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The call this week from the NHS Confederation for care of the elderly and disabled to be transferred from councils ...
The call this week from the NHS Confederation for care of the elderly and disabled to be transferred from councils to the health service is sure of a warm reception in Whitehall. As LGC revealed on 7 April, ministers are considering doing exactly that.

The confederation is proposing primary care trusts should take on the commissioning of residential and nursing care for the elderly and physically disabled. It argues this would allow the care trusts to look at the whole patient. There would be no seam between residential or nursing care and health care. Better links would mean fewer hospital admissions and speedier discharge.

Certainly there is a compelling simplicity to the idea. It is gutsy, commonsensical. But the detailed issues are anything but simple.

To justify this massive organisational upheaval, the health service needs to provide compelling evidence it would be able to transform these services. With pensioners at the forefront of political debate, it would be a foolish government that messed around with elder care without being sure of the outcome.

Take funding. The NHS will always put acute care before residential and nursing care. With relentless pressure to reduce waiting lists, the crisis over winter bed shortages and increasing demands for better heart and cancer treatments, funds for long-term care will always suffer.

The chronic underfunding of psychiatric care serves as a warning of how the elderly and disabled could be treated.

Councils, on the other hand, have an excellent record on spending above the government's spending assessments for social services.

Then there is community representation: the health service has a poor track record engaging with communities. Primary care groups and trusts have been greeted with scepticism even within the health service, and there is no guarantee they will pull off this difficult trick - one even councils with their elected representatives find difficult.

There is a question of democracy. Elderly and disabled people are among the groups most at risk of being marginalised. Democratic representation may be a shaky defence against this, but there is no substitute.

What about commissioning? The NHS has limited experience of commissioning services, a skill local government has been perfecting for many years.

Removing one seam will create another. What about the myriad other services elderly and physically disabled people use that will remain with local government? Will the health service be providing home helps, often a vital link in monitoring care needs?

The NHS Confederation's rush to empire-build misses the truth that seamlessness will not be achieved by making one big bureaucracy run such a diverse range of services.

One thing is certain: organisational change will jeopardise delivery. It will be complicated, risky and hugely expensive. The process of making existing services perform better, both individually and in partnership, is already in motion, and it is in the best interests of those using the services to see this through.

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