Nicola Carroll looks at some of the highlights from the recent NHS confederation conference in Manchester.

Health and social care professionals have recognised the need for greater integration of their services for decades, but progress in actually achieving this has been painfully slow.

The Dilnot Commission, Health and Social Care Bill and funding cuts across the entire public sector mean the question of how local government and the NHS can work together more effectively has now become a burning one.

Dilnot, the Bill and funding cuts… The question of how local government and the NHS can work together more effectively has now become a burning one

The Association of Directors of Adult Social Services (ADASS) has warmly welcomed Dilnot’s recommendations and made it clear that reform and resources are inextricably entwined.

Its president, Peter Hay, strategic director for adults and communities at Birmingham City Council, warned participants at the recent NHS Confederation annual conference session that adult social care departments must make savings of more than £1bn for each of the next two years. The funding gap is varied across the country and core cities are the worst ‘hot spots’ for cuts.

He pointed out that the social care funding gap is a longstanding structural issue and is not just about the current round of cuts. Although councils are reducing adult social care budgets less than for other services, they have struggled with demographics of an increasing elderly and disabled population. Birmingham has had to find £25m to maintain its budget as a result of losing the recent judicial review over care for disabled residents. Councils around the country are currently facing 20 judicial reviews for adult social care – mostly around eligibility and fees, he said. ‘We are now spending an awful lot on lawyers – that trend will grow.’

An ADASS survey last year identified the five key factors impacting on integration of health and social care. In Hay’s view, the initial obstacle of performance regimes has become less troublesome. The other four factors identified were: financial pressures, complexity, leadership and financial complexity.

‘These have all got worse at a time when we are talking about integration more,’ he said. Co-ordination of staff as well as structures needs to speed up. The interdependence of health and social care means it is important to establish evidence for the value of investment in preventative measures.

Dilnot commissioner and former health minister Lord Warner, told delegates at the Manchester event, that the situation started to go seriously wrong when the NHS was getting annual increases of nearly five times those of local government: ‘We have tried to tell the Government if you carry on with that pattern of funding you will need Dilnot part 2, 3 and 4 in future years.’

He believes Dilnot has ‘opened up the capability for better integration.’ It revealed a need for an awareness campaign and better information as people don’t understand the boundary between NHS and social care or what services and financial mechanisms are available.

The commission found the public strongly supported nationwide eligibility criteria and portability, which Lord Warner recognised runs against the grain of the localist agenda for councils. Trying to get a locally accountable care system and centralised health system operating in tandem will therefore require organisational culture as well as financial and administrative obstacles to be carefully considered.

Richard Humphries, senior fellow at the King’s Fund, stressed the impact of pervasive funding problems, with 78% of councils now only meeting needs at ‘substantial’ or ‘critical’ level and greater rationing of care. He also struck a note of optimism however.

Health and well-being boards – with a statutory role for upper tier councils to oversee co-ordination of commissioning across the NHS, social care and public health – are among the few non-controversial aspects of NHS reform and should pave the way for greater integration.

A holistic perspective on health and social care spending is necessary across government. ‘The challenge is to reduce demand and keep people out of high cost settings and promote independence and well-being in the first place. Health and social care need to consider what sort of investments they can make for that,’ said Mr Humphries.

While less than 5% of social services and NHS spend is currently subject to any kind of pooled agreement, shared budget pilots have yielded promising results. The wider role of local government in relation to health and well-being must also be considered by the new boards, as 80% of older people use housing, culture and leisure services, all of which keep people healthier for longer.

Charles Waddicor, chief executive of NHS Berkshire West and a former social services director, said the fact that integration has not happened when people have been talking about it for twenty years points to a failure of leadership in both the NHS and local government. Delegates agreed that building up relationships and trust are key and sustaining conversations during a period of complex organisational change is crucial. But this is difficult when the average turnover period for a social care director is only three years and PCTs are subject to constant turbulence.

Cllr Jonathan Owen, deputy leader of East Riding of Yorkshire Council, highlighted a lack of awareness and capacity among councillors as a barrier. Lord Warner responded: ‘A lot of these things can be done provided you explain that it’s not a financial raiding party by the NHS on local government or vice versa. Councillors need to be willing to talk to counterparts in the NHS. Focusing around purpose helps move away from the blame game.’

Stephen Dorrell, chair of the health select committee, told the conference the following day that relying ‘less on picking up the pieces when it goes wrong and more on stopping things going wrong’ would mean both better care and better efficiency.’ He is expected to start an enquiry into the integration of health and social care in the autumn. This, quite obviously, has some tricky knots to unravel.