Partnership working between local authorities and health professionals has been regarded as central to the integration of services for children and families. Now with health agencies legally obliged to co-operate in the provision of services to children's centres, that link is more important than ever.
But while there are many examples of good joint working between the NHS and local government to drive forward the process of integration, there are also signs at national level of profound tensions between them.
A very public spat began in March, with the Local Government Association (LGA) saying that NHS deficits were 'hurting social care services provided by councils to vulnerable people'.
LGA chairman Sandy Bruce-Lockhart said, 'There are grave financial pressures on both councils and the NHS that are starting to impact on the quality of service that people receive. This is not a name, blame and shame game. Councils do not want to start a war of words with the NHS. The only way we will overcome these worrying problems is to work closer together to deliver the right services to local people at the right time and in the right place.'
Well, a war of words has ensued. In a response to the LGA, David Stout, director of the Primary Care Trust Network at the NHS Confederation, insisted that a survey of PCT chief executives had found that 'the number of local authorities in deficit to be very similar to the number of primary care trusts with financial difficulties'.
This fractious relationship at the top would not seem to bode well for the good-intentioned efforts of practitioners on the ground, striving to work together to ensure the successful delivery of the children's centre programme.
Tightening budgets for both local government and the NHS are clearly at the root of this conflict. Elizabeth Knight, who co-manages the Lark Children's Centre in Plymouth, says that it has lost 45 per cent of its funding this year, prompting centres in her area to club together out of financial necessity to provide services. 'It's a matter of sharing resources across centres as a means of coping with reduced funding, but it doesn't amount to joint commissioning,' she adds.
She says that several staff, including health visitors and a paediatrician, were seconded from the PCT to work for the former Sure Start local programme. 'Now we don't have any seconded staff in this financial year because the funding is much less, so we are looking at other ways of working together. People are really concerned about the change in funding with the switch from Sure Start local programmes to children's centres.'
Universal service
Liz Taylor, Sure Start strategic development manager at Southampton City Council, is well placed to understand the relationship between health and local authorities, as she was seconded to this post after working for the NHS as both a midwife and health visitor.
Ms Taylor is adamant that links with health are not just an option, but a vital necessity. She explains, 'From when a baby is conceived until it is three years old, health is the universal service. So, if you haven't got midwifery and health visiting on board, then you will struggle to engage with local practitioners, the local community and parents. It's important for targeting the most vulnerable families to determine the level of support they need, because midwives and health visitors will be doing those initial assessments.'
She says that from the inception of the Sure Start programme, health has been regarded in Southampton as a major partner and that includes both the acute trust with its maternity services, and the PCT. 'In Southampton the PCT has been co-terminous with the city council. The benefits of this are huge, because you are dealing with the same population, boundaries and indices of multiple deprivation.'
From the outset, the council's city-wide vision laid the groundwork for effective joint working and the new performance monitoring systems as well as local area agreements and co-operation through the children and young people's plan. Ms Taylor says the emphasis from the start was on 'building in and not bolting on', so that the work was not just guided by the evolution of an individual Sure Start local programme but by developing services that could be 'picked up by mainstream agencies in both the statutory and voluntary sectors'.
Sustainability problems
Unlike many authorities, Southampton did not seek to employ health visitors in Sure Start local programmes directly. Ms Taylor says, 'We bought extra hours so those health visitors working in Sure Start programme areas would have reduced caseloads so they could participate in this partnership working.'
She believes that some Sure Start programmes which neglected to build services with an eye on how they could be mainstreamed are now having sustainability problems under the transition to children's centres. And health visitors and midwives in many parts of the country have found that centres simply do not have sufficient funding to keep them directly employed.
In his briefing, entitled Partnership working: the facts, David Stout insists that while in some parts of the country 'the relationship between PCTs and local authorities is less than ideal', the outlook for partnership working remains 'very positive'.
Part of the tension between local government and the NHS can be attributed to the falling rate of growth in funding for both of them, and also ongoing reorganisation. The number of PCTs is being substantially reduced and while this is creating turbulence in the short term, most practitioners believe this will assist joint working in the long term.
Malcolm Hanney, who chairs the Bath and North Somerset PCT and is executive member for resources in the local council, says that it is 'natural when both parties are under organisational and financial pressure' that there will be a tendency for them to 'revert back to their own silos'.
The key, he insists, is that there needs to be 'a degree of organisational and personal trust. At the heart of everything you do must be the community and the people you are serving'.
Instead of arguing about who has the larger deficits, he says, the NHS and local authorities need to strive for larger joint budgets so they can work together across more areas.
Brokering new relations is central to integration. 'My assistant director for children's services in the PCT is now part of the senior management team of the children's trust led by the council and the director of children's services increasingly works with the chief executive of the PCT.'
Conditions of service
Councillor Bob Janes, cabinet member in Derbyshire County Council, says the reduction in the number of PCTs from seven to one bodes well for improved co-operation. 'There is a state of flux because of the PCT reorganisation and the need to rationalise and get all the services pointing in the right direction. But there is a will to do it, and the council has developed good early relationships with the new PCT.'
He notes that differences in conditions of service between NHS and local government employees are a concern. 'We have had problems transferring previous managers of Sure Start local programmes who were employed by health to become employees of the council because of the conditions of service issue.' Malcolm Hanney adds, 'The Government could help a great deal by having an overall public health contract enabling people to move effectively around the patch. However, we have had people working alongside each other in joint teams without them having to change organisations.'
While leading figures in local government and the NHS bicker over whose deficit is to blame for scuppering partnership working, practitioners focus on the need to develop links that will help children and families in the long term.
As Tina Bruce, visiting professor at Roehampton University, told Nursery World recently, 'This requires a highly educated, mature and appropriately trained workforce whose different emphases and expertises coalesce and bring together their strengths in integrated ways... reaching beyond partnerships which remain separate and alongside each other, such that they benefit children and their families with sustained consistency.'