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.
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."
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."
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.
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.
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.
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.
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.
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
Ev p183. Back
First Report of the Health Committee (HC 19, session 1995-96)
para 51. Back
Ev p138; QQ334, 360. Back
Ev p250. Back
QQ170, 503. Back
Ev p241. Back
For example QQ133, 183, 356, 403, 624. Back
Third Report of the Health Committee (HC59, session 1995-96) para
138; Cm 3457, p 10. Back
Appendix 13. Back
Appendix 25; Appendix 17; Ev p 250; Q384. Back
Annual RO3 return to DETR. Back
op. cit., para 4.13. Back
Pathways to Partnership: Legal Aspects of Joint Working in
Mental Health, Camilla Parker with Richard Gordon QC, Sainsbury
Centre for Mental Health . Back
Partnership in Action, op. cit. Back
Modernising Social Services, para 4.53. Back
Appendix 25; QQ26, 505. Back
Modernising Health & Social Services: National Priorities
Guidance 1999/00 - 2001/02, DoH, 1998. Back
Official Report, 6 July 1998, col. 389. Back
For example: QQ267, 518. Back
Ev p176; QQ326, 341, 261. Back
Ev p98. Back
Ev p35. Back