1 Summary
This paper summarises the proposals in the Green Paper `Independence, Well-being and Choice, and it draws attention to the consultation process and period and seeks the following decisions:

1. The principles of the Green Paper are welcomed as they already inform many of the Council's policies.


2. The Director of Social Services is asked to draw up a detailed response for the Cabinet to approve and send to the Department of Health, making particular reference to costs of a major prevention agenda.


Finally it should be noted that the National Director for Social Care, Kathryn Hudson, will be visiting Hampshire Social Services on 18 May to see our services on the ground and discuss the opportunities and challenges the Green Paper presents.


2 Reasons

1.1 To welcome the Government's Green Paper on the future of Adult Social Care.


1.2 To agree to submit a more detailed response on its content and the accompanying guidance on the new role of the Director of Adult Social Services on 28 July. Conflicts of Interest declared by the decision-maker or other Executive Member consulted.


3 Other options considered and rejected

None


4 Conflicts of interests declared by the decision maker or other Executive Member consulted

None



5 Dispensation granted by the Standards Committee

None


6 Reason(s) for the matter being dealt with if urgent -

Not applicable



Approved by: Date of decision:

Councillor Felicity Hindson

1 SUMMARY

1. The principles of the Green Paper are welcomed as they already inform many of the Council's policies.


2. The Director of Social Services is asked to draw up a detailed response for the Cabinet to approve and send to the Department of Health, making particular reference to costs of a major prevention agenda.


Finally it should be noted that the National Director for Social Care, Kathryn Hudson, will be visiting Hampshire Social Services on 18 May to see our services on the ground and discuss the opportunities and challenges the Green Paper presents.

[http://www.lga.gov.uk/Briefing.asp?lSection=0&id=SXDE38-A782D583]

2 RECOMMENDATIONS

2.1 To welcome the Government's Green Paper on the future of Adult Social Care.


2.2 To agree to submit a more detailed response on its content and the accompanying guidance on the new role of the Director of Adult Social Services on 28 July.


3 KEY MEASURES IN THE GREEN PAPER

The Green Paper Independence Well-being and Choice is a discussion paper which sets out proposals for a framework for adult social care to be implemented over the next 10 -15 years. The government is inviting views on the Green Paper and an online questionnaire will be posted on the DH website. The consultation closes on July 28^th. There is also a consultation on separate Guidance on the Role of Director of Adult Social Services.

3.1 Vision

The future of social care will reflect:


3.1.1 Greater choice and control for service users to enable them to maintain independence.


3.1.2 A shift in focus to preventative, low level services with an emphasis on links to communities and social inclusion.

3.1.3 Clear outcomes - improved health, improved quality of life, making a positive contribution, exercising choice and control, freedom from discrimination or harassment, economic well-being, personal dignity.

3.2 Changes to Assessment and Service Delivery Mechanisms

Proposals include:


3.2.1 improved assessment - increased use of self assessment; streamlined assessments between agencies, particularly local authorities and the Department for Work and Pensions (DWP); aligning the Single Assessment Process, Care Programme Approach and Person Centred Planning to provide a common assessment tool for all people with complex needs.


3.2.2 A role of care navigator or broker to advise people on the care system, with social workers involved in complex cases.


3.2.3 Wider use of direct payments including extending these to people currently excluded because of lack of capacity. Direct payments to be renamed to stop confusion with DWP direct payments into bank accounts. Appendix D sets out suggestions for the change of name e.g. direct services payments.


3.2.4 Individual budgets for people with assessed social care needs, possibly extended to other budgets e.g. minor equipment and adaptations, and the independent living fund.


3.2.5 The right to request not to live in residential care requiring service providers to state their reasons if they recommend this option.


3.3 Preventative Services

Early, well-targeted interventions should be developed to reduce the need for intensive, more costly services. The local authority well-being agenda can be used to improve health, social inclusion and quality of life. The wider resources of the community, including universal services, should be deployed to support individuals.


3.4 Service Redesign

Innovative flexible services that have been shown to work should be developed. These include new technology, extra care housing, homeshare, adult placement, connected care centres. The Care Service Improvement Partnership will assist authorities to implement good practice.


3.5 Leadership Role

Local authorities and Directors of Adult Social Services (DASS) have strategic leadership roles in planning services alongside partners. Local authorities should undertake 10-15 year strategic needs assessments of social care and housing needs.

3.6 Strategic Commissioning

A local `community-wide' strategic commissioning framework should be developed by all partner agencies to provide the right balance in investment between


3.6.1 Services for the general population aimed at promoting health and social inclusion.


3.6.2 Preventative services that meet low level needs.


3.6.3 Intensive support for high level and complex needs.


3.7 Partnerships

The government will explore mechanisms for improving collaboration between local authorities and the NHS. It does not want to impose solutions to improve joint working, however `doing nothing will not be an option.' Local Area Agreements are an opportunity to improve public services. A `strong and vibrant' voluntary and community sector is an essential part of the vision, and the government wants to encourage capacity building in the sector to help them engage with local public sector commissioning authorities.


3.8 Regulation and Performance Management

Regulation, inspection and performance management frameworks will be modernised to support the vision for social care. The merger of the Commission for Social Care Inspection and the Healthcare Commission will reflect shared objectives. Headline targets will be aligned across services.


Local Strategic Partnerships can establish local agreements on cross-cutting issues.


3.9 Workforce

The workforce is critical to delivering improved services. The government is working to improve leadership, capacity and skills. Local workforce initiatives should include training and employment for carers.

3.10 Funding

The framework for social care should be met from existing budgets identified through the 2004 Spending Review. This will involve making better use of planned funding for social care spending. Savings identified through the Gershon review or through the modernisation of services should be reinvested in preventative services. The paper indicates that there are questions about how the proposals for preventative services fit with eligibility criteria established through Fair Access to Care Services. It is envisaged that implementing the green paper should be cost neutral to local authorities. However the government will consider the cost implications using the New Burdens Doctrine (government policy should not place a financial burden on local authorities).

3.11 Protection and Managing Risk

The government acknowledges that the desire of individuals to remain independent may conflict with the view in wider society and the media about the need for protection. The paper invites an open debate on risk management and seeks to develop a more supportive framework for social care staff.


3.12 Role of the Director of Adult Social Services

The DASS has a number of key roles: accountability for spending and delivery; professional leadership and championing the rights of adults with social care needs in the wider community; leading on standards and cultural change; promoting partnership working; working with the Director of Children's Services; and promoting social inclusion and well-being.


3.13 General Comments

The value base of the Green Paper is likely to find extensive endorsement. A vision which redresses the overemphasis on assessment and gate-keeping brought about through community care legislation is welcome. The focus on preventative services and engaging with the wider community is a positive development. Furthermore, there is no prescriptive `big change' and measures previously signalled or speculated about, such as independent assessments or compulsory arrangements with the NHS are not included. The Green Paper is an opportunity to develop social care services in line with good practice and user priorities.


The main concerns about the paper are likely to focus on questions of implementation.


Funding is inevitably the first issue, given an environment in which, despite additional funding, social services authorities and PCTs are experiencing severe budget pressures. The Government is making swinging reductions to the Supporting People programme in Hampshire and this, together with the large hole in NHS finances, provides an uncertain backdrop for the introduction of Green Paper type initiatives. The NHS and Community Care Act was itself meant to bring a new era of choice and quality but was affected by resource constraints as well as some institutional inflexibility. We should therefore question how far the measures in the Green Paper can be effective without at least transitional funding.

Other fundamental issues remain unresolved. There are many organisational differences that can lead to barriers in partnership working with the NHS. These include charging policies, NHS continuing care policies, planning cycles, priorities, budgetary control, performance indicators, the national/local dimension and the nature of user choice. While the Green Paper signals some harmonisation of performance management frameworks we can question whether there is sufficient incentive for the NHS to fully engage in the preventative agenda.

However, as a consultation paper, there is further opportunity to discuss problematic issues or areas that are relatively unexplored such as the relationship with neighbourhoods and communities. The consultation questions included in the Green Paper are detailed and specific and authorities would find it helpful to consider and respond to these.

4 DIRECTOR'S COMMENTS

In welcoming the Green Paper it should be emphasised that Hampshire County Council is particularly well placed to take the vision forward and develop its key measures. Five examples are given below:

4.1 Direct Payments

Started in Hampshire 20 years ago; we have advised successive Government's on legislative programmes. Hampshire actively endorses the philosophy of Direct Payments and personalised budgets. We now have more than 1,000 direct payment users - an increase of 20% over last year - and a strong direct payment user network. Hampshire has achieved this increase by ensuring that service users have Direct Payments presented to them as an option particularly at major changes in their lives and by setting itself year-on-year improvements of 10%. Hampshire was a national pilot for MH Direct Payments and now has over 100 people with a learning disability in receipt of a direct payment. Fifty percent of physical disability, non-residential users receive their care through Direct Payments. Strong partnership exists with the voluntary sector which provides DP support workers for all user groups. A successful voucher scheme for carers is being extended to ensure flexible services where users and carers do not wish to manage the finances.


4.2 Personalisation - prevention and choice

Person Centred Planning has become part of the core culture of learning disability services with over 2,000 staff, Members, private and voluntary sector workers trained by Hampshire's PCP team. Providers across Hampshire have signed up to a Person Centred Charter which encourages quality standards as determined by users and carers.

One hundred and ten young people moved into Adult services in 04/05 and this group were targeted to ensure a person centred approach was taken to their planning. The Supporting People programme has also offered service users the choice of independence and supported living. However, as indicated earlier, there are some risks to this programme because of Government funding reductions.

Hampshire has a network of self advocacy groups and a strong commitment to user and carer involvement including: 15 self advocacy groups for Learning Disability; 39 carers cafés/support groups; two vibrant coalitions for disabled people, all working to ensure users and carers receive personalised services which meet their needs. Mental health services have a Care Programme Approach lead strategic manager who works with users and staff to ensure a wellness recovery approach to individual care planning. The County Council offers further choice through its OT Direct and Social Services Direct services which enable a degree of self-assessment.

4.3 Inclusion/Prevention

Mental Health services adopted a recovery model two years ago and this is becoming embedded in practice across Hampshire; vocational employment advisors are placed within CMHTs to make employment a reality for people with mental health problems. Successful campaigns with PCTs and Hampshire Partnership Trust have raised public awareness of discrimination and stigma.

Hampshire County Council adopted the United Nations Standard Rules on the equalisation of opportunities for disabled people, to ensure inclusion of disabled people ten years ago and now has a comprehensive network of local access groups and three access officers employed by the County Council to ensure all its public buildings comply with the Disability Discrimination Act.

Physical Disability Services manage a joint equipment service for Hampshire and Portsmouth (2 local authorities and 8 PCTs) which dispenses over 60,000 pieces of equipment a year. Occupational therapy referrals are managed through a central call centre where users can self assess for equipment and simple equipment is delivered within seven working days.

Joint working with HCC Recreation and Heritage, Adult and Community Learning and Transport Services have ensured access to leisure and educational services for users and carers and inclusion in planning, e.g. Local Transport Plan.


4.4 Integrated working with the NHS and District Council. Joint posts include LD County Manager Strategy funded by HCC and 7 PCTs; MH County Manager Strategy - joint post with the Strategic Health Authority; MH County Manager Operations - joint post with Hampshire Partnership NHS Trust; and a number of joint team manager posts and OT post jointly with District Councils. Mental Health and equipment services have fully integrated management structures and Learning Disability services have partly fulfilled their plans to integrate operational management.

Accommodation strategies have been agreed with eleven district councils and include extra care housing and specialist and mainstream housing for disabled people. The County Council values it partnership with District Councils through the Local Strategic Partnerships and other groups like the Crime and Disorder Reduction Partnership. Hampshire has around 100 adult placement carers.

4.5 E.N.H.A.N.C.E. [Extra Nursing Homes and Nursing Care Extensions]

The most recent example of a major collaborative scheme with the local NHS. Now delivering the first of 500 additional nursing care places to particularly vulnerable older persons, and having a positive impact on delayed discharges.


5 THE WELL-BEING OF OLDER PEOPLE


5.1 "Well Being" is now the accepted term for the hitherto named `Prevention' agenda. There are several related strands to this aim which support the desire to see older people, who may not necessarily receive social care services, retain more control over their own lives, and help maintain their independence and dignity longer.

The "Link-age" scheme is an initiative from the Department of Work and Pensions (DWP) exploring the integration of financial assessments for national welfare benefits, with the assessment for financial contributions for care services. This could increase benefit take up and be more efficient than the current arrangements. Exploratory discussions have been held with the DWP, and experience from pilots in other authorities is being evaluated.

The Council has agreed to fund a strategic approach to promoting "Well Being" A corporate group led by the `Champion' for older people has promoted this approach to take effect this year using the £100k start up money agreed by Cabinet. The aim is to stimulate a wide range of services to allow people to remain at home, independently.

An initial example of this approach is the contractor contribution scheme co-ordinated by PBRS. This has so far raised £20k which will be spent on gardening activity for older persons in the Andover area.

5.2 More broadly the older persons sector is well placed to deliver the Green Paper Agenda of promoting prevention and choice. The Innovations Project [see attached Appendix 1] is beginning to have a positive impact on reducing unnecessary hospital admissions and together with our piloting of new support arrangements with assistive technology, joint initiatives with the County Council's Recreation and Heritage and Trading Standards Departments we can demonstrate Hampshire's early progress in its preparedness for the shift in culture which the Green Paper portrays.


6 We are, however, far from complacent. We recognise for example that we need to do more in terms of collaborative working with the Department of Works and Pensions locally. We also believe the time is right for a review of the Council's Home Care Service, essentially to ensure that we are maximising the opportunities for improving the quality of life for older people and to target our finite resources to greatest effect. These issues will both be the subject of further progress reports to the Executive Member in the near future.


7 The attached Appendix 2 is a copy of the LGA briefing on the first response on the green Paper which is particularly helpful and emphasises the key view that a focus on prevention and workforce development cannot be cost neutral. Whilst welcoming the focus on working with the voluntary and community sector, which is already strongly established, local authorities will have to balance the cost implications with our best value duties and requirements to achieve cashable and non-cashable work efficiencies.

8 CONCLUSIONS

Over all the Green paper should be strongly welcomed but with some cautious comments concerning funding. A more detailed response might best be handled by an Officer group to report to Members to agree the County Council's response to the Green Paper consultation.

9 RECOMMENDATIONS

1. The principles of the Green Paper are welcomed as they already inform many of the Council's policies.


2. The Director of Social Services is asked to draw up a detailed response for the Cabinet to approve and send to the Department of Health, making particular reference to costs of a major prevention agenda.


Finally it should be noted that the National Director for Social Care, Kathryn Hudson, will be visiting Hampshire Social Services on 18 May to see our services on the ground and discuss the opportunities and challenges the Green Paper presents.

Section 100 D - Local Government Act 1972 - Background Documents

The following documents discuss facts or matters on which this report, or an important part of it, is based and have been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents which disclose exempt or confidential information as defined in the Act

NONE


APPENDIX 1

Hampshire County Council

Social Care Policy Review Committee Item

March 2005

Hampshire's Innovation Forum Project

Report of the Director of Social Services

Contacts: Claire Foreman, Ext 7127 mailto:[email protected]

David Browning, 07795 180248 email: [email protected]

1. Summary

1.1 The Policy Review Committee received a paper describing the Innovation Forum Project on 12 November 2004. The project is being developed jointly between the NHS and the County Council, and its purpose is to promote the well-being of frail older people and reduce their need for emergency services - especially emergency hospital stays. It supports Aim Number One of the Corporate Strategy (maximising life opportunities) by contributing to the Cabinet Priority for Older People. It also contributes to the achievement of key milestones and targets in the National Service Framework for Older People, and both national and local Public Service Agreements.

1.2 The project is being undertaken as part of the work of the Innovation Forum of `excellent' local authorities. The project involves deploying nurses and social workers within specific primary care practices to work proactively with older people who are most at risk. The aim is to work with the older people and their families to reduce these risks and promote independence.

1.3 This report brings the Committee up to date with the project and some of the issues emerging.

2. Progress with the Project

2.1 Four primary care trusts (PCTs) are taking part in the scheme with the County Council. They are East Hants, Fareham and Gosport, Eastleigh and Test Valley South and the New Forest PCTs. Teams have now been established in all four PCTs and the social workers and nurses are building up their case loads.

2.2 Fareham and Gosport PCT was the earliest to start, providing support in two practices from April 2004 by two full-time nurses and a social worker. A six month review in October, audited by a community geriatrician, concluded that the scheme definitely prevented 17 hospital admissions, probably prevented a further 10, and could have prevented a further 5 with greater experience. These savings have already more than covered the cost of the scheme. The PCT is now recruiting additional staff to roll out a similar proactive approach with nurses across all 21 practices in the PCT (although there are no funds to increase the number of social workers).

2.3 East Hants PCT already has a network of health care co-ordinators who work directly with primary care practices to help support vulnerable older people. For the Innovation Forum Project, one of these co-ordinators has been paired with a part-time social worker across two linked practices. The extra workload has been difficult to manage for the co-ordinator, and the PCT has made additional funds available for extra nursing support for the co-ordinator.

2.4 In both the New Forest and Eastleigh PCTs, a part-time nurse has been matched with a part-time social worker in a primary care practice. It has taken slightly longer to get these schemes going, mainly because of recruitment difficulties, but both are now up and running, and the staff are working with considerable enthusiasm.

2 Development of the Methodology

3.1 Since the start of the project, staff have been developing the approach. A number of key steps have been identified:

· Case finding

· Assessment and case planning

· Intervention

· Caseload management

· Monitoring and recording

· Assessment of cost-effectiveness

3.2 `Case finding' involves identifying the people who are at risk but not yet in crisis. This has proved to be more difficult than first thought. Initial scans of the files were not very successful. Currently staff rely on two main methods: first, practice staff nominate people that they are concerned about; and second certain `trigger events' are used to identify people. Triggers include attendance at A&E without admission, a rise in the frequency of attendance at the surgery, and calls to a GP at night.

3.3 After identifying that someone is at risk, a full and intensive assessment process follows - to gain the person's trust and uncover an often complex situation, that requires a care plan, drawn up with the person's full involvement.

3.4 The interventions included in the plan involve voluntary and community resources wherever possible, rather than statutory services. The social workers in particular are identifying needs for services and support and are beginning to work with their communities to develop additional services - such as carers' support groups. The aim is increasingly to involve independent agencies as partners in the project.

3.5 Staff are gradually building caseloads of people who need support, and principles for managing these caseloads will need to be developed. They will need to work out how many people they can support actively, and when it is safe to reduce their involvement, making contact less frequently to make space in their workload for new people.

3.6 Monitoring and recording are key to identifying the impact of the scheme. Social workers and nurses are recording information about the use of emergency services both before and after involvement in the scheme. It is too early to come to any firm conclusions, but initial indications from the first 30 people to have been supported for six months are encouraging (Table 1).

Table 1

Average use of emergency services for individuals before and after inclusion on the Innovation Forum Scheme.

Notes:

Sample of 30 people who have completed a six month review - excluding outliers with excessive values in the period before inclusion.

Rates have been converted to an `annual rate' so that the figures are comparable.

3.7 With a sample size of only 30, the improvements are certainly not statistically conclusive, but encouraging patterns are beginning to emerge. Once someone is included on the scheme, their need to keep attending the surgery reduces significantly, although for many people (10 of the 30), the numbers of GP home visits increases - prompted in some cases by the nurse on the IF Team. But overall, the workload of hard-pressed GPs is reduced, and bed-days per year for the 30 people was reduced from just over 500 to 70.

3.8 In addition to recording by social workers and nurses, ways of assessing well-being and quality of life are being explored. The London School of Economics is advising on possible approaches. The hope is that well-being and quality of life improve significantly for people involved in the scheme.

3.9 Overall emergency admission rates and bed days for people 75 and over from practices included in the scheme will be compared with practices outside the scheme, once it has been running for sufficient time.

3.10 The costs of providing the extra support are being recorded. In due course, any effects on emergency admissions and bed days and on GP time will be estimated, and the cost-effectiveness of the scheme will then be assessed. The hope is that there will be major efficiency gains - with the costs of providing proactive care in the community significantly lower than the costs of providing hospital care. If this proves to be the case and well-being measures also show gains, then the project will be improving well-being while reducing the overall cost of care.

3 Funding

4.1 The project is due to run for three years initially, and the first year is nearing completion. Funding for the second year (2005 / 06) has been secured as follows:

· Social Services Department (£50,000 plus management support)

· PCTs (full cost of nursing staff and their accommodation and support)

· Chief Executive's Department management, funding and co-ordination support.

An application has also been made to Hampshire County Council (Community Development and Regeneration) Fund for a further £50,000.

4.2 The Department of Health has announced (3^rd March 2005) a major new fund for supporting `Partnerships for Older People Projects' (POPPs), and the learning from the Innovation Forum Project will be used to help formulate Hampshire's grant application for additional funding.

4 Conclusion

Developments of both methodology and results have so far been encouraging after one year of the project. A further report will be made to the Committee in the autumn.

Recommendation: that the report be received.