RPP 18 3 Caroline Glendinning Taking Your Partners… developing relationships between primary care groups and local authorities

Research Policy and Planning: The journal of the Social Services Research Group – Vol 18 (3) 2000

Taking Your Partners… developing relationships between primary care groups and local authorities

Caroline Glendinning and Anna Coleman, National Primary Care Research and Development Centre, University of Manchester

Abstract

This paper describes the development of partnerships between the new Primary Care Groups (PCGs) and local authorities. It draws on a national sample survey of PC5s to describe the roles of the social services representatives on PCG Boards; and discusses the extent to which they are able to develop links between the corporate, strategic and operational activities of both organisations. Histories of poor relationships between GPs (the largest professional group on PCG Boards) and social services departments (SSDs), and continuing problems of non-coterminous boundaries between health and local authority organisations both constitute major problems and barriers to the development of partnerships. Nevertheless, only six months after PCGs went ‘live’, there are many encouraging indications of new collaborations developing, not just with SSDs but with a wide range of other local authority services as well. In the immediate future, it will be important to ensure that the pressures to move to Primary Care Trust Status, with their associated organisational reconfigurations, do not disrupt these early partnership developments.

Keywords: primary care, partnership, personal social services

Introduction

‘Partnerships’ are a distinctive feature of current government rhetoric and policies. Partnerships are encouraged between statutory organisations, between the public and private sectors and between both of these and local communities, in order to achieve both better services and better governance. This paper focuses on a new episode in the long and troubled relationship between the NHS and local authority services – the development of partnerships between the new PCGs and local authorities. First, it summarises some of the historical and structural barriers to the development of such partnerships. It then presents findings from a national sample survey of PCGs and examines the extent to which these problems are successfully being overcome. Finally the paper outlines some of the challenges facing PCG/local authority partnerships in the immediate future.

Background – a history of (non)collaboration

Although the establishment of the NHS in the 1940s united within a single funding and administrative system many previously disparate services, it nevertheless introduced and institutionalised new areas of fragmentation, both within the NHS and between NHS and local authority services. The NHS itself was split between hospital authorities; executive councils which administered the contracts of individual GPs and local health authorities responsible for other community health services. Meanwhile local education authorities retained responsibility for school health services, and other local authority services had a substantial role in providing health related care for other vulnerable groups (Ham, 1992).

The responsibilities of local authorities for the ‘health and welfare of the family in relation to the community’ (Editorial in Public Health 1954, quoted in Lewis 1999) may sound very unfamiliar now, because in 1974 these were transferred to the (then) Area Health Authorities. Conversely, during the 1980s the NHS withdrew almost entirely from the funding and provision of long-term care and responsibilities were moved to local authorities. This latter development partly reflected the implementation of ‘community care’ policies, with the closure of long-stay learning disability and mental illness hospitals. In relation to services for older people, it was facilitated by the ready availability of social security funding up to 1993 for private residential and nursing home places. However, GPs, the so-called ‘third arm’ of the postwar NHS structure, retained their separate, independent contractor status throughout; indeed, only in 1996 did they become incorporated within mainstream NHS management structures (Glendinning, 1998).

Although these transfers of responsibility helped to clarify and differentiate the roles and functions of NHS and local authority services during the 1980s and 1990s, the problems of collaboration and coordinating services between the two sectors became correspondingly more acute. Health and social services became increasingly dependent on each other for meeting their own, separate sectoral policy and service objectives. Thus from 1993 onwards, GPs, hospitals and health purchasers depended on local authority SSDs (and to a lesser extent housing departments) to provide the support necessary to prevent hospital admission or facilitate early discharge. In turn, SSDs needed GPs and district nurses to arrange appropriate services so that older people could stay in their own homes in the community, rather than entering institutional care. Continuing severe resource constraints, particularly in the funding of local authority community care services (Lewis and Glennerster, 1996) led quickly to allegations of cost-shunting and tensions between the two sets of professionals and organisations.

Both the NHS internal market and the ‘mixed economy of care’ which local authorities were urged to develop during the 1990s also had negative consequences for collaboration, which depends upon the development of trust, underpinned by long-term, stable relationships. In contrast, markets require purchasers to manage relationships with a number of different providers and encourage competitive and major organisational changes – the creation of separate health authorities and trusts in the NHS and purchaser-provider splits and major boundary changes in local government. Further reorganisations have been required since 1997, with the dismantling of GP fundholding, the creation of PCGs, a rolling programme of local government reorganisation (Bransbury, 1996) and the internal restructuring of local authorities to create ‘Cabinets’ and ‘Executives’. This organisational turbulence again inhibited efforts to look outwards, to potential partnership developments with other professions and organisations (Hiscock and Pearson, 1999).

Certainly there have been many efforts since the late 1970s to overcome the ‘Berlin Wall’ between health and local authority social services, but with only limited success. During the 1980s, joint planning was most successful in relation to relatively small scale, piecemeal initiatives, but much less so in relation to broader or more strategic aspects of inter-organisational activity (Wistow and Brookes, 1998; Nocon, 1994). It therefore remained largely marginal, with little impact on the core business and mainstream activities of either set of parent health and social services organisations. During the 1990s, joint commissioning has been more successful in bringing mainstream service programmes, contracts and large budgets within the scope of inter-agency collaboration, and has begun to prompt wider, more strategic approaches to needs assessment and service provision, particularly in relation to services for learning disabled and mentally ill people (DH, 1995; Poxton, 1999).

However GPs, located at the forefront of the latest NHS reforms and the largest professional group on PCG Boards, have had very little experience of either joint planning or joint commissioning. Collaborative activities between primary care and local authorities have tended to focus on improving the operational co-ordination of services with, typically, the desire to have social services staff ‘outposted’ in surgeries and health centres in order to speed up referrals and co-ordinate service delivery (Rummery and Glendinning, 1997; 2000; Glendinning et al., 1998). Thus GP fundholders tended to use their enhanced financial flexibility to purchase practice-based social work services to alleviate pressures on their own services, rather than engage in the strategic review and planning of local needs and services with their local authority counterparts (Myies et aL, 1998). Research on the development of PCGs confirmed the historical and cultural inexperience of GPs in collaborative activities:

The PCG represents a new structure and the partnerships they require involve a group whose own professional culture has not been one of collaboration (Callaghan etal, 2000: 25).

The Challenges of Partnerships and PCGs

Current government policies no longer allow partnership working to remain an optional or marginal activity; it is intended to become part of the mainstream, ‘core business’ of NHS and local authority organisations. Indeed the 1999 Health Act imposed a new duty of partnership working on all NHS organisation. Partnerships provide ‘… a third way between stifling top-down command and control on the one hand and a random and wasteful grass roots free-for-all on the other’ (DH, 1997: 27). This imperative is underpinned by a raft of supporting measures, including Health Improvement Plans (HImPs), which provide a common framework for joint activities by NHS and local authorities; joint National Service Priorities; Joint Investment Plans; Partnership Grants; and other measures contained in the 1999 Health Act which allow NHS and local authority organisations to pool budgets, delegate commissioning to a single ‘lead’ organisation and create integrated provider organisations. In addition the PCGs, which from April 1999 replaced GP fundholding and locality commissioning, are required to include a representative from the local SSD on their Boards.

PCGs are responsible not just for the operational level co-ordination of GP practice-based services; they are expected to commission and improve community and primary health services for the locality as a whole, in line with local health improvement priorities. The inclusion of social services representatives on PCG Boards therefore signals a clear expectation of partnership working in service investment and commissioning, not just in improving front-line service delivery. Given the poor history of collaborative relationships between health and social services and, in particular, the fragmentation of primary care services between individual GP practices with their strong traditions of autonomy and independence, the challenges of developing partner ships are substantial.

The ‘Tracker Survey’ of PCGs

The first ‘sweep’ of a longitudinal study of PCGs, conducted jointly by the National Primary Care Research and Development Centre, University of Manchester and the London-based Kings Fund (Wiikin et al., 2000), illustrates the challenges facing PCGs in developing partnerships, the progress made during the first six months of going ‘live’, and the substantial barriers which still remain to be overcome. The survey was based on a random sample of 15% (72) of the 481 English PCGs, stratified by region. Data were obtained from interviews, postal questionnaires and analysis of key documents. The findings reported here were obtained from interviews with Chief Officers, Chairs and health authority primary care lead officers from the 72 PCGs and from postal questionnaires completed by the social services representatives on the Boards of these PCGs (72% of whom responded).

PCGs are new organisations. Although their creation was intended to harness the experience of managing budgets and commissioning services which had been developed through GP fundholding, only 47% of GPs on PCG Boards are exfundholders. Moreover, the size of the pooled General Medical Services, hospital and community health services and prescribing budgets now devolved to PCGs is far greater than most ex-fundholders have had experience of. Nevertheless there were wide variations in the levels of administrative, finance and IM&T support staff employed in or seconded to PCGs and 79% of Chief Officers – particularly those in the smaller PCGs -thought their current or planned levels of staffing were inadequate.

Above all, the responsibilities of PCGs demand a major shift in focus and culture – particularly among the GPs who form the largest professional group on most PCG Boards – from a narrow, sectional concern to secure improvements in clinical services for the patients of their own practices, to a wider responsibility for improving health and health services for the entire population within the PCG’s boundaries. It was perhaps not surprising, therefore, to find broad agreement between PCG Chief Officers, Chairs and health authority lead officers that PCGS’ most significant achievements during their first six months were building relationships between the different professional and organisational stakeholders and developing the organisation of the PCG itself.

The PCG Board and its various sub-committees are the hub of the organisation and the focus of PCG policy and decision-making. Boards typically consist of between four and seven GPs, one or two community nurses, one social services representative, one lay member, a health authority non-executive member, a Chief Executive and a Chair. PCGs may also co-opt additional representatives onto working groups.

Managing large, dynamic budgets, assessing population needs and providing or commissioning a range of appropriate services within an overall corporate framework are of course everyday activities for SSDs. To what extent had the social services representatives on PCG Boards been able to contribute this expertise to the operation of the PCG?

Progress Towards Partnerships: The role of social services representatives

Early guidance from the Department of Health recommended that social services representatives should be operational service managers (DH, 1998). However this advice appeared to have been widely ignored. Only 10% described their job as only operational-level management; one-third (29%) said it involved mainly strategic planning and service commissioning; while the majority (59%) had both strategic and operational responsibilities – a combination which enabled them easily to communicate with and involve colleagues at all levels in their own organisations about policies and decisions taken within the PCG. Indeed, four-fifths (81%) of social services representatives said they met regularly with their Department’s senior management team; a fifth (19%) also met regularly with divisional or team leaders and a similar proportion (21 %) with elected councillors to discuss PCG matters. Small minorities of social services representatives used additional methods to communicate with colleagues, particularly the local teams and divisions within the PCG boundary. The importance attached to liaison with senior and locality-based social services staff suggests that the development of partnerships with PCGs was accorded considerable importance within SSDs. It also indicates an expectation that strategic issues concerning resources, planning and commissioning are likely to be involved, as much as operational-level matters.

Over three-quarters (77%) of representatives were responsible for services for frail older and/or younger disabled people and 60% also had responsibility for mental health, learning disability, drug and alcohol services or services for people with HIV/AIDS and sensory impairments. This reflects both national and local priorities of improving service co-ordination for these groups. In contrast, only one-third of social services representatives had any responsibilities for children’s and family services.

Social services representatives are also expected to provide a link between the PCG and a wider range of local authority functions (DH, 1999). The evidence suggests that this expectation was being met. In onefifth of PCGs the local SSD was combined with other local authority functions, such as housing, leisure services or community development, thus helping the social services representative to make links between the PCG and a wider range of local authority activities. Sixty per cent of representatives also had lead responsibility for their Department’s activities in relation to the HimP and 54% were involved from the social services’ side in the Joint Investment Plan.

All these findings suggest that SSDs had taken seriously the development of partnerships with PCGs, by appointing officers with appropriate levels of seniority and client group expertise and by supporting and integrating representatives into wider social services and local authority activities.

Integrating social services representatives into the PCG

The history of relationships between NHS and local authority organisations and professionals – previous experiences of collaboration, familiarity with each others’ methods of working and organisational cultures and the levels of trust which have developed as a result – will have a crucial impact on the ease with which partnerships can develop. Social services representatives reported that, before their PCG was established, the quality of relationships between GPs and social services in the area was ‘patchy’; three quarters (71%) said relationships with practices in the PCG area were ‘variable’; 12% said they were ‘largely hostile’; and only 15% said they were ‘mainly good and constructive’. Chief Officers added that operational-level collaboration between social services and GPs in the survey of PCGs was largely ‘poor’ or ‘mediocre’ – only 11% described it as ‘good’ or ‘very good’. Only 10% of PCGs were reported to have social workers attached to all their GP practices (usually on a sessional basis) and a further 20% had social workers attached to some of the practices in the PCG.

Relationships between SSDs and community health services were somewhat better. In over half (56%) of PCGs these were reported by the social services representative to be good and constructive, in 42% variable and in only 2% poor. Chief Officers also confirmed that operational-level collaboration between community health services was ‘good’/’very good’ in 29% of PCGs and ‘poor’/’very poor’ in only 8%.

These findings reflect the historical fragmentation of PG-based services, which have inhibited the development of collaborative relationships with large, corporate organisations like SSDs. The organisational fragmentation of general practice has been underpinned by a robust culture of autonomy, tightly prescribed funding streams, different accountability arrangements and professional ‘tribalisms’ (Lymbery, 1998). In contrast, SSDs and the NHS trusts which provide community health services share similarities in their organisational scale and complexity; moreover, district nurses and health visitors tend to work very closely with front-line social services staff, in delivering co-ordinated services to families, disabled and older people. It is therefore perhaps not surprising to find these different histories of collaboration and trust.

However, the survey suggested that the representation of social services on PCG Boards had already had a positive impact, even after only six months. One-third (37%) of social services representatives reported that attitudes of other Board members towards them had initially been cautious or suspicious but were now improving (60% said relationships had been friendly from the start and only 4% felt that initial suspicions were persisting). Broader inter-agency and inter-professional relationships were also reported to be improving, particularly between GPs and social services, where 85% of representatives reported an improvement. Some improvements were also reported in relationships between SSDs and community health services, although the initially better relationships meant there was less room for improvement here.

Social services representatives appeared to be actively involved in many of the activities of PCGs, but less so in their governance and decision-making processes. Nineteen per cent had been appointed Chairs or Convenors of PCG subcommittees or working groups, particularly those connected with the HimP, with community participation in PCG activities, and with wider aspects of the health-social care interface. Four-fifths (79%) were also members of PCG working groups. The remit of these groups was wideranging and as likely to reflect the clinical core activities of the PCG (developing primary and community health services, clinical governance and commissioning secondary care) as broader, intersectoral activities. Not surprisingly, though, social services representatives felt more involved in activities like commissioning community health services and developing primary care – services which relate closely to and intersect with their own – than in areas such as clinical governance and prescribing. Indeed, one-third of social services representatives felt they would like to be even more involved in commissioning community health services and developing primary health services than they already were.

However, these levels of activity were not reflected in social services representatives’ influence over and involvement in the decision-making processes of PCGs, where traditional professional ‘tribalisms’ seemed more resistant to change. In a very small minority of PCGs, involving the social services representative and developing inter-agency partnerships appeared to have been accorded a very high priority and this was reflected in her/his appointment to key decision-making roles; in 2% of PCGs, the social services representative had been elected Chair and in a further 6% Vice-Chair of the PCG. In general, however, social services representatives felt they had markedly lower levels of influence in PCG decision making than Chief Officers, Chairs and other GP members of the PCG Board. Both PCG Chief Officers and Chairs confirmed these perceptions, that social services representatives had less influence than almost all other categories of Board members. Social services representatives also considered that the views and interests of their department were relatively poorly represented in PCG discussions, compared with the interests of other stakeholder groups such as GPs, nurses and health authority members. Again these assessments were confirmed by PCG Chairs and Chief Officers.

The continuing problem of boundaries

The boundaries of PCGs are determined by those of their constituent GP practices, which in turn serve their registered patient populations. The latter bear no relationship at all to local authority or other administrative boundaries. Thus in urban areas, for example, patients registered with a large group practice may be spread across two or even three local authorities. In other parts of England, the development of inter-agency relationships may be further complicated by two-tier local authority structures and the absence of formal representation of district councils on the PCG Board. (in contrast, the Welsh equivalent of PCGS, Local Health Groups, are all coterminous with unitary local authorities.)

These problems affected a substantial minority of PCGs. Although 88% of PCGs had only one SSD within their geographical borders, only two-thirds (67%) of social services representatives said that most of the population covered by the PCG fell within their Department’s boundaries. Moreover, nearly half (47%) of the PCGs in the survey were located in areas with two-tier local authorities and, in one-third of these, the population covered by the PCG was split between two or more district councils. Most (but not all) of the PCGs in areas with two-tier local authorities had established mechanisms for liaising with the other tier, usually through their mutual involvement in HimPrelated activities, SRB and community regeneration programmes and/or district council-levei health forums.

A few PCG Chief Officers reported meeting regularly with their local district councils, but only one PCG in the survey had co-opted a district council representative onto the PCG Board. Despite these initiatives, social services representatives, Chairs and Chief Officers all agreed that the views and concerns of other local authority departments were even less well represented in PCG Board discussions than those of the SSD. Not surprisingly, about one-third of both PCG Chief Officers and social services representatives perceived boundary differences such as these to present major barriers to closer collaboration.

Identifying priorities for partnership service developments

Despite these problems, a surprising number of PCGs and local authorities had already embarked on the planning or implementation of joint service developments. First, there was a relatively high level of agreement between social services representatives and Chief Officers about the priorities for service developments based on PCG-social services partnerships – a promising basis for inter-agency working. The largest proportions of both groups prioritised improvements in services for older people and people with mental health problems; improving intermediate care and other alternatives to hospital care; improving joint strategic planning and integrating front-line service delivery.

Two-thirds of social services representatives said that collaborative service developments between their department and the PCG were taking place or planned. The most common of these concerned improving the range and/or co-ordination of services for older people, such as hospital at home schemes, rapid response services, improving hospital discharge arrangements and developing front-line service coordination through joint assessment, liaison workers and GIP-attached social workers (each mentioned by about one-fifth of representatives). Other partnership developments, each mentioned by only one or two social services representatives, covered a wide range of initiatives, including mental health services, SureStart programmes, services for families and/or children, Healthy Living Centres, out of hours emergency services, welfare rights services, SRB bids, transport and crime/community safety. (The diversity of these initiatives may reflect the restructuring of traditional local authority departments, particularly in new unitary authorities.) Half the social services representatives also cited joint initiatives between the PCG and other local authority departments which were already planned or under way. These included regeneration and New Deal for Communities initiatives, Health Action Zone and Education Action Zone projects, Health Alliances, mental health and drugs services, Best Value reviews and contraception services in colleges and schools.

Finally, one-quarter of Chief Officers said they were planning to use the new Health Act flexibilities to pool budgets, delegate commissioning or integrate service provision and a further quarter said this was under consideration, although no timescales were given for the implementation of these options.

Conclusions

The establishment of collaborative relationships within the PCG Boards, not just with the SSDs but also with other local authority departments, on a sufficiently sound basis for joint service developments, within only six months of PCGs going ‘live’ is a major achievement. It is clear that these relationships are the result of a considerably wider range of contacts and initiatives than could be created simply by the representation of SSDs on PCG Boards. The shared responsibilities of PCGs and local authorities for improving health and reducing health inequalities in their locality demand the development of collaborative relationships in respect of a wide range of services and functions. Environmental, community development, information and economic regeneration services, at district as well as county levels, are all likely to be involved. The extensiveness of PCG/local authority contacts may also reflect an attempt to overcome the problems created by different administrative boundaries, although considerable difficulties are still perceived to exist.

It will be important in subsequent ‘sweeps’ of the ‘Tracker’ survey to establish the extent to which these collaborative relationships have resulted in new investments, new patterns of services and new arrangements for users to access those services. While better relationships between senior managers, planners and service commissioners are certainly important, the real test will be whether they lead to changes in services and, ultimately, improvements in the well-being of service users. In looking for and evaluating such changes, the commitment to partnerships will need to be sustained, so that a broad range of quality of life objectives and outcome indicators are used, as well as narrower clinical measures.

The survey revealed that, although social services representatives on PCG Boards are both relatively senior and well-integrated into their departments’ and authorities’ management and communications structures, this is not reflected in their position on the Board itself, where GPs are the majority professional group and social services’ interests are relatively poorly represented. This may be inevitable, given the overall remit and responsibilities of PCGs, in which the development of partnerships with local authorities and others is just one of several core tasks. However, the objective of transforming partnership working from a marginal to a mainstream activity may be undermined if social services representatives do not feel they have an equal role in the governance of PCGs.

Finally, there is a danger that these achievements could be seriously damaged by a further round of organisational upheaval, as PCGs move to merge with each other and/or secure Trust status (two-fifths were aiming to become Trusts in 2000 or 2001 and many were considering mergers). In particular, the role of social services or local authority representatives in the governance of Trusts is far from clear. On the other hand, PCG mergers may provide an opportunity to rectify some of the boundary discrepancies which continue to hamper NHS/local authority partnerships.

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