Caring for our future: shared ambitions for care and support. Newcastle voluntary and community sector response

Transcription

1 Wellbeing and Health Open Forum Caring for our future: shared ambitions for care and support Discussion group held on 21 November 2011 Participants Age UK Newcastle upon Tyne Pamela Denham Age UK Newcastle upon Tyne George Aitchison Age UK Newcastle upon Tyne Karen Moses Key Enterprises 1983 Ltd Mike Halsey Newcastle LINk Craig Duerden Newcastle CVS Pam Jobbins Norcare Ltd Mark Davies Open Clasp Theatre Company Roma Yagnik Relate Northumberland and Tyneside Harriette Boyden Sage Gateshead Silver Club Julia Plastino The Welcome Club & Carers Centre Cornelia Moosman The Welcome Club & Carers Centre Trevor Moon Additional contributors to the response Newcastle CVS Sally Young Newcastle LINk Ruth Abrahams Tyne Housing Assoc Ltd Maurice Condie Caring for our future: shared ambitions for care and support The Wellbeing and Health Open Forum event held on 21 November about Caring for our future had a lively discussion and came up with a good range of points to make in the response to the government s engagement exercise. Some of the themes echoed recent Newcastle Wellbeing and Health Open Forum reports on personalisation, prevention, and social prescribing. The reports are attached as appendices and also available on Newcastle CVS website.

2 1. Improving quality and developing the workforce: What do you think? The discussion concluded that there are two measures to ensure that services are of good quality: the service user is at the centre of the process; and the service must be fit for its purpose. There should be basic minimum standards especially on safeguarding. Feedback processes should include both internal methods, and others that have a systematic independence, are externally verifiable and involve significant people such as family, carers and friends. Good quality providers develop a range of feedback methods for different clients including ways of making anonymous comment, proactive contacting, and asking family and friends. But it is important that commissioners and procurement processes recognise a range of formal quality assurance systems. These should be flexible, suitable and appropriate for small local groups; as well as systems such as the ISO series which are geared towards large providers. Commissioners should not disadvantage the sector if groups do not have the capacity to pay for and use ISO. The role of the Care Quality Commission was questioned. Although it has recently started inspection of hospitals there are no similar inspections of other providers of social care. There was also a view that CQC inspections alone will not guarantee quality and that they need to involve family and carers. Although the CQC sends questionnaires indirectly to family members through the provider, they should have a means of asking people directly when they do a visit to a residential or nursing home. Don t know if the CQC reports are worth the paper they are written on; I don t know if they (the CQC) are asking the right questions Quality cannot be done by inspections The service users need to judge the quality Quality means asking family and friends There was a discussion about care within people s homes (domiciliary care). Whilst quality needs to be ensured, there were mixed views about Page 2 of 12

3 going in to peoples homes. It would be intrusive and could be perceived as an inspection of someone s home as much as of the standard of service. If inspectors came to my home I would tell them to bog off. How can they come in and ask service users in their home it s an invasion of privacy People do not like criticising. Some think there is no point in filling in a form, as it will not change anything My mother in law has dementia and she thinks she s getting a good service. But we know she s not; she s missing medication and has lots of different care workers coming in. She cannot remember what she s had for dinner, never mind fill in a feedback form! Quality is also about the care workers. Whilst care work is looked down by society on as a vocation or career choice, it will struggle to attract motivated staff with the right attitude. Care work needs to be promoted and valued more highly. We also agreed that compassion needs to be recognised as innate and that training cannot train unsuitable people to care. You can train and train and if you don t have the right mindset you cannot do it In one example, the local authority hourly charge for cleaning services to a care firm which rented local authority office space was higher than the domiciliary care price they paid to the firm. Care work costs even if someone is only paid the minimum wage the costs of training and management double the hourly cost 2. Increased personalisation and choice See also the Personalisation report* Recent changes in the way that social care is contracted for have had several negative impacts. Page 3 of 12

4 While many users choose to employ a personal assistant (PA) with their personal budgets, the group was aware that for the majority of social care service users this may not be an option. Personalisation may not mean more choice for many older people especially as many people find their care packages have been reduced following a review. If you have to pay for help to go to the toilet and be fed, you cannot spend your budget on something else A lot of older people have such tiny amount in their care package which has been reviewed and reduced under personalisation, they cannot employ someone; the amount in the budget is too small. If they need personal care they couldn t buy an alternative. Older people have no choice but the bare basics Service users are being encouraged to become employers as this will mean it maximises the value from what is a reduced care package, as agency staff cost more. But it does not take into account the problems there can be in being an employer such as being taken to a tribunal, having to initiate disciplinary proceedings, or just not finding the right staff. Few people working in social services know what it s like to employ someone. Most people don t want to be responsible for employing someone They (government/social services managers) are not talking to the right people they are talking to big organisations. You should ask yourselves how difficult it is to get a cleaner you were happy with. You don t get people to do it how you want it done! There are safeguarding concerns. If a service user employs a Personal Assistant (PA) there are no safeguards apart from a CRB check that only shows up convictions and cautions - while agencies have to be approved and quality systems are in place. This is also the case for self-funders of care, as the current situation in which the only safeguard might be a CRB check leaves the way open for abuse. We suggest that a monitoring system is investigated that self-funders of care and those who employ PA s could access. Page 4 of 12

5 Task orientated limited time slots The discussion centred on the way that the current pressures on time and resources militate against personalisation. With contracted care being very task orientated with time slots as low as ¼ hour, it was hard to see that this could be flexible enough for a personalised service based on service users wellbeing. But it was recognised that the current resources allocated to social care are not sufficient for individual personalised care. Even where time slots are longer, commissioners have shifted contracted time slots from one hour to ¾ hour slots, which puts pressure on the assessments. You need to want to care for people how they want to be cared for. You might not want to have a wash, or do your teeth, or want to be washed twice a day it changes Personalisation has created a variety of contracts which costs more in administration for providers. The move away from block contracts to spot (one-off) contracts is a challenge for many smaller organisations to manage. Providers also have to manage individuals with direct payments and also individuals who are self funders. There should be more transition time and support built in. Fair Access to Care Services (FACS) is used to determine whether someone is eligible for social care and support, but is not mentioned in Caring for our future: shared ambitions for care and support. If over 40% of assessments are found to be of people who are not eligible for care, there is a huge unmet need. Some mental health service users receive ongoing support from the NHS but find they are not eligible under FACs for social care; at the very least it appears illogical and confusing. There is such a wide range of activity and services that come within social care it need to be specific. There should be different approaches for different activities and client groups. For example, within the learning disability field, even with large packages of a couple of hours a day; the service user may still have 22 hours a day to fill with support usually from family and friends. For someone else a short amount may be all that they need in order to be supported. Electronic Call Monitoring (ECM) has been brought in by commissioners. This system records the actual time spent in the home on the care visit Page 5 of 12

6 and does not allow for travel time between clients; it does not allow for the client to chat or have any problem that may take longer on occasion. The group suggests that all such systems should build in a flexible approach in order to support individualised care and support. There were concerns that there may be a conflict between the different systems, publicly (or part publicly and part privately) funded care, and fully self funded care. ECM may mean that the unregulated self funders contact time is cut to allow for staff travel to the public sector funded client or if their visit runs over. 3. Ensuring services are better integrated around people s needs The group found that there are a number of different issues to consider around integrated care and improving the joined up arrangements between different public bodies, providers and local groups offering support and involvement in community activities. A major part of integration is better communication and knowledge about what is available, which is made for services users, carers, front line social workers and NHS staff. One suggestion was that GP surgeries should be a hub of information and advice. Other ideas included better signposting and service directories based on an integrated database, with a large number of ways for service users to easily access the information and for local providers to contribute their material. The group suggested integration needs to be improved where people have NHS care, free at the point of delivery, but are not eligible for social care especially in the instance of mental health service users. However there was a question about integration itself: If everything is fully integrated does it become stuck and stultified, with less scope to innovate and do things differently? 4. Supporting greater prevention and early intervention See also the Prevention report* Page 6 of 12

7 Marmot principles, of basic preventative and early intervention work for everyone but more for those in greatest need have been shown to reduce the level of need; to bring down the curve. If those in greatest need are the only ones helped, as is the case under FACS eligibility criteria, this does not reduce overall levels of need. Support must be targeted earlier. There are now numbers of people that previously have had social care support but now cannot get help following a review; they should be prioritised for preventative services. People with medium and low levels of risk still have quite a need for social care, and preventative services should be targeted for them. The group was concerned that whilst many at medium or low risk have in the past been supported by the voluntary and community sector there is an overall reduction in capacity in the sector due to cuts in funding both grant aid and also income from charitable sources. There is a fear that some support and activities will disappear. There was a discussion about the contribution volunteers can make. The group pointed out that volunteering is not free; training and support is needed which costs resources. Even where there are informal volunteers, for example a lot of people do do shopping for neighbours; it is not a substitute for social care. The research underpinning prevention is there, e.g. that an activity keeps people fit and healthier for longer, but the issue is how to ensure that savings in one budget might be re-invested in another. For instance savings in the NHS may be due to preventative work funded by the local authority social care budget. Local Authorities should gain in order to reinvest. Similarly VCS work on prevention which saves statutory funds should be rewarded by the statutory sector. Prevention often means not being in hospital; if prevention works it would reduce the need for some hospital services. The group was aware that closing hospital beds is a sensitive area. The group discussed social accounting models and the Social Return on Investment which is a model that is working on how to attribute savings to budgets in different organisations. The work is developing a story, Page 7 of 12

8 building a holistic picture about prevention and engagement. Social accounting models should be investigated for use in the future. It was noted that in one local example, what the service users say they value about the service is often be completely unrelated to the target and outcomes that the funders want. If someone goes out of business because they were rubbish, it s not a bad thing. If someone goes out of business, who provided a small high quality local service valued by users but it s because they are not talking with the same words as the commissioners, that s a bad thing Social accounting models have been used for many projects over the years and should be the first choice in social care and preventative work. 5. Creating a more diverse and responsive care market Creating a more diverse and responsive care market has to begin with the commissioners who need to commission diverse activities and services in a proactive way. Do the criteria look at how a provider looks at the needs of the individual? Are smaller organisations supported and involved? We respond to what is commissioned We d provide different services if they would pay for it local authorities are only interested in task based work, fixed time slots; they go for large organisations and only contract on price Under personalisation and direct payments, it s assumed service users will use PAs, not use (personal budgets) to buy care individually; care providers are unwilling, not flexible to do quickly, such as providing a care worker for a short term. There is no choice unless people become employers themselves it s hugely problematic Services users and carers need more and better information about what is available locally and is possible, with the details of all who are on the framework agreement, i.e. a service directory. The information should be written and publicised for service users and carers, not just for commissioners. This would create a demand for more varied services Page 8 of 12

9 and promote the service user as the commissioner. It would avoid individual social workers using the same known organisations. Providers need to be supported by commissioners to develop shared structures and outcomes so that there is a range of activities and services from large and small organisations. Procurement often works against this. To support the development of diverse services, the group suggested commissioners could use models such as: a framework agreement model a competitive dialogue model set aside budgets for smaller organisations. Having a range of providers on a framework agreement is working; it means not having only a single large provider. It protects a variety of services and activities, and allows them to be service user focused Within the competitive dialogue procurement, the providers can be involved in moulding the specification and engage in the process first which develops services that are better as a whole. For set aside, a budget is allocated for smaller organisations to develop new innovative services. Then if it is not used it is put it back into the pot. The group recommends the Treasury guidance should be promoted more to commissioners and there should be more support for the VCS to bid for big contracts. The group noted that if commissioners are judging evaluation criteria of 70% price and 30% quality this works against smaller organisations. It was recognised that TUPE causes problems for VCS bids as it now includes pension liability which was not the case in the past. 6. the role of the financial services sector in supporting users, carers and their families The group felt strongly that government should look at not-for-profit models such as credit unions, mutuals and charities to provide finance packages, and not private insurance. It also agreed that financial advice should be developed in the voluntary sector rather than the private sector. Page 9 of 12

10 There were a number of concerns about the financial services sector The private sector motivation is to make profits while the voluntary sector motivation is to benefit their service users An insurance company only looks at the amount it pays out and seeks reasons to not pay out The pension cost and insurance premiums are likely to be highest for the most vulnerable with the highest need. In health care, some people are uninsurable Insurance discriminates against people with long term care needs it would charge more for these with more care needs Any scheme would need to guard against miss-selling there have been a lot of bad experiences of equity release Age UK is a model of a non-profit making equity release advice and scheme for people who are over 50. It will focus on the individual and come to agreement about what is best for them. Contradictory aspects were identified, for instance, part of finance planning for those with funds is to minimise the tax contribution paid by the individual or corporation. On the other hand access to better financial planning would be welcomed by those with private pensions and other means, in order to avoid relying on state provision; it would then leave more for others by being less of a strain on public funds. Individuals would have a personal choice between equity release and being in full control of care services by fully funding care, or deciding to leave an amount to children but being within the constraints of state provision. 7 Commission on funding care and support There was concern that FACS criteria would be tightened further if the eligibility criteria become national and only those at substantial risk would be able to access care. People assessed as at critical risk have high care needs and are also very frail and vulnerable. But there is a general view that services allocated by postcode are unfair. There were grave concerns about the proposed reduction in Disability Living Allowance (DLA) of 20% Page 10 of 12

11 The cap on payments for care was supported suggested by the Commission as for home owners and others with means this would mean equity release would pay for care up to the cap, and still leave a reasonable amount to pass on to children. There was concern that if social care contributions were linked to pension contributions a 2 tier system would develop. After discussion the group concluded that social care should be paid for by general taxation; this could be moved towards over the long term. Additional contributions made to response Care and support are not interchangeable There is the potential for increasing confusion in the definitions of care and of support. Supporting People (SP) was established in 2003, following a 3 year transitional phase. In the legislation that introduced SP there were clear definitions as to what constituted support and it was made clear that certain functions were not to be considered support because they were legally defined as Care and were the statutory responsibility of statutory authorities. These functions were also separately regulated and still are. Caring for our future: shared ambitions for care and support focuses on services for people with health and social care needs. Support (as defined in SP) however is delivered to a much wider range including exoffenders, rough sleepers, gypsies and travellers as well as some with social care needs We need to remind government that in the interests of probity, governance and the avoidance of confusion and potentially double funding of services, there needs to be clear definition of terms. Care and support are not interchangeable. *Appendices Newcastle Wellbeing and Health Open Forum reports are attached as appendices and also available on Newcastle CVS website Page 11 of 12

12 Personalisation report Prevention report Social prescribing report Visit Page 12 of 12