MEDWAY COUNCIL CABINET 6 NOVEMBER 2007 FAIR ACCESS TO CARE SERVICES ELIGIBILITY CRITERIA FOR ADULT SOCIAL CARE 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 Framework. 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 being. 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: 3.2.2 C O U N C IL FACS THRESHO LD ADULTS’ STAR 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 maintained. 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 follows: 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% Substantial 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 report. 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: email@example.com 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. Appendices 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. outcomes? 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 orientation? What evidence exists Data from a 5% sample cohort of adult social care (presumed or otherwise) for recipients this?