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									                          MEDWAY COUNCIL


                          6 NOVEMBER 2007


Portfolio Holder:    Councillor Tom Mason, Adult Services

Report from:         Ann Windiate, Director of Community Services

Author:              Amanda Rogers, Assistant Director, Social Care

1.     Summary

1.1    This report provides information to Cabinet to facilitate a decision to be
       made on the appropriate threshold for access to adult social care in
       Medway for implementation in 2008-2009.

2.     Decision Issues

2.1    This decision is a matter for Cabinet because it supports the Council’s
       agreed Policy Framework through both the Community Plan and the
       Performance Plan. The Community Plan states a priority to enable
       people to remain healthy and independent, especially older people and
       other vulnerable groups. The proposed Fair Access to Care Services
       eligibility criteria support this by ensuring that social care support is
       targeted to those in greatest need. The Performance Plan sets out how
       we will achieve our aims for older and vulnerable people to maintain
       their independence. It is important to state that the preventative and
       rehabilitative initiatives within the Performance Plan and elsewhere
       support Fair Access to Care Services Eligibility Criteria by minimising
       the number of people whose frailty, disability, or dependence results in
       an entitlement to social care. This report does not include any proposal
       or implication that affects these important initiatives.

2.2    An outcome of the decisions in respect of Fair Access to Care Services
       will support the most effective use of resources within the Budget
3.    Background

3.1   Department of Health Guidance

3.1.1 Department of Health Guidance on eligibility criteria for adult social
      care (Fair Access to Care Services) states that councils with adults
      social services responsibilities should ensure that they can provide or
      commission services to meet eligible needs, subject to their resources.

3.1.2 The guidance clarifies that this does not mean that different councils
      would make identical decisions about eligibility, nor does it prescribe
      what services should be available to service users who have similar
      needs. However it is expected that, within a council area, individuals in
      similar circumstances should receive services capable of achieving
      broadly similar outcomes, and that local implementation should lead to
      a more consistent approach to eligibility and fairer access to care
      services across the country. Through Fair Access to Care Services,
      councils will ensure that eligibility criteria do not discriminate against
      older people, and therefore are able to demonstrate that Standard One
      of the National Service Framework for Older People, to root out age
      discrimination, is being achieved.

3.1.3 The Government has set levels to measure a person’s needs in four
      categories of care. These levels are:

      Critical        Risks that threaten life if action is not taken
      Substantial     Risks that represent a severe threat to health and well
                      being if action is not taken
      Moderate        Risks that present some threat to health or well being
      Low             Risks that represent a minimal threat to health and well

3.2   Comparator Authorities

3.2.1 The existing eligibility criteria used in Medway means that in general
      the threshold for access to care is between moderate and low. Many
      Councils with Adult Social Services Responsibilities have recently
      reviewed their Fair Access to Care Services Eligibility Criteria, and
      several have raised the threshold as a means of managing the
      demographic pressures faced by adult social care. The current Fair
      Access to Care thresholds among Medway’s neighbours in the South
      East are as follows:

          C O U N C IL                               FACS THRESHO LD                                  ADULTS’
                                                                                                      R A T IN G
   B r a c k n e ll F o r e s t   C r itic a l & S u b s ta n tia l                                       *
   B r ig h to n & H o v e        C r itic a l & S u b s ta n tia l                                      ***
   B u c k in g h a m s h ir e    S ile n t                                                               *
   E ast S ussex                  C r itic a l ( Im m e d ia te ) a n d S u b s ta n tia l ( u p to       *
                                  12 weeks)
   H a m p s h ir e               C r itic a l & S u b s ta n tia l                                       **
   Is le o f W ig h t             C r itic a l & S u b s ta n tia l                                       **
   Kent                           C r itic a l, S u b s ta n tia l & M o d e r a te                      ***
   M edway                        S ile n t                                                              ***
   M ilto n K e y n e s           C r itic a l & S u b s ta n tia l                                       **
   O x f o r d s h ir e           C r itic a l & S u b s ta n tia l                                       **
   P o r ts m o u th              S ile n t                                                               *
   R e a d in g                   C r itic a l, S u b s ta n tia l & H ig h e r M o d e r a te            *
   S lo u g h                     C r itic a l & S u b s ta n tia l                                      ***
   S o u th a m p to n            C r itic a l & S u b s ta n tia l                                      ***
   S u rre y                      C r itic a l & S u b s ta n tia l                                       **
   W e s t B e r k s h ir e       C r itic a l                                                           ***
   W est S ussex                  C r itic a l, S u b s ta n tia l & M o d e r a te                       **
   W in d s o r &                 C r itic a l & S u b s ta n tia l                                       **
   M a id e n h e a d
   W o k in g h a m               C r itic a l                                                            **

3.2.3 The table above demonstrates little discernable correlation between
      the Fair Access to Care threshold and the star rating of adult social
      care in each council. However it should be noted that where councils
      have implemented a critical only threshold and maintained a good (2
      star) or excellent (3 star) rating significant additional investment has
      been made into the voluntary sector. This enables the council to
      maintain acceptable levels of key performance indicators around the
      number of people helped to live at home, through signposting to
      alternative provision with available capacity in the voluntary sector.

3.2.4 The Adult Social Care performance rating is an important contributor to
      the Comprehensive Performance Assessment.
    4. Options

             Option                              Advantages                            Disadvantages               Potential Saving            Comment
 No Change                         Provide social care to all those in need    The number of clients              None. In fact the
                                   who meet existing eligibility criteria.     meeting the eligibility criteria   current overspend
                                                                               will outstrip the council’s        of £2,779,000 on
                                   No negative impact on performance           ability to fund the care           adult social care
                                   indicators such as numbers of Direct        services needed.                   will increase as
                                   Payments and number of People Helped                                           more clients are
                                   to Live at Home.                                                               referred.
 Set Threshold at Substantial      Medway Council will continue to offer       Up to 1,755 current service                            This is the recommended
 and Critical                      services to everyone with a clear need      users will no longer receive       £2,854,640 net in   option.
                                   and entitlement.                            a service.                         a full year.

                                   Staff would welcome the support and         Challenges and complaints
                                   clarity afforded by transparent stated      from affected service users
                                   criteria.                                   and their families.
 Set Threshold at Critical Only    None                                        Up to 2,695 current service        £2,768,828 net in   The calculation of this
                                                                               users will no longer receive       a full year.        potential saving takes
                                                                               a service.                                             account of the impact of
                                                                                                                                      service withdrawal of those
                                                                               Higher levels of challenges                            in substantial need of social
                                                                               and complaints.                                        care services quickly
                                                                                                                                      resulting in reassessment at
                                                                               With services so tightly                               a critical level.
                                                                               restricted, staff morale will
                                                                               be difficult to manage and
                                                                               may lead to recruitment and
                                                                               retention issues.

                                                                                 Impact and resultant strain
                                                                                 on relationships with the
                                                                                 NHS and community and
                                                                                 voluntary sector.
It should be noted that the potential savings take account of the loss of income to the Council of charges from a reduced number of service users.
5.    Advice and analysis

5.1   The application of a new threshold must apply to everyone who
      accesses social care services in Medway, both current and new service
      users. It is proposed to implement the revised threshold on 30 June
      2008, which will allow time to train Care Managers, recruit temporary
      cover and reassess existing service users.

5.2   The reassessment of the existing 8,200 service users during the first
      quarter of 2008-2009 will be a massive task. A modest half day has
      been allocated to each case to include a visit for reassessment by a
      qualified care manager; moderation of the outcome; communication
      with the service user and their family; and updates to the electronic
      social care record. The cost of back-filling the Care Managers engaged
      in this exercise is estimated at £400,000.

5.3   Both new and existing service users will need to have information that
      clearly sets out the process and basis for decisions about their access
      to care, the moderation process and how to complain.

5.4   To ensure that the people who do not meet the new threshold are
      appropriately advised and supported, an estimated figure of £750,000
      will need to be invested for voluntary organisation(s) to provide advice
      and signposting on accessing community and universal services. This
      figure is based on the experience of Wokingham Council who have
      evaluated their successful implementation of a raised threshold as
      being due largely to investment in voluntary sector infrastructure. This
      expenditure would be necessary in year for pump priming and then
      recurrent. Customer First will also have a role to play in effective advice
      and signposting, and staff training will be provided accordingly.

5.5   Work with individuals and families to ensure that their needs are met in
      alternative ways such as developing networks of family and community
      support, accessing community groups etc. is essential not only for the
      wellbeing of individuals but also to ensure that key performance
      indicators in the social care performance assessment framework are

5.6   Links need also to be made with other public services to ensure that
      people are accessing their full entitlement to benefits in order that they
      are in a position to arrange their own support if necessary.

5.7   A programme of training for all staff needs to take place throughout the
      early part of 2008 to ensure that all qualified practitioners are in a
      position to work with the new threshold as from 30 June.

5.8   Diversity Impact Assessment

5.8.1 A completed Diversity Impact Assessment is attached at Appendix 1.
5.8.2 Analysis of the service data reveals the impact by service area as

      Service Users Who Would No Longer Be Entitled to Social Care with a
      Raised Threshold

                      Older People %        Physical           Learning
                                            Disability %       Disability %
      Critical and           19%                 27%                23%
      Critical Only          30%                  48%                30%

6.    Consultation

6.1   A series of focus groups were undertaken to explore a number of
      issues relating to the introduction of criteria for the provision of Adult
      Care Services. One group was drawn from general Medway
      population, and three groups were drawn for corporate focus groups.
      One each of older people, people from black and minority ethnic
      communities, and people with disabilities. There were two phases of
      the consultation with each group. The purpose of phase one was to
      ensure that participants had sufficient understanding of what is meant
      by the term “adult social care”, and who is entitled to these services,
      who delivers and funds these services, how services are accessed and
      allocated. Participants were then well equipped to make a meaningful
      contribution to the second phase of consultation. This considered the
      need to introduce criteria to fairly allocate resources.

6.2   There was broad consensus that introducing criteria was necessary
      and would help to make the process of allocating care fairer and more
      transparent. While there was broad agreement that a threshold was
      needed because of financial constraints, there was no consensus
      about where this should be set.

6.3   Both the disabilities and the ethnic minorities groups had particular
      issues that were reflected in their responses throughout. Several of the
      participants in the disabilities group had personal past experience of
      Medway Council’s services that pre determined their view. They raised
      particular concerns around means testing.

6.4   The ethnic minorities group were concerned about the appropriateness
      for them of the assessment process and available health and social
      care services.

6.5   All groups were unable, and in some cases unwilling, to reach an
      agreement about where the threshold should be set.

6.6   The following statutory sector partners have been consulted:

      •   Medway Primary Care Trust
      •   Medway Maritime NHS Trust
      •    Kent and Medway Partnership Trust
      •    Kent Probation Area
      •    Medway Council Children’s’ Services
      •    Kent County Council

6.7   The results to date of this consultation generally reflect the
      interdependency with social care of the organisations concerned. They
      demonstrate the understanding and support of our partners for the
      reasons behind these recommendations. Officers are seeking written
      confirmation of their views and in most cases are exploring them further
      through executive management meetings and Board meetings.

6.8   An ongoing dialogue will be held with the voluntary sector throughout
      the autumn. As described in paragraph 5.4, Fair Access to Care
      Services offers important opportunities for the voluntary sector to
      contribute to the way that social care is provided and accessed in the
      future. A series of workshops are planned to engage with voluntary
      organisations to shape new services and understand where existing
      provision may need to change.

7.    Financial and legal implications

7.1   The table below summarises the estimated financial implications of
      setting the Fair Access to Care Services eligibility criteria at Critical and
      Substantial and applying these revised criteria to all new and existing
      clients as outlined in the report.

7.2   Summary of Projected Financial Impact

                                                    2008/2009      Future Years
                                                        £              £pa

       Revenue Savings                              (2,703,480)      (3,604,640)

          Additional Investment Required
          - Reassessment of 8,200 clients               400,000
          - Investment in the Voluntary Sector          750,000          750,000

       Net Revenue Savings                          (1,553,480)      (2,854,640)

7.3   Members should note that these estimates make assumptions about
      the number of potential clients who would no longer qualify for services
      under the proposed revisions to eligibility criteria, as well as pre-
      empting the number of existing service users who would lose their
      entitlement to services following re-assessment under the new criteria.
      These estimates are based on the reassessment of 5% of current
      service users. This cannot be forecast with any certainty, but there can
      be no doubt that significant savings will be generated by this exercise.
      It should also be recognised that Adult Social Care Services will still be
      subject to the same demographic and economic pressures it currently
      experiences – an ageing population, price pressures above RPI – and
      this will need to be reflected in the medium term financial plan.

7.4   In 2002 the Government issued policy guidance on Fair Access to Care
      Services (FACS) under Section 7(1) of the Local Authority Social
      Services Act 1970. The guidance is mandatory and must be adhered to
      when reviewing eligibility criteria. Care cannot automatically be
      withdrawn from all users who no longer meet the threshold, and each
      case will be considered on its merits even if it is decided that the
      service user falls outside the revised criteria.

8.    Recommendations

8.1   It is recommended that Medway Council set its threshold for Fair
      Access to Care Services at Substantial and Critical.

8.2   That Cabinet note the potential revenue savings and the cost
      consequences arising from the need to increase voluntary sector
      capacity and complete care assessments as set out in section 5 of the

8.3   That the Director of Community Services is given delegated authority to
      exercise discretion and authorise the provision of services to individual
      clients outside of the usual criteria in exceptional circumstances.

9.    Suggested reasons for decision(s)

9.1   Setting the threshold of eligibility for social care services at “substantial
      and critical” will generate significant savings in 2008-2009 and beyond.
      These savings are marginally greater than would have occurred for
      moving to “critical only” because analysis of sample files indicated that,
      without social care support at the substantial level, service users would
      soon deteriorate to critical and put greater demand on both Council and
      NHS services.

9.2   It is vital to have a vibrant and positive community and voluntary sector
      to support people with low and moderate needs, in order that their
      conditions do not quickly deteriorate to substantial, and to minimise
      levels of dissatisfaction.

9.3   For staff to achieve this massive task it is essential to provide effective
      training and to backfill team resources in order that qualified
      practitioners are available to meet the challenge of undertaking over
      8,000 half-day reviews in three months.

Lead officer contact

Lead officer: Amanda Rogers, Assistant Director Social Care
Tel. No: 01634 331212 Email:
Background papers

  •   Fair Access to Care Services Guidance on Eligibility Criteria for Adult
      Social Care.

  •   Conclusions and Recommendation Relating to Issues Raised in the
      Fair Access to Adult Care Services Research; Mary Slevin Consultants

  •   Comparative Report of Focus Groups into Issues Surrounding Adult
      Social Care in Medway – Phase 2; Mary Slevin Consultants.


Appendix One:      Diversity Impact Assessment
Initial Equality Impact Assessment

Social Care               Fair Access to Care Services – Proposed Change to the
                          Eligibility Criteria for Adult Social Care.

Officer responsible for assessment           Date of assessment        New or existing?
Bridget Bygrave-Relf                         28th Sept 2007            New
Defining the function, strategy or policy being assessed
1. Briefly describe the purpose   Department of Health Guidance on eligibility criteria for
and objectives of the             adult social care (Fair Access to Care Services) states that
policy/function                   Councils with Adults Social Services Responsibilities
                                  should ensure that they can provide or commission
                                  services to meet eligible needs, subject to their resources.
2. Are there any associated
objectives of the                 Financial control and demand management.
policy/function? Please explain
3. Who is intended to benefit     Existing and potential users of adult social care services,
from this policy/function, and in and their carers will receive consistent access to services.
what way?
4. What outcomes are wanted       Fairness and consistency in access to social care
from this policy/function?        services.

5. What factors/forces could       Lack of rigour / consistency in implementation and
contribute/detract from the        application of agreed Eligibility Criteria.
6. Who are the main stakeholders in           7. Who implements the policy and who is
relation to the policy/function?              responsible for the policy?
Users and carers of adult social care         Assistant Director of Social Care, supported by a
services                                      Lead Officer and Implementation Team.
Adult social care staff
Independent sector social care providers
NHS primary, community and specialised
health services
Assessing impact
8. Are there concerns that the      YES The policy change will be applied to ALL existing
policy could have a differential            and new service users
impact on racial groups?           NO
What evidence exists
(presumed or otherwise) for        Data from a 5% sample cohort of adult social care
this?                              recipients
9. Are there concerns that the      YES As above
policy could have a differential
impact due to gender?              NO
What evidence exists
(presumed or otherwise) for        Data from a 5% sample cohort of adult social care
this?                              recipients
10. Are there concerns that the    YES
policy could have a differential           All people in receipt of a social care service have
impact due to disability?          NO      a long-term condition.
What evidence exists
(presumed or otherwise) for        Data from a 5% sample cohort of adult social care
this?                              recipients
11. Are there concerns that the    YES
policy could have a differential           The policy change will be applied to ALL existing
impact due to sexual               NO      and new service users
What evidence exists               Data from a 5% sample cohort of adult social care
(presumed or otherwise) for        recipients

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