The Costs of Home Care

Today, the Guardian published an article about the inequitable costs of home care services throughout England and the shrinking of access to council-paid support for care in the home.

The article refers to a survey and report comprised of a number of Freedom of Information requests. It says

The survey, seen by the Guardian, shows the average charge for an hour of home care has risen by 10% in the past two years – from £12.29 to £13.61.

Also stating

…there are wide disparities in the price people pay for care depending on their location. Home care, for example, is free in Tower Hamlets but costs £21.50 an hour in Brighton and Hove.

The data show that fewer older people – in excess of 7,000 – had their care services fully paid for by a local authority in 2011 a reduction of 11% compared to 2009.

This certainly reflects my experience in practice. There are a number of concerns that result from this report which merely confirms what everyone in the sector knows.

Eligibility criteria are moving upwards.

If we look at the Fair Access to Care Services which are the supposed ‘standardised’ entry point to ‘care provision’ in local authorities – the lower ‘access’ point has moved higher. From moderate needs being ‘covered’ more local authorities are moving to only allowing ‘substantial’ or ‘critical’ needs to be covered. This moves a lot of the preventative work away from local authority provision.

This has a significant impact on the manner which personal budgets are implemented. A lot of the leisure type activities we see as examples are being pushed out in favour of budgets which are strictly intended to meet immediate personal care needs. Options for choice are much more limited in this context, particularly if a person does not have support around them.

More people refusing care on the basis of cost

This is something I’m seeing much more as my own council has increased the costs of care. More people whom I assess as needing care are refusing it or refusing discharge from hospital solely on the issue of cost of care. There may be an assumption that ‘working hard all my life’ means that social care provision will be free in the future but it’s very hard to argue the value of a personal budget at (for example) £10 per hour when the charge will be £10 per hour. It is counter-intuitive and yet by bypassing the local authority ‘processes’ there is potential support that can be lost in terms of assistance in recruitment of staff/tax related issues. We are forcing more ‘cash in hand’ work sourced via Gumtree or notes in the newsagent windows.

Longer term costs as people supported at home less

This also means that people remain at home without the support if they do not wish to pay for it and the potential for much higher costs will come at a later point. Either through preventable or delayable hospital admissions or by admission to residential care sooner than might have otherwise been necessary.  Seems obvious but I see it happening every day. We can’t ‘force’ care on anyone (putting the capacity issue aside for one moment) and if someone is adamant they don’t wish to pay for care which is assessed as being needed, we just sit on our collective hands and wait for things to deteriorate –by which case, it may be too late.

Personal budgets and the ‘personalisation’ agenda.

I’ve mentioned some of the counterintuitive ways that services can cost as much as they are charged for – that’s particularly evident if we are considering a direct payment. There’s another problem with the implementation of the systems of ‘personalisation’ as they exist in reality. We were told initially it was intended to be a shift in ‘power’ from professional to user – which is fantastic – however the reality is often far from that. Assessment forms look similar (and ask similar questions in similar formats) to DLA application forms and focus heavily on physical rather than mental health needs.

The RAS (resource allocation system) pushes these assessments through an accountancy system which is non-transparent and spits out an ‘indicative budget’ based on a number of often unknown factors. So you get more money according to lack of ability to do things which perpetuates a top down model which doesn’t build on strengths of what someone CAN do – rather what they CAN’T do.

This process is convoluted and opaque. However well explained, sometimes people want good services delivered. Choice is only choice when it’s actually offers options. Seems obvious but it isn’t the reality.

Commissioning decisions

I am sad to say when I arrange support via a managed personal budget, I can’t necessarily guarantee quality of care to the user. We use agencies that have won their tenders for the contracts with the council purely on the basis of cost rather than quality. There may be carers rushing in and out on minimum wage without being paid travel time, between 30 min visits in disparate geographical locations. Is it any wonder that people are refusing these kinds of services when we can’t guarantee consistency or quality of support. There are some fantastic care workers. Really, they are gems but it can be hit and miss because the way that costs are being driven down mean the agencies cut costs at every moment. We aren’t delivering value for money.

This shrinking of provisioned support for older adults and people with disabilities will lead to much higher long term care costs both with costs shifting to health care services as people are admitted sooner into hospitals and care costs as residential care becomes an option sooner. In some ways, more importantly, it will and does lead to a reduction in independence and quality of life which is much more important and can’t have a price put on it.

What is Choice?

Lansley and Burstow and those in the Department of Health have extolled choice as an aim to strive towards in both health and social care. ‘Choice and Control’ was used as the key phrase as the agenda moved in Adult Social Care and it has been picked up as the NHS and Social Care Bill made it’s way through Parliament. After all, who doesn’t want choice? Who doesn’t want control? The answer is that not everyone is has the capacity or desire to make a number of choices in critical situations . It worked to an extent in social care in so far as those who are able and willing to choose or those who are well equipped with better funding and family advocates are able to choose.  However we have also seen the policy struggle behind in promoting true choice or in fact, any choice to those who are not as able to pick up the mantle themselves nor who have informal social networks to assist in this respect.

Does having ‘choice’ mean seizing control? Are choice and control two parts of the same coin? Does one lead to the other? Perhaps. My concern is with those who are either unable through issues of capacity or illness or unwilling (because – you know – sometimes that’s a real choice to be made too) to actively ‘choose’ the type of care they receive or the way the care is divided into a support plan.

Where we see the ‘managed’ local authority support plans, we see little ‘choice’ and no control. We see the same large agencies with block contracts tied into providing the same packages of care on the same terms that they always did. The promises of more flexibility have evaporated into the ether of local government spending cuts.

I’m not against ‘choice’  but I’m completely against false choice. I’m against the meaning of the word ‘choice’ being warped into something that makes good political capital for the government with no meaning when ‘choice’ has not been extended in any real terms. I’m against lazy use of the word ‘choice’. The government (and that’s the last government as much as this one) seem remarkably fond of it. Funny, that.

I urge anyone who hasn’t read Max Pemberton’s piece in the Telegraph a couple of days ago to take some time to read it. He writes about contract won by Virgin Healthcare to run services in Surrey.  He explains this notion of ‘choice’

. The emphasis on choice was something that was repeated ad nauseam by ministers in an attempt to sugar the bitterest aspects of the Bill. The legislation would provide choice, we were assured. Everyone likes choice, don’t they? And we all nodded in innocent agreement.

I have argued before that in a healthcare setting, choice is a misnomer: all hospitals should provide an excellent level of care because so many people – the old, the infirm – are unable to exercise choice because of geographical or physical limitations. But only now that we can see the shape of the NHS Bill can we truly assess what choice actually means.

And this is the reality as it exists more starkly in health care than in social care.

I chose my local hospital for treatment because it was the only one I could reach within an hour by public transport. The people who live where I live will be making similar ‘choices’. Those with access to cars may make other choices and go to ‘better’ hospitals further away (although I have to emphasis my treatment was great at the local hospital even though it’s ‘ratings’ and ‘feedback’ are poor!). Those who can only access public transport will have less choice.

Similarly, my GP is on the same road as me. I have had gripes. Do I go to another? No, because when I’m sick, I want the nearest surgery. I don’t have time to research the different specialisms and natures of the GPs around me. This would be even more notable if I were in a rural area.

So who is this ‘choice’ for? For the class of people that the politicians pander to. Those who have the means and ability to choose? How can we truly make choice genuine and meaningful in systems which inherently try to blind themselves to the different cultures. attitudes and natures which do discriminate in the way access to choice is made.

Perhaps this is a way to increase equitable services and access to services across health and social care. I have long believed that advocacy may be a solution. Sometimes I walk away from work and realise that the people that I spend time with on a day to day basis are not the people that politicians either speak for or to. That’s why, as a social worker, it’s important for me to remind and nip away at these groups of people who won’t be clamouring for their pens (real or virtual) to engage elected members.

We have left behind a whole swathe of people who have not been able to ‘choose’ are a part of the personalisation agenda. We must push on and the voices will grow louder as others see this happening in healthcare.

Choice is a luxury of the more able. Good universal services for everyone must be the essential bedrock.

The NHS and Social Care Act has passed, but the voices must increase. We who can choose much speak for those who cannot.

What would be better than the Resource Allocation System?

The Resource Allocation System (RAS)  in adult social care in England is the means by which local authorities determine the size of the ‘personal budget’ pot in social care and the money that will be paid (or services in lieu) to the recipient.

The ethos of the personal budget, whether delivered by a direct payment or a ‘managed’ budget or an Individual Service Fund is clarity. The user/recipient of the service knows how much ‘money’ is in the pot to spend – even if they aren’t making those spending choices directly.

So why is there a problem with the RAS? Lucy at The Small Places explains in her excellent and highly recommended post here. She has undertaken a piece of research asking various local authorities for details about their Resource Allocation Systems. What this means in effect is asking how the algorithms are calculated that assigned particular values (money) to ‘needing help with preparing meals’ or ‘having a family member to help’.  Lucy explains that two reasons she was given by different local authorities for not disclosing were that revealing the formula might ‘distort’ future requests (i.e. people could fiddle the system if they knew which questions were weighted in particular ways) or that the RAS is a commercially sensitive document.

Quite rightly these arguments are picked apart in the blog post referenced so I won’t go over that again.

I did want to consider a question that was put to me last night (via Twitter) namely ‘What’s the solution?’.

I’m sure I’d be in a position in a very different grade to the one I’m in now if I had a bullet proof solution but it raises some thoughts in me that needed longer than 140 characters.
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Will Adult Social Care Reform Stall?

younger hand and older hand

The Health and Social Care Bill currently limping through Parliament is a mess. Even though I try to take an active interest in its progress, even as someone who is desperately concerned and involved (working, as I do, in an NHS team), I lose heart at trudging my way through some of the details which have been changed, adjusted and repackaged beyond the level of human (oh, ok, maybe it’s just me!) comprehension.

I was baffled though by this piece which turned up on the Guardian website yesterday.

Announcing that Lansley, having been stung and having lost credibility as his health reforms (hopefully) hit the buffers, is going to be delaying his announcement of reform in social care.
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Rethinking Personal Budgets in Social Care

Reading Community Care, I saw that NLGN (New Local Government Network) have published a report stating that the ‘rush towards personal budgets’ must be slowed down.

I’ve tried unsuccessfully to find this report on the NLGN website but haven’t been able to do so am reliant on the third party reports from Community Care but I thought it raised a number of issues that are worth pondering.

The author of the report, Daria Kutsnetsova says in the article

.. in a lot of cases, personal budgets do not mean choice and control for service users because people are not given the choice of direct payments. Their budgets are handled by a care manager, which can be a choice in the personal budgets system, but in many cases it is not a choice and people are receiving the same care they were always receiving, she said.

It’s just called a ‘personal budget’ to push this government target,” she added.  (my emphasis)

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Personalisation , Personal Budgets and Demos

I have a lot of thoughts on the push towards the personalisation agenda in general, unsurprisingly as care and support planning plays a large role in my job.

Over the last week, a variety of meetings that have taken place which have pushed this issue to the forefront of my mind locally and have given me time to pause and think, not only about the focus of the agenda and where we are along the path but also where we are going.

It has been frustrating. As I noticed in a Twitter-related conversation yesterday, the language almost seems to have a form of it’s own. I start mentioning PBs, IBs, SDS, RAS, ISF, SSAQ, DP (see Glossary below)  assuming the person beyond knows exactly what I mean in each of those circumstances and you realise how over-complicated what should be a fundamental principal about putting the keys to the power dynamic into the hands of those who use the services.

Rumbling in the background is the government agenda to push personal budgets (PB) as a way to deliver ‘personalised’ care and a push into ‘health budgets’. I think there have been a number of issues that have either not been addressed or pushed under the proverbial carpet in the meantime.

I have tried to express some of my frustrations internally but often came up against the ‘you are either for us or against us’ mentality to those promoting the push towards personal budgets for all at any cost – so by raising criticisms and concerns, that automatically seemed to push me into the ‘controlling professional’ category who obviously just didn’t want to relinquish what I saw as my ‘right’ to dictate forms of care to service users and carers. I dispute that of course. I was one of the few care managers who actively moved many people onto direct payments historically. I am very well aware of the benefits of direct payments but the move towards direct payments for all I felt, was pushed by a few particular groups of people and I was concerned that it was moving the universality of self-directed support away from a large group of people I work with who do not want direct payments regardless of how much support is offered.

I was delighted to read over the past day or so, a report by Claudia Wood called Tailor Made – it’s a long document and my reading has so far been on a superficial level (warning – um. if you are going to print it out  be aware that it’s.. er.. well over 200 pages.. )

It is a document that almost made me cry with joy because it addresses in a more coherent and less histrionic way than I have, exactly my concerns about the way the personalisation agenda has been couched while remaining (as I am) absolutely positive about the process and idea.

We have been too fixated (and Paul Burstow is guiltiest of this) of pushing personal budgets delivered through direct payments as the ‘gold standard’ option of providing self-directed support.

As Wood says in the executive summary

‘The emphasis placed on direct payments as a primary form of personal budget is too restrictive and risks excluding large numbers of people who do not have the capacity or desire to use a direct payment. No one should be excluded from having a personal budget if they wish , but to make personal budgets as accessible as possible for all groups and in all care contexts, we need to think beyond direct payments as the only, or even the preferred, form of personal budget’

For me, Wood expresses clearly my own thinking on this matter. So much energy has nationally focussed solely on direct payments as a delivery mechanism (which is fantastic for some) that local authority managed budgets have become a second-best, second-class service and ‘transferring’ support from standard support to a ‘so-called’ personal budget managed by the local authority has been a fallacy and a lesson in tick box culture at its worst. The issue is that it is  social workers, yes, like me, who have been complicit in this deception. I tick a few boxes and automatically Mr Smith has a personal budget managed by the LA where previously he had a directly provided care package. The delivery is the same service, by the same people in the same way,  but now, after these boxes have been ticked (because he expressly does not want a direct payment) – he is suddenly on the local authority ‘figures’ as having a managed personal budget.

Whereas Mr Brown next door, who has a service of the same cost but a direct payment, is able to access a personally chosen personal assistant and goes to a sports centre instead of a day centre etc etc.

This seems inherently wrong but it is merely because the managed support is so poorly serving Mr Smith. The answer isn’t to give Mr Smith a direct payment because – and this is the issue that Burstow seems to ignore – he doesn’t actually want it.

Wood writes

‘Local authority commissioners… must.. scrutinise their ‘managed budgets’ processes, to ensure they deliver choice and control and are not part of a tick box exercise’

Finally, it feels that someone ‘out there’ is listening to our worries and genuine concerns about a system that seems to have been designed to deliver inequity.

She goes on to say

‘An inclusive personal budget strategy is… one where more innovative uses of personal budgets are developed’

And that, I think is the key. We have had direct payments for a long, long term. Where the real innovation is needed is on pushing out new ways of delivering personalised care within the context of managed budgets.

Wood helpfully specifies the different ways that personal budgets can be used saying

‘There are six forms of personal budget used in social care in England

– a direct payment (held by individual)

– an indirect payment (held by a trusted other – eg a friend of family)

– a trust fund (held by a trust of people)

– a brokered fund (held by a professional broker)

– an individual service fund (held by a provider)

– a care managed fund (held by local commissioners) ‘

and then goes on to say

‘There is a danger.. that as the Scottish and English governments focus on direct payments as the default and preferred modus operandi for personal budgets (in social care at least), people may assume these other forms of personal budget are not capable of ‘real’ personalisation.

This can become a self-fulfilling prophecy, with providers spending less time developing their systems for these other forms of personal budget and them becoming tokenistic forms of personal budget, which do not offer real control’

If Claudia Wood were in the same room as me, I would applaud her. THAT for me is the crucial point in all of this. I want to deliver more personalised services but the only tools I have been given within my local authority are direct payments (or indirect payments)  or care managed fund. All these other options have been theoretical and none have developed any flexibility.

I want to see as much effort nationally in developing new ways of delivering services through all these methods and I want Burstow to at least read this report to have an understanding about why he seems to be fixated on the ‘direct payment or bust’ preferred model.

Of course, when it works, it is fantastic but we need more work on the other models too to ensure an equitable system for all needing care.

As for the report, there is so  much more in it than I’ve touched on about personalisation in residential care particularly. If you have any interest in the subject read it.

GLOSSARY

PB – Personal Budget (delivered by social care – (or health in the future)

IB – Individual Budget (envisaged to include different income streams eg health + social care budget)

SDS – Self Directed Support

RAS – Resource Allocation System (‘points’ that are translated into cash to make an ‘indicative budget’ after an assessment)

ISF – Individual Service Fund where a provider holds the budget on behalf of a service user

SSAQ – Supported Self Assessment Questionnaire – the way that needs are often assessed initially.

DP – Direct Payment