From collaboration to commissioning: developing relationships between primary health and social services

Since the publication in 1989 of the white paper, Caring for People, the benefits of collaboration between primary health and social services have been emphasised—albeit with little guidance on how to achieve this.¹,² The success of emergency initiatives to reduce pressure on hospital beds and, in future, health action zones,³ will also depend on good relationships between agencies. The recent NHS white paper also emphasises the importance of partnerships, and proposes that local authority representatives are involved in both primary care groups and health authority meetings.⁴

Collaboration is important, particularly since the 1993 changes in community care, because general practitioners and social services staff act as gatekeepers to other services. General practitioners control access to secondary and community health services through patient referrals. Social services departments manage funding for home care services and residential and nursing home places and control access through assessment and care management. When one professional or organisation depends on another professional or organisation to obtain services, their ability to achieve their own professional or organisational objectives is affected crucially. Thus, general practitioners depend on social services’ funding of nursing home places or intensive domiciliary services to avoid admission to hospital for some patients or to support other patients after discharge home.

For many general practitioners, closer links with their social services department are a high priority. Some writers have argued that the surgery is an ideal base for social services because of the universality that characterises primary care.⁵ Others have suggested that general practitioners should be given an integrated budget from which they can purchase both health and social services.⁶ Although some studies have indicated a lack of success in achieving collaborative working, this may reflect a lack of clarity and realism about the goals and barriers associated with joint working.⁷,⁸

We describe several initiatives designed to improve collaboration between primary health and social services. We have drawn on two data sources. Firstly, we searched databases such as BIDS, HELMIS, CAREDATA, and DHS-DATA and professional journals for publications about collaboration between primary health and social services (excluding initiatives focusing only on children’s services) since 1990. Secondly, we investigated a number of joint primary health/social services initiatives through site visits, interviews with key stakeholders, and scrutiny of project documents.⁹

Summary points

• Basing a social worker or care manager in a general practice improves relations between primary health and social services

• Joint needs assessment and service commissioning are also needed if patients are to have speedier access to a wider range of services

• Joint assessment and commissioning do not require new legislation or pooled budgets

• Health and social services are likely to benefit appreciably, but the benefits for patients are largely unevaluated

• Success of joint commissioning initiatives depends on a commitment to joint ownership and equal involvement of primary health and social services staff

“Outposting” social services staff

The most common initiative involves the outposting, on a full or part time basis, of a social worker or care manager to a health centre or general practice. He or she takes referrals from practice staff, carries out assessments, and arranges services funded by the local authority for practice patients, from either a central or devolved budget.^10–18 Process evaluations of these initiatives have found widely acknowledged improvements in the sharing of information and in mutual understanding of the different professional roles, responsibilities, and organisational frameworks within which social and primary health services are delivered. These gains seem to be even greater if the outposting is preceded by joint training or team building exercises. Better communication and collaboration between practice based nurses and social workers were thought to be particularly valuable, possibly more than those between general practitioners and social workers.¹¹,¹⁵ Closer collaboration led, in turn, to quicker referrals from primary health care to social services,¹² fewer inappropriate referrals,¹⁰ and routine feedback on the outcome of referrals.¹¹

However, these schemes are not without their problems. Care managers based in general practice risk isolation from both their peers and the managers who provide essential professional supervision.¹⁰,¹²,¹⁷ Many general practitioner lists are smaller than the populations covered by the area office of a social services department, so a social work attachment to every practice and health centre is unrealistic, particularly with the very tight control on local authority community care expenditure.²,¹⁶,¹⁹ Moreover, social services departments are likely to be concerned about the equity implications of having social services staff based in some practices but not others.¹⁸ Finally, few schemes have had rigorous summative or case-control evaluations, so the potential benefits for patients, such as faster access to better coordinated services, have yet to be confirmed.¹¹

Collaboration to commissioning

Some initiatives have gone further and have developed joint needs assessments and service commissioning between primary health and social services teams. Joint planning and purchasing has had a rather variable history, and has not generally included primary health services.^20–22 However, the new primary care groups are expected to have a strategic role in purchasing and commissioning a broad range of health services, and all NHS organisations will have a clear duty to work in partnership with local authorities.³ What can be learned from the involvement of primary health services in joint commissioning to date?

The use of the term “commissioning” is deliberate. It denotes a strategic as well as an operational involvement in service planning, without necessarily controlling budgets or setting contracts.²³ Three different models of joint commissioning between primary health and social services can be identified.⁹

Joint commissioning based on area or locality

As exemplified in the box, primary health services may participate in joint health and social services commissioning forums based on the area or locality. This can also provide opportunities for primary care staff to work with the main voluntary sector organisations, which are frequently members of joint commissioning forums.

Area or locality as basis for joint commissioning

Since 1972, Northern Ireland has had integrated health and social services authorities; in 1990 these became integrated purchasers, with community health and social services provided by integrated trusts. The extension of total purchasing to Northern Ireland has therefore given general practitioners in total purchasing pilot schemes (TPPs) access to budgets that include responsibility for mainstream social services. However, these potentially extensive new purchasing powers are constrained by the statutory responsibilities which remain incumbent on the area directors of social services. The North Downs total purchasing pilot, for example, operates as a subcommittee of the Eastern Health and Social Services Board, on which the director of social services sits. Nevertheless, it has begun to consider how to improve relations between general practices and trust based social work services. Measures include having a named social worker for each patient and attaching social workers to practices, as happens with community health staff.

Developing opportunities for discussions with local authorities about new service developments will be an important priority for primary care groups. Moreover, the involvement of community nursing professionals (who hitherto have often been excluded from area or locality based joint commissioning) in primary care groups is a major new opportunity to contribute their knowledge to discussions on joint commissioning. Involvement in partnerships at locality level will also enable primary care groups to contribute to health action zones.³

Joint commissioning at practice level

A second model, illustrated in the box, is joint commissioning at the level of the general practice. Here, practice and social services staff together assess needs and develop new services, typically to fill gaps at the interface between local health services and social care. Some of the total purchasing pilot projects have been able to facilitate this by contributing funds for joint funded social work posts and new services.

Practice as basis for joint commissioning

At Bromsgrove total purchasing pilot, Worcestershire, the primary care manager and social services development manager together identified problems in obtaining respite care for patients. The scheme now purchases respite beds for practice patients, regardless of whether these are needed for health or social reasons; funding responsibilities are sorted out afterwards. Similarly, the Arley Joint Commissioning Project, Warwickshire provides, with health authority funding, intensive home and respite care services for patients to prevent admission to hospital.

Joint commissioning at the level of a practice or group of practices allows both health and social services professionals to contribute their expertise to assessing local needs. If new services are developed, they are likely to make transfer across the interface between health services and social services easier for patients with complex or changing needs. This is important if primary and community health services are to be able to deal appropriately with the consequences of shifting patterns of hospital admission and discharge. However, there is a risk with this model that health related concerns will dominate and undermine the contribution and commitment of social services staff. In addition, it may increase inequities between the patients of different general practitioners, some of whom may come to have access to more services than others; this may in turn have implications for patient registration, list size, and income related to capitation.

Joint commissioning at patient level

A third model, shown in the box, is joint commissioning for individual patients. Here, different professionals—district nurses, social workers, and occupational therapists—form a single practice based team, carrying out assessments, recommending services, and providing continuing management of care.

Patients as basis for joint commissioning

The Malmesbury Integrated Community Care Team, Wiltshire, includes district nurses, social workers, and occupational therapists. An assessment carried out by a district nurse is accepted as the basis for allocating local authority home care services; conversely, a social work assessment can form the basis for allocating community nursing or other health services.

This model reduces the risk that people with complex needs receive repeated assessments for different services. However, it offers fewer opportunities for more strategic action in developing new services to fill local gaps. Health professionals may also feel uncomfortable carrying out the financial assessments required for social services.

Discussion

These models of joint commissioning can all take place within existing legislative frameworks—none requires pooled budgets or other radical changes. All offer opportunities for closer working relationships, so that primary health and social services professionals can better understand each other’s responsibilities, professional perspectives, and organisational frameworks. They therefore all provide opportunities to reduce the frustrations that primary health staff may experience in negotiating the changing priority frameworks and resource allocation processes that determine access to local authority services. Joint service commissioning between primary health and social services is therefore as likely to improve communication and teamwork between professionals as the more common models of attaching outposted social workers to general practices.

However, joint commissioning between primary health and social services goes much further. It allows both health and social services professionals to contribute their respective experiences, expertise, and insights to assessing local problems and needs and, where resources are available, to develop or purchase new services at the margins of both health and social services responsibilities. For general practitioners and community nurses, joint commissioning with social services staff offers the same benefits as co-location but with the additional opportunity of contributing to service developments that meet patients needs better.

The importance of equal involvement and shared ownership cannot be overestimated. Local authority staff may have anxieties about the medical approach to social problems or about the diversion of pooled resources into the acute hospital sector. It will be important to show that these fears are groundless. The model of general practitioner fundholding, in which practitioners use their purchasing leverage to make changes in other services that they think are required, does not acknowledge the expertise of social services staff in assessing non-medical needs, prioritising risk, and working with networks of specialist provider organisations.²⁴ Moreover, social workers based in primary healthcare teams need to maintain close links with their employing organisations. Social services managers provide professional supervision and regulation and most social services departments allocate services according to priorities and procedures with which outposted staff need to keep up to date.

Realism about what can be achieved is essential. Closer working—whether through basing social services staff in general practice or joint commissioning—will almost certainly increase general practitioners’ understanding of local authority priorities and speed up formal referral procedures. However, neither is likely to enable formal procedures to be circumvented or additional local authority resources to be allocated for the patients of one particular practice.

The same conclusions apply in respect of those projects where health authorities or total purchasing pilots have been able to contribute towards the costs of a social work post based in a practice. Again this will undoubtedly lead to easier communication and better working relationships between agencies. However, local authorities have their own views about democratic accountability and equity. It is therefore unlikely that NHS funding for additional practice based social work posts will lead to the allocation of extra local authority services for the patients of those particular practices. But if some resources at practice level can be contributed to the development of new joint service initiatives at the interface between health and social services, real benefits for practice patients may occur—albeit at the cost of greater inequity for others in the locality.

Finally, all these initiatives still require careful evaluation to determine whether, and which, benefits claimed by primary health and social services staff are also shared by service users. Which model of joint commissioning delivers most gains for patients? How easy is it for them to find out about services? Are services better coordinated? To what extent are patients’ preferences taken into account? What are the consequences for equity and citizenship? These questions will be particularly important for primary care groups. As discussion of pooled budgets gains ground, it is vital that the lessons from today’s experiences are taken into account.