Eligibility Criteria – Thoughts on Draft Guidelines #swjcchat Thurs 1 August 8pm

28 07 2013

The document to discuss this week on 1/8/13 is the Draft National Minimum Eligibility Threshold for Adults.  While the government isn’t necessarily known for creating snappy titles for policy documents, eligibility criteria for access to Adult Social Care are at the heart of services and how they are and will be provided so the fundamental importance of this consultation can’t be underestimated – to those who use and work in adult social care.

Eligibility Criteria – a background

Fair Access to Care Services (FACS) were introduced in 2003 as a way of trying to ‘standardise’ and clarify decisions across local authorities in England and Wales when decisions were made as to who would receive social care services. There are four ‘bands’ of services and there are descriptions of what each ‘level’ consists of. The bands are ‘low’, ‘moderate’, ‘substantial’, ‘critical’.

Gradually as money has been squeezed, there has been a tendency for the band which is provisioned by local authorities has edged higher.  There’s a useful introduction to FACS here (PDF) which explains the system as it currently is succinctly.

Why Draft New Thresholds?

There has been much criticism of FACS and that will be an issue we can explore more as a part of the chat – why has FACS failed? I  have a lot of ideas myself. Part of the issue the government has identified to be ‘solved’ in the new Care and Support Bill is the ‘postcode lottery’ issue. Each local authority can which criteria it will provide support for. This has been seen as unsatisfactory as people in neighbouring authorities can be entitled to vastly different levels of service.

So we are looking at new national thresholds which will not be reliant on the judgement of local authorities. The idea is that this will create more clarity about who can and can’t receive services funded by local authorities. This is a crucial draft document which will have enormous repercussions.

Where will be national eligibility criteria sit?

The first chapter of the document explains the need for change. The document dwells on the inequity and lack of clarity about people knowing what they may be entitled to in terms of care services and how different this can be in different local authorities. The paper explains that from April 2015, the government is committed to introduce national eligibility criteria at least as a minimum (LAs will be free to provide more than the national minimum if they wish/are able to afford to). The ‘postcode lottery’ will not disappear.  There is a thinking that the national minimum threshold will be at the ‘substantial’ level which is currently pretty much where most local authorities have their threshold at the moment. The immediate difference might, then, be very little. But there have been difficulties in definitions through the lifespan of FACS. ‘Substantial’ to me could be interpreted differently to ‘substantial’ by another social worker in the same team as me. This is where some of the difficulties lie.

What will the new Care and Support system look like?

There’s an interesting part of the paper which pushes to how the ‘new’ support system will work and uses the lovely government language of adjusting the way that they envisage this system will be delivered. ‘Assessments’? They won’t be primarily used to gatekeep to services (or not) but will be used to ‘supporting people to identify needs’ and look at where support will come from. Well, to be honest, I don’t see how this is different from what happens now – except the language but perhaps that’s the key.

The govt do envisage people accessing assessments from local authorities ‘earlier’ when they have lower needs so that support which might take place outside that which is funded can be provided earlier. The difficulty is that there has to be support available to be signposted to and if people are not assisted with funding for low level needs, those who are able to self-fund will have an obvious advantage. Mind, money, in itself, creates advantages which may or may not be fair (not but I’m a bit of a closet socialist at times!).

What will an assessment look like?

I was interested that the paper looks at what an ‘assessment’ is and emphasises that it should not be deficit-led. This will be a real change if it is what happens but I have doubt and the reason for my doubt is that it is not the way that systems have and are built. If I look at my experiences in mental health social work over the last few years, we have been increasingly moving away from ‘needs-led’ ‘strengths-based’ models of assessment and running towards ‘deficit models’. Clustering means we are being asked to look at the greater impairments people have and not at their strength. That is what the system asks us to do. I wonder if the people writing this draft guidance are actually aware of that the move has been far and away from the strengths-based models that they claim to embrace. This is an example of the Department of Health not having a clue what is actually happening in social work currently.

The paper also looks at the need to work across health and social care for assessments. Again, I sniggered. Seriously. Do the people writing the document know what work we did with the Single Assessment Framework – trying to simplify assessments across health and social care so they could be jointly undertaken – and do they know or have they properly evaluated what happened there and why it didn’t work?

It’s easy to make broad statements of ‘assessments will take place across health and social care’ but there needs to be an understanding of all the times this has been attempted in the past and what the barriers have been because those barriers (mostly about different pots of funding) have not been removed.

Draft Regulations

The govt have presented some draft regulations to be used. They are in the paper and I won’t go into them in detail but the paper asked a few questions specifically about these draft regulations. They want feedback and I think it’s something we could have quite a focussed discussion on. The question the paper asks are

Whether the draft regulations have any holes in terms of groups who may not be covered by them?

Nothing sprang out at me specifically but thats something that might need someone with a more detailed knowledge of Community Care Law than me to establish.

Are the regulations equivalent to current ‘substantial’ threshold?

This made me chuckle because ‘substantial’ is so hard to define. The draft regulations are sufficiently woolly and unclear to ensure that interpretation will continue to be the key. That’s no shock really.

What are the practical implications for implementing the regulations?

Here the government ask about how easy they will be to implement and what statutory guidance should be included. The definitions within the regulations are vague enough to be useless but what would be better? I am going to have a ponder about whether better regulations could be written by people who actually use, know and understand the system. I’m interested that the government talk about  having focus groups with users, carers and local authorities? I’d ask how they choose the people who sit on these focus groups. I hope there are people who have cognitive impairments included and social workers who work in the teams that implement these criteria and that the representations from ‘local authorities’ are not simply at the management level (which is what I fear!).

What’s the impact of the Draft Regulations

The paper presents rough cost estimates for implementing the new draft regulations. There is a rough costs between £18-25million given. I wonder how much of this will come from central government – and these costs don’t include additional services provided to carers which increase those potential costs exponentially.

Where now?

In the discussion on Thursday I’d like to look at the following questions (and please do feel free to add your own)

Have FACS failed?

What would be the implications of new national criteria?

Is the government plan to move from defining needs to identifying support realistic?

Experiences/examples from practice?

New regulations – are they clear enough?

will they make a difference to anyone?

Can they be improved?

Is ‘substantial’ the only realistic place to draw the line?

How do you define ‘substantial’ – do these regulations make it clearer?

Anything else!

I hope at the end of the discussion we’ll have enough to submit a response to the consultation which I’ll post here if I can work out how to do that!

So join me on Thursday 1 August at 8pm to discuss the draft document about adult eligibility criteria – I know there’s no better way to spend an August evening!





Right care, Right place, Right time – How can we improve care for vulnerable older people – a consultation

9 07 2013

As well as articles specifically to discuss, I thought it would be useful to use this space to bring in policy and consultation documents as well as journal articles which we come across which might be useful to others.

The Department of Health launched a consultation last week on ‘improving health and care for vulnerable older people’.

I’m not enamoured generally with the Dept of Health and their knowledge and understanding of social care and the feeling I get from looking at the initial consultation is that there is a lot of confusion about what exactly ‘care’ means. This is a ‘health’ consultation that doesn’t seem to have a consideration of social care or its place in the lives of ‘vulnerable older people’ but if we are, or have been, involved in or used social care, it’s important that we do contribute. Not only for ourselves but for those we have worked with who may not be able to contribute directly. The Department seem undecided on whether ‘care’ includes a broader understanding of the team but I’m going to share my consultation response in the hope it urges more people to contribute.

There are six ‘domains’ to the consultation and they seem to focus on primary care. Coming from a position of working with rather than working in health services, gives a particular perspective on how things can, should and most importantly, do work – to focus on how they can work better.

STAYING HEALTHY FOR LONGER

 

How can we strengthen the incentives or increase the flexibility for GPs to effectively manage the health of the local population?

Of course the language is one of ‘incentive’ which makes me cringe. But I accept that I don’t have a lot of experience in the health service and none at all in primary medical care. The world is oiled on incentives, apparently. Flexibility and capacity though is an issue I have come across working with a lot of GPs in the community, particularly with older people. I’ve worked with some fantastic GPs and some – less so. My concern is around GPs attached to care homes – and again, this is by no means a universal impression – but certainly there have been some who have shown a lack of care to those in the area. I’d like to see much better, embedded connections between health and social care for a start, including a stronger understanding of the way these links between community and residential care are managed.

In your experience, how can people be better supported to manage their own care?

Speaking as, very much, a layman, I’m a great fan of more information and peer support groups. Generally, there is no reason ‘vulnerable’ (I don’t like that word because it is so vague and lacks any purposeful definition) older people are any different from any other group in terms of extending self-understanding, knowledge and management of their conditions. The issues though that remain are, perhaps, increased lack of mobility.

Better uses of technologies can help people to link with others. I don’t want to see this dismissed because people are ‘old’ or ‘vulnerable’. That’s a whitewash because the potential cost could be high but if people can’t come to peer support groups, they can be linked through forums and voice conferencing. There are also more mobile tools for self-management available. We can’t assume that everyone has a carer. Again, rather dull, but I refer back to using the communities around people too – if they are involved in lunch clubs or day centres (dying out now) the tools and groups should base there. If they have formal care going in to them, use those people to share information and give information, same with district nurses. People generally want to be better.

Can you share any best practice examples of how to strengthen prevention and early diagnosis in primary and community services?

I’m going to pass on this for the moment  but I hope people take the opportunity to present back where things work although it’s important that those within the govt take account of what hasn’t worked too.

 

NAMED CLINICIAN: PROVIDING A SINGLE, NAMED CONTACT TO COORDINATE AN INDIVIDUAL’S CARE

I wonder if anyone finds it as odd as I do that Hunt has announced this as a policy aim even as its out to consultation. To me, that typifies ‘consultation’ in the NHS sense of the word. Let us tell you what we are doing. You can tell us what you think. If you like. But it won’t make a blind bit of difference. We are doing what we want anyway.

Enough of my cynicism and on to this ‘idea’.

How do you identify vulnerable older people or people most at risk in your local area?

This is a question based firmly at primary care clinicians so it seems a bit foolhardy to respond genuinely and with seriousness because I don’t actually think the DH wants my opinion but I’m going to go with it anyway. Firstly I wonder what on earth they mean by ‘vulnerable’ older people. When does an older person become ‘vulnerable’. Certainly in London, in terms of safeguarding, we have moved away from use of the word ‘vulnerable’ in consultation with service users who did not like it. However this is a different use and shows the difficulty of a Dept that doesn’t know it’s own language or definitions. Equally ‘people at risk’ doesn’t define what ‘people’ are at risk of. People at risk of deteriorating health? People at risk of being ignored by society? I’d like some better definitions to understand exactly what is being asked for.

In terms of my experiences in social care and mental health we were alerted through a number of sources, sometimes GPs, sometimes hospitals, sometimes self-referrals, friends, families, neighbours. Sometimes we’d be alerted by the police or the ambulance service. How did this information move? In the Mental Health team, as a secondary health services,  all information would be channelled through GPs. This didn’t happen as a matter of necessity in adult services. Should it? I’m not sure. What I am sure of is sharing information is better than not. Maybe we can go back to the idea of having GPs and Social Work collocated. I think there has to be a link between health and social care but with social care being ripped apart, this probably isn’t the ‘answer’ the government want.

 

Who do you feel is best placed to perform the role of named accountable clinician in primary care setting?

 

This is a bit of a leading question in my opinion as it’s assuming that this is a good idea and the focus is on the primary care setting which immediately moves us into the territory of health rather than any hope of looking at joined up health and social care coordination. I’m biased because I’ve been a care coordinator and had to work with trying to build links across health and social care and in my opinion it isn’t something that can be just tacked on. I do though, think social work is specifically well-placed to be a link between sectors however in the question asking for a ‘clinician’ (and social workers not being clinicians), it seems my answer isn’t one that the Dept of Health want – which is a shame. I am curious how this role differs from the GP role? What will this ‘named clinician’ actually do? Will they ACTUALLY coordinate between primary/secondary/social care because if they will, I think the lead needs to come from social care. If they are there just to coordinate between primary and secondary care, I have to ask, isn’t that just what GPs do now?  Then, I haven’t even mentioned community matrons. Weren’t they supposed to have a role in this? This question makes me angry by the amount of ignorance it displays of what actually happens now and the way it ignores the skills and role of social care in providing a cohesive connection with medical care. Surely this is an opportunity for more ‘integration’ if I believe (ha ha ha) what noises Lamb makes about more integration. Surely this is an opportunity for that. But no, the question asks for ‘clinician’. Hunt doesn’t remember that social care is a responsibility of his as its less interesting and needs more money but giving people lots of ‘lead people’ responsible for them – one ‘named community clinician’, one social worker, one community matron, one occupational therapist, one or two outpatient consultant – and yes, one person could ‘coordinate’ all that – but if we ignore the social care aspect then we don’t really make things less complicated.

 

Named clinician: Providing a single, named contact to coordinate an individual’s care

Aha. This is the crux. It’s a question that isn’t even a question. It’s a statement. So what is the Dept asking us for? To tell them it’s a good idea. Here’s what I’d tell the Dept. LOOK AT WHAT HAS ALREADY HAPPENED!!! Look at the Community Matron model. Look at the social care-led care coordination and management role. Look at how we tried to implement the Single Assessment Framework in adult services across health and social care and please please, learn from what has already been done, what’s worked (personally, I found collocation and working in teams with district nurses worked well) and what didn’t (trying to pretend ‘health’ and ‘social care’ can exist without each other) and they wouldn’t need yet another consultation with statements instead of questions.

 

IMPROVING ACCESS: MAKING IT EASIER TO BOOK APPOINTMENTS AND GET ADVICE

Here, the govt/dept are asking for ways that technology might be able to improve access. I’m probably far from the best person to advise on this but would encourage those with ideas to contribute.

Can you share some ideas of introducing new technologies and new ways of providing primary care services?

This is beyond my experience so I probably won’t comment extensively except to say we need to get the basics right and not all ‘innovative’ solutions need to have a technological base.

What are the barriers to introducing new technologies to improve access?

Again, I probably am not best placed to respond although interesting that the questions don’t necessarily relate to the heading about ‘booking appointments’. For me, personally, it isn’t technologies that would assist me although I do think that being able to book by email would be a nice start, it’s more about capacity of GPs and not having to wait  4 weeks for a regular appointment. Not feeling like the doctor’s surgery was doing me a favour by fitting me in sometime next month might be a start about making it easier to access appointments.

 

OUT OF HOURS: ENSURING A SAFE AND CONSISTENT SERVICE

I honestly think this discussion needs to move beyond the ‘vulnerable’ older people and towards a general understanding of what makes a good and reliable out of hours service because I’m far from convinced (I know, I’m bright like that!) convinced its where we are at the moment.

How can we ensure clear accountability for out of hours services?

Repeal the legislation that privatises anything the sector can get it’s hands on? I’m not sure that’s the answer they, in govt, want. These questions are, by the way, incredibly leading. Accountability can’t be held to companies which are run on profit, in my, very simple, brain.

What is the role of other primary health care services, for example, pharmacists, in providing safe and consistent out of hours care?

Well, clearly there is a need for all services to ‘join up’ but I’d include social care in their too although this is just focused on primary care.

Do you have any examples of good practice and innovation in out of hours provision?

I wish they would ask for examples of where things haven’t worked too – sometimes there can be as much learning in that – particular when there may have been an over-reliance on ‘technology’ and ‘innovation’.

CHOICE AND CONTROL: PROVIDING CLEAR AND ACCURATE INFORMATION TO HELP PATIENTS MAKE DECISIONS

I waver when I see ‘choice and control’ mentioned because I see how it has been done in social care and it has overpromised and under delivered. Hopefully Health can learn from Social Care – when it realises (starting with the Dept of Health) that social care exists. Cynical? Maybe just a little bit.

How do you think patient choice can be supported in out of hospital care for example, transparency, flexible provision and support for decisions?

Interesting that ‘out of hospital care’ is the term used rather than primary care. For  me this has to include social care because it’s vital that we join up the choices available both in health and social care sectors. I’m not sure that’s what the consultation is demanding but that’s what it’s getting from me.

The important thing about supporting choice is ensuring that people who may lack the capacity to make particular choices are not subject to second class services because they don’t have the voices of those who are better able to advocate for themselves. I’d suggest that there needs to be a role for independent advocacy to help people to make choices – not the named clnician – who may have a vested interest in promoting ‘cheaper’ options – especially if they are part of a CCG. We need an element of independence in providing options to people.

 

What do you think are the barriers to choice in out-of-hospital services?

Where to start..

People who lack the capacity to make decisions and who are not supported to make decisions bout choices

Lack of availability of choice or preference or quality services for that matter.

Geographical barriers – people want good services which are close. Choice is over-rated if we have consistently good quality, responsive services.

Where is the ‘control’ – this question is all about choice and not control? How and who to users who are ‘vulnerable’ older people have a stake in controlling the services that are provided to them?

I’m sure you can all think of more. Please do respond to the above question.

 

Do you have examples of patients who have been supported to make better outcomes through the use of choice and control?

I don’t because I’m not a clinician but I do think that this consultation talks about choice but says nothing whatsoever about ‘control’ so it’s interesting it asks for examples of ‘control’ being handed over without explaining it. I think that’s a fault in the consultation but I hope we will be able to flood with real life examples in the hope that someone listens.

 

JOINING UP SERVICES: SHARING UP TO DATE AND ACCURATE INFORMATION AND SUPPORTING COORDINATION OF CARE

Finally we see some mention of social care although only briefly because the consultation refers to ‘clinicians and carers’ resolutely ignoring social care! It’s funny because we’ve been trying to work on integration and seamless information sharing for, well, at least a decade and this consultation seems to lack understanding of that.

What do you see as the main barriers to achieving integrated out of hospital care and how can these be overcome?

For a start those in policy need to understand and appreciate the role of social care and not completely ignore it as seems evident in this consultation.  The main barriers are the lack of conversation between the two sectors and the lack of any incentive and time to create pathways across health and social care. The coordination is better coming from a non-clinician in a social care setting because we have experience in care coordination across health and social care sectors so it’s important that the experiences are learnt from.

Do you have any examples of integrated out of hospital care happening in your local area and having a positive impact on patient outcome?

I have some examples which I’ll share more fully as a part of the consultation but I’m not at all sure what this consultation means by ‘integrated’ – does it mean primary/secondary care? Does it mean medical/social care? I wish it was a bit clearer but I think there’s a role in feeding information back about what has worked (and not worked) in terms of ‘integration’ over the years so we don’t end up making the same mistakes two, three, four times.

 

What do you think are the barriers to data sharing between sharing between services to support patient care?

At the moment the systems that don’t allow social care systems and NHS systems to ‘talk’ to each other is a massive barrier to information sharing. We need to look at the basics before getting over-excited about the potential of data sharing. Until the basics of sharing information between local authorities and NHS is solved, anything more imaginative and innovative is impossible.

Can you highlight any examples where data sharing to support patient care is happening effectively?

Um, no – but maybe I’ve just been unlucky.

 

So that’s the consultation – although it’s based and focused on primary care with a few nods towards other areas, I think it’s important that those who have experience in social care respond to. We need to make our voices heard in order to help the Department of Health understand what life is like for practitioners rather than leaving it to people who sit in rooms deciding to be ‘experts’ on policy without any understanding of the reality of the situation as it occurs.