"A desire to improve service users' experience often drives joint arrangements," says today's Audit Commission report on joint funding for health and social care.
But while local authorities and NHS bodies may want to improve their care for people and to manage resources more efficiently, this report makes it clear that good intentions are not enough. Joint working has failed to demonstrate results.
Councils and local NHS bodies can "usually describe how they now work better together but often not how they have jointly improved user experience," concludes the report. "Partnership agreements often fail to include quantifiable outcome measures, and partners rarely monitor them when they do."
Assessing the impact of partnership is not straightforward, acknowledges the Audit Commission. But it has made a pretty valiant effort. The report has analysed a wide range of data. Its findings make depressing reading for those committed to the idea that partnership working should improve care.
There are, for instance, no statistically significant figures showing that in mental health, joint arrangements have resulted in people spending less time in hospital; joint financing has resulted neither in better treatment for older people nor any reduction in the number of older people being admitted to hospital as a result of falling over.
Despite a national drive to increase partnership working between local councils and the NHS, formal joint financing is only a small proportion – 3.4% – of total spending on health and social care. In 2007-08, total spending by the NHS was £86.4bn and adult social care spending was £13.1bn. A mere £3.4bn of the total of £99.5bn was allocated to joint spending arrangements. The figure went up slightly last year, to £4.4bn, but is still tiny.
Partnership and joint working has been a cornerstone of government policy since Labour came to power in 1997. But the message has been repeated than acted upon. The recent green paper on reform of care and support funding called, yet again, for more joint working between health and social care, based on local partnership, rather than structural change.
It's an aim that is difficult to achieve, as the Audit Commission makes clear.
The report demonstrates that there are many reasons for local bodies to pursue joint working, but arrangements can be complex, requiring careful consideration of accountability and governance frameworks, and not all bodies understand the options that are available.
Central government doesn't always help, either. "Central government's approach is to support integration and partnership but, in practice, some detailed policies can hamper progress," says the report. "The numerous policies relating to integration are also not always easy to implement, often owing to the different systems and processes PCTs and councils have in place."
Different financial regimes, for instance, are often perceived to be a barrier, although this need not be the case, according to the Audit Commission, which cites arrangements in Bath and North East Somerset, where the council and the NHS primary care trust drew up an integrated financial policy framework earlier this year.
Worse, though, than not getting joint arrangements under way is getting bogged down in the mechanics of the arrangements and failing to see the wood for the trees.
"One of the dangers is that people, with the best of intentions, get mired in bureaucracy," acknowledges Michael O'Higgins, chair of the Audit Commission. "Rather than looking at the protocols for joint working, it's about saying what would constitute a better service. You join up by looking at the user experience. That's the only way to improve."
Both O'Higgins and the report draw attention to the fact that structural issues – whether the local authority and the PCT cover the same geographic area, for instance – are not particularly relevant factors. What really makes a difference are relationships between people and organisations at a local level, enabling them to set structural factors aside and focus on what people really need.
"Paradoxically," concludes the report, "where relationships are good, formal joint financing may not always be required". Conversely, if relationships are acrimonious, pooled funds will be difficult to operate.
It rests, says O'Higgins, with the leaders of local councils and PCTs to convince frontline staff that the change to joint working is practicable. "Leaders need to say that if there's a rule that is getting in the way, their staff should talk to them about it," he comments. "A lot comes down to the trust between people and organisations."
From Bubb's Blog
From Whitehall Watch
