Older people who self fund their social care: A guide for health and wellbeing boards and commissioners

Older people who self fund their social care: A guide for health and wellbeing boards and commissioners Clive Miller, Antonia Bunnin, and Vic Rayner SEPTEMBER 2013 Helping you to improve social outcomes

TABLE OF CONTENTS Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 2 Table of contents Part 01 Introduction PAGE 03 Purpose of the guide PAGE 05 Part 02 Who are the self-funders? PAGE 06 Pre-Dilnot PAGE 06 The impact of Dilnot PAGE 08 Part 03 Estimating the numbers of older people who self-fund PAGE 10 National estimates PAGE 10 Estimating the local self-funding population PAGE 12 Drivers influencing the numbers of self-funders PAGE 14 Part 04 Enabling self-funders to secure effective and sustainable care and support PAGE 16 Support planning PAGE 17 Finding the right care provider PAGE 18 Financing care PAGE 20 Provider development PAGE 21 Self-funder engagement PAGE 22 Part 05 The self-funder commissioning scorecard PAGE 24 Using the scorecard PAGE 25 Self-funder commissioning scorecard PAGE 26 Endnotes PAGE 27

PART 01 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 3 1 Introduction In England, older people who pay entirely for their own social care and support account for 45% of residential care home places 1, 47.6% of nursing home placements 2 and 20% of home care support. These people are often referred to as 'self-funders'. The self-funded registered residential care and registered nursing home market is worth 4.9 billion per year, and the self-funded home care market 652 million 3. Whilst some local authorities have modest numbers of social care self-funders compared with those receiving state-funded support, in other areas self-funders are in the majority. Yet self-funders are often ignored in official statistics, and in national and local social care and health strategies and policies. In 2011, the Dilnot Commission on the funding of care and support published its report 3 to government. Its aim is to reduce uncertainty about the total cost of care that any individual might incur and provide conditions for development of an affordable insurance market that will help individuals make best use of, and where possible, conserve some of their assets. The proposals are also intended to enable behaviour changes. These include people spending on care and support when they need it, rather than holding off for fear of not being able to fund all of their care, and making better financial preparations for future care and support needs. Whilst the Dilnot changes, which are proposed in the Care and Support Bill, apply to all adults in need of social care, this report focuses only on the changes to provision for older people. In response to the Dilnot report, the government has committed to introducing a cap on total care costs of 72,000, and to raise the upper means test threshold for residential care to 118,000 (i.e. people will only pay 100% of their care costs if they have assets above this amount), which is intended to be implemented from April 2016 4,5. Thus, new systems will need to be developed for councils and individuals to work together, to agree care needs and to monitor the amount people spend on their own care up to the cap, after which the state will meet ongoing care costs. Local authorities will need to be aware of, and work with, people who previously would have been 'off the council's radar' because they were self-funding.

PART 01 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 4 There are four main reasons why health and wellbeing boards and health and social care commissioners should be concerned about self-funders: 1. Legal obligation local authorities, in collaboration with their local partners, have a legal obligation to promote the health and wellbeing of their entire population 6,7. They are also required to ensure the provision of information and advice, and to carry out assessments of people's care needs, irrespective of their financial circumstances. If local authorities fail to take into account those who are potential or actual selffunders, then they are not meeting these obligations. The 2011 Local Government Information Unit (LGIU) survey 8 found that many local authorities were falling well short of meeting their obligations towards selffunders. Only around half (53%) of local authorities had estimates of the number of self-funders in their area. Advice and information services are highly variable in quality and availability; many provide general rather than personalised advice and are difficult for self-funders to access. Many social care self-funders did not see the relevance of local authority services to them, or avoided contact because of perceived stigma or a wish to avoid state interference. Specialist financial advice on planning for and managing care costs was also in short supply. 2. Avoidable health and care costs self-funders have the potential to become very costly to the state and to local authorities in particular. If self-funders make uninformed choices about care, or purchase care which after a time they can no longer afford, they risk running out of funds and becoming dependent on their local authority for ongoing care funding. The 2011 (LGIU) survey estimated that the outcome of uninformed choices by self-funders represented 3.5% of the average council s residential care budget. If self-funders are not well informed at the outset about the preventative support services and care options available to them, the result may be earlier-thannecessary loss of independence and premature use of registered residential care and registered nursing homes. Furthermore, the impact of reduced independence on an individual s health may also lead to greater strain being placed on NHS resources. 3. Implementing Dilnot once the recommendations of the Dilnot Commission are implemented, self-funders who are eligible for support will want to register their spend on care with their local authority. This will then provide an agreed account of their cumulative spend and indicate, when and if, they reach the 72,000 cap on individual contributions to their care costs. In the future, all those who wish to claim the protection of the cap, will need to be assessed by the local authority, made aware of how much care and at what price will count towards the cap and provide the local authority with an account of their cumulative care expenditure. Many selffunders currently have no contact with their local authority. Contacting and informing them of their rights, as well as undertaking the extra assessments and dealing with the financial implications, is part of the challenge this report seeks to address.

PART 01 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 5 4. Synergy between personal budget holders and self-funders with rising numbers of personal budget holders exercising choice over their care and support, distinctions between personal budget holders and self-funders continue to decrease. Both are individual purchasers of care. Some social care providers do not know which clients are self-funding and which are using personal budgets. Hence there is a strong argument that commissioners should treat self-funding as another type of self-directed support, and aim to enable a social care market that works well for all. This should include enabling all who use social care (whether self-funded or state-funded) to contribute to shaping the market to better meet their own needs. Hence it is in the interests of health and wellbeing boards and commissioners to work together with self-funders and other users of social care, to stimulate the development of more effective and personalised services. Purpose of the guide This guide aims to help health and wellbeing boards and health and social care commissioners improve in the following areas: Awareness become aware of the importance of having a strategy for enabling self-funders to best meet their health and social care needs and learn from the practice of leading edge local authorities. Scoping, planning and system design quantify the numbers of self-funders, understand the drivers, and identify the ways in which people can move from selffunding to being partly or wholly state-supported. Commissioning advise commissioners of the key tasks they need to prioritise as they transition to a new funding system. The guide makes extensive use of findings published in three reports from the Institute for Public Care (IPC) at Oxford Brookes University and Melanie Henwood Associates 1,9, and the Local Government Information Unit (LGIU) 8. These are recommended reading for all commissioners and health and wellbeing board members who wish to work alongside self-funders to help them better meet their own needs.

PART 02 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 6 2 Who are the selffunders? The groups of older people who self-fund will be, to some degree, changed by the implementation of the Dilnot Commission recommendations. However, commissioners will want to get to grips with the issues raised by self-funding now, as well as having to deal with both the transition to, and the continuing impact of, the implementation of Dilnot later. The selffunding position for both pre and post Dilnot implementation is explored below. Pre Dilnot Prior to the implementation of the Dilnot Commission recommendations, older people receiving social care can be divided into a number of groups according to their funding arrangements 10 : People who fully fund their own care, without any state financial support for care costs. People whose care is partly funded by their local authority and partly funded by their own means-tested contribution to the cost. People whose care is partly funded by their local authority, and partly funded by a top-up payment from a third party (usually a relative). These top-up payments may be used to purchase care from providers who charge more than the rate the local authority is willing to pay, or to buy more hours of care than the local authority is willing to fund.

PART 02 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 7 People whose care is partly funded by their local authority, partly funded by their own means tested contribution to the cost, and partly funded by a top-up payment from a relative (or other third party). People whose care is entirely funded by their local authority. Throughout this guide, when referring to self-funders we mean people in the first group 11. Surprisingly, despite their large numbers, self-funders rarely figure in official social care statistics, which tend to focus on those who are partially or wholly funded by the state. Information on whole population health needs are available but, as health is a universal service, there are no separate breakdowns of figures for self-funders. Another group to be aware of are potential self-funders: people who are not currently using social care services, but whose financial assets mean they would have to fund any care and support they might seek or require in future. Some potential self-funders do not yet have care and support needs. Others do have care and support needs, but for various reasons may not have had a formal needs assessment from their local authority, or may not actually be using any social care. As people can move from being potential to actual self-funders, and some can move onto receiving state funded support, commissioners will want to keep track of these different groups. Table 1 illustrates how the focus of commissioners on different funding groups will vary according to the commissioning task being addressed. Table 1: Examples of how commissioners focus on different groups of social care user varies according to commission task COMMISSIONING TASK ESTIMATING WHICH PEOPLE MAY LATER RUN OUT OF FUNDS AND BECOME ELIGIBLE FOR LOCAL AUTHORITY FULLY-FUNDED CARE GROUPS OF SOCIAL CARE USER Self-funders (fully fund own social care) People whose care is funded partly by local authority, and partly by own means-tested contribution People whose care is funded partly by local authority, and partly by third party top up payment People whose care is funded partly by local authority, partly by own means-tested contribution, and partly by third-party top up payment 12 Potential self-funders COMMISSIONER CHECKLIST How are self-funders defined locally? How much is known about self-funders in your area? UNDERSTANDING THE PRIVATELY DETERMINED AND FINANCED SOCIAL CARE MARKET ESTIMATING HOW MANY PEOPLE TO TARGET TO ENABLE THEM TO BEST PLAN FOR THEIR FUTURE CARE AND SUPPORT Self-funders (fully fund own social care) Potential self-funders Self-funders (fully fund own social care) People whose care is funded partly by local authority, and partly by third party top up payment People whose care is funded partly by local authority, partly by own means-tested contribution, and partly by third-party top up payment Potential self-funders

PART 02 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 8 The impact of Dilnot In February 2013, the government produced its official response to the Dilnot report, which was then refined and slightly amended in the Chancellor's Budget of 20 March 2013. Key elements include: A national needs-based eligibility threshold there will be one national needs threshold above which people will be eligible to be considered for state-financed care. A cap on total care costs of 72,000 13 for older people with care needs 14 individuals whose care needs are above the national threshold, and who fully fund their care, will be required to pay up to this level before they become eligible for state funding. The cap will only take into account payments based on the care costs that the local authority is prepared to fund (based in turn on the assessment of the individual's needs). Any extra care costs that people may choose to incur by purchasing more expensive care will not be taken into account. The cap will increase in line with earnings, prices or at 2.5% per annum whichever is the highest. 118,000 15 assets threshold for means testing people with assets above this amount will be expected to fully self-fund their care until they reach the care cost cap. General living costs people purchasing registered residential care and registered nursing home places will be required to pay a fixed sum towards their general living costs (i.e. non-care costs), possibly between 7,000 and 10,000 per annum. This will apply both before and after people have reached the 72,000 cap on care costs. This is intended to reduce the incentive for people who could continue living at home to move prematurely into residential care. Universal access to deferred payments for self-funders in residential care from April 2016, no one will have to sell their home in their lifetime to pay for residential care those unable to afford the fees will have the right to defer paying during their lifetime. This will enable people to fund care through a future charge on their assets agreed with the local authority, rather than directly from their own funds or via insurance. When implemented, these policies may significantly change the proportions of differing groups of social care users, as categorised by funding arrangement, within the social care market. The actual balance in any given area will depend in part on local factors. However, it is possible to identify the range of individual funding options, from full selffunding to full means tested state support, that are likely to result from the government s policy response to Dilnot (See Figure 3).

PART 02 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 9 Figure 3: Example of the range of ways in which people will fund their social care when Dilnot is implemented NO Top-up fees? YES NO YES Fully self-funded Fully state funded + top up Fully self-funded 'General living' costs + top up YES Top-up fees? NO 'General living' costs only Above the care fees cap? YES YES Living at home? NO YES Income above 'general living' costs? NO Top-up fees? YES NO Means tested contribution to 'general living costs' + top up Means tested contribution to 'general living costs' Above assets threshold? NO Top-up fees? YES NO Means tested state support + top up Means tested state support COMMISSIONER CHECKLIST Are you clear about the steps you need to take to understand how Dilnot will impact on your local profile of selffunders? Can you begin work to streamline your assessment processes to prepare you for an increase in assessment from 2016 onwards? The degree to which the Government's response to Dilnot will impact on the profile of self-funders will vary from one local authority to another, due to: The distribution of income and total assets across self-funder population and how they change over time. The extent to which self-funders use the introduction of the expenditure cap to reduce their total care expenditure or recycle the money that they would have previously paid in care fees to purchase more or higher quality care. The level at which the national eligibility threshold for care will be set compared with that currently set by individual local authorities. The maximum cost (per unit of service) that a local authority will allow to be taken into account in calculating two aspects of allowable care costs. This is determined by two factors. Firstly, whether an individual s total expenditure on care has reached the cap. Secondly, the maximum annual amount that the local authority is prepared to contribute towards an individual s care once the cap has been exceeded. The introduction of national eligibility criteria and new funding system for adult social care means that councils will need to ensure that their systems are streamlined as far as possible and can cope with the increase in number of people requiring assessments. The Think Local Act Personal Partnership has undertaken work to assist councils in reducing unnecessary process with the delivery of Personal Budgets. Details can be found on the TLAP website. The approach taken and learning from this work would be an excellent starting point for authorities thinking about how they might approach process change in preparation for increased level of assessments.

PART 03 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 10 3 Estimating the numbers of older people who selffund Much of the work on estimating the numbers of self-funders has been focused at the national level. Whilst this is useful in gaining an overview and raising a political profile, commissioners will be required to estimate their local populations. There are a number of approaches that have been used to estimate national self-funder populations and service take up that could be adapted to produce local estimates, which we have summarised in this chapter. National estimates Many different estimates have been made regarding the number of self-funders in the UK as a whole and in England in particular. Tables 2, 3 and 4 show the IPC estimates 1. IPC s residential care figures (see Table 2) are based on Care Quality Commission (CQC) and Laing and Buisson data. These indicate that self-funders accounted for 169,748 of care places, i.e. 39.6% of nursing home residents and 47.6% of care home residents.

PART 03 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 11 Table 2: Estimated number of people who pay for their own care home place in England based on data from QCQ and Laing and Buisson TYPE OF HOME RESIDENTIAL CARE HOME NURSING CARE HOME 9 A Total numbers of places available at 30.0.09 187,330 179,393 B C D Vacancy levels Local authority funded placements 18,809 93,247 17,830 75,521 NHS funded placements A-B-C-D=E Number of self-funders by each local authority 1,118 74,156 673 85,359 TOTAL 378,053 37,749 168,768 1,788 169,748 Estimates for those receiving home care is based on the data from English Longitudinal Survey of Ageing ELSA (Wave 3 2006-7) and the Projecting Older People Population Information (POPPI) project. These indicate that in England there are 168,701 self-funding older people buying help for tasks involving: moving, washing, dressing eating and preparing meals. If additional help with practical tasks such as shopping, work around the house, answering the phone, managing money and taking medicines is taken into account, the number of self-funders rises to 271,536. Table 3 draws on this data to estimate the proportion of older people, in different age cohorts, who currently fully fund their home care. Table 4 applies these proportions to the POPPI population data to produce estimated numbers of self-funders. Table 3: Percentage of those 65+ paying for help with moving, washing and dressing, eating and preparing meals MEN WOMEN TOTAL 65-69 0.53 0.61 0.57 70-74 0.56 1.15 0.87 75-79 80-84 85+ Total 0.51 1.45 2.26 0.82 3.42 3.16 9.31 2.87 2.18 2.40 6.86 1.96 Source: ELSA Wave 3

PART 03 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 12 Table 4: Forecast for those 65+ paying for help with moving, washing and dressing, eating and preparing meals based on applying the percentages from Table 3 to the POPPI data. Males 65-69 70-74 75-79 80-84 85+ Total TOTAL 2010 6187 2015 7502 2020 6816 2025 7476 5417 3819 7446 5948 4268 8445 7279 4771 9863 6656 5894 11,255 8875 11,180 14,188 18,188 31,076 6.86 36,011 6.86 39,601 6.86 43,752 6.86 2030 8539 7333 5428 14,035 22,602 48,814 6.86 Females 2010 2015 2020 2025 2030 65-69 7642 9306 8486 9256 10,664 COMMISSIONER CHECKLIST 70-74 75-79 12,472 31,426 13,525 33,656 16,559 36,898 15,170 45,448 16,606 41,898 How would you go about finding accurate local data? 80-84 85+ Total TOTAL 23,343 24,155 26,727 29,761 74,517 82,021 92,309 109,029 137,625 6.86 153,003 6.86 164,945 6.86 180,187 6.86 36,944 130,356 200,484 6.86 Table 4 provides a useful indication of the current size and likely growth of the selffunding population. However as some of the data on which the above forecasts are based is now over 6 years old it should be treated with care. The provision of more upto-date data needs to be addressed. Estimating the local self-funding population Whilst it is important to be able to understand the national picture, the extent of selffunding in local populations can differ significantly from this average. A follow up study by IPC 21 in four local authority areas showed the proportion of self-funders in care homes varied from 15% in Hartlepool, to 57% in Hampshire. Residential care The numbers of self-funders purchasing residential care in a local area can be estimated using the IPC study methodology. This methodology works backwards from the total number of people receiving care and deducts vacancies and any placements that are local authority or NHS funded to calculate the number of self-funders. You can use the equation on the next page to calculate this.

PART 03 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 13 How to estimate the number of selffunders purchasing residential care in a local area Total available residential care beds Vacancies Total NHS and local authority funded residential care placements Total self-funder purchased residential care beds Health and wellbeing boards will also want to be able to forecast future numbers. This can be achieved by: 1. Using local data to break down the total number of self-funders purchasing residential care beds by gender and then into age bands for men and women on a percentage basis. 2. Using local population data to calculate the percentage of men and women within each age band who self-fund their own residential care. 3. Apply these percentages to local population projections for older men and women to obtain an estimate of the future numbers of self-funders in residential care. Local population projections need to take into account the net migration of older people in and out of local authority areas as this can be very significant in places. How to forecast the number of selffunders who will purchase residential care beds in the future. Percentage of a given gender who self-fund their residential care in an age band Total number of selffunders of a given gender, in residential placements, in an age band Total number of all people, of a given gender, in residential placements, in an age band Domiciliary care The same approach as that used for residential care can be used to estimate the number of self-funders of domiciliary care. However, obtaining base data for domiciliary care may prove challenging. If local data is not easily available, an initial rough estimate could be achieved by using the national percentage figures on the proportion of selffunders (see Table 3). Tracking self-funder use of services is a key commissioning task. Box 1 on the next page shows how one authority achieved this for people in residential care.

PART 03 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 14 BOX 1: NOTTINGHAMSHIRE COUNTY COUNCIL: MONITORING SELF-FUNDERS 16 In order to ensure that public receive appropriate care fees advice, the council awarded a contract to Capita IB to develop a software solution that will monitor and record the occupancy and vacancies of beds within care homes in Nottinghamshire. The council implemented the care home bed monitoring system from March 2012 for care homes for older people. The system is web-based and will enable people to search for all care homes in Nottinghamshire and find out how many beds are available at any moment in time. Additionally, it provides Nottinghamshire County Council with statistics on the number of self funders across the county. Drivers influencing the numbers of self-funders Enabling a larger proportion of older people to enjoy good health and well-being for longer is beneficial to individuals and can also reduce potential strain on health and local authority resources. Major drivers that will influence the local picture include economic and demographic trends, as well as the impact of changes in levels of funding, service delivery practice, and the implementation of the Dilnot recommendations. Therefore, understanding and, where possible, influencing the drivers that lead to both increases and decreases in the number of self-funders is of paramount importance. These major drivers are: Drivers that increase numbers of self-funders Increased top ups as more people who have previously self-funded exceed the cap, those who opt for local authority support will become state funded. As they will, in effect, receive a discount on their previously expected costs of care, this may lead to some paying to top up their care. It might also increase the degree to which those who would have previously topped up their care do so. People who previously would not have self-funded Dilnot and the government point out that the proposed changes are designed to both reduce the uncertainty about the full extent of the costs people will have to bear for their care, as well as stimulate the growth in affordable insurance products. One possible outcome of this is that people who would not have previously purchased care then do so. Hence this may increase the number of self-funders. Reductions in public sector budgets prior to any decision on the adoption of a national threshold, budget reductions may lead local authorities to raise their eligibility thresholds for state funded support. This would increase the number of people who will have to fully self-fund. Reductions in budgets may also lead to increases in the amount that individuals are expected to contribute from their own funds. This would reduce the income or remaining assets of this group of selffunders. More people with occupational pensions would both increase the number of people who receiving state funding who will be required to contribute towards the cost of their care, and also increase the incomes of people who fully self-fund.

PART 03 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 15 Increased equity should the housing and equity markets begin to appreciate faster than the general level of inflation, then the value of property equity that selffunders hold is also likely to rise. General increases in the standard of living for many people may also lead to higher levels of savings. Both of these trends would increase the number of older people whose assets could exceed the means tested threshold for state funded social care and require them to spend more on their own care. Migration self funders moving to an area from other parts of the UK or returning from abroad. COMMISSIONER CHECKLIST Does your strategy reflect the balance of drivers to both increase and decrease selffunding numbers within your community? Drivers that decrease numbers of full self-funders Self-funders with lower levels of assets self funders whose total assets place them above the current asset threshold ( 23,250) but below the new post Dilnot threshold ( 118,000) would move from being fully self-funding to being eligible for means tested state support. Self-funders who have paid care fees in excess of the 72,000 Dilnot cap will be eligible for local authority funding. Assuming they opt for local authority support, their care, minus general living costs, will be funded up to the annual limit set by their local authority. More older people as more older people live longer there will be an increase in the number of older people whose assets and incomes make them eligible for fully funded state social care. Reduced value of assets and occupational pensions falls, or lower than inflation increases in house prices and shares, would reduce the value of selffunders assets. Lower or slow growth in equities would also reduce the final value of pension pots for those dependent on private pensions. If lower interest rates were to persist then yields from annuities would remain low or drop, further reducing the income that can be realised from private pension pots and the ability of people to afford inflation proofing for their pensions. Together, these changes would reduce the number of self-funders and their ability to self-fund. Reductions in public sector budgets could lead to cuts in universal services on which older people rely, or increase the likelihood that local authorities charge for these services. Reductions in the budgets provided to the third sector could also affect the amount and variety of subsidised low level support on which self-funders draw. Examples of this include a reduction in the number of libraries, higher charges for leisure services and a reduction in luncheon clubs. These cuts, or rising costs, of services may lead to an accelerated loss of independence, resulting in more selffunders reaching the needs threshold earlier and progressing more rapidly onto local authority funded support. Pressure on NHS to move people more quickly out of hospital unless this is accompanied by intensive and effective re-ablement it may lead to an increase in the number of people having to fund social care to enable their own recovery, or a greater use of residential care as a default option and then a more rapid progression into local authority funded social care. Higher prices of care if the price of social care services were to continue to increase faster than any rises in real pension and asset values, the assets of selffunders would be reduced at a faster rate, enabling more to become eligible for some local authority funded support.

PART 04 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 16 4 Enabling selffunders to secure effective and sustainable care and support The support provided to self-funders to help them secure effective and financially sustainable care varies widely from one area to another, is often of a very general nature and is difficult to access. This can lead to self-funders: Being unaware of the need to plan for their care and support needs. Having to make decisions at crisis point. Not being aware of the full range of care and support options. In turn, this can adversely affect people s quality of life; cause loss of independence and increase both health and social care costs; and lead some self-funders to require local authority funded support rather than being financially self-sufficient.

PART 04 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 17 Support planning Little systematic knowledge exists about how self-funders assess their needs and find out about the care and support options that are available. Anecdotal evidence suggests that few people plan ahead and that, for many people, key decisions are taken at times of crisis. This can lead to a lack of consideration of alternative options and premature use of residential and nursing home care. Pressure on hospital beds and lack of access to re-ablement can mean that many people, who could, with additional support, continue to live in their own homes, end up in residential or nursing home care instead. This can lead to a loss of independence and self-funders paying for more expensive types of care than they actually need. Research 9 shows that whilst local authorities offer assessments to older people in need of care and support, there are a number of barriers that mean self-funders to do not take them up: Lack of information many self-funders do not know that local authority adult social care offers a free assessment service to those above the needs threshold. Eligibility self funders knowing that they would not be eligible for local authority funded social care wrongly assume that they would also not qualify for an assessment. Stigma local authority services may also be perceived as being only for the poorest and being basic in nature. Difficult to contact getting through to the right person can be an exhausting and confusing process with people being passed from one contact to another, none of whom can help. Unhelpful signposting when people are not eligible for an assessment they will be signposted to other organisations for help. However, having contacted the signposted organisation, self-funders often do not get the detailed advice they need. Instead, they are signposted on to further organisations. This can happen so frequently that some people give up trying to find help. Limited access to universal services reduction in public expenditure on universal advice and information services can mean that individuals or the relatives or carers are put off asking basic questions around eligibility or services to even begin the journey. This means both critical information about potential self-funders, and the ability to divert potential crises can be lost. Personalised advice where advice is received it is often of a general nature, and not the personal advice that people require. The implementation of the Dilnot recommendations is likely to lead to a rise in the number of self-funders contacting local authorities for assessments and advice. The reason for this is that self-funders will need to be able to prove that their needs are above the nationally set threshold and to be able to appropriately account for the expenditure they then incur towards the total cap on their care and support costs. Raising self-funder awareness of the support and financial options available to them is now a major task for local authorities. This will require a shift from a reactive to a proactive approach (see Box 2).

PART 04 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 18 COMMISSIONER CHECKLIST Is re-ablement routinely available to older people, including personalised advice about their continuing needs for care and support and how to meet them? What sources of personalised help are available to advise older people who potentially will self-fund about the extent of their support and care needs and what can be done to meet them? What feedback is there from older people on the accessibility of these sources of advice and the degree to which they meet people s personal information needs? How proactive are these information services, and what is being done to improve the accessibility and effectiveness of them? How do you plan to respond to the likely increase in demand for information and assessments that is predicted to arise from the implementation of the Dilnot recommendations? BOX 2: RAISING SELF-FUNDER AWARENESS Use many different channels 17 It is essential that local authorities get the message out to as many people as possible that the system for paying for care is changing. It is also important to stress what the local authority can do for potential self-funders, as well as raising awareness of organisations that may be able to provide specialist financial advice. This requires the use of a wide range of channels such as: building in new pathways to existing adult social care processes to proactively support self funders, library promotions, editorials in council magazines and newsletters; press promotion, pop up banners and leaflets at older peoples' events; information in bereavement packs; engagement with meals on wheels; and working with acute partners and promotions through GP practices. FirstStop Advice FirstStop Advice is an independent, free telephone service offering advice and information to older people, their families and carers about housing and care options for later life. The service is provided by EAC in partnership with a number of other national and local organisations, and brings together a wealth of expertise to help older people and their carers explore the options and choices open to them. It can provide specialist help on any aspect of care, support or housing for elderly people, including financial issues as well as statutory rights and entitlements. A growing network of affiliated FirstStop Local services bring additional local knowledge, and in many cases can offer face-to-face advice including home visits. Finding the right care provider Regardless of whether advice for support planning is available, self-funders will require further help in finding service providers who both suit their needs and budgets. Whilst local authorities do provide advice, it is often only in the form of lists of providers. This does not go far enough. Self-funders also need help with: Choosing what to look for in a service, how to find out if it is provided and what the quality is like. Value for money knowing the prices of different services, and how this relates to what is provided and its quality. Doing the leg work at crisis point many self-funders and their carers, particularly at times of crisis, are not able to undertake the leg work required to check out and buy the services they require. The lack of independent brokers, or information about those that exist, means that what help that is available may not be accessed.

PART 04 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 19 COMMISSIONER CHECKLIST Is there a simple way in which self-funders can find up to date information on who provides what care and support and its availability, quality and price? How can the local authority stimulate and support user-led organisations to get engaged with the provision of advice and support to potential and existing selffunders? Is brokerage help available to selffunders who require it? How are self-funders advised when choosing a broker and the quality and pricing of brokerage services? How are self-funders advised on what to look for when choosing a provider and how to access the information they need? BOX 3: PEOPLE NOT LEAFLETS 17 Key learnings from a local authority developing their focus on self-funders was developed into an action plan which recognised that providing leaflets alone does not enable people to move on from awareness to action as intended. They used a three phased approach to reach out to self-funders: 1. Identify all council teams that interact with actual and potential self-funders and introduce new processes to identify an individual s funding status. 2. Identify avenues through which the council can raise public awareness of this issue. For example, council press releases in local newspapers, radio interviews, promotion in libraries, inclusion of information in council publications, leaflets, websites and newsletters. 3. Work with the care supply chain (care providers, GPs, CCGs, Acutes, thirdsector) to raise awareness and create new pathways to a chosen provider of advice. In addition authorities should consider how they can broaden their advice provision through proactively and ideally, formally, engaging with user-led organisations (ULOs), who can carry out active advice, initial assessment and support planning. The recent evaluation of the Right To Control Trailblazers 18 demonstrated that there were gains to be made from local authorities formally involving ULOs in directly supporting those taking on personal budgets for the first time. This support could also be extended to self-funders. Areas of benefit identified in the evaluation included: By acting as an entry point and making referrals, ULOs reached customers that would otherwise have been missed. ULO offices were sometimes considered a more neutral place. ULOs could write more creative and inclusive support plans which better met customers needs, and sometimes enabled customers to get more for their budget. What is the health and wellbeing board and its partner organisations doing to stimulate the development of brokerage and to ensure its quality?

PART 04 Older people who self fund their social care: A GUIDE FOR HEALTH AND WELLBEING BOARDS AND COMMISSIONERS 20 COMMISSIONER CHECKLIST How will you track the numbers and cost of self-funders who will fall back on state funding? Are all self-funders who approach the LA and other local advisory organisations signposted or referred to sources of specialist, personalised financial advice? How is the health and wellbeing board and its partner organisations encouraging financial advisers to obtain the necessary care specific financial advisory qualifications and supporting selfregulation? Financing care The LGIU study 8 of how self-funders finance their care showed that few had access to the information they required to make an informed choice. Although good information was available on local authority funded care, the financial assessment process and the cut off point for self-funding. However, the IPC/ Henwood Associates study 1 found that people still had misconceptions about who pays for care, with some (given their financial circumstances), erroneously believing it will be provided free. Once self-funders know what they have to fund, they require advice about the options open to them to meet the costs. Apart from pension income, most self-funders major asset is their own home. There are many ways of releasing funds from your own home but each has its advantages and drawbacks. Being aware of what is possible and what best suits a person's own circumstances is essential information. Some councils do provide information on financial products that can be used by selffunders to cover the costs of their care but this information is of a general nature. Where councils work with voluntary agencies who offer financial information it is also often of a general nature and does not guide individuals to the appropriately qualified advice that they need. Some councils are wary of the implications of referring people to specialist financial advisers. This difficulty can be overcome by working with an intermediary who is able to explain the broad range of financial options available, and then refer people onto specialist quality assured advice providers. Of the local authorities surveyed by the LGIU only half signposted people to specialist financial advice. A third of those that did had a proactive service that connected people with advisers. Very few provided lists of financial advisers who could advise specifically on care funding products. LGIU 8 quotes research by Oliver Wyman showing that out of 53,000 self-funders surveyed, only 14,000 (26%) had received independent financial advice and, of those advisors providing advice, only 50% had care specific qualifications. BOX 4: 'Airgap' providers Nottinghamshire, Hertfordshire, Gloucestershire and Suffolk County Councils have used the air gap approach to enable self-funders to access advice from specialist care fees advisers, who have are accredited Later Life Accredited Advisers. The local authority then refers all potential and current self-funders to the air gap provider for information and advice who then, if they wish, are referred on to a specialist care fees adviser. Suffolk work with Care Aware and Nottinghamshire, Hertfordshire and Gloucestershire work with PayingForCare as their air gap providers. Using intermediaries can also bring other significant advantages such as the provision of important tracking and outcomes data so that the local authority can develop a picture of how any potential self-funders are seeking advice, and how many end up deciding to use which financing solutions.