Royal Commission on the NHS Chapter 16

The NHS and Local Authorities

16.1 In this chapter we consider the relationship between the services the NHS provides and those provided by local authorities. There are important relationships between the NHS and housing, environmental health, education and other services provided by local authorities, but the most direct is with the personal social services. The importance of effective collaboration between the NHS and the personal social services, and indeed their interdependence, was a recurring theme in much of the evidence we received. Caring for people in the community is of increasing importance, and it is essential to have the easiest and most efficient collaboration between the NHS and local authorities.


16.2 Good co-operation between the NHS and local authorities is import­ant because their responsibilities overlap. The most common example of joint responsibility is the care of infirm elderly people. Many of them can be looked after at home without overburdening the family if the local authority is able to provide a home help and meals on wheels, or day care and social work support, or sheltered housing; and the NHS provides family practitioner, health visiting and home nursing services. If these services are not available and properly co­ordinated where they are needed, an elderly person may need to go into an old people’s home, or hospital. Effective co-operation is similarly important to the other main patient and client groups who require help from both NHS and local authority services – the mentally ill, the physically disabled and the mentally handicapped – and for the individual person at risk. Cost considera­tions apart, most of us would prefer to live at home rather than in an institution or hospital, however congenial. It is obviously desirable that services should be provided in a way which makes the life of the patient as independent and satisfying as possible.

16.3 The importance of collaboration between health and personal social services was fully recognised at the time when the NHS and local government were being reorganised. Government white papers published in 1971 and 1972 emphasised the point, and NHS reorganisation legislation laid a duty on health and local authorities to co-operate with one another in order to “secure and advance the health and welfare of the people of England and Wales”. There was a similar provision in the Scottish legislation. In Northern Ireland health and personal social services are administered jointly, and we deal with them below (paragraphs 16.26-28). A special working party on collaboration between the NHS and local government in England and Wales was set up and produced three reports between 1972 and 1974. A similar Scottish working party reported in 1977. Post-reorganisation experience shows that effective collab­oration requires that those involved should have appropriate training and sufficient authority within their own organisations to carry out the task which is to be performed jointly. Continuity in post of the personnel involved is particularly necessary. Before any collaboration begins, its purpose, form and resource implications should be identified with the different agencies and professions involved, and we so recommend.

16.4 Before dealing with the problems of collaboration we comment briefly on the arrangements for the provision of social work support to the NHS. Since NHS and local government reorganisation this has been the responsibility of local authorities. Before that the qualifications of hospital social workers were prescribed. The indications are that since reorganisation social work support to the health service has been maintained and is developing, particu­larly in attachments to general practice and in liaison schemes where the stimulus of joint financing has encouraged progress. The provision of social work services is essential to good patient care. However, by 1976 fewer than half of all social workers in the UK were professionally qualified and fewer than 5% of those in residential social work had a recognised social work The Central Council for Education and Training in Social Work stressed in its evidence to us the need to sustain a 5% growth in training in the short term and we fully accept the importance of this to the NHS.

There are a number of formal arrangements for facilitating effective collaboration:

coterminosity— at NHS reorganisation health authority boundaries were drawn so as to conform to those of the reorganised local authorities responsible for providing education and personal social services, ie the non-metropolitan counties and metropolitan districts in England and Wales, and the regional councils in Scotland;

common membership of local goverment and NHS authorities— one-third of AHA members in England and Wales are selected directly by the local authorities in their area. Ministerial appointments to RHAs are made in consultation with local authorities as well as other organisations. In Scotland a proportion of health board members are appointed by the Secretary of State after consultation with local authorities;

interchange of staff— health and local authorities have power to provide each other with goods and services. Health authorities make staff available to local authorities to help them to discharge their environmental health, education and personal social services functions; and local authorities make available social workers to health authorities;

joint consultation— in England and Wales a statutory joint consultative committee for each health and associated local authority is appointed to advise the authorities on the performance of their duties. Joint liaison committees with similar functions are being established administratively in Scotland;

joint financing— since 1976 joint financing of projects of benefit both to health and local authorities has been possible in England and similar arrangements have more recently been introduced in Wales and are under consideration in Scotland.

Criticisms of Present Arrangements

16.6 Despite the considerable efforts made at the time of reorganisation to ensure the close co-operation of health and local authorities, we have heard a great deal of criticism of the existing arrangements. The main complaint has been that responsibility for the individual patient or client is unclear, and that as a result he or she may fall between two parts of what should be an integrated service.

16.7 There are more specific complaints. For example, we were told that a patient may have to be sent to hospital or kept in hospital, because of a lack of suitable accommodation or support in the community. On the other hand, some local authorities considered that because of shortages of hospital beds the community services had to deal with people who should really have been in The Association of District Councils told us:

“In some instances there has been a tendency to regard the warden service provided by a housing authority as a reason for leading an elderly or disabled person in his or her home long after institutional care has become necessary”.

16.8     Another complaint is that patients may be discharged from hospital without proper arrangements being made to support them in their homes because of lack of communication and understanding between professionals in the two services. Despite the obvious need for close co-operation between health and personal social services in such cases, doctors and social workers were often critical of each other’s roles and capacity to fulfil them. We were told that in some social services departments, collaboration arrangements did not run smoothly because the liaison officers at senior level, recommended by the collaboration working parties, had not been appointed. Better mutual understanding and planning of services is needed to co-ordinate social work support to the NHS and to contribute to joint planning.

16.9     The disappearance of the medical officer of health, with his dual responsibility for preventive and many environmental services, has been mourned in some places since reorganisation. There were also complaints that in Scotland the relative responsibilities of health boards and local authorities for the control of communicable diseases was unclear. We deal in Chapter 5 with the role of environmental health services in preventing ill-health and in Chapter 14 with the important role of the community physician.

16.10 These and other deficiencies occur despite the elaborate arrangements described in paragraph 16.5. A number of causes were suggested, the most important  of which  is  that  NHS  and  local  authority  priorities  are different when it comes to providing complementary services. There are at least two reasons for this. One is financial: since the NHS is funded centrally there is a built-in incentive for the local authority to push as much expenditure as possible onto the NHS. Equally, of course, a health authority’s expenditure will be reduced for every potential hospital patient who is looked after in his own home or in local authority accommodation.  Second, health and local authorities have different functions: while health is the sole preoccupation of health authorities, it is only one of several competing responsibilities of local authorities. The provision of hostels by local authorities to enable patients to be supported in the community instead of in hospital has to compete with new schools or housing, both of which may be more attractive to the local politician and voter.

16.11 The lack of progress made by some joint consultative committees may be a symptom of health and local authorities’ differing priorities. The Institute of Health Service Administrators told us:

“The way in which the joint consultative committees and their officer groups have developed clearly differs enormously. Some health service administrators find it very difficult to see how far they have had any beneficial effects on what they have achieved, whereas others are able to report upon them as vehicles of close collaboration and worthwhile development.”

The Institute also commented:

“It is perhaps significant that local government officer participation in joint consultative committees has tended to be at a lower level of seniority than that of the health service”.

16.12    Effective co-operation is clearly in the interests of both services. A fresh impetus is needed. There was a strong feeling in the evidence that many of the problems of collaboration could be overcome, or at least eased, if money were not so tight. Local authorities have been under the same kinds of financial pressures as other public authorities in recent years, and it is hardly surprising that they should have found it difficult to develop their services as fully as they and the interested health authorities wished. Joint financing seems to have helped, but as the report of a working party, set up jointly by the Personal Social Services Council (PSSC) and the Central Health Services Council put it:

“Inadequate resources are clearly a great obstacle to adequate service of any sort. . . Joint financing … is clearly insufficient to overcome the overall shortage of resources.”

16.13 Finally, there is the question of coterminous boundaries. Opinion on the value of coterminosity was sharply divided. There was support for it particularly from those concerned to see the development of a more integrated service and closer links between hospital and community services. On the other hand Professor Kogan found in his study that:

“A surprisingly large number of respondents, and in all disciplines, positively expressed the view that the principle of coterminosity was irrelevant, or worse, to the running of the health service and the relationship with the cognate local authority services.”

We deal in Chapter 20 with coterminosity in the context of our discussion of the structure of the NHS at local level.

Suggested Solutions

16.14    The three health departments in Great Britain told us in their introductory evidence that they were keeping a close watch on the progress being made towards the aims of collaboration but added:

“there is a general impression that [joint consultative committees] have not yet been able to reach their full potential”.

A more positive step is the growing amount of money health authorities can make available for joint financing of health and local authority projects. This was expected to rise in England from £34.5m in 1978/9 to £44m in 1980-81 and we hope that it will enable more rapid progress to be made in developing complementary services. Although the take-up of the funds available under the scheme has improved considerably, we understand that some local authorities are reluctant to commit resources to projects which they would have to take over in the long term. We hope the current discussions between the DHSS and the local authority associations will resolve these outstanding difficulties.

16.15    Several more radical solutions have been suggested to help overcome complaints and criticisms. We discuss here suggestions that responsibility for the NHS should be transferred to local government; that the personal social services should become the responsibility of the NHS; and that responsibility for certain “client groups” should be transferred from the NHS to local government or vice versa.

Transfer of NHS to local government

16.16    The proposal that the NHS should be wholly run by local govern­ment is not new. Before the introduction of the NHS in 1948 most hospitals and a number of other health services were provided by local authorities. The 1944 White Paper “A National Health Service”, pointed out that:

“in a long series of Public Health Acts and similar measures Parliament has placed the prime responsibility for providing the health services -hospitals, institutions, clinics, domiciliary visiting, and others – on local, rather than central, authority”

The possibility of transferring the hospital service to local authorities was considered and rejected by the Guillebaud Committee in 1956, although Sir John Maude, a member of that Committee, looked forward to the day when a reorganised local government would assume responsibility for a unified NHS. Thirteen years later, the Royal Commission on Local Government in England3 envisaged the transfer of the NHS to a reorganised local government. The government of the day rejected this recommendation. Mr R H S Crossman’s Green Paper published in 1970 which preceded NHS reorganisation, concluded:

“that the unified National Health Service cannot be directly or indirectly controlled by local authorities, and that special area health authorities must be established to administer it”.

Despite the fact that local authority control of the NHS has been rejected more than once in the past, some of the organisations sending us evidence continue to support it.

16.17    Transferring responsibility for the NHS to local authorities would certainly be a logical way of dealing with problems that arise at present from divided   responsibility   for   the   complementary   health   and   local   authority services. Local government has made in the past, and continues to make, a very important contribution to health, in particular through housing, environ­mental health and personal social services. If responsibility for health were transferred to local government all these services would be concentrated in the hands of one organisation and this would facilitate comprehensive planning. The local administration of health services could no doubt be carried out in much the same way as the administration of education services, supervised by a committee of the authority. Finance could be provided through the existing rate support grant mechanism or by direct grant from government. National priorities could be set and their achievement encouraged by a combination of exhortation and earmarked funds. Central negotiation of terms and conditions of service, and the control, for example of medical manpower, could continue. Those who, like the local authority associations in England and Wales, argue for local government control of the NHS point out that health is no more expensive to run than education, and suggest that special arrangements could be made to safeguard the interests of the health service professions.

16.18     A further substantial argument for putting the NHS in the hands of local government is that the health services would be controlled by people directly elected and accountable to local users of the services. Local priorities – the closure of a hospital, the provision of a health centre – would be settled at local level. It can be argued that local government control of the NHS would bring greater local accountability. The chairman of a health authority is appointed by a health minister; the chairman of a local authority health committee would be elected by his fellow councillors.  Officials of local authorities might be more accountable than health authority officers who are responsible to appointed rather than elected members. In the course of making a strong case to us for transferring the NHS to local government control, the Association of County Councils said:

“The Association believe that the most crucial decision before the Commission is whether the service will be returned to the public. Such a step, with the agreement of the professions, would go a long way to ensure a Health Service which belongs locally and to which people feel committed”.

The Association also argued that community health councils would not be needed if the NHS were democratically controlled at local level. A further advantage would be that additional funds could be levied from the rates to help meet local priorities and express local commitment.

16.19    The 1970 Green Paper which we quoted earlier gave two main reasons for rejecting the transfer of the NHS to local government control:

“First, the professions believe that only a service administered by special bodies on which the professions are represented can provide a proper assurance of clinical freedom. Secondly, the independent financial resources available to local authorities are not sufficient to enable them to take over responsibility for the whole health service”.

16.20    Our evidence suggests that there would be great resistance in the NHS to a local government “take over”. The Confederation of Health Service Employees, for example, were emphatic that “the NHS has no place in local politics”. The Regional Administrators in England declared themselves “totally opposed” to a transfer. Part of this opposition no doubt comes from those who have an interest in the management of the service at present, plus fears that the special needs of the NHS could not be properly appreciated by those outside it. Moreover it is inevitable that the service would be run by those committed to the policies of one political party or another, and committed to many interests other than those of the NHS.

16.21 A number of other objections to the transfer of the NHS to local government have been advanced. First, there is no equivalent in the present pattern of local government to the regional tier which has been considered necessary for the effective administration of the NHS in England. Second, although collaboration between the present local government services and the present NHS services might be improved, there is no strong reason to think that health services would be better run by local government as presently Third, while it is true that local authorities are responsible at present for public education, the addition of another public service as large again would inevitably impose great pressures on local authority administration. Finally, it is arguable that the gain in local responsiveness would be matched by a loss in momentum towards achieving national standards.

16.22 Proper consideration of the question of transferring the NHS to local government requires thorough inquiry into local government itself as well as the NHS. This would have been clearly outside our terms of reference, and would in any event have taken far more time than we could afford. After much debate, we decided that, although a transfer has many attractions and is in some ways a logical development from the present structure, we could not recommend it at the present time. We think that a further reorganisation of the NHS of such major dimensions should be avoided at least in the short term, and we note that at present there is no regional level of local government. Joint administration  of health  and  local  authority  services  might  become feasible if regional government reached the political agenda; and we consider that any small scale changes which may take place in the structure of the NHS or of local government in the next few years should not make more difficult an eventual joint administration of these services at regional level.

A transfer of personal social services to the NHS

16.23 There was also support in the evidence for transferring responsibility for the personal social services to the NHS. The British Medical Association told us:

“The administration of the health and personal social services should be functionally reintegrated. This is particularly important in those areas – care of the elderly, of the mentally ill, handicapped (mentally and physically), and those requiring after care – where health and social workers are dealing with the same patients.”

This would be a less radical solution to the collaboration problem and would avoid some of the objections to shifting responsibility for the NHS to local government. A number of professional bodies and trade unions, the Royal College of Nursing and the National Union of Public Employees, for example, supported it. It would integrate the NHS with that part of local authority responsibilities with which it has most contact. There is a precedent for it in Northern Ireland. For those social workers who were previously employed by the NHS it would mean reverting to a position similar to that before 1974.

16.24 On the other hand, the potential benefit from this less radical solution looks to be smaller than that from transferring the NHS to local government, and for the majority of social workers it would mean a major and unwelcome change. It would not by itself produce the integrated planning of the full range of health and local authority services which many people consider necessary. It would shift the dividing line between the NHS and local government but the dividing line would still remain: housing and education with which the NHS is also closely involved would remain on the local authority side of the line. In any case, while the NHS depends heavily on personal social services, it probably generates well under half the caseload of social workers, the rest coming from their other responsibilities. Transferring the personal social services into the NHS would disrupt these other functions and import into the NHS responsibilities for matters outside its scope. It would certainly be strongly resisted by local authority interests.

Transfer of client groups

16.25 Another suggestion is that the primary responsibility for the care in the community of particular patient or client groups might be wholly assigned to one service or the other with the object of achieving greater continuity of care for the groups in question. For example, the NHS might assume responsibility for all services for the elderly, while local authorities might take over those for the mentally handicapped. This would have the advantage of making quite clear where responsibility for particular groups lay and of avoiding the criticisms of divided responsibilities to which we referred in paragraph 16.6. However, it would also mean that local authorities would have to employ nurses and doctors, and the NHS social workers and home helps. This would cut across the grouping of the professions following reorganisation. Difficult problems of definition such as when a patient is to be considered “geriatric” rather than “acute” would still need to be resolved, and financial arrangements would need to be worked out. We think the possibilities of transferring the main responsibilities of services for particular patient or client groups might be the subject of local examination and experiment. The effectiveness of such arrangements in practice cannot be assumed.

Northern Ireland Experience

16.26 Experience in Northern Ireland is particularly interesting because of the integration, since October 1973, of the health and personal social services. There were special factors which led to the transfer of major local government functions to the four health and social services boards. The structure of local government in the Province had been reviewed and the pattern adopted was one of 26 single-tier local authorities which, with one exception, covered small populations ranging from 13,000 to 90,000. They were not considered an adequate base for the provision of personal social services. In addition these authorities did not carry the other related local government functions of housing and education.

16.27 The integration of health and personal social services has been criticised. There was a fear that the personal social services would be dominated by the health services and absorption into the new boards would lead to a de-personalisation of social work. On the other hand there have been advantages. The director of social services is a member of the management team at area and district levels. This has made the job of planning health and social services simpler and more effective. The Department of Health and Social Services in Northern Ireland told us that the total resources can be more easily allocated through the PARR formula, not only at departmental level but throughout the services. Services can be planned without recourse to the more difficult exercises of joint funding and joint planning which are required in Great Britain where the services are administered separately.

16.28 It seems clear that the full potential of this experiment has not yet been realised. The planning systems are still in an embryo stage and as we saw on our visits to Northern Ireland, there are practical difficulties in the field which need to be ironed out. However, Professor Rea and Dr O’Kane found that:

“While some respondents considered that the system was not working as well as it should, nevertheless the impression gained was that integration was inherently beneficial with, at its best, an improved continuity of care between hospital and community for all patients and special care groups.”

Although special political factors present in 1973 may have encouraged integration there should be no turning back. We recommend that in Northern Ireland the present integration of the health and personal social services should be encouraged and further developed.

Conclusions and Recommendations

16.29 There is no doubting the importance of effective collaboration between health and local authority services. While eventually the integration of these services may become possible, there is little in the present administrative arrangements to prevent or even hamper such collaboration, though its success depends on the attitude of the parties to it. If there is determination on both sides to work together, many of the problems referred to above could be solved. If, however, authorities or professions are at loggerheads, coterminous boundaries, overlapping membership and joint committees will be ineffective. Post-reorganisation experience shows that effective collaboration requires that those involved should have appropriate training and sufficient authority within their own organisations to carry out the task which is to be performed jointly. Continuity in post of the personnel involved is particularly important.

16.30 It is clear from our evidence that relations between health and local authorities range from indifferent to excellent. It is hardly surprising that this variation exists, given the differing circumstances in which the new authorities found themselves when the new services were introduced. Changes which we recommend in Chapter 20 to the local management of the NHS will, we believe, greatly improve working relationships.

16.31 The improvement will be assisted if there is more emphasis in the education and continuing training of health and social work professionals on the importance of inter-professional collaboration and we recommend accord The PSSC/CHSC document on collaboration identifies such training carried out jointly, and better communication, the development of multi-disciplinary working and the development of agreed procedures as ways in which better collaboration can be achieved at field level.  Good working relationships   are clearly of the essence. We endorse the PSSC/CHSC Committee’s approach and in paragraph 16.3 we identified a number of requirements for effective collaboration and planning at all levels.

16.32 We recommend no radical changes in the responsibility for either the health or the personal social services. The evidence we received tended to divide according to the interest of the organisation concerned: local authorities often argued for local government control of the NHS, and health authorities advocated the absorption by the NHS of the social work services. We are also doubtful of the benefits which might arise from an allocation of responsibility for patient and client groups. It is obvious that no radical structural solution would command general support, but in any case we do not think changes of this kind are necessary at present simply to achieve better collaboration between the NHS and local authorities. Joint administration of health and local authority services might become feasible if regional government were introduced in England. If such a change reached the political agenda in the next 20 years, joint administration of health and local authority services would merit serious consideration.

16.33    We recommend that:

  1. before any collaboration begins, its purpose, form and resource implica­tions should be identified with  the different agencies and  professions involved (paragraph 16.3);
  2. in Northern Ireland the present integration of the health and personal social services should be encouraged and further developed (paragraph28);
  3. there should be more emphasis in the education and continuing training of health and social work professionals on the importance of inter-profes­sional collaboration (paragraph 16.31);
  4. there should be no radical change in the responsibilities for either the health or the personal social services (paragraph 16.32).