of these areas. One of its proposals is that JCCs might be abolished once new partnership arrangements are in place. JCCs are widely seen to be ineffective and there is an argument for replacing them with bodies which have more specifically defined responsibilities and powers. We urge the Government to ensure that, under any replacement system, full local accountability arrangements are maintained and that voluntary bodies retain their representation. We discuss the importance of accountability within the health and social care system in paragraphs 72-74 below.

67 Q273. Back

68 Q446. Back

69 Q661. Back

70 Ev p183. Back

71 First Report of the Health Committee (HC 19, session 1995-96) para 51. Back

72 Ev p138; QQ334, 360. Back

73 Ev p250. Back

74 QQ170, 503. Back

75 Ev p241. Back

76 QQ36-38. Back

77 For example QQ133, 183, 356, 403, 624. Back

78 Third Report of the Health Committee (HC59, session 1995-96) para 138; Cm 3457, p 10. Back