MIDLOTHIAN COUNCIL SOCIAL WORK DIVISION ELIGIBILITY CRITERIA FOR COMMUNITY CARE SERVICES POLICY AND GUIDANCE This Policy is Authorised by: Colin Anderson This Policy was issued on: This Policy supersedes: This Policy was circulated to: None All Community Care SW Staff Date of circulation: Contact within the Midlothian Council Social Work for Further Information: Nina Lomas Review Date (Maximum of 2 Years from Issue): October 2011 SW_PROC\COMMCARE\PROC003\001.3
Document Control Information Revision Date Revision Description First Draft 21 February 2007 None Version 1.0 9 March 2007 none Version 1.1 18 July 2008 Addition to section 3.7 and 5 Version 1.2 8 October 2008 Addition of section 7 to part B (page 12) Version 1.3 Addition to section 1 SW_PROC\COMMCARE\PROC003/001.3 2
Index Page No. Introduction 4 PART A. The Council s Policy on Eligibility Criteria 1 Policy Statement 4 2 Background 5 3 What are the Eligibility Criteria? 6 4 Experience of Eligibility Criteria 7 5 Impact of Eligibility Criteria 8 6 Information and Publicity 8 7 Impact on Service Users 8 PART B. Guidance 1 Legislation 10 2 Criteria 10 3 Eligibility threshold 11 4 Care Plan Reviews 11 5 Outcome of Assessment 11 6 Decisions of the Panel 11 SW_PROC\COMMCARE\PROC003/001.3 3
INTRODUCTION Return to index This document is divided into two main parts: Part A sets out the Council s Policy on eligibility criteria. This part is based on a report to Cabinet in May 2006, describing the background and reasons for implementing the eligibility criteria proposed and subsequently approved at that time. Part B contains the Guidance issued to staff on the implementation of the eligibility criteria. PART A. THE COUNCIL S POLICY ON ELIGIBILITY CRITERIA 1. POLICY STATEMENT 1.1. This document sets out the Council s eligibility criteria for access to personal Community Care Services provided directly by, or commissioned through, the Council. 1.2. It is important that clear information on Services is available to the public. In order to achieve this and confirm the Council s responsibility to target resources to those most in need, elected members approved these eligibility criteria and decided that services will be targeted on those within the critical and substantial bands. This policy was implemented from 19 th June 2006. 1.3 The Council reviewed its approach to funding packages of care as part of the 2009-10 budget preparation process. It decided to ensure that the Division was allocated sufficient resources to meet the projected increase in need. This has ensured that, providing the service of choice is available in terms of capacity, services are provided immediately to those in critical and substantial need - and certainly within the new national guidelines of 6 weeks SW_PROC\COMMCARE\PROC003/001.3 4
2. BACKGROUND Return to index 2.1. Demand for Community Care Services for older people and adults, including residential, day care, respite care and support at home, continues to increase and place significant pressure on a finite budget. Specific performance criteria set by the Scottish Executive and policies promoting and encouraging independent living within the community also creates increasing pressure on providing services for people with complex needs. 2.2. Delivery of these services is provided within the context of a range of legislation, which includes: The Social Work (Scotland) Act 1968 The NHS and Community Care Act 1990 Community Care and Health (Scotland) Act 2002 Chronically Sick and Disabled Persons Act 1970 Disabled Persons (Service, Consultation and Representation) Act 1986 Mental Health (Care and Treatment) (Scotland) Act 2003 National Assistance Act 1948 Health and Social Services and Social Security Adjudication s Act 1983 The Housing Act (Scotland) 2001 Adults with Incapacity (Scotland) Act 2000 Carers (Recognition and Services) Act 1995 Community Care (Direct Payment) Act 1996 The Regulation of Care (Scotland) Act 2001 2.3. Assessment for service is recognised as a statutory duty and is a service in its own right and is distinct from the provision of services. 2.4. As the Social Work Service has continued to provide services to meet legislative and policy requirements, decisions have to be made regarding the appropriate provision and targeting of resources. This is in the context of an ageing population and, more recently, greater understanding of the vulnerability of some adults and the need for reassurances regarding safe services and protection of vulnerable people. 2.5. As a means of targeting resources at those with highest need and to face the responsibilities of managing within budget, new interim eligibility criteria were introduced for new clients in the Community Care Service of the Social Work Division in November 2005. These criteria were based on guidance from the Department of Health Fair Access to Care Services and are being used by a number of local authorities in Scotland as well as England and Wales. They are intended to address pressures on services and at the same time attempt to control expenditure on services supporting vulnerable people. The eligibility criteria take account of the Judicial Review of MacGregor v South Lanarkshire Council (December 2000). 3. WHAT ARE THE ELIGIBILITY CRITERIA Return to index SW_PROC\COMMCARE\PROC003/001.3 5
3.1. Criteria provide a framework for helping to ensure that decision-making is transparent, fair and consistent. The term eligibility refers to whether or not an individual may be entitled to receive services. The decision is not made until after needs have been assessed and the level of priority identified. 3.2. Eligibility for service is based on the single shared assessment process focussing on individual needs and seriousness of risk to their independence if their needs are not met. 3.3. The eligibility criteria support the principles which underline current legislative and policy initiatives including promoting inclusion and choice, maximising independence, involving individuals in care arrangements, considering the needs of users and carers and focussing on issues of protection and safety. 3.4. The eligibility criteria are graded into four bands, which describe the seriousness of risk to independence or the consequences if needs are not addressed. These are identified as follows: Critical when life is, or will be, threatened; and/or significant health problems have developed; and/or there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or serious abuse or neglect has occurred or will occur; and/or there is, or will be, an inability to carry out vital personal care or domestic routines; and/or vital involvement in the work, education or learning cannot or will not be sustained; and/or vital social support systems and relationships cannot or will not be sustained; and/or vital family and other social roles and responsibilities cannot or will not be undertaken. Substantial when there is, or will be, only partial choice and control of the immediate environment; and/or abuse or neglect has occurred or will occur; and/or there is, or will be, an inability to carry out the majority of personal care or domestic routines; and/or involvement in many aspects of work, education or learning cannot or will not be sustained; and/or the majority of social support systems and relationships cannot or will not be sustained; and/or the majority of family and other social roles and responsibilities cannot or will not be undertaken. Moderate when SW_PROC\COMMCARE\PROC003/001.3 6
there is, or will be, an inability to carry out several personal care or domestic routines; and/or involvement in several aspects of work, education or learning cannot or will not be sustained; and/or several social support systems and relationships cannot or will not be sustained; and/or several family and other social roles and responsibilities cannot or will not be undertaken. Low when there is, or will be, an inability to carry out one or two personal care or domestic routines; and/or involvement in one or two aspects of work, education or learning cannot or will not be sustained; and/or one or two social support systems and relationships cannot or will not be sustained; and/or one or two family or other social roles and responsibilities cannot or will not be undertaken. 3.5. In May 2006, Cabinet decided that services will be targeted on the Critical and Substantial bands. 3.6. The introduction of the interim eligibility criteria in 2005 identified a threshold between substantial and moderate. This now means that persons falling in the moderate or low category are to be advised that there may be a delay in providing service and their name will be held on a waiting list. People are advised to make a further referral where they believe circumstances have changed and risks have apparently increased. 3.7. It will be seen from the criteria that prioritisation is made on the basis of immediate and longer term critical consequences for independence based on risk and safety of individuals rather than improving quality of life Note: In February 2008, the Scottish Government issued guidance on NHS Continuing Health Care. This may be relevant to some service users in the Critical band. 4. EXPERIENCE OF ELIGIBILITY CRITERIA Return to index 4.1. The introduction of criteria within the Community Care Service is overseen by a Resource Panel which meets weekly and is chaired by a Service Manager from Community Care. This replaced a number of resource allocation groups which met to consider requests for service for adults and older people. Submission to the Resource Panel includes assessment of need of the user and relevant assessment of carer needs together with a risk assessment. This requires significant time investment from Managers in order to consider in detail and make decisions within the existing pricing policy on provision of services covering care in the community, respite and other care arrangements for older people and adults. SW_PROC\COMMCARE\PROC003/001.3 7
4.2. This rigorous framework has been beneficial to staff who are able to present clear criteria to service users and partner organisations. Information is available to users and carers explaining the criteria and information and meetings have been held with staff in other services, specifically health care, to explain the reasons for the introduction of these criteria and the potential impact. This is particularly important because of joint arrangements regarding single shared assessment with colleagues in health. 5. IMPACT OF ELIGIBILITY CRITERIA Return to index 5.1. The purpose of introducing eligibility criteria is to control expenditure, target services on those in greatest need and provide a clear framework in which users, carers, staff and partner organisations have a clear understanding of services the Council is able to provide or commission within its legal responsibilities. 5.2. The immediate impact on service users did not identify any significant difficulties. Where these arise they will be dealt with through line management arrangements seeking reconsideration of decisions. Users and carers are always advised of the availability of the complaints procedure. 5.3. Rigorous review of existing packages of care is required in order to ensure that they continue to be in line with the eligibility criteria. 6. INFORMATION AND PUBLICITY Return to index 6.1. It is recognised that information for the public and partner organisations is important. An information leaflet has been produced and made available on the Midlothian website, confirming the eligibility criteria and the assessment process for accessing services. Similarly information for partner agencies has been confirmed, especially in the context of the joint responsibility for single shared assessment. 7. IMPACT ON SERVICE USERS Return to index 7.1. The report to Cabinet in May 2006, stated that it is probable that implementing eligibility criteria across all adult and older people services would mean for some a reduction of service which they view as fundamental to providing an improved quality of life. This will be the case for users and their carers often for different reasons. The framework, however, provides a consistent reference for service users and carers to understand how resources will be targeted in future to facilitate equity in service provision. It is also important that all members of the public understand the limitations placed on the Council by budget pressures. SW_PROC\COMMCARE\PROC003/001.3 8
7.2. Ultimately the Council s Social Work Service, together with partners, has to work within a policy and legal framework to promote independence and protect vulnerable people. This is a complex service designed to meet individual needs and expectations in supporting people in the community and in residential and other care placements. Budget pressures and equity of access to service demand that eligibility criteria are used in order to assist the management and delivery of services. SW_PROC\COMMCARE\PROC003/001.3 9
PART B. GUIDANCE Return to index The following Guidance is based directly on the Policy document above. It re-states the legislative background and confirms the priority given to the criteria banded as Critical and Substantial. The following criteria are based on the Department of Health Fair Access to Care Services. This is an interim measure to deal with the current projected over-spend in the Social Work budget. 1. Legislation The following list reflects the relevant legislation that supports the delivery of a Community Care service. The Social Work (Scotland) Act 1968 The NHS and Community Care Act 1990 Community Care and Health (Scotland) Act 2002 Chronically Sick and Disabled Persons Act 1970 Disabled Persons (Services, Consultation and Representation) Act 1986 Mental Health (Care and Treatment) (Scotland) Act 2003 National Assistance Act 1948 Health and Social Services and Social Security Adjudication s Act 1983. The Housing Act (Scotland) 2001 Adults with Incapacity (Scotland) Act 2000 Carers (Recognition and Services) Act 1995 2. Criteria We have based the eligibility criteria on the two bands: Critical and Substantial They will apply to all new referrals and requests for additional services to existing packages of care. Critical when life is, or will be, threatened; and/or significant health problems have developed or will develop; and/or there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or serious abuse or neglect has occurred or will occur; and/or there is, or will be, an inability to carry out vital personal care or domestic routines; and/or vital involvement in work, education or learning cannot or will not be sustained; and/or vital social support systems and relationships cannot or will not be sustained; and/or vital family and other social roles and responsibilities cannot or will not be undertaken. SW_PROC\COMMCARE\PROC003/001.3 10
Substantial - when there is, or will be, only partial choice and control over the immediate environment; and/or abuse or neglect has occurred or will occur; and/or there is, or will be, an inability to carry out the majority of personal care or domestic routines; and/or involvement in many aspects of work, education or learning cannot or will not be sustained; and/or the majority of social support systems and relationships cannot or will not be sustained; and/or the majority of family and other social roles and responsibilities cannot or will not be undertaken. 3. Eligibility Threshold Return to index If a person s needs fall below the Eligibility Criteria threshold currently set at the level of Critical and Substantial then we must inform clients that there may be delays in offering a service, and in the meantime their name will be held on a waiting list. In addition clients, carers or referrers will be asked to re-refer where they believe the circumstances have changed and the risks have apparently increased. Where the assessment clearly indicates that, within 6 months, needs will increase and the above criteria will be met, then funding will be considered. 4. Care Plan Reviews Where there is an established care plan and following review there is evidence of increased need this should be measured against the criteria and, if appropriate, a submission made to the Panel. In general, where reviews are conducted, the criteria will apply and it should be noted that care plan cover may be increased or be reduced. 5. Outcome of Assessment Return to index Where the assessment confirms that the need meets the criteria, the Allocation Panel will meet every Wednesday at 11am to consider each request for funding. The chairing of the Panel will be by the Fieldwork GM CC or their depute. The application for funding must be submitted to the Panel on the Resource Panel Submission doc. which incorporates supporting risk assessment detail. In order to support a case for funding and to meet the current criteria threshold, you are likely to have completed a full Risk Assessment and extracts should be used to inform the application to the Panel. The worker who is submitting a report to the Panel must state whether the user has been screened for eligibility for NHS Continuing Health Care and state the outcome of the screening. If the user was initially assessed as may be eligible, then a multi SW_PROC\COMMCARE\PROC003/001.3 11
disciplinary assessment is required (normally the Single Shared Assessment). The Panel needs to know the outcome of the assessment, specifically with regard to whether the person is eligible for NHS Continuing Health Care. This will only apply to some service users in the Critical band. (Scottish Government Guidance on NHS Continuing Health Care (CEL6 2008), 6. Decisions of the Panel The decision will be given in writing by the chair of the Panel and will be recorded in the client s file. 7. Decisions outwith the Panel It is recognised that following a risk assessment, and community care assessment it may be necessary to provide a package of care or find a residential placement in between the meetings of the Panel. In these circumstances the Service Managers have the delegated authority to agree funding up to the meeting of the next Panel. The worker should provide an update of its circumstances to the panel. SW_PROC\COMMCARE\PROC003/001.3 12