SERVICE SPECIFICATION FOR THE BEST VALUE REVIEW OF : CARE MANAGEMENT

Customer: Best Value Review Committee

Sponsor: Neil Jones

Review Team Leader: Yvonne Le Brun

Project Managers: Peter Knight Clive Lindsay

Overview

Over the past 50 years, the methods of delivering of social care have changed substantially. Previously accepted practice was for people to be "slotted into" pre-existing services that were often segregated and remote. Thus someone with a learning disability, a mental health problem or an older person would commonly be offered permanent residential care away from their family and friends.

Throughout the 1970's and 1980's this approach came under increasing criticism for the following reasons:

- people in these institutions often did not get better; rather they became more dependent on the rigid structure of the regime and learnt a range of behaviours from other residents that made discharge less likely (ref "Asylums", Goffman)

- improvements in medications available meant more people could have their symptoms improved, leading to the provision of social care in a non medical environment

- strong representations from user groups (e.g. Values Into Action), that questioned the justice of incarcerating people because they had a disability or were old.

In response to this, alternative ways of arranging care for vulnerable people were trailed in England, including care management as practiced in America. Following extensive evaluation by the University of Kent, this care management process was refined and established in the SSI document "Care Management and Assessment - Practitioners' Guide" (1991). Essentially this is the framework that Hampshire and many other local authorities continue to use, although the details of practice are revised and updated through relevant policy guidance. The stages of the care management business process are:

1) Providing information to the public about the range of services available

2) If an enquirer requests more than information or advice, basic information is taken to determine the type of assessment required

3) If appropriate, a practitioner is allocated to assess the needs of the individual and their carer

4) Assessing and arranging the resources available to best meet the individual's assessed needs

5) Starting the delivery of care to the individual

6) Monitoring and making necessary adjustments to the care provided

7) At regular intervals, formally reviewing the quality and appropriateness of the services provided.

The philosophy underpinning care management is that services should be:

- shaped to the individual needs of service users

- as least intrusive as possible, complimenting existing sources of support and the client's abilities

1 Aims of the Service

1.1 Following the implementation of the NHS and Community Care Act (NHSCCA) 1990 local authority social services departments reappraised their method for arranging and providing social care. Section 47 of the above named Act is of particular relevance in this context, as it instructs each authority that:

"where it appears to a local authority that any person for whom they may provide or arrange for the provision of community care services may be in need of any such services, the authority-

(a) shall carry out an assessment of his needs for those services; and

(b) having regard to the results of that assessment, shall then decide whether his needs call for the provision by them of any such services."

1.2 At a local level, the aims of care management are described in the Care Management Practitioners Manual (1999) as:

"Care management ... is the key to achieving effective outcomes for users and carers which enable them to live in the community wherever possible {and to} "empower {users and carers} to exercise power over the decisions which are made about their lives"

1.2.1 This clearly supports the overarching departmental aim stated in the departmental development plan 1999/2004, in which we aim to:

"work with the people of Hampshire to ensure that their assessed needs are met with high quality, cost effective services, within available resources. In doing this, we want to offer users and carers the greatest possible choice; and to preserve their dignity, safety and independence"

1.3 The aims of care management are also stated in the Hampshire community care charter for Hampshire "Better Care, Higher Standards 2000/1". Within this it states that Hampshire Social Services will:

· "treat you with courtesy and honesty and respect your dignity

· help you to achieve and sustain the maximum possible independence

· seek your views and preferences (you will be helped in giving your views through advocacy and other representative organisations if needed)

· take these views into account and fully involve you in all decisions about you and how your needs will be addressed

· give you enough information to make informed choices

· treat you fairly on the basis of need and will not discriminate against you on the basis of age, sex, race, religion, disability or sexuality

· make sure you feel able to complain about the standard of services you get and that you are not victimised if you complain."

2 Objectives of the Service

2.1 In support of these aims, the objectives of care management are as follows:

2.1.1 To ensure that up to date and accurate information on a range of health and social care matters is readily available to users and carers, to cover all stages of care provision

2.1.2 That the care management service is convenient, consistent and accessible to the public.

2.1.3 That callers only have to initiate contact once and the responsibility for the next step in the referral process belongs to the social services department

2.1.4 That callers are listened to with courtesy, respect and in confidence, and will have their request responded to promptly

2.1.5 That the assessment of needs is comprehensive, user focused and consistent and takes into account a full range of health and social care needs

2.1.6 That the views of users and their carers are central to the care management process from initial assessment to review

2.1.7 That care managers are supported to carry out their role effectively

2.1.8 That care managers shall have the necessary skills and guidance to carry out comprehensive assessments

2.1.9 That partnership working with other professionals is a priority for all care managers

3 Links to the Corporate Aims

3.1 Partnerships for strong communities; all of the services included in this review contribute significantly towards this corporate aim through supporting vulnerable people to live in and participate within their community. Examples of this include:

3.1.2 enabling older people to remain within their own homes for as long as possible, through the use of domicillary care packages

3.1.3 providing or commissioning developmental and social activities for disabled adults, preferably in non segregated settings, to mitigate against the effects of social exclusion and afford a greater community presence

3.1.4 financial and other forms of support for client self help and social action groups

3.1.5 Social services actively supports the mixed economy of care through commissioning and referring clients to charitable, voluntary and private sector forms of service provision, through the care management process. This activity encourages the development and sustenance of community based responses to identified need, as evidenced by the Hampshire Compact with the community and voluntary sector.

3.1.6 Partnerships with related public sector agencies are also actively managed, as described in "New Directions" (p. 28-9), including joint working arrangements with colleagues representing:

District Councils (e.g. community safety partnerships)

Health

3.1.6 Indeed our commitment to work with the NHS, in keeping with the 1999 NHS Act, is embodied in departmental objective 6 Developing our partnerships with other agencies

"We have a new duty of partnership with the NHS which continues to include strategic planning with health authorities, with a new focus on tackling health inequalities. New links have been made with primary care groups to better co-ordinate health and social care locally, with the department's managers representing the County Council on Primary Care Boards. We are also working more closely than ever before with NHS Trusts to avoid unnecessary hospital admission, and to ensure that people who are admitted to hospital are able to leave as soon as possible with appropriate care arrangements"

3.2 Developing the quality of life in Hampshire

3.2.1 This corporate objective is clearly supported by both:

Departmental objective 1 "Promoting independence and personal development

In all that we do we will ensure that, wherever possible, services will promote independence and personal development. This means giving people more control over their lives and their care, encouraging and supporting them to do as much as possible for themselves in their own homes for as long as possible"

and Departmental objective 2

"Protecting vulnerable adults and children

The department will continue to lead work across the County Council to develop a corporate approach to protecting vulnerable people and tackling health inequalities. We will ensure that vulnerable people have access to training and employment."

4 Other Links

4.1 Equalities

4.1.1 Equality of access to services is guaranteed under the Community Care Charter and compliance with this is monitored through performance information generated internally and for the purposes of RAP and PAF returns.

4.1.1.1 The Race Equality Monitoring and Implementation Team (REMIT) update action plans to ensure that access to services is equitable and fair on the basis of ethnic origin. Additional work is also undertaken to ensure that information about services is in formats accessible to people for whom English is not their first language. services . Furthermore, qualitative assessments and support is offered to promote the use of culturally sensitive responses to identified need.

4.1.1.2 In common with other social services Best Value reviews, it is proposed that the new Equality Assessment tool designed by the Race Policy Advisor will be used to determine how ethnically sensitive service are.

4.1.2 The National Service Framework for Older People specifies that an individual must not receive a different level of service based on their age. Relative access to services is monitored by age group on a monthly basis, although it would be premature to state that the target of offering services based on need rather than age has been achieved. Figures for the service purchased for these client groups in 1997/8 indicate that 41% (£74.5m)of the department's gross budget was spent on services to older people, whilst 28% (£51.5m) was spent on services for working age adults. Yet this resources split does not reflect the relative proportions of referrals from these 2 groups

4.2 Sustainability

4.2.1 Care management clearly contibutes towards the 12 themes of sustainable development, as identified in the corporate strategy (HCC 2001). These include:

4.2.1.1 Theme 1: Community co-operation Both care planning at an individual level as well as strategic service commissioning at locality and regional level are based on the full invcolvement of stakeholders

4.2.1.2 Theme 6: Improving health and social wellbeing Care management os the mechanism through which vulnerable people access care and support through their social services department. With 108,000 people in receipt of services (correct at 8/5/01), almost 10% of the population of Hampshire are helped through care management.

4.2.1.3 Theme 7 - Waste

Through the use of the computer based Assessment and Care Management System, a substantial portion of client records are held electronically, thereby reducing the need for paper based recording.

4.2.1.4 Theme 8: Social Inclusion The explicit drive towards community based responses to identified need via the care management system has made substantial strides towards this aim. Examples

of this include: restoring disabled adults to their community of origin supporting people to stay in their own homes providing services within mainstream locations

4.3 E-government

4.3.1 Some potential activities to promote e-government could include:

- the increased use of Hantsnet 2000 as a mechanism for publicising the range of support commissioned or provided by social services

- the use of electronic self assessment forms for client to complete (as currently occurs in paper based format for OT self assessment). The potential advantages accruing from this, both in terms of speeding access to services and empowering the user are both worthy of exploration

- enabling electronic referrals from partner agencies

- agreeing access protocols to electronic files by partner agencies, particularly members of the NHS.

4.4 Crime and disorder

The Departmental Development Plan states that social services is actively working to reduce crime in the community, with an especial emphasis on tacking youth crime.

5 Service Policies

5.1 The main service policies that inform the delivery of care management and the out of hours service are the:

- Care Management Practice Manual

- Care Management Standards

- Community Care Plan

- Care Management Competencies

- Access to Services policy

- Records Management Policy

- Carers Support Policy

- Performance Development Policy

- Supervision Policy

- Risk Taking with Older People Policy

- Abuse Policy

- Hampshire County Council Staff Charter

- Lone Working Policy

- Management of Stress Policy

- Non Residential Charging Policy

- Residential Charging Policy

6 Summary of existing services and delivery methods

6.1 Care Management

6.2 The majority of practitioners undertaking care management are based within the 13 area offices located in the major conurbations of Hampshire. Please refer to Appendix 1 for indicative information of the distribution of care managers across the County.(NB These figures are from the early stages of a larger assessment of care management by Professional Services. A definitive picture will be produced during the Best Value review by Professional Services that will supplant this information).

In addition there are care managers based within some of the main Hospitals who take lead responsibility for taking new referrals directly from the wards and initiating community based packages of care to support the patient on discharge.

6.3 In one are area Care Managers have been linked with GP surgeries taking referrals directly from GPs and nurses. In several other areas, Care Managers are physically based within the GP surgeries and take referrals directly from the General Practitioners, nurses and the public

6.4 Recent evaluations of both these patterns of service delivery have found clear gains from the perspective of Health colleagues, care managers and clients. Chief amongst these have been:

- speedier access to care management assessment and subsequent support from social services

- improvements to the quality and appropriateness of referrals taken by the care managers

- more appropriate and cost efficient service outcomes

6.5 The Emergency Duty Team currently operates from a base in the South of Hampshire and provides an out of hours service to the entire County and, in addition, is contracted by Portsmouth City Council to provide a service to them.

6.6 Gross running costs for EDS are projected (at 28/2/01) to amount to £695,000 for this financial year, although income to the service will reduce this to £619,000.

In the period 1/4/00 to 30/9/00 EDS received a total of 4482 contacts (of which 1,029 were from Portsmouth), broken down in the following way:

Children 2751

Adults - general 582

Adults - mental health 434

Older persons - 715

(Source: Out of hours six monthly report)

6.7 Compared with the same 6-month period last year, this actually represents an overall decrease in contacts from Hampshire residents (-6.6%, all client groups), with the largest decrease in the field of mental health. By area, the most significant reductions in contact over this period were from Alton/Aldershot (-13%) and Winchester/Andover (-15%)

7 Recent Consultation

7.1 For the purposes of this scoping report, the following consultation exercises have been undertaken

7.2 Internal consultation

7.2.1 An electronic questionnaire was sent to all team and unit managers within social services, with the request that they submit their views on the priority areas that the Best Value review needed to address. In addition, the request was made that this questionnaire be disseminated to front line practitioner care managers, which generated useful qualitative information.

7.2.2 On 11/4/01 an internal stakeholder consultation event was held with a specific focus on the care management element of the review. Using the EFQM Excellence model as an analytical framework, 12 participants were directed to assess areas of strengths and weakness of the current care management systems in relation to the 9 constituent elements of service identified by the Excellence model. This consultation event was composed of both team manages and care managers and included a member of the Emergency Duty Service.

The results of this and other consultation activity contained in appendix 2.

7.2.3 On 12/4/01 a separate consultation event was held to prioritise elements of the Care Programme Approach (mental health) that the body of the Best Value review should investigate. Membership of this group included both internal stakeholders (service manager, Approved Social Worker, Commissioning Officer and Manager) as well as stakeholders from key partner agencies (Community Psychiatric Nurse & PCG leads for mental health). This group similarly used the EFQM Excellence model as an analytical framework to assess services provided for people with mental health problems and identify areas for improvement that the review should address, as well as areas of comparative strength that should receive less attention.

7.2.3.1 Within this consultation event, a second group of key external stakeholders were also consulted. This included representatives of user groups as well as external service providers (e.g. day service managers from the voluntary and charitable sector). In total, these 2 groups comprised 14 individual contributors

The results of this consultation are discussed at 7.5 below

7.3 External consultation

On 20/4/01 a dedicated half-day consultation and challenge event for key external stakeholders of care management was held. 14 delegates attending this event included:

- general practitioners

- consultant psycho-geriatrician

- consultant geriatrician

- Community Psychiatric Nurse

- Nurse Discharge Manager

- carer representatives

- District Audit

- PCG nurse manager

- Member of Hampshire Care Association, representing the private residential care sector

- Member of Community Action Hampshire, representing the charitable and independent sector

7.3.1 A highly productive meeting with the project manager of the Portsmouth Best Value review of care management occurred on 17/4/01, with subsequent examination of their scoping report and activities in support of the main body of their review. Whilst recognising the areas of difference between our 2 authorities, it is or relevance that we both operate highly similar processes: particularly the computer based Assessment and Care Management System.

7.4 Existing recent consultation activities

The MORI poll of Hampshire County Council staff in June 2000 surveyed the views of 38% of all social services staff and the results were analysed in such a way that messages from staff at specific grades within social services could be identified. A major finding of this poll was the very low job satisfaction ratings (only 4% expressing satisfaction) that was evident at grades SO1 and SO2. As the majority of care managers fall within this grading, this prompted 2 half-day conferences (9^th and 26^th February 2001) to explore some of these issues further with a view to addressing some of the areas for concern.

Attendance at these consultation activities was very high, with over 100 care managers taking part from a variety of workbases, with the conferences addressing the following areas:

- Status

- Working Environment

- Resources

- Management and Support Services

The results of this consultation exercise are attached within Appendix 3

8 Current performance information

Performance information relating to the operation of care management is required by central government in the form of the Performance Assessment Framework (PAF) and the Reception Assessment and Packages of Care (RAP) returns. Information in support of this is generated by the Information Analysis team, through interrogation of the computer based Assessment and Care Management System (ACMS). Relevant performance information fields are contained within Appendix 4

8.1 In addition to these requirements, regular performance information is generated for internal commissioning purposes. Examples of this relating to current numbers of referrals, open cases, proportion of cases by client group and by area are contained in Appendix 5.

8.2 Across Hampshire there are 281 care managers, of whom 166 (59%) have achieved the Hampshire certificate of care management competency(figures correct at 29/2/00). They support in excess of 108,000 cases, taking an average of 3,000 new referrals per month. Please see appendix 1 for a more detailed breakdown of staffing by area.

8.2.1 The Emergency Duty Service produces comprehensive reports on its performance on a 6 monthly basis. This profiles both their activity type (response to given presenting case) on an aggregated client group basis and a geographical basis. Additionally details of the referral source are recorded and reported.

8.3 Financial performance data in relation to care management is also collated routinely, with regular reports supporting the decisions of the Departmental Management Team and Commissioning teams.

8.4 It has been recognised that a better service could be provided for users in this area, with attendant improvements to the use of care manager's time and maximising the financial contribution of clients of social services. Work is currently in progress to address this through 2 pilot schemes. Please refer to Appendix 6 for specimen examples of current financial data.

8.5 Based on performance information, client and staff opinion surveys and responses from partner agencies, we have identified the following division between areas of comparative strength as opposed to areas for improvement.

8.5.1 Strengths

8.5.1.1 Provision of information to the public

8.5.1.2 The interpersonal skills of care managers in contact with the public

8.5.1.3 Speed of response to emergency referrals

8.5.1.4 The recognition of carers' views within the overall assessment

8.5.2 Areas for improvement

8.5.2.1 Rigorous and timely reviewing of the care existing users receive

8.5.2.2 Accuracy of financial assessments

8.5.2.3 Ensuring users receive written copies of their care plans

8.5.2.4 The care pathway between initial assessment and full assessment by specialist practitioners.

9 Competition and other providers

9.1 There are currently no other direct competitors or providers of care management assessment. However, future developments in the interface with partner agencies enabled through recent legislation (Modernising Social Services; The New NHS Modern and Dependable") enable other providers to enter the market.

9.1.1 Of particular note is the potential for nurse practitioners to be trained in care management practice and for them to undertake assessments that lead to the provision of social care services.

9.1.2 The potential to further develop client self assessment tools is also of note, building on the tools developed by the Occupational Therapy service and the Hampshire Direct Payments workers.

9.1.3 Internal competition can also be facilitated. In the context, the training of internal service providers to undertake a form of care management will be considered within this review (Romsey and Waterside day care care management pilot, 2000).

9.1.4 Comparison will be made with the Children and Families Sector approach to undertaking Comprehensive Assessments in Child Protection cases. These complex assessments can be completed by service providers in Family Centres, rather than solely by qualified care managers. Thus we will be exploring the viability of devolving some of the assessment function to other bodies, whilst mindful of any potential conflict of interest issues

9.1.5 Previous Best Value reviews in Hampshire (e.g. Day Care for older people, Day Care for people with learning disabilities) have identified that many people who receive a service from Social Services do not have an allocated care manager who is in a position to effect an annual review of the service and the person's needs as well as re-applying the eligibility criteria on an annual basis. Thus the review will also be giving attention to devolving the reviewing element of the care management business process to other bodies and developing costed options around the benefits and disbenefits of such an approach

9.2 The prime competitor for the out of ours social work service is NHS Direct, which from July 2001 will be matched by the Social Services Direct regional pilot.

9.1.1 The extended hours of service provision from other bodies (e.g. Community Mental Health Teams) is already having an effect on the workload of the out of hours service. In the 6 monthly returns April-September 2000 a 15% reduction in the number of referrals to the out of hours service relating to people with a mental health problem was recorded. Please see the attached report on Care Management - Mental Health for further details.

10 Challenges facing the service

10.1 The biggest challenge facing the service currently is managing rising levels of referrals and supporting increasingly dependent people within available resources

10.1.1 Within this challenge are a number of separate elements

10.1.2 Dealing with the volume of referrals and current open cases.

Last year Social Services across Hampshire received in excess of 34,000 referrals resulting in over 11,000 full assessment of needs per month (Source: Professional Services report, July 2000). The majority of these relate to older people and the ageing population nationally indicates that this rate is set to rise. Locally, the demographic profile is even more demanding, with the population of people aged 75-84 years old projected to rise by 6.4% between 1999 and 2004 (compared to a national average rise of 4.3%).

10.1.3 With the rise of community care and in keeping with departmental objectives, people with increasing levels of dependency and consequent risk to themselves and others are being supported through community based packages of care. This is evidenced by the findings in "Social Services Facing the Future" (SSI, 1998) where it was found that the average domicillary care package to support people in the community had more than doubled in the period 1994-1997 (from 2.2 hours per week to 4.8 hours per week). This phenomenon has been accelerated by the drive towards deinstitutionalisation in the adult sector client groups towards community based patterns of care and by research findings demonstrating that 76% of older people in residential care would prefer to be living at home ("Care Management, Empowerment and the Skilled Worker" Tuscon and Smale 1993)

The result of this is that care managers must devote larger amounts of energy towards ongoing monitoring of risks to the individual and managing the logistics of complex and often fragile care packages. Even relatively minor changes to the input enabling a person to remain at home (for example, suspending services whilst the client receives hospital care) can be time consuming (esp. in relation to altering contracted orders for care and billing arrangements), as is the restarting of such packages.

10.1.4 As well as insufficient funds to meet client demand, practitioners are also facing a growing shortage of resources to purchase. Over the past financial year the rate of closure of nursing homes has increased, as has that of residential homes. Nationally, it has been calculated that there are in excess of 7,000 fewer residential homes in business than last year (ref. John Hutton's speech to NISW 3/01). In the domicillary care market there are similar problems in finding providers with available spare capacity to new requests for service.

10.1.5 Service providers report that this problem partly results from the demographic "double greying" effect, whereby fewer young people of employment age are available to meet the needs of the growing population of older people. It also stems from the difficulty in recruiting and retaining staff into what is seen as a poorly paid and demanding profession. This appears to be of particular concern in Northern Hampshire, where the relatively higher costs of accommodation make low paid work in the domicillary care field even less viable.

10.2 Nationally there is a shortage of qualified social workers/ care managers & the Department of Health's efforts to rectify this is welcomed. However there are currently a serious problems in recruiting and retaining staff to fill care management positions. The conversion of the Diploma In Social Work to a 3 year qualification from 2003 means that these problems will take time to resolve.

10.3 The requirement within the National Service Framework for Older people is that people aged over 65 must receive an equitable service from local authorities that is on a par with that received by adults of working age. The larger volume of referrals from older people will make this a challenging target to meet and may have implications for services to other client groups.

10.4 The intention of Social Services Direct is to provide a high quality information and care management system to users, carers and care professionals outside office hours. The impact of this upon the overall number of referrals to social services will not be known until some time after it's launch on July 2^nd 2001.

10.5 A final challenge is that of being full partners with the NHS in the development and implementation of the new single assessment tool for older people. The difficulty of balancing the need to be closely involved in this whilst maintaining other operational responsibilities in a tension that social services is aware of.