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FEATURES - CARE UNDER PRESSURE

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Spiralling deficits are stretching relations between health trusts and councils to the limit. Nick Golding investig...
Spiralling deficits are stretching relations between health trusts and councils to the limit. Nick Golding investigates in collaboration with LGC's sister publication Health Service Journal

As every agony aunt knows, relationships come under pressure when financial difficulties mount.

So it is scarcely surprising that when NHS trusts find themselves saddled with a gross budget deficit of£1.3bn, simmering tensions with their council partners have spilled over into public rows.

But in some areas, their couplings have been strengthened - as with Romeo and Juliet, adversity strengthens the bond.

Last month's Local Government Association survey of directors of social services in areas which have experienced primary care trust (PCT) budget deficits reveals the pressures partnerships have been under.

Over one third reported the loss of NHS beds, with community hospital closures, reduced district nursing and increases in waiting times also widespread.

The knock-on effects to social services departments have been huge.

Nearly 36% said local PCT funding had been withdrawn from joint services and 20% said the NHS was refusing to pay more than an additional 1% to cover inflation in the cost of its existing contracts.

Perhaps the greatest impact was in terms of an increased burden on council-led services. No fewer than 40% of directors said they were being asked to fund cases which had previously been considered an NHS responsibility.

Social workers are unhappy with their rising workload, as Ray Jones, chairman of the British Association of Social Workers, explains: 'Where you have people with quite profound impairment, including conditions previously cared for by nurses where patients require tube feeding, they say that's no longer an NHS responsibility. Now it's social care's responsibility.'

Social care budgets are limited too - extra money spent covering what used to be the job of the health service means new restrictions have to be placed on who receives other services.

Over three-quarters of councils are tightening eligibility criteria, an Association of Directors of Social Services (ADSS) survey revealed in March. Tighter restrictions often mean it is only those with the most profound needs who receive significant support.

'We need a clearer definition of what's a health responsibility,' Mr Jones says.

'Social carers are finding their work skewed. They have to review the services people are receiving as a means of trying to restrain the local authority overspend.

'That's not what they came into social care to do. We want to improve services, not reduce them.'

Other social care professionals say NHS cuts to community nursing and transport have forced councils to fill the void. Meanwhile, local area agreements have been undermined as PCTs pull out of s28 and s31 commitments to jointly fund services.

Many say community hospitals are being closed or reduced in size, despite ministers stressing their importance.

With NHS cuts costing councils dear, some directors have even called for a specific grant to be given to councils to compensate for the impact of health cuts.

The case of Wiltshire CC, where Mr Jones previously served as director of social services, perhaps best illustrates the impact. The council said a withdrawal of PCT funding left it with a£4m gap, forcing it to tighten its existing social service expenditure and transfer resources. Mr Jones took early retirement, saying he did not want to deprive the elderly and disabled of facilities including respite and residential care.

But before councils start thinking they are the only ones hard done by, they might be keen to bear in mind the results of an NHS Confederation straw poll from May this year.

While 14% of PCTs admitted pulling out of arrangements with a council, the same percentage said their council had withdrawn from a joint scheme.

And 18% of respondents said their council had raised the eligibility criteria for services, resulting in more people requiring health treatment.

Social services' finances are in a similarly parlous state to those of PCTs, with the ADSS reporting a national budget shortfall of an astonishing£1.77bn. Directors of social care complain they are being forced to make cuts - and these will undoubtedly impact on the NHS.

Councils are regularly being fined for their tardiness in supplying care to those leaving hospitals, which has led to beds being blocked and unnecessarily long hospital stays.

Neither health or social care has been entirely saintly with regard to its relationship to the other. But when both the acute health and social care sectors are under such pressure, it is often hard for one side to avoid letting the other down.

Jo Webber, the NHS Confederation's deputy policy director, says: 'People need to work together to find solutions, they need to approach this as a joint health and social care community.

'We mustn't get into tit for tat arguments, it should be about people working together. We get nowhere by saying in these areas it is this particular group of people who are pulling out from supporting a service.'

One area which has witnessed occasionally fraught relationships is Hampshire where Blackwater Valley & Hart and North Hampshire PCTs have respective deficits of£8.25m and£4.37m. In addition, Hampshire CC will feel the effects of an additional£47m of savings planned across the county's PCTs for this year.

Both the council and the seven primary care trusts in the county have agreed to plough on with improvements. A number of preventive projects have been piloted to identify those, such as elderly diabetes sufferers, who are at the greatest risk of ill health and offer them additional support in their own homes, reducing the risk of expensive hospital stays.

However, when finances are stretched it can sometimes be difficult to fund such innovation, as Rea Mattock, Hampshire CC's director of social services, explains.

'What concerns me is when we don't plan together. When we face these deficits we really need to work together to ensure the whole system works and patients and clients don't get compromised.

'We haven't done that well in Hampshire.'

She says greater planning is required to improve co-ordination between health and social care to ensure hospital patients are discharged at the right time and have the most appropriate support when they arrive home or move to a care home.

With the NHS emphasising the importance of shorter hospital stays, the council finds itself dealing with people with more complex conditions, many of them requiring 24-hour support which would have previously been provided on the ward. This has raised the average annual cost of the council's care packages from£9,000 to£13,000.

Although there is a consensus that it is better to support people at home, rather than in hospitals which are more costly and often lead to a sense of dependency, the council believes the PCTs are not picking up their fair share of the tab.

'We haven't yet worked well enough to ensure a shift of resources to that area. At the moment we can't do enough preventative work to stop people getting ill in the first place,' Ms Mattock states.

Chris Evennett, the chief executive of Mid-Hampshire PCT, agrees there needs to be a greater emphasis on preventive work, even if he has a more upbeat assessment of PCT-council relations.

'I don't think the relationships we have with the council are dysfunctional. But it has been difficult to build permanent relationships with all the changes we've seen in PCT boundaries,' he says.

He refutes the suggestion that the reduction in the average length of hospital stays means costs have unfairly shifted from the health sector to councils.

'When we put people out into the community, the NHS still picks up the cost of nursing care but not their accommodation costs. We don't try to put people out into the community simply to cut costs in the NHS.'

However, Hampshire's period of uncertainty is coming to an end - in October the county's PCTs will be merged into one with the same boundaries as the council.

It is hoped the new PCT will be better able to take the more strategic decisions required to ensure users benefit from more co-ordinated services.

'If you have seven directors of older people's services within the council's area and you're trying to get agreement, that can be very difficult. But if you've a one-on-one relationship that will make an agreement much easier to reach,' Mr Evennett says.

With PCT boundaries being redrawn this autumn - making them the same as top-tier councils' in many areas - there are high hopes that council-PCT relations can be improved nationwide.

Hampshire shows the practical difficulties with implementing the government's Our health, our care, our say white paper, which calls for ever closer links between the NHS and social care.

But even in areas where relationships remain good, the two sides find it difficult to forge a way ahead.

In Hertfordshire, where massive PCT deficits have contributed to a shortfall of£100m across the Bedfordshire & Hertfordshire Strategic Health Authority, the director of adult social care has much sympathy for her health colleagues, even though she anticipates a loss of community hospital beds having an immense impact on social care.

Sarah Pickup says: 'I can see the situation my health colleagues are in - they've been told to break even and have to do whatever they can.

'This is irritating. You could invest a smaller amount of money in community facilities and get a good deal but because of the speed with which this is happening, they can't do that. You don't get the transfer of finance to social care to provide the community support to make up for cuts elsewhere.'

Even before its PCT difficulties, Hertfordshire CC's costs were rising as a result of increased numbers of people with severe disabilities surviving into adulthood and a growing elderly population.

With Britain's population - and its voters - ageing, the pressure is on ministers to finally make social care an investment priority. Sir Derek Wanless's report for the King's Fund this year called for a huge increase in social care funding.

More progress was made when the Department of Health set out the principles by which health and social care should work together when it launched a consultation on its continuing care framework in June.

But, although such forward thinking might make things a little clearer, it does not entirely remove the potential for conflict.

Penny Banks, fellow in social care at the King's Fund, says: 'In theory the continuing care framework should be very helpful - to some extent it should make more of an even playing field - but there will always be grey areas and battlegrounds.

'The Wanless proposals, although they don't resolve all the issues, offer a way ahead. They make the state and personal responsibilities more upfront.'

Some areas are taking more immediate measures to minimise the scope for future strife. Children's trusts are being piloted in areas such as Brighton & Hove, resulting in local government children's services departments and local NHS specialists operating with a single joint management.

And in some areas such as Knowsley, social care and health specialists are working together in a single executive team. A single management will, it is believed, take a holistic view of service development and cut management costs.

Jan Coulter, director of health and social care for both Knowsley MBC and PCT, says: 'Both the council and the PCT faced enormous inequities in terms of health - the only thing to do was to work together.

'There's nowhere to hide on our executive leadership team - the books are open so we have to take a collaborative approach to solving our problems.

'We are both investing in the same sets of priorities - it gives us a holistic view of our care.'

'We were lucky when we were setting this up - we had a lot of visionary people around on both sides.'

As both NHS deficits and social care's under-funding continue to bite across the country, many more visionaries will be required to avoid future disagreements.

With local government and the NHS united by the knowledge that only closer relations can bring about the seamless working practices which are required to improve support for the most vulnerable, both parties know what they have to do.

However, when cash is short, real vision is required to avoid the disputes which embarrass both local government and PCTs and, more importantly, result in poorly planned fluctuations in services which hit service users so hard.

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