partnership working and eligibility criteria: what can we learn from the implementation of guidance...

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S

P

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0144–5596V

. 36, No. 5, O

2002,

. 532–543

Blackwell Publishers LtdOxford, UKSPOLSocial Policy & Administration0144–5596© Blackwell Publishers Ltd. 2001Octover 20023651000Original Article

Partnership Working and Eligibility Criteria: What Can We Learn from the Implementation of Guidance

on Continuing Health Care?

Stephen Abbott and Helen Lewis

Abstract

Current government policy places great importance both on clinical governance and on partnershipworking between health and social services. Separately and together, these policy emphases requiregreater clarity in and between organizations about who should provide what care where than hasoften been achieved in the past. A study of the implementation of continuing health care policiessuggests that clarity about appropriate long-term health and social care provision was difficult toachieve in the

s quasi-markets, because there were too few financial and structural incentivesfor agencies to cooperate in developing and implementing precise and comprehensive eligibilitycriteria. This problematic interplay between financial and structural factors is being addressed bya number of government initiatives designed to stimulate joint working, although the difficulty ofdrawing a clear boundary between health care ( free at the point of delivery) and social care (whichcan be means-tested) remains.

Keywords

Partnership; Eligibility criteria; Continuing health care; Social care

Introduction

The new NHS: Modern, Dependable

(Secretary of State for Health

) heraldeda whole range of striking innovations in the NHS. In particular, emphasiswas placed on clinical governance, a concept which to some extent overridesprinciples of clinical autonomy in assuming that the judgement of indi-vidual professionals is not sufficient to guarantee quality, consistency and appro-priateness of care. Similarly, the White Paper introduced a formal duty ofpartnership, replacing years of exhortation to health services to work inpartnership with social services departments. These themes are taken up andextended in the NHS Plan (Secretary of State for Health

).

Address for correspondence:

Mr Stephen Abbott, Public Health and Primary Care Unit, School ofNursing and Midwifery, City University, Philpot Street, London, E

EA. E-mail: [email protected].

SPOL_269.fm Page 532 Thursday, August 29, 2002 10:55 AM


The emphasis on clinical governance is part of a number of intercon-nected developments. Growing emphasis on evidence-based medicine hasdrawn attention to the undesirability of clinicians operating in ways unsup-ported by, or antithetical to, existing evidence of what constitutes effectivepractice. A number of scandals have eroded confidence in professionals’capacity to regulate themselves. The introduction of the National Institutefor Clinical Excellence and National Service Frameworks (NSFs) is anattempt to ensure that local health services offer evidence-based treatmentsin appropriate settings. It is also aimed at improving consistency of deliverybetween settings and putting an end to “the lottery of care”: the element ofchance being due not only to geography (“postcode prescribing”) but also tothe clinical autonomy of health care professionals, not hitherto seriouslychallenged by British governments.

The emphasis on partnership reflects not only a major thrust of currentgovernment policy across all departments, but also a series of developmentsat the interface between health and social care over a decade. In mentalhealth, the Care Programme Approach (Department of Health

) was anattempt to address the challenge of achieving joined-up working. Later in the

s, Challenge Fund and Winter Pressures monies enabled and stimulatedlocal health and social care partners to work together more effectively onspecific projects, and the Partnership In Action flexibilities embodied inthe Health Act

built on and extended this approach. Care trustsnow exist which combine the provision of health and social care within oneorganization.

Both improved partnership working and the development of clinical gov-ernance should increase explicitness and clarity about what constitutesappropriate care and how and where it should be provided, and about howsuch clarity informs decisions about what care should be provided to meetthe assessed needs of individual patients.

This paper considers these two aspects of the NHS in combination, in thelight of a study (Abbott

et al.

) of a previous attempt to develop clearcriteria for services in a context of partnership, the implementation of thecontinuing health care guidance (Department of Health

). It first out-lines the continuing health care policy and its context; then it reports theaims and methods of the study, and presents the findings; finally it discusseswhy implementation of this policy was seen as being so problematic, and towhat extent new arrangements and policies are likely to improve joint working.

Background

The debate over responsibilities for “continuing health care” in the UnitedKingdom has been fuelled in recent years by a number of developments.The growth of independent-sector nursing and residential homes during the

s reduced the perceived need for the NHS to provide long-term care(House of Commons Health Committee

). Community health servicestaff increasingly provide elements of post-acute care previously providedby hospital staff, because of the increasing pressures on NHS providersto reduce lengths of stay to demonstrate “efficiency gains”. Social services



departments of local authorities (SSDs) increasingly provided the type of careand support at home which would previously have been the responsibility ofdistrict nursing services (Wistow

; Waddington

et al.

), and the vastmajority are now charging for such services (Lunt and Baldwin

; Laingand Buisson

), but on very different bases (Audit Commission

).These developments led to increasing public disquiet during the late

sand early

s over who pays for services, not least because of the need forsome older people to sell their homes to fund long-term care placements(House of Commons Health Committee

). The Department of Healthresponded by issuing guidance to “remind health authorities of their respons-ibilities for securing long term health care” (NHSE/SSI

). Healthauthorities (HAs) were given lead responsibility for developing local policiesand criteria, although they were expected to do so in close collaboration withSSDs and GP fundholders.

The guidance began with an explicit commitment to continuing healthcare as an “integral part of the NHS”. Purchasers were required to invest infurther provision “where they were currently failing to arrange and fund afull range of services”. The guidance covered not only NHS responsibilitiesfor continuing inpatient care, but also a range of other service areas: rehab-ilitation and recovery, respite care, services for people with palliative andterminal care needs, and continuing health care services within communityand primary health care. Purchasers were required to develop and publishlocal eligibility criteria for all these services. The guidance was intended tolead to “greater consistency between different parts of the country althoughthe pattern of services will appropriately vary to meet local circumstances”(House of Commons Health Committee

).The introduction of eligibility criteria represented a significant policy

development, as HAs had not previously been required to develop explicitcriteria for such a wide range of health services. In the past, criteria hadmainly been used by HAs to assist decisions about relatively unusual andcostly treatments, usually through extra-contractual referrals.

Research Study and Methods

This paper draws on three sets of research data: documentary analyses of thefinal continuing health care policies produced in three NHS Regions (Lewis

et al.

); a series of interviews with policy-makers and commissioners fromthe NHS and Social Services (“policy leads”) in those three regions (Abbottand Lewis

); and a small number of focus groups with clinical and carestaff (“frontline staff ”) ( Johnson and Lewis

; Abbott

; Johnson

).

Documentary analysis

In order to highlight areas of similarity and of difference between the documents,the research team developed and piloted a proforma for the documentaryanalysis of

continuing care documents produced in three NHS regions.The proforma included the main requirements for policies and criteria setout by the government.



Interviews with policy leads

Twenty-nine interviews with a sample of senior health and social servicespersonnel were undertaken between summer

and spring

. The aimwas to explore attitudes to, and perceptions of, the continuing care policyitself and of the process of developing the documents and eligibility criteria.Interviews were conducted in nine districts across three regions. The choiceof districts was opportunistic, and depended on the willingness of agenciesto participate. In total, there were

respondents from health authorities,

from NHS regional offices,

from SSDs and

from the Social ServicesInspectorate. The interviews were semi-structured. The interview topicguides were designed to elicit information and views about: the nationalpolicy context; the development of local policies; the aims and content of thepolicies; the implementation process; and monitoring and reviews. Writtenrecords of the interviews were analysed, and emerging themes identified.

Focus groups with frontline staff

These were held in three districts. In one district ( Johnson and Lewis

),the seven groups each comprised a variety of professional disciplines workingwith disabled adults; in the second (Abbott

), the two groups representedcommunity therapists (both professionally qualified and unqualified) from anNHS trust and social services respectively; and in the third ( Johnson

),two groups comprised a range of members of multidisciplinary teams work-ing with people with dementia. The groups were held in response to pointsmade by policy leads: in the second case, there was an acknowledgementthat the views of community therapists were not known; in the other twocases, policy leads believed that services provided were of particularly highquality.

The topic list included: familiarity with and understanding of policy andeligibility criteria; degree of use in practice of policy and criteria; trainingreceived; expected and perceived advantages and disadvantages; effect onmultidisciplinary working; and new initiatives/opportunities resulting frompolicy. Detailed notes were taken during the discussions, and emergingthemes were identified during analysis.

Findings

Although there was considerable variety between districts in the nature ofthe communities served, the range of services available and the reportedhistory of inter-agency working, analysis showed substantial thematic consist-ency between and within the sites and the three data-sets. In particular, thefollowing themes should be emphasized:

• the absence of specific detail in eligibility criteria;• the difficulty of negotiating policies and criteria;• the failure of the process of developing policies and criteria to solve

boundary disputes about responsibilities for care.



Documentary analysis

In general, policy documents were much less detailed than might have beenexpected from a reading of the original guidance. For example, althoughHAs were required to assess their population’s needs for continuing healthcare and to set out plans for how these were to be addressed, most docu-ments contained relatively little information either about needs assessment,current services and expenditure, or about detailed and costed strategicplans.

The eligibility criteria were characterized by a similar lack of detail. Mostdocuments drew heavily on the national guidance in setting eligibility criteriafor fully funded NHS care in an inpatient setting, and further detailed workon protocols would have been needed for the criteria to be useful aids toconsistency in clinical decision-making. Most documents did not specify anycriteria for accessing community health and primary care services, more orless explicitly leaving to clinicians the task of setting priorities for servicedelivery within block contracts. Services at the interface between domiciliaryhealth and social care services were not usually addressed. Although theguidance stated that local policies should include protocols for rehabilitationand recovery and palliative care services, very few included these. Furtherguidance (NHSE/SSI

) had recommended lists of services and equip-ment which were the respective responsibilities of the NHS and nursinghomes, but only about half of the documents provided these lists, and somedid not make it clear whether the lists were prescriptive or illustrative.

Interviews with policy leads

All informants stressed the importance of perceived resource constraints ininfluencing the discussions about eligibility criteria. Each felt the need to beextremely careful in committing limited resources, particularly in the absenceof information about likely levels of take-up; there was thus virtually no roomfor manoeuvre in discussions about service gaps. There was also a preoccu-pation with the perceived disinvestments made by each agency. There was aperception in SSDs that they had allowed HAs to disinvest in the provisionof long-stay beds and to fail to reinvest in community services. Since theirown funding was perceived to be less generous in relation to expresseddemand, SSDs were more inclined to challenge any further perceived cost-shunting. On the other hand, given the pressure of demand for hospitalinpatient beds, HAs (and indeed trusts) tended to feel frustrated by the failureof SSDs to move patients out of hospital as soon as it was judged clinicallyappropriate. SSDs were perceived to be disinvesting too, for example bywithdrawing domiciliary care from those with low-intensity needs.

Although HAs and SSDs were supposed to work together, this was not a

requirement

. This permitted “stand-offs”, which often occurred over the detailsof proposed eligibility criteria, both sides being very mindful of cost implica-tions. Although one informant commented that it was striking how muchSSDs and HAs had been able to agree at a general policy level, it was aboutdetail that most disagreements had so far arisen. In some districts, the process

SPOL_269.fm 36 Thursday, August 29, 2002 10:55 AM


of developing policies had exposed and exacerbated disagreements aboutdetailed responsibilities which agencies had sometimes previously “fudged”in order to retain amicable relationships. Greater clarity inevitably increasedthe potential for disputes, although agencies continued to work together toresolve such difficulties. Some said, however, that the debates about detailhad become sharper and harder to resolve, as both sides became clearerabout the implications of each part of the policy and criteria, and as resourceconstraints became ever more pressing.

Indeed, the lack of a joint and equal responsibility meant that it had beenpossible for some SSDs to change their minds suddenly, and to produceposition statements which were less in harmony with the developing continuinghealth care policies than had hitherto been the case (Ackroyd

et al.

).Such changes in position meant that discussions became “very emotive”.

For example, at the time of these interviews, a number of SSDs in thenorth-west of England were collaborating to produce a “framework of guid-ance” for their staff (ADSS North West Branch

). Some HA informantsbelieved that in taking a very clear and uncompromising stance on a wholerange of details, the framework was likely to worsen relationships betweenhealth and social services, particularly as HAs had not been consulted duringthe preparation of the document. This SSD document went into much moredetail than did any of the HAs’ continuing care documents.

It is also significant that this framework was a

collaborative

documentbetween a number of SSDs and endorsed by the North-West branch of theAssociation of Directors of Social Services. HAs, by contrast, generally pro-duced continuing care documents individually, although there was collab-oration between some HAs which related to the same local authority. Thislack of widespread collaboration meant that local policies would be less likelyto reduce inequities in service provision across the country. Indeed, policyleads expressed scepticism that such a mechanism could ever have broughtabout such an outcome. It was clear that districts had very different serviceconfigurations.

Focus groups with frontline staff

Although some frontline staff had initially welcomed the introduction ofeligibility criteria as likely to bring greater clarity and consistency to decision-making about individual care packages, such expectations were said gener-ally to have been disappointed. A few people, working in specialist multidis-ciplinary teams, found the criteria useful; otherwise, criteria were regardedas vague and unhelpful, making inter-agency discussions about services andfunding no easier and on occasion creating divisions which had not previ-ously existed. The implementation of the criteria tended to be inconsistent,because different professionals or teams applied them differently. In addition,some professionals (consultants and GPs were mentioned in particular) weresaid to be taking little or no notice of the criteria. Local availability ofservices and the assertiveness of individual patients or carers were otherfactors which meant that the application of the criteria was inconsistentwithin districts. In any case, such application was often entangled with decisions



about how to use the limited resources available, so that the criteria weresometimes seen more as financial than as clinical instruments, i.e. excludingpatients from care which might previously have been provided.

In two of the three districts, particular problems were associated with thefact that decisions about care packages or elements of care packages whichrequired extra funding were taken at HA level. (Interestingly, the very phrase“continuing health care” was virtually redefined in these districts as encom-passing

only

such referrals to the HA, i.e. for funding for health care whichwould not be carried out within the existing contracts for services.) Frontlinestaff found this unsatisfactory for a number of reasons: the decision-makingprocess was slowed down (even when patient needs were urgent); and deci-sions were taken by staff who did not have a clinical background, did notknow the patients, and who were felt to be preoccupied with financial man-agement rather than clinical care. Some frontline staff felt that they wereunable to predict the outcome of such applications, which made it difficultto know whether to apply at all, and what they should tell patients andcarers. (In another district, HA policy leads had expressed discomfort withsuch referrals. They felt that it was inappropriate that they should beinvolved in individual clinical decisions to such a degree, believing that trustswere calling too often on HA and SSD staff to sort out decisions about bed-blocking and/or the care of people with complex needs. As a result, policyleads themselves were beginning to feel more like provider managers thanpurchasers.)

Discussion

It is a limitation of the study that the second and third data-sets wereobtained by opportunistic, not random or purposive sampling, anddepended on the cooperation of policy leads locally. Presumably, districtswhere senior managers believed they had nothing to hide were more likelyto agree than others, in which case, our sample districts may have engagedmore positively in the implementation of continuing care guidelines, and/orhave provided better continuing care services, than others. However, it can-not be assumed that such managerial perceptions reflected reality.

Our findings show that, in these districts, eligibility criteria failed to clarifythe nature and scope of continuing health care services, which oftenremained imprecise and unclear. In particular, questions about whetherparticular services were the responsibility of HAs, SSDs or both were notadequately answered. Why was this the case?

One reason relates to resource constraints: NHS and SSD staff believedfirmly that resources were inadequate for all types of services. SSDs in par-ticular were cautious about their responsibilities for purchasing institutionalcare and concerned with over-committing themselves to recurrent expenditure.It is therefore hardly surprising that they sought to “draw a line in the sand”,and to define the boundaries of their responsibilities, in order to keep withinlimited budgets.

It might, however, have been expected that “drawing a line in the sand”would encourage, rather than discourage, precision. For example, the



“Framework of Guidance” (ADSS North West Branch

) produced bysome SSDs in the north-west was both detailed and precise, at least aboutthe boundaries of social care. Why, if SSDs were able to achieve this degreeof precision, did HAs not also manage to do so?

The answer relates to the interplay of

financial

and

structural

factors in bothhealth and social services, which developed rather differently during the

s. To take social care first: the Conservative government had sought tocontain the costs of publicly funded social care and nursing home care bytying its availability to professional assessment of need (Secretaries of State

). This linkage aimed to balance an assessor’s incentive to use moreresources with a budget manager’s incentive to spend less. Assessors needbenchmarks against which they can assess each client; this ensures compar-ability of needs assessment and care provision across the service. In addition,SSDs which charge for social care need to means-test clients, a process whichin its turn requires benchmarking of some sort.

Detailed local eligibility criteria were therefore widely developed for thecommissioning of social care. Such criteria inevitably exclude as well asinclude: they exclude from care packages services which have been assessedas not necessary; and they exclude from free service provision those who aredeemed to be able to contribute. Such processes and policies could be relat-ively coherent because they were the responsibility of a single organization,the SSD.

If we turn to the commissioning of health care, a very different pictureemerges. The NHS is not a single organization, but a family of very variedorganizations: health authorities, NHS trusts, GPs. In the reforms of theearly

s, the roles of budget-holding and clinical assessment were alloc-ated to

different

organizations (with the exception of GP fundholding, seebelow). It is not health care commissioners but clinical staff in primary careor NHS trusts who assess the continuing health care needs of individuals;and not clinicians but commissioners who contract with providers of care for(usually) local populations rather than individuals. HAs and trusts were notin general used to talking to each other about individual cases at all, exceptas regards rare and high-cost treatments, and HAs employed few if anyclinically trained staff able to check on the quality of assessments by truststaff.

Because they lacked mechanisms for adequate participation in clinicaldecisions, and because of resource constraints, HAs were likely to set criteriawhich were vague and which reflected the

status quo

. If they set precise crit-eria which erred on the side of inclusivity, trusts might well argue that theyneeded more resources from the HA to meet the needs included. If precisecriteria erred on the side of exclusivity, trusts would then request specificfunds for the care of some patients whose needs, now excluded, would, priorto the setting of criteria, have been met from within existing contracts.

Policy leads reported that it had not been easy for HAs to engage NHStrust staff in discussions around continuing care and eligibility criteria. Thisis unsurprising. Trusts were used to managing large volumes of work, forwhich they had a range of block contracts, by means of individual cliniciansprioritizing cases within their own workload. There were no incentives for trust



clinicians to change this custom and to participate actively in the devisingof precise eligibility criteria which would be seen as “outside interference”with clinical autonomy; nor would trust managers wish to encourage suchinterference with their clinicians.

Fundholding GPs generally did not take an active part in the consultationsabout eligibility criteria (Glendinning and Lloyd

): in our study, both theanalysis of policy documents and interview data suggest strongly that GPparticipation in the consultation process was unusual. In general, GPs valuetheir financial and managerial independence as well as their clinical freedomto treat and to refer, and GP fundholding gave them freedom to purchaseindependently of HAs. In requiring GP fundholders to sign up to districtpolicies, the guidance eroded this freedom. It is hardly surprising, therefore,that most fundholders opted out of the consultation process. Some HAssought to enlist non-fundholding GPs’ help in negotiating with trusts, butthere was no obligation on GPs to provide such help, nor to work within theresource constraints faced by HAs. Indeed, GPs, regarding themselves asadvocates for patients, might have seen as unethical any cooperation withsuch constraint, if this appeared to prejudice patient care (Glennerster

et al.

). GPs, therefore, like their hospital colleagues, lacked incentives to signup to restrictive criteria.

The interplay of resource constraints and organizational difference oper-ated to influence the implementation of community care policy in a furtherrespect. The market in the NHS was in many ways at best a quasi-market(Glennerster and Le Grand

): for example, NHS organizations could notuse market means to increase their income, such as increasing their activity,when it was clear that purchasers had no more money to pay for such anincrease. In order to create additional capacity within restricted budgets, orto maintain financial balance, there was therefore an incentive to shunt coststo the social care sector. Although each side had an incentive to prevent suchshunting by defining criteria tightly, only the social care sector, which wasnot the lead agency in continuing care, had the necessary experience andorganizational structure to be able to do so. SSDs had the further ability toshunt costs to service-users by changing the criteria for means-testing, astrategy largely unavailable to NHS organizations. (Although some consult-ants do have incentives to encourage NHS patients to become their privatepatients, this is more common in acute than continuing care.)

The present government is trying to dismantle the “Berlin wall” betweenhealth and social care. Will its attempts to promote better joint working(Health Act flexibilities, the duty of partnership, a strong emphasis on inter-mediate care, and care trusts) create adequate structures and incentives forsuccessful joint working? Will it enable both cooperation between agenciesand clarity about the responsibilities of individual agencies?

In a number of respects, the structures and incentives do look more robustthan before, at least on the surface. Like fundholding, primary care trusts(PCTs) bring together primary care clinicians and the commissioning func-tion, but they do so much more extensively: PCTs will be universal, notvoluntary, and they will commission or provide all, not just a specific rangeof, hospital and community health services. PCTs are now required to plan



services themselves, rather than delegating the task (and the blame) to thehealth authority. Bringing responsibilities for commissioning and provisiontogether should enable a more coherent strategy than was possible for HAsworking alongside GP fundholders. Indeed, HAs will no longer havecommissioning responsibilities (Department of Health

).Moreover, National Service Frameworks (NSFs) offer guidance on

where

and

how

care should be offered; this should reduce the danger both of shunt-ing work from health to social care, and of PCTs moving services out ofsecondary care into primary care for primarily financial reasons (includingthose of maximizing personal income) (Killoran

et al.

). Well-developedsystems of clinical governance should describe and prescribe appropriatecare in a way never required by block contracts with HAs. However,although there is evidence that PCTs are making progress in clinical govern-ance, the challenges should not be underestimated (Campbell and Roland

). All NHS trusts will need to develop clear criteria for different serviceelements, both to ensure clinical consistency and appropriateness (clinicalgovernance), and to optimize resource use.

New flexibilities for joint working in the Health Act reduce theincentive for health and social care agencies to cost-shunt between themselvesby enabling them to share responsibilities and resources, although suchflexibilities are voluntary and not yet widely implemented (Hudson et al.). Even when these are not used, the presence of SSD representation onPCT boards ought to encourage closer engagement between the NHS andSSDs, although research evidence suggests that such a simple structuralmechanism will not resolve the structural, cultural and historical complexitiesof partnership (Callaghan et al. ; Hudson ; Glendinning et al. ).The requirement of a joint assessment process outlined in the NSF for olderpeople should stimulate joint working in detailed and specific ways. In itself,such a process does not reduce the scope for disputes about responsibilities,but it may promote better and more consistent inter-agency communicationabout both individual care and service criteria. Care trusts, which willcommission and/or provide both health and social care, should be less likelyto indulge in border disputes, and will presumably develop clear criteria forsocial as well as health care.

A similar driver for close joint working is the government’s emphasis onintermediate care. Intermediate care schemes will undoubtedly include theprovision of continuing primary and community care. However, agencieshave to decide just what are the health and social care components of inter-mediate care packages, as they do in the case of domiciliary and institutionalcare. The difficulty of doing this is evident in the government’s unsatisfactoryattempt to define “nursing care”, subsequent to its promise to fund thiscomponent of nursing home care (Henwood ). Local definitions of socialand health care determine how much personal care can, if classified as socialcare, be charged to service users who can afford to pay. Incentives thereforeremain for SSDs and care trusts to shunt costs to service users in this way.

Overall, the prognosis for the future is very mixed. A number of innova-tions and policy emphases encourage health and social care agencies to workmore effectively by being detailed and specific about their respective



responsibilities for care. But these innovations all require prolonged andchallenging work if they are to succeed. Besides, the rationality of changes inclinical practice or management arrangements will continue to be underthreat whenever resource-constrained organizations are tempted to redefinecriteria so as to be able to charge service users for social care.

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