Special Report on commissioning of adult social care 
Community Care, 08/06/2005 

There are to be no shotgun marriages - the language is now about 'virtual' care trusts, closer partnerships between the organisations, more pooled budgets and sharing of staff. 

Then there is 'cross-commissioning', where community matrons and nurses commission home care, or social workers commission equipment or health interventions as part of their case management role. 

Meanwhile, adult social services departments will be allowed to contract out even their statutory functions, while still retaining overall responsibility for them. 

Should this sort of closer working not materialise, the government warns it may 'strengthen the duty' for local authorities and NHS bodies to co-operate in commissioning adult services and sharing responsibility. 

Two other major green paper themes are the need to give clients choice and independence and the need to prevent more ill health and social exclusion, thus saving on complex care needs later on. 

New partnership arrangements - Local Area Agreements and now Local Public Service Agreements - are the means to bring commissioners together with their communities to address these themes. 

Getting people into primary services 

Local authorities see their role as helping people access free universal services - the preventive part - and as guarantors of quality for the more complex care packages that they buy in the marketplace. 

"We need to be looking at how do we get people into universal services, like primary care; to accessing ordinary services rather than specially tailored individual services which tend to be stigmatising and expensive," says John Dixon, social services director in West Sussex and co-chair of the Association of Directors of Social Services disabilities committee. 

But a headache for commissioners is that one of the engines of the choice agenda - direct payments - also threatens to unsettle their long-term planning and block-contracts with big care providers. 

"I know that providers are very bothered about hundreds of thousands of people all buying care packages from cards in newsagents windows and small ads - the potential destabilisation is horrendous," says Dixon. 

"It's a myth that social service departments have been dragging their feet over direct payments. The problem is service users don't want the bureaucracy and the risk of having to assure the safety for themselves. They want someone to turn to if things break down." 

Local government is therefore keen to see personalised budgets introduced well before the projected date of 2012. "With personalised budgets I expect them to be able to buy off of local authority block contracts, something you can't do with direct payments," says Dixon. 

"The local authority can still do the commissioning and users can go to those providers safe in the knowledge they have been assessed by the council - there's much less risk to the service user." 

Direct payments should not be restricted to social care 

The other sticking point with direct payments is they are not available to NHS bodies - creating real headaches for any arrangement in which the NHS and adult social services share care. 

"Direct payments must not be restricted to social care as service users will look to have the same level of flexibility and choice in other services, including health care, as this agenda progresses," says Jeni Bremner, programme manager on the Local Government Association's community wellbeing board. 

"The provision of community based health care such as district nursing and chiropody can be fundamental underpinnings of independence. It is essential that the choice agenda in the NHS and other areas of public service keeps pace with the social care agenda as it develops." 

There is a way around this bar on NHS direct payments, but it's a complex agreement known as a Section 31 arrangement. Dixon argues: "It should be written into the White Paper that we will allow the NHS to have direct payments, otherwise someone who moves from social care to community care loses that option." 

"Boundaries will be blurred, says Webber" 

From the NHS point of view, a big change in commissioning habits may come once GPs' practices are again allowed to hold commissioning budgets. "Patients will have more choice about what and where they want their care to be delivered," says Jo Webber, policy manager at the NHS Confederation. 

"There always will be issues around resources" 

"Front line professionals have been trying to make care packages fit round patients, so it's nice to have that reinforced in the green paper. 

"There always will be issues around resources, but now there are more open and honest conversations.' 

The green paper points to some innovative ideas such as adult placements (i.e. fostering for adult clients) but is not prescriptive about new service configurations. 

"What you are going to find is some of boundaries between health and social care workers will get more blurred as time goes on,' says Webber. 'It makes no sense to duplicate going in to see someone when, with cross training, one person could deliver a package of care.'