Working with local government

With their long tradition of working in the community, as well as in the acute sector, physiotherapists have the knowledge and skills to play a significant role in shaping services to tackle inequalities, improve access and provide more choice. These aims are at the heart of reforms to improve the delivery of health and social care services. But what are the reforms and what will the changing relationship between health and local authority services mean for physiotherapy? This third article in our series sets out to provide some answers. Research and reports by Andrew Cole

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What's happening and why?

Seamless working between health and local government has been a cherished goal for as long as the NHS has existed. The latest guidance from the government, Commissioning Framework for Health and Well-being, seeks to impose an obligation on trusts and councils to work together, but it is only the latest in a long line of policy pronouncements designed to encourage closer working.

Joint working also offers significant savings by streamlining services and cutting overheads.

And perhaps most importantly, by providing timely care in a more flexible manner it should produce better outcomes.
The main building blocks of the new approach now seem to be in place. Last year's reorganisation of primary health care trusts means 70 per cent are now coterminous with their local council. The health department's latest guidance requires trusts and councils to produce joint strategic needs assessments mapping out the needs and priorities of their local population. This then flows through to the local area agreements that provide the protocols for joint action locally. Finally, at grassroots level clients should increasingly experience joint, unified assessments by all the agencies involved in their care rather than the fragmented, overlapping approach of the past.

The home front

WALES AND SCOTLAND

Wales and Scotland have, like England, separate health and social care structures. In Wales all 22 health boards are coterminous with their local authorities. In Scotland there is less overlap, with 32 unitary local authorities and just 14 health boards. Scotland is in the process of rolling out community health partnerships, which operate at a more local level to the boards and work across health and local government boundaries. In a similar move, Wales plans to introduce local service boards. All health boards are supposed to be introducing unified assessments to encourage joint working. But these have run into some problems, not least the difficulties of sharing information and protocols.

NORTHERN IRELAND

Joint working between health and social services is the norm for the simple reason they are one unified service, overseen by the Department for Health, Social Services and Public Safety. The current reorganisation embeds that further by introducing a single strategic authority with five mixed acute and community trusts beneath it.

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What are the obstacles?

FINANCE

At the moment the two services have distinct budgets, often tied to different accounting regimes and spending criteria. These tensions have been exacerbated by recent financial cutbacks in both trusts and local government. In a recent Local Government Association survey, seven out of 10 councils said NHS deficits were having an adverse effect on their services and over half of primary care trusts said councils' tightened eligibility criteria had impacted on their services. Nearly 40 per cent of PCTs said that cutbacks had forced them to restructure existing partnership projects.

MEASURING PERFORMANCE

Local authorities and PCTs have different targets and priorities, which don't always coincide.

  •  Information sharing. There are still practical problems in sharing information between all the agencies involved in a client's care because of confidentiality and IT compatibility. It is also proving difficult to agree joint protocols.
  • Coordination. Most health and social services staff still work in different locations, which does not help partnership. The NHS Confederation's survey showed only 10 per cent of PCTs and social service departments shared back office functions such as human resources, IT and admin.
  • Cultural differences. The two services have been developed in different ways with different philosophies. Even the terminology – patient or client? - is different.
  • Different charging systems. The fact that healthcare is free and social services means-tested poses particular problems in aligning services. Decisions about where NHS care stops and social care starts can have big implications for users.

What does it mean for healthcare?

Health and social services, it is increasingly recognised, will sink or swim together. The two services are undoubtedly collaborating more than ever before. A recent NHS Confederation survey showed that, despite recent financial problems, three-quarters of primary care trusts rated the relationship with their local authority as good or very good and not one said it was poor.

Many believe that partnership working is the key to transferring services from hospital to the community. But the biggest dividend is probably in preventive health. Many of the underlying determinants of ill health such as housing, employment, crime and community safety are in the local authority domain. ‘That's where the joint strategic needs assessment comes in,' says David Stout, director of the Primary Care Network. ‘By identifying the big issues in an area you can determine what the solutions are - and some of those solutions will be upstream preventive measures. The fact is there is a relatively small amount that health can do if it does not have good links with the local authority.'

Practice-based commissioning is likely to be one of the main drivers in this process. Increasingly practices are being encouraged to consider not just medical treatment but also social care as a means of combating ill health.

They could, for example, prescribe an exercise programme at the local leisure centre for a patient at risk of heart disease or set up physiotherapy and occupational therapy interventions in the home for someone with arthritis.

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What does it mean for physiotherapy?

Joint working in England is probably most advanced in children's and mental health services. In mental health most physiotherapists now work in integrated community mental health teams, which include nurses, occupational therapists and social workers.

That allows them jointly to assess a user's needs and then find the most appropriate solutions from across the full spectrum, says Sharon Greensill, a clinical specialist physiotherapist in Rotherham.

It also engenders greater flexibility in professional roles. A physiotherapist might lead an anxiety management course together with a social worker, for example.

In children's care, a duty ‘to work together to improve the health and well-being of children' was enshrined in the Children's Act of 2004. The growing number of children's trusts, which bring health, education and social services under one roof, is accelerating this process.

In Kent and Canterbury, a new children's centre brings together a range of professionals from health and local government including physios and OTs. This means there is now a single point of referral for all children and their families, says Peta Smith, a clinical specialist physiotherapist with Eastern and Coastal Kent trust.

‘Before if a child required a lot of support from different professionals it could lead to fragmentation,' she says. ‘But now, by working together and having a common assessment framework, we can identify what is needed and support the family in a more cohesive way. And it produces better clinical outcomes.'

The new approach gives physiotherapists a greater chance to expand their role, she suggests. It is also set to change the nature of physios' work and that of their assistants. ‘Instead of having physio and OT assistants you are likely to have generic assistants working for the joint goals of that family. That must be better for the families.'

On the ground – Greenwich

Greenwich's community intermediate care team is made up largely of care workers - but it's a shining example not only of co-operation between health and social care but also the difference that physiotherapy can make.

The team, which has 20 staff, has been running for the past two years. Patients are referred by the multi-agency rapid response team on discharge from hospital if it is thought their main need is rehabilitation, such as exercise or speech therapy.

But what's really different is that while the rapid response team is responsible for putting together the care package, it is the intermediate care team that then implements it, following training from the professionals, and always under their supervision.

So if the specialist physiotherapist decides a patient needs to practise sitting and standing exercises they will instruct the carer, who will then help the patient to carry it out in their home. Conversely, if someone is not making the expected progress in their mobility, the carer can call in the physio for advice.

Under the new approach the initial care plan only lasts for six weeks and will then be revisited at regular intervals, depending on the patient's changing needs.

The interventions have already helped cut A&E admissions and reduce the length of time many patients stay in hospital, says acting intermediate care manager Saadi el-Behiesi. Some no longer even require care packages because the intervention has enabled them to manage themselves.

It's also proving popular with patients. ‘When people are frail and elderly the one thing they don't want is to get dependent on others,' says Mr el-Behiesi. ‘They like this [approach] because we try and give them as much independence as possible. They want to be able to do basic things like washing and dressing themselves for as long as they can.'

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On the ground – Lisburn and Down

Multidisciplinary rapid response teams in Lisburn and Down in Northern Ireland are helping to keep patients with chronic conditions such as stroke and COPD out of hospital.

The teams work across health and social services to prevent patients from being admitted to hospital and to facilitate early discharge once admitted. At the moment there are four different teams, covering stroke, brain injury, respiratory conditions and intermediate care, for a population of around 180,000.

The respiratory team includes two community physiotherapists who have overall responsibility for patients in their home, arranging oxygen supplies with the local pharmacist and overseeing local pulmonary rehabilitation classes - all activities that would previously have taken place in hospital.

Patients know that if there is a problem they can always call on members of the team for support. And if they do have to be admitted to hospital the process will be quicker and discharge earlier because of the close coordination between hospital and the community. From the trust's point of view, the rapid response teams have more than paid their way by cutting A&E attendance and reducing hospital stays. Last year 1,428 bed days were saved as a result of interventions by the intermediate care team.

Useful references and resources

  • Primary Care Trust Network/NHS Confederation (2007). Partnership Working: The Facts
  • DH (2007). Commissioning Framework for Health and Well-being
  • DH (2006): Our Health, Our Care, Our Say: A new direction for community services
  • Department for Communities and Local Government (2006): Strong and Prosperous Communities - the Local Government White Paper.

In England, these include section 31 of the 1999 Health Act, enabling social services to delegate functions to trusts and vice-versa. Children's trusts and care trusts have formalised that partnership in some areas. Our Health, Our Care, Our Say envisaged a shift from hospital to community care predicated on seamless health and social services. And the latest local government white paper, Stronger and Prosperous Communities, puts forward a series of measures designed to strengthen working relations between the two sectors.

This government has always supported greater local government involvement in healthcare decision-making as a way of making the NHS more democratically accountable. Beefing up overview and scrutiny committees to give them greater monitoring powers over trusts is an example of this.

But a bigger reason for the government's enthusiasm for joint working is the increasingly urgent need to cut hospital admissions and reduce secondary care spending. The key to this is shifting care into the community, which in turn demands close coordination between health and social services.

Allied to this is the growing recognition that the health service cannot resolve many of the nation's most fundamental health problems, such as the obesity epidemic, by itself. Local government has a vital role to play.

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This text on this page was last updated on 16 May 2007.