Archived decisions

HAMPSHIRE COUNTY COUNCIL

Decision Report :

EXECUTIVE SUMMARY

1) Summary of Decision Area:

1.1. This report includes proposals for consultation on revised criteria to assess how the needs of disabled children and young people could be met within available resources. Revised Eligibility Criteria are included in appendix 3 to this report.

1.2. The report also proposes changes to the operation of the Direct Payment arrangements to allow for Direct Payments to be used to access a broader range of services than currently included in the scheme.

1.3. It is proposed that consultation should commence in March 2009 for 12 weeks and be completed by early June 2009, with a further report to the Executive Member on the 2^nd July 2009.

2) Issues Covered in Report:

2.1. Government guidance in relation to the Aiming High service improvement programme requires Local Authorities and partners to review eligibility criteria to ensure that the criteria support a focus upon those with complex and severe needs and also that the criteria themselves are transparent and allow users to understand what services they may expect and how decisions will be made.

2.2. The Executive Member on the 16^th October 2008 approved the service improvement commissioning plan which is summarised below.

· Support to parents and carers by providing information and participation networks, including better information to assist families in accessing universal services.

· A targeted short break `offer' for children and young people attending special schools, including evening, week end and holiday short break care schemes accessed without further needs assessment

· An offer to fund the additional care supports those claiming higher rate care and or mobility DLA may need in accessing a short break in a universal service, also accessed without a further needs assessment and to include evening, week end and holiday short break care schemes

· Improvements in specialist services for those with the most complex or severe needs to provide better opportunities for short breaks. These services include care supports within the home, in overnight short break services, access to family link carers and include the use of Direct Payments in appropriate circumstances

2.3. Tendering has now commenced in relation to the information and participation service and for services to those attending special schools. Discussions are also under way with sports partnerships, community colleges, extended services coordinators, early years services and youth services in relation to the service offer for those claiming higher rate care and or mobility DLA. It is intended that some new services will begin to be available from July 2009, with full capacity developed during 2010/11.

2.4. The `offer' of access to short break services for those attending special school and claiming higher rate DLA can be taken up without a needs assessment and it is proposed that access to specialist services for those with complex and severe needs will continue to be via a needs assessment, often jointly conducted with health professionals and in the context of special educational needs assessments.

2.5. The approach to eligibility criteria set out in this report builds upon the commissioning strategy by clarifying the definitions of severe and complex needs and the factors managers will take into account in determining the nature and level of service that will meet assessed need, within available resources. Specialist services, which may be either directly provided by the County Council or purchased on behalf of families are summarised below

· Overnight short break services, including in some cases transport arrangements

· Long stay residential care

· Care support, in and outside the home, providing a short break, including sitting and escort services and support to behaviour management

· Family link carers

· Specialist community child minders

· Social Work support and supportive therapies

· Aids to daily living, including adaptations to family homes

2.6. The approach to defining eligibility criteria is based upon the following key features.

· That the criteria for defining those complex or severe needs that could be met by access to specialist services are easy to understand and support an element of self assessment to allow parents to consider whether to seek a full needs assessment

· The criteria include consideration of the needs of carers

· That the factors managers take into account when considering the level of service necessary to meet assessed needs, within available resources, are clear and support accountability

· That the definitions of need are compatible with the emerging revised Continuing Care criteria, which guide how the County Council and the PCT consider sharing the cost of health and social care services in some circumstances

· That arrangements are available to appeal and review the application of the criteria in individual situations

2.7. The report also proposes that Direct Payments are made available, for parents to make their own care arrangements, for a broader range of services than is currently the case.

2.8. Currently a Direct Payment is offered to those parents and carers wishing to make their own arrangements for domiciliary care and sitting services at a rate of £10.09 per hour (2008/9). It is proposed that a Direct Payment is, in future, an option for parents to consider in relation to a broader range of specialist community services or those delivered in family homes. It is not intended to extend Direct Payments at this stage to include residential care services.

2.9. The proposed changes to the Direct Payment scheme will be included in consultation and subject to the views of parents and stakeholders it will be necessary to develop very detailed implementation arrangements. This will include a means of identifying a value for services following a needs assessment and to consider the impact upon existing contracts for purchasing services. For example where block contracts for domiciliary care or sitting services could be affected by a broader and greater take up of Direct Payments with parents making arrangements outside existing service contracts.

2.10. It is anticipated that any revised eligibility criteria could be in place by October 2009 and changes to the arrangements for Direct Payments in place from April 2010 to allow more time to develop the detailed arrangements.

3) Recommendations:

It is recommended that:

3.1. That the Executive Member for Children and Families approves that consultation shall be undertaken on revised criteria for disabled children and young people to access specialist services and receive a further report in July 2009

3.2. That the Executive Member for Children and Families approves in principle the proposed outline changes to the operation of Direct Payment arrangements and receive a further report setting out the detailed arrangements prior to implementation in April 2010.

MAIN REPORT

1) Contextual Information

1.1. The current eligibility criteria, for accessing specialist social care services, are attached at appendix 1 and have been in place for some years. During earlier consultation in relation to Aiming High there was considerable comment that they were difficult for parents and partners to understand and that there were inconsistencies in how decisions were made following a needs assessment, resulting in inequity of access to services.

1.2. Government guidance includes a need to review service access criteria to ensure they are clear and transparent and also that they focus upon those with complex and severe needs, including teenagers, those with moving and handling needs, those on the severe end of the autistic spectrum and those with challenging behaviour.

1.3. The recent national consultation on the arrangements for Local Authorities and PCTs to develop protocols on the sharing of costs for those with continuing health care needs also supports the need to ensure that the criteria in place to access both social and health care are compatible and reduce as far as is possible the need for assessments to be repeated by different agencies.

1.4. There are current arrangements with the PCT for considering how costs should be shared to meet complex needs and once final guidance is available in relation to continuing care criteria the existing arrangements can be reviewed to include the new circumstances.

1.5. The PCT statement for eligibility for health care services contained in the existing protocol with the PCT for sharing care costs is repeated below.

"A health need requires an intervention from a fully registered health practitioner; the health care intervention may be delegated.  The health need is identified through a comprehensive evidence-based assessment process"

1.6. The following summary shows the likely sequence of assessment and decision making for those with complex and severe needs who may need access to specialist services, a more detailed flow chart is included at appendix 2 to this report. It is anticipated that the majority of decisions will be made at a local level utilising local budgets, although the process allows for local interagency care planning and for a decision by a senior manager for sharing costs with the PCT for very specialist care services

· Self assessment using published criteria or initial assessment by local Reception and Assessment teams or assessment forwarded by another professional, including a Common Assessment Framework Assessment (CAF)

· Fast track to specialist assessment if there is already an SEN assessment showing a high level of need, including autism or a severe learning disability, or if there is an existing Health Continuing Care assessment, as these indicate likely complex and severe needs requiring a full assessment

· A Full or Core Assessment by specialist teams jointly with health and special education needs colleagues where necessary - leading to identification of needs and options for how those needs could be met, to include a consideration of carers needs and if a Direct Payment.

· Consideration by a local manager as to the level of service that can be offered within available resources and confirmation of level of Direct Payment if appropriate. This phase might include an interagency care planning meeting to coordinate services.

· Reference to local interagency group for access to some overnight short break care services jointly managed with the PCT

· Reference to a county panel in those complex cases where additional resources are required or where there is a consideration of a long stay residential care service, to include potential cost sharing between the County Council and the PCT in the context of continuing care needs.

2) Eligibility criteria

2.1. The following summarises the appendices attached to this report Appendix 2, 3a, 3b and 4 will be subject to consultation

· Appendix 1 - current eligibility criteria

· Appendix 2 - a flow chart indicating how decisions are made through the assessment process

· Appendix 3a - definition of those needs considered to be complex or severe

· Appendix 3b - definition of low or moderate needs likely to be met through universal services or by access to the targeted offer for those claiming higher rate care and or mobility DLA or attending a special school

· Appendix 4 - risk factors taken into account during assessment.

· Appendix 5 - summary of model to show how needs may be met

2.2. The proposed draft criteria at appendix 3b define those low or moderate needs which could be met though access to universal service or by taking up the targeted offer to those attending a special school or claiming higher rate care and or mobility DLA. Appendix 3a identifies those severe and complex needs that could be met by access to specialist services, including through a Direct Payment.

2.3. Currently there are just under 900 children and young people accessing specialist services and the following chart shows the distribution during 2008/09

2.4. The intention of the revisions to the eligibility criteria is largely to clarify the definitions of need and to allow for greater transparency in how managers make decisions. It is not anticipated the revised criteria will lead to any increase in eligible children and young people.

2.5. During consultation there were strong views expressed that services were valued and appropriate but that the level of service was inadequate to support those with complex needs. As additional resources for short breaks become available it will be possible for managers to allocate additional levels of service to those in the greatest need. The distribution of the new grant is included in section 5 and allows for additional budget to support a higher level of service from 2010/11 in relation to overnight short breaks, care support in the home and family link carers particularly.

2.6. In considering how best to meet assessed needs, local managers are able to take resources into account and seek to meet the needs of those with severe or complex needs before considering if services can be offered to those with low or moderate needs.

2.7. The management judgement in balancing needs against available resources is summarised below.

· Do the assessed needs fall with the definitions of severe or complex needs (appendix 3a)

· Are some of the additional risk factors identified in the assessment present. E.g. single parents, other disabled people in the household (appendix 4)

· What is the nature and level of service necessary to meet these needs within the family circumstances

· Allocate resources including identifying the level of any Direct Payment

· If resources are available, consider if services can be offered to those whose needs fall with the low to moderate descriptors (appendix 3b)

3) Continuing care

3.1 The Department of Health have now completed consultation, in December 2008, on a new draft continuing care framework for children. This framework is intended to assist Primary Care Trusts and Local Authorities in applying a consistent and transparent approach to assessing the healthcare needs of children and young people and in providing services. The Framework will apply in respect of children and young people under the age of 18 years and a final version, together with guidance on implementation, is anticipated during 2009/10

3.2 The framework includes an assessment and decision support tool to assist in determine the severity of need and eligibility for continuing care funding from the PCT. The decision tool does not indicate service types or how funding between partners may be shared. The proposed decision and assessment format includes descriptors for behaviour, communication and mobility and these will correlate with the revised eligibility criteria for access to social care set out in this report. (appendix 3a and 3b)

3.3. Hampshire's response to the consultation welcomes the principle of a joint assessment and confirmation of the shared nature of services to children with a disability . The draft framework does not include a mechanism to define how the cost of services may be shared in individual situations and in many cases there will be health, social care and educational supports for children with severe and complex needs. It is likely that the approach to this will need to be developed locally with the PCT and there is an existing model for considering shared costs in other complex situations which could be developed to include continuing care.

4) Direct Payments

4.1 The existing service framework for considering if a Direct Payment shall be offered have developed over a number of years and more recent guidance is now available. In addition the Government proposals to develop personalisation of services will later include children and young people and there is a joint pilot with Adult Services in the Basingstoke area to explore the issues around transition.

4.2 The recent guidance confirms that a Direct Payment must be offered to all children and young people and their parents and carers where their needs are included in the eligibility criteria for services.

4.3 Currently a Direct Payment is offered to all consumers whose needs fall within the existing eligibility criteria and is restricted to arrangements for domiciliary care and sitting services.

4.4 The proposed change to the Direct Payment arrangement is summarised below

· A Direct Payment will be offered to all consumers whose needs fall within the revised eligibility criteria

· Direct payments can be used in relation to a broader range of services but exclude at this stage residential services.

· The payment remains subject to audit as to it proper use and can be withdrawn if misused

· The level of service considered necessary to meet assessed needs will be identified through the application of the eligibility criteria following a needs assessment

· Revised indicative values for a range of services will be developed to allow for a calculation of the value of a Direct Payment

· Direct Payments made via the Aiming High Grant must be used to support short breaks in order to comply with grant conditions, although payments made from other budgets may be used for a broader purpose

· Where it is not possible for parents to make their own arrangements for all or some services agreed to meet assessed needs the County Council will continue to make arrangements for access to directly provided or purchased services

· Where the actual cost of services being purchased via a Direct Payment exceeds the indicative value used to calculate the level of payment, and where there is no other service available to the consumer at the indicative value, the County Council will consider r additional costs as long as the actual cost is reasonable in the circumstances and represents good value

4.5 Currently there is a separate budget for Direct Payment and as the proposed changes are made it will be necessary to review how a range of service budgets are managed.

4.6 There is a risk that some service budgets supporting block contracted services will need to be moved away from contracts and towards Direct Payments and these issues will be addressed as final implementation arrangements are put in place for the intended start date for the revised arrangements in April 2010 .

4.7 The application of eligibility criteria will ensure that managers meet assessed needs of those with severe and complex needs within available resources.

5) Financial implications and spending plans

5.1 The available Aiming High Grant is indicated in the chart below and is subject to conditions as to use. In general terms the Grant must be used to support additional short break care and claiming the grant will require evidence that additional short break opportunities are available through commissioning or directly provided services.

5.2 The following chart also shows the intended allocation of the grant in the two years from 2009/10. It is known there can be no carry forward. In general the allocations have been calculated to support a priority to the `offer' to those attending special schools or claiming higher rate DLA in the first year, and for that reason there is little scope to improve the level of service opportunity in specialist services or through Direct Payments in 2009/10.

5.3 The offer to those attending special schools or claiming higher rate care and or mobility DLA will reach in the order of 3600 young people, many of whom will not be supported through specialist social care service currently. The proposed budget allocations will support in the order of 50% take up of services in special schools and for those claiming higher rate DLA from July 2009 in the first year and 100% take up by the end of 2010/11.

5.4 It is proposed to allocate an additional £1.3m in 2010/11 to local budgets to support managers in considering higher levels of access to specialist services within the eligibility criteria, with a focus on supporting a broader range of short break opportunities for those with severe or complex needs.

5.5 There has been no Government announcement of funding for service improvement beyond the end of the initial Aiming High Grant (31^st March 2011). For this reason all proposed service contracts will have a break point at the 31^st march 2011, with suitable extension clauses that can be activated as the funding arrangements for 2001/12 are confirmed.

5.6 The recent letter to Local Authorities and PCTs confirms that similar match funding (£340m Nationally) has been made available to PCTs over the 2009 -2011 period to respond to the need to consider service improvements and strategic developments, including Continuing Care, Palliative Care and a Child Health Strategy. These funds are not ring fenced and are subject to other demands upon the PCT.

5.7 Priorities have been agreed with the PCT for potential future investments and more detailed proposals will be considered by the PCT Board during 2009/10 as their budget position is clarified. These include, improving and integrating the Occupational Therapy service, improvements to the Joint Equipment Store, access to supportive therapies and development of some jointly managed overnight short break services.

5.8 The following chart summarises the infrastructure costs intended to be supported from the Aiming High Grant to Hampshire. These costs represent in the order of 10% of the total grant available in 2009/10 and in the order of 5 % of the total grant in 2010/11. A contingency factor has been included in infrastructure costs in 2010/11 as payment arrangements in relation to some contracts are dependant upon the results of tendering, which may costs.

5.9 The following chart shows the proposed revenue allocations for 2009/10 and 2010/11 in relation to the 12 priorities within the agreed commissioning plan

Proposed revenue spending plan

5.10 The following chart shows the proposed spending against the capital element within the grant

5 Outline of Options

5.1 Direct Payments

5.1.1 To make no changes to the existing Direct Payments scheme and continue to offer a payment only in relation to domiciliary care

5.1.2 To expand the use of a Direct Payment to a broader range of services

5.2 Eligibility Criteria

5.2.1 To make no changes to the existing eligibility criteria

5.2.2 To lower the threshold in order to meet a lower level of need that could be met by specialist services.

5.2.3 To clarify the definitions of complex and severe needs which can be met by specialist services

6 Option Analysis / Comparison

Direct Payments

7.1 Current guidance on Direct Payments clarifies that a payment must be offered to all those who meet the eligibility criteria for the defined services and who are eligible to receive a payment. In order to improve the offer of care the existing Hampshire scheme must be changed as proposed in section 4 to allow for a payment to be made in relation to a broader range of specialist service than is currently the case.

Eligibility Criteria

7.2 It would be possible to make no changes to the existing eligibility criteria (option 1) as they operate satisfactorily from the point of view of managing the allocation of services to meet assessed needs within available resources. However the present criteria are difficult for parents and other agencies to understand and are not compatible with the emerging revised Continuing Care guidance.

7.3 The option to expand the range of needs that could be met by specialist services (option 2) would be unaffordable. Currently in the order of 900 consumers are supported by specialist services and of these in the order of 170 receive a Direct Payment to make their own arrangements for domiciliary care. The current total budget for a number of specialist services is in the order of £11m and a change in eligibility that resulted in say a 10% increase in the number of consumers -just a further 90 consumers - included within the eligibility criteria would result in a £1m increase in spending. This would be unaffordable from existing resources and whilst additional funds could be made available from the aiming high grant, conditions apply that the grant must result in additional short break services.

7.4 The Aiming High commissioning plan includes an offer of service to over 3600 children and young people many of whom will not be supported by any services currently and would not meet the criteria to access specialist service. The proposal to offer a service in this way to a broader range of children and young people was supported through consultation with parents and stakeholders. In this way an additional 3600 children and young people are offered additional services and those with the most complex needs are able to be supported with a greater level of service accessed through the application of eligibility criteria. Subject to resources being available local managers can consider if higher levels of services can be offered to those with low and moderate needs.

7.5 The option to clarify and make more transparent those complex and severe needs which fall within the eligibility for specialist services (option 3) represents the best opportunity to respond to the issues raised in consultation and to ensure that better short break support is available to those with the greatest need. The eligibility criteria, and the risk factors managers take into account in determining how needs could be met within available resources, will ensure that grant conditions are met and that service commitments are managed within available budgets.

7 Conclusions

7.1 Earlier consultation with parents and stakeholders indicated that many were satisfied with the nature of services but that the eligibility criteria were difficult to understand, that it was not clear how decisions were made and that higher levels of service would be appreciated

7.2 The revised eligibility criteria included in appendix 3a to this report seek to respond to these views by offering a clearer set of definitions of need which, subject to resources being available, could be met by access to a range of specialist services.

7.3 The flow chart at appendix 2 proposes arrangements for a degree of self assessment to enable a fast track to assessment by social workers in specialist teams. The factors set out in appendix 4 and in paragraph 2.7 in this report seek to clarify how managers will make decisions on the nature and level of service that is available to meet assessed needs, having taken into account available resources.

7.4 The proposed changes are compatible with the emerging revised arrangements for the PCT and the County Council to consider how costs should be shared for those with continuing health care needs.

7.5 The proposed changes to eligibility criteria are intended to confirm a priority to those children and young people with severe or complex needs who might access specialist social care services. Application of the criteria alongside increased funds will allow for a broader range of services to be offered to those with a priority need.

7.6 The spending plans set out in section 5 support the offer of service for those attending special schools and claiming higher rate care and or mobility DLA and will provide , without a further needs assessment, a service to over 3,600 disabled children and young people who do not current access specialist services.

7.7 The proposed future direction for the Direct Payment arrangements will support access to a payment for those parents who wish to make their own arrangements for a broader range of services than is currently offered.

CORPORATE OR LEGAL INFORMATION: