Select Committee on Health Minutes of Evidence

Memorandum by the NHS Confederation

RELATIONSHIP BETWEEN HEALTH AND LOCAL GOVERNMENT (HSS 33)

SUMMARY

  The NHS Confederation, as the representative organisation of NHS bodies, welcomes the opportunity to submit evidence to the Select Committee in its inquiry into the relationship between health and local government, and looks forward to developing its evidence in an oral hearing.

  The NHS Confederation is committed to the maintenance of the NHS as a nationally organised, universally available, largely free at the point of use, needs driven public service.

  The NHS Confederation strongly supports a multi-sectoral approach embracing public health in its wider dimension. It recognises the need to work within a multi-agency strategy, designed and driven locally by health bodies and local authorities. The wider environment and social care agendas are the lead responsibility of local authorities but the NHS recognises its vital support role.

  At present local authorities have no constitutional right to determine the policies and services of the NHS. The NHS Confederation considers any change in organisational arrangements that might bring health commissioning within the scope of local authorities would put at risk the Government's desired intention to implement a national health strategy.

  The key challenge is to ensure that the boundaries between the respective responsibilities and funding traditions of NHS bodies and local authorities become gateways to care not barriers.

  Effective local joint working can only be achieved by an open sharing of values and priorities, in order to build complementary health, health services and social care strategies.

  The creation of health action zones is designed to maximise the potential for multi-agency working, based on agreed health improvement programmes. Such programmes will inevitably extend beyond the present annual planning and resource allocation cycle for both the NHS and local authorities. Their ultimate success must not be put at risk by these constraints.

  The introduction of primary care trusts, in the context of the NHS White Paper, provides opportunities for service integration at a local level, although the history of close working between primary care and social services is mixed.

  There is a need for much stronger links between NHS and social services eligibility criteria and methodologies of assessment of need. There is scope to explore the potential for pooled NHS/social services budgets.

  There remains scope for further joint initiatives in the education, training and development of staff.

1.   INTRODUCTION

  1.1  The NHS Confederation is the representative organisation for NHS Boards in England and supports its counterpart organisation in Wales. Through representation on its Councils of Scotland and Northern Ireland, health interests across the UK are covered.

  1.2  With strong working relationships to bodies representing primary care interests it is well placed to speak on behalf of its membership and welcomes the opportunity to do so on the relationship between health and local government.

  1.3  This paper relates to England. The White Paper for the future of the NHS in Wales remains to be published, whilst Scotland and Northern Ireland have statutory differences. Nevertheless many of the principles reviewed have an application across the United Kingdom.

  1.4  The paper focuses on a limited number of issues within the list of topics identified by the Committee. The Confederation is please to have been invited to give oral evidence when it will respond to questions on further issues.

2.   AGENCY RESPONSIBILITY

  2.1  The NHS Confederation is committed to the maintenance of the core ethos of the NHS—a universally available needs driven public service, largely free at the point of use.

  2.2  The starting point (as is reflected in the White Paper for the New NHS published in December) is that of the patient and the patient's perspective.

  2.3  As far as patients are concerned their expectation of being able to obtain a service when they need it should be broadly the same everywhere. Primary, secondary and tertiary services, wherever they are provided, should be expected to meet agreed quality standards. However, health authorities' strategic plans should be geared towards obtaining best value from available resources to meet local needs. There will always be a need to balance equity of access to healthcare across the nation with differential solutions to meet local needs.

  2.4  The NHS Confederation recognises and supports a multi-sectoral approach embracing public health in its wider dimension and the need to work within a multi-agency strategy, the main designers of which will be health and local authorities.

  2.5  NHS bodies lead on the diagnosis and treatment of illness and injuries and on the provision of the healthcare dimensions of community care. They make a major contribution to health maintenance and promotion.

  2.6  County, district, metropolitan and unitary authorities identify, commission and provide a range of services which support the economic, social and environmental wellbeing of their areas—tasks which the Government intends to strengthen.

  2.7  Collaboration between these and related prime responsibilities of the respective agencies is a key feature. Clarity of respective responsibilities needs to be sought and recognised. However, the NHS Confederation considers that the achievement of the goals of the NHS will only be possible given shared values, policies, procedures and, where appropriate, integrated commissioning and service provision between health and personal social services agencies. The themes of social exclusion—poverty, homelessness and unemployment must feature in this agenda.

3.  ORGANISATIONAL STRUCTURES

  3.1  There are historic statutory constitutional distinctions between local authorities and NHS bodies. These are enshrined in law. It is worth restating the principal differences then to move on to the more positive opportunities for improving services for individuals and families:

—  local authorities are locally accountable, NHS bodies nationally accountable;

—  local authorities are elected with officers in support as opposed to NHS bodies with appointed boards of executive and non-executive directors; and

—  local authorities have the freedom to levy charges for services at the point of delivery as opposed to the broad NHS principle of services being free at the point of delivery.

  3.2  The further distinction of local authority standard spending assessments allocated over a wide range of services as opposed to a cash limited NHS vote are also features which demonstrate that there will continue to be a challenge as to the balance to be struck between national responsibilities and local freedoms. The crossover point of these is often the citizen in receipt of services, hence making the imperative for partnership very real irrespective of differing statutory accountabilities.

3.3  Structural change

  3.3.1  Notwithstanding the above distinctions, the NHS Confederation considers that a change in organisational structures, for example to bring health commissioning within the scope of the local authorities, would put at risk the continued drive of the integral national strategy for health. Strong leadership from the centre and an inter-sectorial approach is vital if the new health agenda, including that of public health, is to be effectively addressed.

  3.3.2  There is no evidence available to the NHS Confederation which suggests that the public want a change in the organisational structure of the NHS in so far as its accountability to the Secretary of State for Health is concerned. Indeed at successive general elections the retention and improvement of the National Health Service has been a topic to which the public has shown its commitment. The present Government is building on the strengths of its national identity.

  3.3.3  Local authorities and their social services departments have a wide range of statutory powers and duties to help vulnerable people in the community. The fact that housing, other than in unitary authorities is a district rather than a first tier local authority responsibility adds structural complexity.

  3.3.4  Wherever structural boundaries are placed issues of cross-agency working arise. There is also the combination of statutory and independent sector agencies which cut across housing, social services and health.

  3.3.5  These has been a further loss of coterminosity of health and local authorities occasioned by the merger of health authorities and the creation of smaller unitary authorities. This makes joint planning for a defined population more difficult but the concept of primary and community trusts would enable locality boundaries to be clearly identified. Consideration should be given to adjustment of the natural community boundaries to avoid the extremes of multiple authority involvement given the important of equitable services in health care. The relationships of primary care practice populations to these boundaries should be explored.

  3.3.6  The NHS Confederation believes that a willingness to work across all these boundaries, for example, by locality mapping and local commissioning working to agreed strategies is more productive than any attempt to redraw them in statutory terms.

  3.3.7  In noting that the duty is proposed to be placed on NHS bodies for partnership working, the NHS Confederation would recommend like statutory duties being placed on local authorities so that the authority and duty inherent in such arrangements addresses the needs of local communities.

  3.3.8  The key challenge is to ensure that the boundaries between the respective statutory responsibilities and funding traditions of NHS bodies and local authorities become gateways to provision rather than barriers.

4.  ACCOUNTABILITY

  4.1  The accountability of health authorities and Trusts is clear and unambiguous. Accountability is via the Secretary of State for Health to Parliament and thence to the people. Other instruments of Parliament, such as Select and Public Accounts Committees, the role of the Health Service Commissioner, the National Audit Office and the Audit Commission, the intervention powers of the Secretary of State and the new role of regional chairs to ensure that local partnerships are developed between the NHS and local authorities are all important elements in the accountability framework. These provide a full answer to those who take the view that the NHS has a democratic deficit. The proposed NHS Charter will be a further means to ensure that the accountability of the NHS is to those whom it serves.

  4.2  Local authorities have no constitutional rights to determine the policies or operational activities of health authorities or Trusts. The recent White Paper on the New NHS, whilst making proposals that will enhance the relationship between health bodies and local authorities, confirms that health authorities will be given enhanced powers to improve the health of their residents and to oversee the effectiveness of the NHS locally. They will take the lead in providing the framework within which all NHS bodies will operate. Consultation with the public at large is an important feature of both assessing needs and overseeing effectiveness. The NHS Confederation welcomes these trends.

  4.3  If the basic tenet of equity of access and provision is to be maintained, and indeed enhanced, openness about NHS activities and plans must extend to those many issues which arise at the meeting point between health and local authorities, between housing and care agencies, between mainstream and voluntary agencies, between users and carers.

5.   INCENTIVES FOR JOINT WORKING

  5.1  The first incentive for joint working is the sharing of values in relation to the community identified for the purposes of an agreed health and social care strategy.

  5.2  The shared values which led, for example, to the healthy cities initiative sprang from the shared values of social wellbeing, housing and health inequalities.

  5.3  This approach needs to be underpinned by an understanding of respective organisational cultures, values and constraints by the development of good communications and by sharing both data and information.

  5.4  The opportunity of membership of NHS Boards by people put forward by local authorities enables successful local authority nominees to play a full corporate role rather than acting as representatives of the local authority. The background of local authority strategy is a vital contribution to the work of a health authority which might be further strengthened by co-opting health representatives on to appropriate local government committees or task groups having health dimensions to its work.

  5.5  Funding mechanisms themselves (as is discussed in Section 8 below) can be incentives to joint working, promoting cost effective responses to opportunities for collaboration.

  5.6  The needs of individuals with identified health, social or related needs must stimulate a response which can be most effective from joint working whether this is at the strategic or operational level.

6.   ORGANISATIONAL SYSTEMS: PLANNING, COMMISSIONING AND SERVICE DELIVERY

  6.1  The recent White Paper on the New HNS recognises the sound foundations on which the new NHS can be built with the NHS working in partnership being one of the six important principles.

  6.2  Such an arrangement does not, however, absolve the agency in which the statutory duty is vested to escape that responsibility. Collaborating agencies should recognise that there are alternatives to cost-effective partnerships which improve the service provision, for example through a contract enabling a unified provision to be made by one body on behalf of another.

  6.3  But there is the wider agenda of social functioning in which the local authority is the corporate lead. It is not for the NHS to accept responsibility for the quality of the environment, for tackling poverty or for economic functioning. It has, however, an important role in supporting local authorities in these areas. The NHS White Paper identifies that health authorities will contribute to local action on social, environment and economic issues and how most impact can be made on the health of local people with a strengthening of the public health function.

  6.4  The NHS Confederation welcomes the proposal for local authority chief executives to participate in meetings of the health authority. This will serve to support the relationship to the wider role of local government to which, in addition to social services, health services relate.

  6.5  There is thus a need to identify the strategic approach which will govern the intensity of the partnerships across the agency responsibilities and indicate the preferred working.

  6.6  In this context the initial tranche of health action zones offer further opportunity to develop successful collaboration between the relevant local agencies.

  6.7  The health contribution, working in partnership with local authorities can be shown to have three main components:

—  the policy interface which governs the health care and related strategies;

—  the commissioning interface; and

—  the service provision interface.

6.8  Policy interface

  6.8.1  The key principles which should underpin this approach are:

—  a clear rationale for improving services;

—  the need for an agreed local plan acceptable to the accountable health and local authority;

—  decision making as close as possible to the localities affected;

—  pooling of resources to allow flexible working; and

—  effective links with primary care, social services, housing and education.

  6.8.2  In this context the initial tranche of health action zones offer further opportunity to develop successful collaboration between the relevant local agencies.

  6.8.3  The contribution of the Health Improvement Programme to the strategies of health action zones, having been developed in consultation with all the identified partners will inform the policy interface and identify targets for action to which the partners will be committed.

6.9  Commissioning interface

  6.9.1  Health authorities and local authorities through their social services departments have established mechanisms for joint planning and joint commissioning of appropriate services. They range from well defined effective mechanisms to deliver jointly managed services to statements of intent. Locality commissioning has the advantage of focusing on identified and mapped communities in which the role of care managers in purchasing integrated care are well established. There are, however, statutory limitations on the extent to which service funding and delivery can be undertaken by statutory authorities other than those in which the responsibility is vested in law.

6.10  Service provision interface

  6.10.1  This interface can take a number of forms:

—  the provision of health care which is self-limiting and in relation to which the NHS will take a lead co-ordinating role;

—  the contribution to services led by local authorities where a health input by way of professional expertise or service delivery is required; and

—  a balanced continuing service provision across a number of agencies, especially services to people with mental illness, learning disabilities or a package of care to those whose needs are best met by continuing care and support requirements.

  6.10.2  The service provision of health care by NHS trusts and primary care and community health services of the NHS make demands on social services, housing and other services such as transport dependant upon the level of need in an individual case.

  6.10.3  In some for example accident injury treatment or elective surgery there may well be no need for services outside the NHS. If the patient is elderly and following surgery has needs outside the responsibility of the NHS, other agencies may be called upon to contribute their support services.

  6.10.4  Principles that govern these relationships are especially relevant to services for people with mental illness and have been established by the NHS Confederation working with the Sainsbury Centre for Mental Health. They have an application beyond mental illness.

—  assessment, where appropriate multidisciplinary, of individual need;

—  services which are competent, staffed by people with relevant expertise;

—  effective services with anticipated and achieved outcomes for the service user;

—  a user focused approach; and

—  accessible and appropriate services.

  6.10.5  As is commonly acknowledged in many papers on this topic, having stated the statutory basis of the responsibilities of agencies, there is no simple answer as to who does what in health, housing or social services.

  6.10.6  Each of the agencies organises their work differently and the approach varies to the discharge of these responsibilities.

  6.10.7  A number of jointly managed schemes have been established by which, under one manager, acceptable to the agencies concerned, integrated provision of community mental health services is being achieved including referral to and management of the hospital services.

  6.10.8  This model has an application to learning disability services, to services for children. So far integrated provision of services for continuing health and social care needs of elderly people is generally less well developed.

  6.10.9  In order to make the best match of agency responsibilities, health authorities, NHS trusts, primary care teams in a given locality should share detailed information on how commissioning and provision is currently organised and plan for the best fit of agency responsibility. In this the opportunity of one agency carrying out functions on behalf of another should always be considered. Examples from health boards show that whilst much attention has been paid to joint commissioning, joint provision is as important in developing seamless services.

6.11  Regulation

  6.11.1  Health and local authorities respectively have regulatory duties under the provisions of the Registered Homes Act. These are due to be reviewed in a White Paper anticipated in spring 1998. A number of different models are currently used by which some respective authorities work jointly in the registration and inspection of residential homes and nursing homes but as things stand occupants of residential homes are denied the benefit of a nursing Inspectorate unless this has been jointly agreed.

  6.11.2  The Nurses Agency Act, which provides for the registration and inspection of employment agencies providing nurses, is operated by local authorities—in some cases health authorities act as the agent in carrying out these functions. There would be merit in the forthcoming White Paper reviewing all these regulatory arrangements with a view to ensuring that the health care needs of those accommodated in homes and those to whom domiciliary services are provided are safeguarded.

7.   BUILDING INTEGRATED CARE

  7.1  There is already a requirement for community care plans to be the subject of consultation between local and health authorities.

  7.2  The NHS White Paper identifies a health improvement programme as the local strategy for improving health and health care.

  7.3  The creation of a limited number of Health Action Zones will demonstrate the potential of multi-agency working in identifying and carrying through a health improvement programme.

  7.4  The identification of the programme to a three-year period will enable coherent planning by health and social services, a process underpinned by the new statutory duty of partnership. A three-year programme will require resource commitment for that period if years two and three of such a programme are not to be at risk from budget led adjustments caused by the inadequate annual financial allocations to local and health authorities.

  7.5  The fact that NHS and local authority budgets are under extreme pressure results in financial considerations being a severe constraint on preferred options for service delivery.

  7.6  The NHS Confederation considers that there is a responsibility on health authorities, primary care and local authorities to ensure:

—  clear agreements are in place covering their respective responsibilities for arranging and funding care;

—  effective co-operation between services to ensure a co-ordinated response to the needs of individuals, patients or users; and

—  good quality and sensitive arrangements for transferring responsibility for a person's care between agencies and between different parts of the NHS.

  7.7  The continuing work of the Department of Health and the Social Services Inspectorate in identifying practice guidance supports these principles.

7.8  Eligibility criteria

  7.8.1  The establishment of eligibility criteria for the provision of NHS continuing health care, an integral part of the NHS, was a requirement of a Department of Health circular (HSG(95)8/LAC(95)5). It spelled out action which health authorities working closely with local authorities, GPs and others were to take for the NHS to arrange and fund services to meet the needs of people who require continuing health care.

  7.8.2  This central guidance with a national framework of conditions which the eligibility criteria of all health authorities must meet is more prescriptive than that relating to eligibility criteria for social services, which are determined locally and which are set, as the Audit Commission reported in 1993: "in order to allow through just enough people with needs to exhaust their budgets exactly".

  7.8.3  Eligibility criteria for social services provision are not stable. The threshold for service delivery is changed by local authorities, the change being triggered by financial pressures. The funding of a nursing home place on the basis of "one out-one in" does not achieve the needs led provision of service that was the aim of the community care reforms.

  7.8.4  Thus the eligibility criteria for social support varies widely. It is the absence of national standards, or the absence of robust local agreements, which place the issue of eligibility criteria at the heart of much collaborative difficulty between health and local authorities. If services are to dovetail, the respective eligibility criteria must be supported by health and social services agencies.

7.9  Assessment of need

  7.9.1  Assessment of need is the preliminary step before application of eligibility criteria. There is not a nationally recognised accredited assessment of need tool which has the support and respect of all the professions concerned in order to identify care needs of individuals.

  7.9.2  The absence of such a mechanism gives rise to allegations of cost shunting.

  7.9.3  The Audit Commission report "Coming of Age" makes this reference to assessment methodology:

"Health trusts and social services staff should review assessment arrangements, clarifying responsibilities for different members of staff, standardising procedures and documentation and monitoring the completion of documentation. They should consider introducing panels to monitor proposed placements in residential and nursing homes and establishing links with geriatric medicine."

  7.9.4  A further example of the absence of assessment criteria is the variation in definitions of palliative care which, notwithstanding detailed guidance on NHS responsibilities, continues to give rise to extended negotiation between health and social care agencies as to the financial responsibility for palliative care services to an individual.

  7.9.5  Shared eligibility criteria firmly based on the user focus has an enormous potential in the setting of health and social care policies.

  7.9.6  Such a position would both generate confidence of users and provide a basis by which care provision can be more effectively monitored.

8.   FUNDING

  8.1  The funding of health and social services is complex and involves formulae which do not link across these services. Other formulae and a mix of national and local mechanisms relate to housing, environmental health, transport, education, all of whose provision has a profound effect on levels of need for health care. There remains a lack of clarity as demonstrated in Section 7 above over the linkage of eligibility criteria which is only partially overcome by joint commissioning.

  8.2  The Audit Commission report, "The Coming of Age" states that social services departments are becoming increasingly concerned at the level of demand they face.

  8.3  In some departments the Government policy of a needs-led provision has reverted to a finance driven service.

  8.4  Earmarked allocations from health resources may be made available, in specified circumstances, to local authorities—notable examples being mental health challenge monies and those allocated in respect of winter pressures.

  8.5  In response to managing the pressures on health and local authority services through the winter of 1997-98 it is clear that a significant number of social services budgets are being supplemented by NHS funds in order to enable a social services provision to support the availability of hospital beds. Clearly this is an acceptable short term expedient demonstrating a good example of agencies working together to tackle difficult short-term problems. Nevertheless, large scale movement of NHS funds can have the effect of solving one challenge at the expense of another.

  8.6  In addition, appropriate transfers of NHS funds are negotiated to enable local authorities to meet the community care needs of people being discharged from long stay institutions. Arrangements under these headings are generally cumbersome to arrange and are subject to complex rules.

  8.7  Innovative schemes for joint provision frequently do not proceed because they lead to an extinguishing of income support rights of the people to whom the schemes relate. The further difficulty is that of meeting what are seen as over-restrictive requirements of the statutory provisions.

  8.8  At the level of operational services to individuals, complexities of statutory responsibilities arise. One example is the supply of disability equipment, the supply of which may be critical to hospital discharge. Over 4 million adults use one or more items of disability equipment. Local authorities and health authorities both have statutory duties in relation to such equipment but there is a lack of clarity which gives rise to disagreements about who provides what.

  8.9  Some local and health authorities have found ways of working in this area, for example:

—  a social services run joint equipment service has a system of operation for the health trust combination, based on management information which can quantify the health demand on the service; and

—  a NHS health trust runs the service, but the Social Services budget is managed separately—the effect is of joint provision but from two separately managed budgets.

  8.10  Despite these difficulties good progress has been made on some partnership schemes between health and local authorities, not least in funding from their respective allocations, mental health services, services to people with learning disabilities and continuing care programmes.

  8.11  The establishment of joint management boards for the purchase of integrated mental health care is but one example.

  8.12  Nevertheless, in any such scheme, an audit trail to the origin of the funds must be maintained and be able to demonstrate that the source of the funding and its application is related to the health or social services responsibility of the agency concerned.

8.13  Pooling of budgets

  8.13.1  The transfer of health voted funds to the use of local authorities and voluntary bodies through grants is governed by Sections 28 and 64 of the NHS Act 1977.

  8.13.2  The facility to pool budgets would have the advantage of reducing these bureaucratic distinctions. the NHS Confederation would welcome the facility to pool budgets but sees this as a facility rather than an end in itself.

  8.13.3  The joint planning and services framework is the first requirement. In order to support pooling a number of prerequisites would need to be in place. Pooling of funds means that the respective organisations give up some autonomy. They thus lose their individual ability to set and control their own agenda and having entered into a programme financed by a pooled budget, modify their individual priorities.

  8.13.4  This approach woud therefore entail:

—  a service strategy in which there is a joint or multi-agency commitment to the loss of the individual "stakeholder" autonomy;

—  the ring-fencing of committed funds in their totality;

—  no agency being in a position to recover its funding contribution without mutual agreement and programme adjustment; and

—  agreement on the duration of pooling.

  8.13.5  It seems likely that a significant number of pooled budgeted programmes would need to span more than a financial year. The commitment of the funding authorities would be expected to extend beyond the normal annual funding cycle which would place the committed funds outside the operation of cross-departmental consideration in annual budget programmes.

  8.13.6  A further consideration is the range of agencies whose budgets could be drawn into a pooling arrangement. For example NHS funds have been utilised to improve the damp proofing of housing. It can be argued that such expenditure should fall to housing services. However, it cannot be denied that poor housing contributes to poor health. For example, the National Housing Federation suggests that adults who live in temporary accommodation have more than twice the level of mental health problems of people living in permanent homes in the same area.

  8.13.7  It follows that signing off a pooled budget has implications which need to be thoroughly explored before programme commitment is agreed.

8.14  Primary care

  8.14.1  With the development of general practitioner fundholding in its various forms a significant part of the health budget is now managed by primary care teams. This will be further enhanced as primary care trusts are established in the context of the NHS White Paper.

  8.14.2  In developing further programmes of integrated care the primary health care team working within a strategic framework agreed with the health authority would need to be a partner in programmed budget and pooled funding arrangements.

9.   SOCIAL SERVICES/PRIMARY CARE

  9.1  GP fundholders and commissioners are developing primary care by joint working across practices and recognising that in such development and its links with community health services, there is a social services linkage to be further developed.

  9.2  One example of the NHS Confederation working with local authority interests was a study of links between GP fundholders and five social services departments in England carried out in 1996.

  9.3  The emergence of primary care commissioning raises questions about the capacity of social services and fundholding practices to collaborate to identify and meet the local health and social care needs and the opportunity for "micro level" purchasing of services.

  9.4  The joint study showed that there had been little development of joint planning beyond the field operation level but examples of positive steps identified were:

—  a joint strategy for primary health and social care; and

—  practical support in identifying health and social needs together.

  9.5  This study showed that whilst there was a standard model, effective local collaboration would benefit from a combination of:

—  planned face-to face contact by practitioners on both sides developing into a regular "team" pattern; and

—  planned review of joint working by senior partners, practice managers and social service managers.

  9.6  The study showed that starting with limited goals there was opportunity for common cause with a local joint commissioning plan as an eventual goal.

  9.7  The proposals for primary care trusts raise the possibility of an integration of the relevant social services provision to such Trusts.

  9.8  The attachment of social workers to primary care increases the provision of services on a seamless access basis. The attached social woker nevertheless works within the policies and procedures of the parent department. It is unusual for any significant budgeting freedom to be delegated.

  9.9  The NHS Confederation recommends that the opportunity offered by primary care trusts should be taken to explore whether the social services provision arising from a health care led need could, with an appropriate transfer of funds, be an integral part of the Trust.

10.  STAFF ISSUES

  10.1  Relatively little attention has been given to harmonising the professional education, skills and training implications of joint working.

  10.2  Joint funding has created some posts, which work across the health/social care boundary. Professional training bodies have generally remained in the context of uni-disciplinary training, for example occupational therapists train within the NHS, are a scarce skill, and are attracted to employment by local authorities to work in assessing the needs of people in community care rather than in the NHS. There is a remuneration disadvantage to them in working in the NHS.

  10.3  The NHS Confederation is supporting a bid for the setting up of a Health Care National Training Organisation. Amongst its objects will be the creation of joint development plans with the social care sector through the proposed training organisation for personal social services.

  10.4  Education and workforce planning consortia have been established throughout the NHS. Funding of the training programmes commissioned by the consortia is that of the NHS. There would be potential advantage to the partnership agenda developing parallel, if not joint, programmes. Whilst the initial focus centres on nursing and the professions supplementary to medicine, the opportunity is there to plan laterally for the multi-agency approach.

  10.5  In mental health the NHS Confederation is contributing to an initiative by the Sainsbury Centre for Mental Health in analysing the competencies required in a cross-professional disciplinary approach to training. Currently the response of training bodies concerned with mental health is being assessed by an inter-professional steering group. This initiative could lead to major changes in realigning skills to work across traditional boundaries both of discipline and sector.

  10.6  More simple innovations such as joint training of social care assistants and health care assistants working in the people's own homes would obviate the difficulties that can arise, for example if each has been trained in lifting techniques which do not relate.

  10.7  An alignment of human resource agenda of health and local authorities would further develop integrated working and to make the best use of scarce skilled resources.

11.  CONCLUSION

  11.1  Much of the focus of this submission is on the statutory and working relationships of health and social services. The Confederation considers it helpful that a number of local authorities are establishing departments which span both social services and housing. The role of housing associations is now crucial in the provision of acceptable low cost housing, often to people with disabilities or continuing health care needs.

  11.2  As the public health agenda develops in its new shape, the contribution of health to the corporate agenda of national regional and local multi-agency working will be crucial. Central government will need to recognise that adequate resources, both of skills and revenue, will be essential if the potential both for the diagnosis and treatment of illness and for the NHS contribution to positive health is to be met and maintained.

December 1997

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Prepared 20 May 1998