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The Berlin wall between the health service and local government finally appears to be coming down, says Anne Gullan...
The Berlin wall between the health service and local government finally appears to be coming down, says Anne Gulland

Five years ago, as a lowly health minister, Alan Milburn made the bold statement that he wanted to break down the Berlin wall between health and social services. Ministers, and NHS and social services staff, were fed up with squabbles about who picked up the bill and interminable debates about whether a client was having a 'health bath' or a 'social services bath'.

Mr Milburn was eventually elevated to secretary of state status. But what happened to his lofty ideals of seamless service and joined-up government?

Janice Miles, policy manager of the NHS Confederation, says that in the beginning the words partnership and joined-up government were seen as the latest diktat from central government, but these days most council and NHS managers would agree that working together is crucial.

'A few years ago NHS managers would have said joined-up government was just a buzzword, but there are clear examples of where local organisations are beginning to realise the benefit of working together across a whole range of areas. The response we get from members is that working in partnership is now the norm,' she says.

A recent policy document from the confederation revealed a dizzyingly long list of initiatives that health service staff and their council counterparts could be involved in. These ranged from healthy living centres to health action zones to care trusts.

Perhaps nowhere has health and local government come together so closely than in the development of care trusts - organisations that will provide and/or commission a wide range of health and social care services.

Northumberland Care Trust was one of just four trusts to go live in April this year. It has a budget of£380m, employs 1,200 people and provides all the area's primary care services and nearly all its adult social care services.

David Parkin, former assistant director of social services at Northumberland CC and now director of social care and planning at the trust, says the trust could not have been set up if it was not for the close relationship that already existed between health and social services.

'If Northumberland social services has been noted for anything over the last 10 years it has been for its relationship with health. We had joint teams and pooled budgets and staff were seconded backwards and forwards between the two sectors throughout the last decade so the trust was the logical next step.'

For Mr Parkin it is natural that health and social services should come together in this way.

'If you look at the referral rate into community services, over 50% come from primary or secondary care. And a huge wadge of the remaining 50% comes in because people have difficulties where there is a significant health component. Planning a response to these needs is better done in a co-ordinated way.'

For many, the fact that just four care trusts have been established suggests that a root-and-branch organisational change is too radical. Many parts of the country have been content to use the flexibilities in the Health Act 1999 to promote partnership working. The Act, which imposes a duty of partnership on health organisations and councils, enables the transfer of funds between agencies. Money can go in either direction as long as it is directed towards health.

A spokesman for the King's Fund, a health think-tank, says it is right there are a range of choices.

'When care trusts were first announced there was a sense that everyone would end up being one, but this seems to have gone somewhat off the boil. Care trusts are useful in some areas but not in others. It's a pragmatic approach to take to allow people to work out what's best for them locally. You can spend a lot of time foisting mergers on people but staff end up in a state of flux,' he says.

Fiona Campbell, co-ordinator of the Democratic Health Network, which is part of the Local Government Information Unit, says that when health and social services come together they have to be wary of not shutting out other essential services.

But she points to public health as an example of where joined-up government has made inroads.

She says: 'The idea of prevention has always been a Cinderella in the NHS as acute services drew in all the money. Directors of public health were traditionally people who looked at outbreaks and epidemiological and population statistics. But now they're in a much better position to use this statistical knowledge to target prevention. For example if a local authority is developing a transport policy they're much more likely to look at the health impact of it.'

Some local authorities, pioneered by Oxford City Council, have even gone as far as introducing a health impact assessment whereby all new policies - anything from housing to education - are assessed for the impact they have on the local population's health.

Of course, partnership working at a local level is all very well, but if the Department of Health is issuing statements at odds with press releases from the Office of the Deputy Prime Minister, staff are bound to get frustrated.

So-called cross-cutting units have been put in place across government to combat this, such as the Teenage Pregnancy Unit, the Social Exclusion Unit and the Children & Young Person's Unit.

Ms Miles says: 'The children and young people's unit is publishing a strategy later this year and we're having meetings with them telling them that what they say has to be the same as the Department of Health and the ODPM. The message has to be consistent.'

But Dennis Reed, director of the LGIU, is critical of the department for riding roughshod over the central/local partnership (LGC, 6 September). He is angry the Department of Health announced proposals to fine social services for delayed discharges and the piloting of care trusts without consulting local government colleagues. He is calling for a Central Government Unit to monitor policies emanating from each department and check that everyone is singing from the same hymn sheet.

But he believes that even at local level joined-up government is not happening.

'Local strategic partnerships are supposed to join

up services strategically, but there's a huge lack of

clarity surrounding them. Issues such as probity, accountability and transparency have not been thought through. People are going to LSP meetings from completely different backgrounds and don't understand what they're about.

'The government is guilty of ignoring the fact that there is a local co-ordinator best placed to take on this work - the council.'

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