A shake-up of social care services in England will be announced towards the end of this month by Alan Milburn, the health secretary. Although the final shape of the new regime is still under discussion in Whitehall, it seems certain that the outcome will involve an unequal trading of powers between the NHS and local authorities. Elected councillors will be allowed to commission a wider range of services for children, in return for abandoning their monopoly of control over the much larger and more costly range of social care services for mentally ill and elderly people.
"The current inflexible partitions between primary care, social care and hospital care leave patients bewildered, sometimes lost, in a maze of conflicting services," Milburn told the NHS Confederation conference in Glasgow. "That is why the national plan will include new roles for staff and new means for integrating health and social care services."
Mental health services and mental health social work could be delivered through a single provider trust. And services for older people could be commissioned by primary care "super trusts" - partnerships under the 1999 Health Act allowing the NHS and local authorities to pool their budgets to deliver an integrated package of medical and social care.
"But this is not one-way traffic, with health organisations taking on social care functions," Milburn said. "It is perfectly possible, for example, that more child care and child protection services could become part of the early years directorates with in local authorities."
He added that the local authorities' role might extend to commissioning medical services for children with disabilities, tackling their health and educational needs together.
For local government chiefs there are too many unanswered questions to feel relaxed about the plan. The first is uncertainty about what Milburn means when he talks about partnership.
"If he is suggesting a new approach to commissioning that would bring more consistent consultation and partnership, then we have declared ourselves naturally interested," says Jim Kennedy, the Local Government Association's head of social affairs and health. "But that is in stark distinction to giving the whole process of commissioning social care to one side or the other."
In other words, the local authorities could live with local arrangements allowing a pooling of health and social care budgets and a sharing of control over how they were distributed. It would also retain an element of local democratic accountability.
But would there be an equal partnership? Or could the NHS have such a dominant role that the local authority does little more than sign the cheques?
Ministers have not yet decided the balance of power, but the signs are that they will not be seeking to emasculate the local authorities. They want reform to proceed quickly and they know the integration of health and social care will be smoother if it can be done on a voluntary basis - although legislation may be needed to universalise the changes at a later date.
There is also uncertainty about which children's services may pass from NHS control into the hands of local authorities. Jo Williams, president of the Association of Directors of Social Services, points out that Milburn's Glasgow speech could theoretically open up the possibility of councils taking over GP services for children, respite care and hospital paediatrics. But nobody is expecting such a radical shift. A consolidation of local authorities' responsibilities for child protection is the more likely outcome.
The reforms will have far-reaching consequences for the social care professions. The action team advising Milburn on partnerships in the health service has said that "a new, flexible, multi-skilled care worker is required to act as a personal carer, addressing the basic health and social care needs of patient/users". A new type of "specialist older people's nurse" able to work across the health and social care boundary is also envisaged.
