DISABILITY UK TASK FORCE The Liberal Democrat Care Review

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Liberal Democrat council 'rubber stamps' controversial SOCIAL SERVICE CHANGES
Comments:- Needs many parts further detailed, alterations and clarification. Bad faults are:- Entire policy geared towards over 65's. Discriminative towards under 65's wishing more independence. Social exclusion. Care hours replaced by temps and 'drop ins'. Fraught with legal minefields. A very 'backwards' step in social care. Contravenes several laws in present form. Users were not consulted, external expertise not involved.
Erred under sections of discrimination & human rights act.

We Suggest "This document needs further clarification and consultations with users, as per the law. Any attempt to force this document upon users in present form will invoke revolt from disabled within the community, charges levelled against the council and extremely damning national media".

DOMICILARY CARE EFFICIENCY REVIEW.
Submitted by Geoff Elford. Head of Adult Services 020 88917608

Summary of erred document approved by the Liberal Democrat Council of Richmond on Thames.

A report on the outcome of the Domicilary Care Review.  It includes proposed strategic objectives for the service, proposed efficiency savings and cost reductions, revised eligibility criteria, a revised structure for the "in-house" service and improved income collection targets.  Additionally the report provides information on the implementation of the new IT/IS system and the implications for the Domicilary Care Review.

Recommendations

That the Committee approve:
the proposed strategic objectives for the commissioning and provision of domicilary care services (see section 3.4);

the proposed further efficiency savings and cost reductions of £320,000 for 2001/2002 and an additional £80,000 for 2002/2003; to realise the total savings target of £600,000 (see section 5);

2.3       revised eligibility criteria (see section 3.4.5;
2.4       the proposed new structure for the "in-house" Domicilary Care Service including the creation of Enablement Teams and Brokerage" arrangements (see section 3.7 and 3.9);

2.5       the creation of a Practical Support Scheme funded from the Promoting Independence Grant; further to this the Committee are asked to determine if clients on Income Support should receive a subsidy from the Council for this service (see section 3.8);

2.6       the proposed amendments to the staffing establishment of the "in house" Domicilary Care Service, subject to staff consultations and the Resources Committee being informed(see Section 4);

2.7       the proposed changes to the income collection system using the TCO IT/IS system (see Section 3.10) and note the progress made in the implementation of the new IT/IS system provided by TCO.

3.Details

3.1       Background

3.1.1    On 25 September 2000, the Committee approved an efficiency savings targets of £600,000 for Domicilary Care in relation to the Council"s budget programme for 2001/2002.  On 13 November 2000, the Committee approved the first tranche of proposals from the Efficiency Review of Domicilary Care Services which identified £200,000 of efficiency savings for 2001/2002 based on the extension of the rehabilitation model plus reduction in mileage payments and monthly pay.

3.2       This report provides a completed account of the Efficiency Review including proposals, in service and resource terms to achieve the overall savings target by 2002/2003.  The cost reduction proposals are based on clearer targeting of resources and improved efficiency and effectiveness.

3.3       Proposed strategic objectives for the Domicilary Care Service

3.3.1    The Efficiency Review has involved a comprehensive analysis of the policies, procedures resources and user needs across the "in-house" service and services commissioned from the independent sector.  From this work a statement of strategic objectives has been produced which will provide the framework for the proposals for change and development of the Service.

3.4       Strategic Objectives

To focus domicilary care services towards service users with higher levels of need and complex needs.

To place a strong emphasis on rehabilitation by creating Enablement Teams within the "in-house" service which will work in tandem with the Hospital to Community Teams, Community Occupational Therapists and the Health Service.

Additionally to focus the "in-house" service on specialist work with individuals with complex needs.

To improve contracting arrangements with the independent sector and to reduce spot purchasing by the wider use of block contracts.

To implement a new IT/IS systems provided by TCO with project management from Kendric Ash.

To implement an effective income collection system.

To meet the Council"s cost reduction targets for 2001/2002 and 2002/2003 and to ensure that services are cost effective, efficient and meet Best Value requirements.

To meet the Department of Health performance targets and relevant Best Value Performance Indicators.

3.5       Eligibility Criteria

3.5.1    The proposed strategic objectives will need to be reflected in the priorities and the eligibility criteria for the service.  Additionally with the integration of care management for older people and younger people with disabilities into the Social Care Teams and Hospital to Community Teams, there is a need to provide integrated eligibility criteria.  Consultations with staff, user groups and voluntary sector organisations regarding proposed eligibility criteria have been held including a consultation meeting with user and voluntary sector groups on 15 February 2001.  A variety of comments were made and the feedback has been drawn upon to finalise the proposals.

3.5.2    Current Position

The criteria approved for Older Peoples services were:

i) This care is for people who need help with maintaining an adequate nutritional intake, getting in and out of bed, essential personal hygiene, and with dressing and undressing, all of which are daily requirements.

Domicilary care is for people who would otherwise, because of their high level of need, be unable to continue to live in their own home without such help.

Domicilary care is also for people whose carers are in imminent danger of being unable to maintain that support, or who would, for other reasons, need help to continue their support

ii) This care can be provided for people leaving hospital who would otherwise be unable to return home.  They will receive help on a short-term basis, sometimes up to a period of four weeks.

3.5.3    The previous Services for Adults (clients 18-64 years) used a score of ten or over on the Self Assessment form, as the qualifying criterion, and an overall assessment of need within the “Community Care Assessment.  No upper limit on the level of care was set.

3.5.4    Proposed Domicilary Care Eligibility Criteria

The following criteria would be used for the integrated service, in order to clarify assessment processes and to provide an equitable service for older people and younger adults.  It is essential that the new service criteria are easily understood and are open and fair.  The criteria must also ensure that services are targeted at those with the greatest need, using available resources in the most efficient way.  The principle of promoting independence rather than creating dependency in clients should be followed with the aim of ensuring that the abilities and potential of service users are engaged to the full.  The needs assessment would be undertaken in close liaison with the client and their carers.

3.5.5    Proposed domicilary care eligibility criteria

(a)        Higher level of need
This is defined as:

(i) Clients who need care/direct support with personal tasks and daily living tasks on a daily basis to remain in their own homes.

(iii) Clients who are leaving hospital in line with the agreed discharge policies who would be unable to return home unless personal care and help with daily living tasks is provided.  This care would be reviewed within four weeks of discharge.  After the four-week period the usual criteria would be applied for ongoing service provision.

(b) Medium level of need

This is defined as:

i) Clients who need care/direct support with personal care/daily living tasks on a regular basis to remain in their own home.

Ii) Clients for whom the living environment would deteriorate to the point of risk if they do not have assistance with the following services:

A regular full wash or bath/shower

Assistance with laundry and changing of bed linen

Household cleaning which maintains an acceptable level of hygiene.

Assistance with meal preparation in addition to the Council"s meals service.

Personal care/daily living tasks to provide essential relief to carers.

These clients will not need these services on a daily basis.

(c) Low level of need

This is defined as:

i) Clients who do not have personal care needs.

Ii) Clients who do not have environmental hygiene needs on a regular basis but may require:

These clients will not need daily services.

3.5.6    Definition of personal care

Personal care is defined as follows:

Help getting up and going to bed

Washing and bathing to maintain essential personal hygiene

Dressing and undressing

Toileting

Assistance with management of continence

Assistance with personal safety where a client would be at risk or cause harm to

Assistance with taking prescribed medication.

This is defined as:

cleaning

simple household tasks

collecting pensions

paying bills

arranging laundry

3.5.8    Proposed "ceiling" for allocation of domicilary care services.

Currently there is a 15 hour per week ceiling on domicilary care packages for older people but no specific upper limit for adults under 65 years with disabilities.  It is evident that there is a need to establish a more balanced and equitable policy.  This was included as a consultation issue in the recent consultation exercise.  The policies, used in other boroughs have also been checked and, following this, it is recommended that a general ceiling of 21 hours per week.  It is proposed that in exceptional circumstances additional hours could be approved for individual clients at the discretion of the Principal Manager Community Services e.g., where there is a definite risk of admission to residential care if the additional domicilary care is not provided.  This will enable the particular needs of individuals to be considered, including people with severe disabilities.  The proposed ceiling relates to the level of care commissioned or provided by Services for Adults on behalf of the Council. 

3.5.10 Assessment of need

Clients being referred for services must be offered an assessment to identify their needs and to consider their independence or ability to become more independent.  The assessment, in relation to domicilary care services, will be undertaken using the approved eligibility criteria, with clients in the Higher needs category receiving top priority and those in medium category being next in priority.  Clients with low levels of need would either be referred to the new Practical Support Scheme (see section 3.8) or where appropriate to alternative community services, Section 3.7.3 below contains proposals for the extension of the current rehabilitation scheme by creating Enablement Teams.  This would allow the majority of clients to be provided with a four to six week period of rehabilitation or provision of equipment/adaptations, following the initial assessment.  After the rehabilitation period the package of care would be reviewed.  Exceptions would be made if the client was terminally ill, was severely confused or if there was information supplied proving that such a service was not necessary or was detrimental to the client.  For clients with sensory disabilities, the involvement of specialists from the Sensory Services Team would be arranged whenever required, to ensure that needs are appropriately understood and identified.

2) Carers Assessment

The specific needs of carers require assessment, on a separate basis in terms of the Carers Act.  In the assessment for the circumstances of the carer and their implications for the care of the client will be clearly identified and reflected in the statement of need.  Consultations will be undertaken with the Carers Association as to the design of this assessment.

3.5.10  Reviews of Needs for the service

All clients receiving a domicilary care service would receive an initial review after six weeks.  Thereafter individual reviews would be undertaken at the Team Manager"s discretion at a minimum of once a year.

3.5.11  Review of current care packages

The proposed change to the eligibility criteria would have implications for clients currently receiving a domicilary care package.  The Head of Legal Services advises that there has been a significant amount of litigation in this area of law.  The law as it currently stands is that those clients currently receiving a domicilary care package cannot have that service withdrawn or altered without a lawful reassessment.  Case law has established that a change in eligibility criteria can justify a reassessment downwards.  The review of current clients would be undertaken on a progressive basis.

3.6 The current structure, staff and resources of the in-house Domicilary Care Service

3.6.1 The current management structure of the in-house Domicilary Care Service.  The service to clients is provided by Domicilary Care Assistants (DCAs).  The current staffing budget for DCAs (including provisions for evening and weekend work and overtime payments) is £2,968,700.

3.6.2 This provides for a total of 7,599 hours per week (including client contact and non-contact time) which equates to 163 whole time equivalent at a cost of £14,315 per post; currently there are 26 vacant whole time equivalents.

3.6.3 The "in house" service currently provides services to 700 clients with an average of 420 referrals per annum.  The main service operates from 07.00 am until 10.00 PM on a seven-day week basis.

3.6.4 There is a separate Peripatetic Night Care Scheme which provides support on evenings and night-times for older people with dementia and their carers.  The service is funded through the Mental Health Grant and provides 5FTE staff at a total cost of £116,500 per annum (including on costs).

3.7 The proposed new structure for the "in-house" Domicilary Care Service

3.7.1 The "in-house" service has demonstrated a particular expertise in providing services to clients with complex needs and is generally viewed as a reliable provider of these.  Additionally the pilot Rehabilitation Project, which was described in the report to the Committee on 15 November 2000, has proved extremely successful in supporting clients to achieve greater independence through the recovery of independent living skills and confidence.  The general impact of this has been to lessen the dependence of the clients concerned on continuing domicilary services.  Given the very strong emphasis in Government policy for Social Services on rehabilitation, a key proposal is that the "in-house" service should extend its work in the area of rehabilitation and in services for people with complex needs.

3.7.2 The impact of the current pilot rehabilitation project on reducing the continuing reliance on domicilary care services and supporting independent living was detailed in the report to Committee on 13 November 2000.  The extension of rehabilitation services through the Enablement Teams proposed in 3.7.3(i) will achieve a further reduction in the level of demand for continuing domicilary care services which is reflected in the proposals for the revised staffing establishment of the "in house" service.

3.7.3 From the above it is proposed that a new service structure should be approved.  The components of this new structure are as follows:-

(i) 2 x Enablement Teams

Two teams would be set up, one on each side of the Borough, with newly designated posts of Social Care Assistants.  These posts would have an extended brief focussed on undertaking rehabilitation tasks under the direction of the occupational therapists.  It is proposed that each team should comprise of 14fte Social Care Assistants (SCAs) to work during the daytime plus 2.5 fte SCAs for evening and weekend work (a total of 33 fte SCAs).  It is proposed to re-designate 33WTE DCA posts to create the SCA establishment.  The personnel implications of this are set out in paragraph 4.2.  The Community OTs would work with the Enablement Teams on rehabilitation programmes for individual clients.  The Public Service Agreement bid, will provide two additional Community OTs for the Enablement Teams.

The teams would work to the criteria currently used by the Rehabilitation project.  The majority of new referrals for domicilary care from the Hospital to Community Teams and the Social Care Teams would be referred to the Enablement Teams who would arrange a rehabilitation programme for a four to six week period in conjunction with Health Services professionals such as Hospital OTs and physiotherapists.  The aim would be to enable individual clients to achieve maximum independence.

From the clients analysis it is estimated that the Enablement Team would be working with c100 clients at anyone point is time.  The management structure for the Enablement Teams is set out in APPENDIX B.

3 x Continuing Support Teams

It is proposed that three locality based teams should be set up each led by a Domicilary Care Manager with an additional Manager post to manage the evening and weekend service provided by the teams.

The teams would provide services for clients with complex needs requiring more specialist domicilary care involvement in the following areas:- clients with dementia, complex care packages, complex "manual" handling, terminal illness and palliative care.

The needs analysis indicates that these teams would be required to provide support to c156 clients requiring 15 hours domicilary care per week, or above.

This would involve a total of 85 fte DCAs with a management structure as set out in APPENDIX "B".

3.7.4 The proposal would result in a smaller but more highly trained "in house" work force, with specialist skills.  A formal training and development plan would be produced aimed at the achievement of appropriate of appropriate NVQ levels for the staff concerned  It is proposed that a Senior Care Assistant from the present establishment be designated as NVQ Assessor to ensure that 50% of all Care Assistants attain NVQ Level 2 by 2004 (National Care Standards target).  The Enablement Team Social Care Assistants will work towards NVQ Level 3.  The TCO system will release management time from office duties to provide the necessary Assessor time for the NVQ Level 3 work and increased levels of supervision for care staff.  This will require a revised grading structure as reflected in Section 5 below.

3.8 Practical Support Services

3.8.1 Practical support services are defined in paragraph 3.5.7 above as shopping, cleaning, single household tasks, collecting pensions, paying bills and arranging laundry.  Currently c190 clients are receiving just practical support with no personal care.  If the proposed eligibility criteria are approved persons applying for such services and not requiring personal care would not receive a direct service from the Council, indeed this is reflected in the current eligibility criteria for older people.

3.8.2 The Royal Borough of Kingston has a well established scheme named "Kingclean".  This scheme has been carefully researched and appears to provide a positive solution which would support the proposed eligibility criteria and the required cost efficiencies. 

3.8.3 The proposal has been discussed with voluntary sector organisations with a view to one of the local organisations managing such a scheme with funding from the Council.  However, at this stage no voluntary sector organisation is able or prepared to take on this role.  Consequently it is proposed that the scheme should be managed by the in-house service but separately from other services.

3.8.4 The scheme would comprise:

A scheme co-ordinator (provisional grade S02) with a scheme budget.

The co-ordinator would have the role of setting up the scheme including the creation of an approved register of self-employed workers who would be required to meet specified standards in terms of their skills, personal integrity, employment history, etc.

As the register became established clients who require only practical support services (as defined in the proposed eligibility criteria) would be referred to the scheme co-ordinator who would "link" individual clients to workers on the register.  An appropriate hourly rate would be recommended to users of the scheme

The client would meet the costs of the practical support from their own resources.  However, if the scheme is approved the Committee are asked to consider, as part of the decision, whether all clients on the scheme should be required to pay for the service or whether those on zero income assessment should receive a subsidisation of the costs.  Information on current clients indicates that if all those on zero assessment were offered a subsidy of £5 per week, this would cost c £20,000 per annum.  At present, an average of 2 hours per week of practical care is provided to each client

3.8.5 The Head of Legal Services advises that the implications for the current group of clients receiving just practical support services, are that it would be unlawful to withdraw or alter the services without a reassessment.

3.8.6 If the Committee approve the Practical Care Scheme, a period of six-months would be required to bring the scheme into full operation, given the need to recruit the co-ordinator, set up procedures and get in place a register of workers.  Clients currently receiving practical services would be gradually transferred to the new scheme, subject to a reassessment of their needs.

3.9 Brokerage Scheme

3.9.1 The present system for arranging domicilary care operates on the following basis.  Once the care manager has undertaken the assessment of need, they make individual approaches either to the "in house" provider or independent sector provider to arrange the service.  With the current high level of "spot purchasing" from the independent sector this can be a time consuming process with duplication of effort.

3.9.2 A number of other Local Authorities have developed what is termed a brokerage function.  Such schemes provide scope for greater efficiency and cost effectiveness in the use of staffing and resources and enable the care managers to be freed up to make fuller use of their professional skills.  Following the needs assessment by the care manager, the broker identifies the provider which is able to provide the package of care.  Given the proposal to refer the majority of new clients through the Enablement Teams it is proposed to pilot such a scheme during 2001/2002 under the management of the in-house Domicilary Care Service.  This would not in any sense reduce the role of the care manager in determining the care package with the clients and their carer but would create a more efficient approach to identifying the appropriate care provider for individuals.  The care manager would retain full responsibility for commissioning and overseeing the care package and conducting reassessments and reviews, as required.

3.9.3 An additional benefit would be that this function would mesh in extremely well with the TCO system.

3.9.4 The pilot brokerage arrangement would be reviewed after six months of operation.  Given that the proposed contract arrangements are based on locality contracts the pilot would be used to test the feasibility of decentralising , depending on the outcome of the review, the brokerage functions from 2002/2003 onwards.

3.10 Income Collection

3.10.1 An important objective is to improve the effectiveness of the income collection system.  On 15 November 2000, the Committee approved a pilot income collection system with charges based on the care plan rather than the data from the scanner system.  The pilot has been undertaken in two localities and involves both in house services and independent sector providers.  This pilot will bridge in to the implementation of the new IT/IS system.

3.10.2 The TCO system which is being introduced in April includes the facility for ensuring that amendments to the planned service (in the care plan) are fed into the system, resulting in accurate billing.  The independent sector providers will be required to return information regarding the actual level of service provision so that this can be reconciled with the care plan and duly authorised.  It is estimated that the new system will produce an increase in income of c£75,000pa.

3.10.3 A focus will be placed on improving the uptake of relevant welfare benefits for clients in liaison with the Income Section and Richmond AID.

3.11 Contracts with the independent sector for domicilary care

3.11.1 A key strategic objective for the Domicilary Care Service is to improve contracting arrangements and the commissioning of domicilary care from the independent sector and to replace the current over reliance on spot purchasing by the extension of block contracting.

3.11.2 A separate report to the Committee sets out proposals for new domicilary care contracts including contract specifications and the tendering process.  The service and financial implications of the contracting proposals and commissioning need to be viewed in conjunction with this report.  This is another area where improved value can be obtained from budgetary resources.

3.11.3 The financial implications of the proposals on commissioning and contracting are cross referenced in the financial section of this report (Section 5).

3.12 Direct Payments Scheme

3.12.1 Clients using the Direct Payments Scheme managed by Richmond AID would be affected by the proposals in this report, in terms of the assessment procedure, the enablement process and the eligibility criteria for care commissioned by Services for Adults.  Consultations with Richmond AID and the user group (Richmond Users Independent Living Scheme) will be undertaken in terms of the implementation of the new procedures and schemes.

3.12.2 An important strategic objective is to extend Direct Payments to other client groups including older people.  A review of the current scheme is scheduled to this end and it is envisaged that investment from the Department of Health Promoting Independent Grant will be utilised to extend the scheme.

3.13 Implementation

3.13.1 A project of this scale and complexity would require an implementation plan and timetable to enable a smooth transition to the new service structure including the transfer of staff to the new roles.  This will require a great deal of management and human resources work during 2001/2002.  If the Committee approve the proposal

Contact Officer

Geoff Elford, Head of Services for Adults, telephone 020 8891 7608.

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