Archived decisions

Hampshire County Council response to the Government's Green Paper

`Shaping the Future of Care Together'

1. Introduction

1.1 Hampshire County Council welcomes many of the aspects of the Green Paper, which echo the findings and recommendations of the report of our Commission of Inquiry into Personalisation1, `Getting Personal', which was published in November 2008.

1.2 The Cabinet backed a cross-party approach for the Inquiry and invited leading local councillors of all political parties to join national experts as Commissioners. The Commissioners worked throughout 2008, held four public hearings, a BBC-style question time public debate, attended all three party political conferences and took evidence from over 150 people and 36 organisations.

1.3 The `Hampshire Model' of Personalisation which emerged from the recommendations of the Inquiry's report, is now being implemented across Hampshire. In brief, the Hampshire Model consists of eight work streams:

    1. Universal Offer - making sure everyone gets something, and ensuring that Hampshire is a good place for vulnerable and disabled people to live

    2. Market development - to stimulate the care market so that services are developed which reflect people's choices, and ensure that services are of good quality

    3. Self-directed support - in line with the Government's Putting People First agenda

    4. Free Crisis Care - for those at risk of hospitalisation or at point of hospital discharge or at risk of admission to permanent long term residential or nursing care in a crisis

    5. User involvement - involving service users in shaping the future of social care

    6. Carers - implementing Hampshire's Carers' Strategy

    7. Learning disability transformation - focusing on integration with Health

    8. Processes and efficiencies - to promote the infrastructure and processes required to deliver the change programme

1.4 Our response to the Green Paper reflects our learning from the Commission of Inquiry and our experience as a large and high-performing social care authority. Several consultation events, involving older people and other service users and carers, were also held during September and October 2009 to gather views on the Green Paper proposals.

2. Response to consultation question 1

1. We want to build a National Care Service that is fair, simple and affordable. We think that in this new system there are six things that you should be able to expect:

· prevention services

· national assessment

· a joined-up service

· information and advice

· personalised care and support

· fair funding.

a) Is there anything missing from this approach?

b) How should this work?

2.1 We concur, in particular, with the importance of:

    - prevention and early intervention

    - information & advice, as part of a wider `universal offer'

    - personalised care & support

    - fair funding

2.2 There are however aspects that should be added or enhanced in this model, particularly:

    - free crisis care

    - the broader aspects of a universal offer

2.3 In the Hampshire Model of Personalisation, a move towards free crisis care is an important element. It supports integration with health at the point of crisis by removing the "free health care" versus "means tested social care" tension that can become a barrier to truly seamless working. It also supports the re-ablement model, providing a period of free care at the point of crisis and enabling time for longer-term decision making, where appropriate. This provides better outcomes for vulnerable people, helping them to maximise their independence and reduce the likelihood of needing higher levels of care. For us this is also firmly linked to early intervention for those at risk of crisis or needing long-term care. We have been expanding our Community Innovations Team that works with this group, to prevent unnecessary admission into hospital or long-term social care. This is also a free service, which is important to avoid barriers or delays to entry. In Hampshire, we are already committed to providing six weeks of free care for those at risk of hospital admission or being discharged from hospital.

2.4 Hampshire County Council recognises the importance of information and advice as a universal service, and therefore a key component of Hampshire's movement towards a `Universal Offer'. Our analysis concluded that one of the issues for adult social care is that it has become too narrow in its focus, with little to offer self-funders or those who fall below eligibility criteria. In addition to information and advice, we believe that the Universal Offer should also include:

    - advocacy (where appropriate) and navigation

    - access to universal public services, which requires both planning for and

    active targeting of disabled, mentally ill and older people

    - the development of community-based support, from informal neighbour

    support through to more formally organised voluntary support, such as the

    excellent NeighbourCare schemes which run across Hampshire

    - links to other local services that promote health and well being, such as

    housing and equipment and adaptations

2.5 The Hampshire Commission concluded that there is merit in a national Resource Allocation System, whereby people across the country are asked the same questions and their needs are assessed in the same way. This would be seen to be fair and allow assessments to be portable. However, we do not believe the national element should extend to the allocation of resources based on this scoring. We think it is naïve to believe that this can be done at a national level in a way that is fair. Individual Budgets need to reflect the costs of acquiring care, whether this is done by the individual through a direct payment or commissioned on their behalf. Costs vary significantly across the country and even within regions and sub-regions, as costs reflect the local demand and supply of labour and land. A national Individual Budget scale would also prevent local responses to local needs. For example, an authority may want to incentivise the take-up of community-based solutions where there is an over-reliance on day care or to promote employment. The degree of rurality in a local authority area is also a significant factor, which can affect the options available, the mix of support required and the costs of care and support.

2.6 It is also unclear from the model presented, how the costs of prevention, safeguarding, universal services (such as information & advice) and crisis care would be funded if resources flowed only through the Resource Allocation System/Individual Budget process on a national model. We do not believe that this funding model is the right response to crisis care.

2.7 The Green Paper is also largely silent on the issues facing people and services for people with learning and physical disabilities and mental health issues. We understand that the Department of Health is prioritising the ageing population, a trend that is disproportionally affecting Hampshire. However, there are also demographic pressures in Learning Disabilities and Physical Disabilities. People are living longer with much more complex needs, which is increasing the average cost of care. The paper does not address how their care will be funded, and seems to assume that people with life-long disabilities will have no means. This is wrong for a number of reasons:

      - it seems to accept the low levels of employment and consequential lack of

      financial independence of people with disabilities;

      - it ignores people who acquire serious disabilities, such as brain injuries, but

      may have acquired significant means beforehand or as a result of

      compensation.

2.8 The Green Paper rightly asserts the importance of informal and family carers. It is probably the most important issue in the economic viability of the care system. However, the paper fails to recognise that a significant proportion of carers are older people, caring for older parents, partners and disabled children. They are significantly disadvantaged financially, particularly later in life. Financial assistance schemes for carers need to be simplified and more customer friendly to improve take up. The age discrimination in the Carers' Allowance is not addressed in the Green Paper, and we believe that this should be addressed as a matter of urgency. We also believe that there is a need to recognise the role informal and family carers play in other ways, such as through social credit schemes.

2.9 Portability has rightly been raised in the Green Paper as an issue that needs to be addressed in the care system. It is no longer right to assume that people will live in the same area for their whole lives. The portability of assessments is welcome. However, the Green Paper does not address two significant issues: housing and ordinary residence.

2.10 There is little or no portability of social housing, making it very difficult for disabled or older people in social housing to move, for example for work or closer to family who might have moved away. This can create greater dependency.

2.11 The Green Paper does not address Ordinary Residence and the uneven impact across local authorities, although it notes that guidance is currently being revised and updated. County Councils like Hampshire tend to be net importers of service users and thus face significant financial pressures without any means of recompense. Ordinary Residence can create perverse incentives to place out of the authority area and to encourage de-registration even where this is not in the interests of the service users or does not represent any real change in the model of care. There needs to be greater synergy and clarity between the rules on ordinary residence and responsible commissioner guidance in the NHS, particularly in relation to continuing healthcare, which can cause unnecessary disputes between agencies and localities to the detriment of individuals.

3. Response to consultation question 2

2. We think that, in order to make the National Care Service work, we will need services that are joined up, give you choice around what kind of care and support you get, and are high quality.

a) Do you agree?

b) What would this look like in practice?

c) What are the barriers to making this happen?

3.1 Choice over quality and joined up services are obviously key aspirations. However, there are a number of issues that need to be addressed to make this happen.

3.2 Care markets have developed in the face of two key drivers:

    - block purchasing by local authorities and health

    - atomised purchasing by individuals

      This has produced a limited range of services, of variable quality and that do not always treat service users as customers.

3.3 The transition to broader, more flexible markets will take time and this transition will require funding for pump priming and dual-running, as more traditional services that are in less demand are de-commissioned. For example, user-led and micro-enterprises will need support to develop the infrastructure to begin offering personalised support. Equally, we will need to continue to meet the needs and wishes of those who choose traditional services whilst overall demand for them declines. In a large geographical area like Hampshire it is simply not possible to keep shifting people around the remaining provision, and it will be necessary to sustain some services with reduced capacity. This transition in the market will take considerably longer than the three years of Social Care Reform Grant, particularly given the over dependence on buildings-based provision in the past.

3.4 There is a real need to invest in the social care work force, particularly those providing hands-on personal care. This workforce is ageing and care is not seen as an attractive career option for new entrants where there are poor career structures, especially where service users are employing their own personal assistants. There is a need to develop a more highly skilled workforce to provide personal care for those with more complex needs and opportunities need to be developed with health for integrated core competencies for this staff group. This will require ongoing investment in training, but also may impact on pay rates if care is to compete with the rest of the service sector as the economy recovers.

3.5 More joined up services with health are our aim. Indeed we are actively pursuing this through our involvement as a demonstrator site in the Department of Health's Common Assessment Framework project, the only pilot led by service users and carers in the country. However, there are a number of barriers to this:

    - the health service is driven by a performance regime that does not prioritise

    partnership with local authorities in general or social care in particular. It

    would be very helpful if the key health performance indicators set from the

    top by ministers did more to emphasise the importance of partnership and

    community outcomes.

    - The health service is comparatively inward looking in its commissioning.

    Keeping NHS resources within the NHS can seem to be a primary driver of

    NHS commissioning. This reduces opportunities for evidence-based

    commissioning across the health and care systems.

    - The NHS is at a very early stage in personalising health care. It does not

    yet seem to be an accepted ambition as it is in social care.

4. Response to consultation question 3

3. The Government is suggesting three ways in which the National Care Service could be funded in the future:

Partnership - People will be supported by the Government for around a quarter to a third of the cost of their care and support, or more if they have a low income.

Insurance - As well as providing a quarter to a third of the cost of people's care and support, the Government would also make it easier for people to take out insurance to cover their remaining costs.

Comprehensive - Everyone gets care free when they need it in return for paying a contribution into a state insurance scheme, if they can afford it, whether or not they need care and support.

a) Which of these options do you prefer, and why?

b) Should local government say how much money people get depending on the situation in their area, or should the national government decide?

    General points

4.1 It appears that the financial consequences of all three options are similar in the balance they provide between public and private spending and the public spending consequences of change from the current system. To that extent, differences between these three options can be assessed in a "cost neutral" manner. However, the Council would like to flag up that more information is needed in order to assess key questions around the implementation of any of the three options compared with the current system:

      · Exactly how much additional public money (taking account of the effects of

      demographic change and sector or inflation predictions) do all three

      solutions assume is needed compared with the current position?

      · What funding mechanisms are proposed to meet the difference between

      current expenditure and the proposed new models?

      · What assumptions have been made about the level at which eligibility to

      service would be set? For example, if people are paying into an insurance

      scheme, whether private or state run - they are likely to expect that an

      element of paid-for support will be available to them before they reach the

      level of need currently served by most local authorities (in the main, only

      those in the `critical' and `substantial' care categories are supported). This

      will inevitably increase costs. (Estimates by Forder and Fernandez2

      suggest that around 3% or 257,000 of the older population may fall into the

      `moderate' care category and the majority of these people would not

      currently be receiving services.)

      · On what split between accommodation and care costs are the models

predicated?

      · Given that split, what are typical examples of how an individual fares under

    the current and proposed systems?

4.2 There are also other funding issues related primarily to the new service offers for provision of information to all, early intervention and a better deal for carers. These also appear to arise regardless of the choice of new model. Some of these costing and funding issues are addressed to some extent in the impact analysis which accompanies the Green Paper, but there is insufficient detail here for any clear conclusions to be reached. Accordingly, the Council would preface its remarks on the choice between the three options put forward with the caveat that more understanding of the financial consequences of all three models is needed in order to inform the assessment of whether any of them will successfully tackle the future funding difficulties faced by adult social care.

4.3 Looking at all the models, the splitting out of accommodation costs does not sit entirely logically with the aim of clarity for individuals about what costs they face. If someone goes into care but his or her partner remains in their house, the actual saving in accommodation costs is minimal, amounting merely to food. Property costs would not be significantly reduced, but that aspect of the care home will be being paid for. If there is no property, then clearly that point does not arise but it is not clear in assessing how much the State should pay for and how much the individual should be expected to contribute, that accommodation costs should meaningfully be treated any differently from care costs. From the individual's point of view, they have a defined level of resource from which to contribute towards care and accommodation: splitting the two merely confuses matters.

    Choice between models

4.4 Setting those overall issues to one side, the County Council welcomes the broad principles of the models. All three give "something to everyone" which is a helpfully inclusive approach. There is also a powerful recognition that there is a perceived inequity in the current arrangements in that those who manage their own finances well then pay heavily for care in old age whereas those who have not saved do not have to pay. Hampshire's extensive consultation with its local people confirmed the strength of feeling on this issue. All the models help with that, but it is worth noting that the Insurance model allows a significant and very visible element of the imbalance in justice between the thrifty and those who have not saved to remain in place. People who choose to take out insurance will pay for themselves. Those who do not so choose, and have no other resources, will have to be paid for by others.

4.5 The County Council is also less persuaded by the Insurance model for another reason. It depends on voluntary participation which in turn depends on individual psychology - and experience to date does not suggest that people will opt in practice to pay towards their future care costs, whatever they may say in consultation exercises. There is therefore the risk that potentially complex scheme arrangements are set up but that the scheme does not come to worthwhile fruition.

4.6 The Comprehensive model, then, is more attractive on the grounds of social justice, and there is no danger of "inadequate participation". This option is therefore probably the most socially just, and provides the greatest overall community benefit, albeit that it introduces an element of compulsion for those who can afford to contribute. An additional benefit is that it could work within existing local authority funding mechanisms.

4.7 One potential problem with the Partnership model is that it still leaves individuals exposed to the danger of very significant care bills if they are in the unlucky minority who require an extended period of residential care. Again, Hampshire's local consultation confirmed that this is a worry. The Council's original response to the social care debate proposed that this could be dealt with by doubling the level of capital which is disregarded for assessment purposes from £23,000 to £50,000. This remains a viable option if the Partnership Model were to be pursued, but at the same time it is understandable if funding constraints make it a difficult one to implement.

4.8 Alternatively, the worst of such worries could be taken out of the Partnership system if the Government operates what one might term a "stop loss scheme". Under that, the public purse would pay not just for a proportion of all the costs for everyone, but for all of the costs for everyone beyond a certain point, e.g. from the fifth year of residential care onwards. If set correctly, that would provide a relatively cheap (because so few people reach that point) additional element of security and reassurance which could be funded by adjusting the proportion of total costs paid by the State for all.

    Should the system be national or local?

4.9 Our preference in Hampshire is for a system which gives local people the greatest chance of flexibility and control over the care and support they receive. For this reason we would argue for a part-national, part-local system, not a fully national system. Our experience in working with users and carers to begin the implementation of the Personalisation agenda, and our engagement through the Commission of Inquiry has strongly demonstrated the value of the direct relationship between the local authority and users and carers and we believe that there is much greater chance of local people influencing the services they receive if they are both funded and planned locally.

4.10 There would be significant constitutional issues for local government in having such a big proportion of its spending removed from local control. If the levels of social care spend were to be nationally determined, then that would remove what (after education, which is already treated in a national manner) is the second main area of local government spending from any meaningful local control. It is hard to see how this would be compatible with anything other than specific ring-fenced funding along the lines of the Dedicated Schools Grant. Otherwise, national decisions would be determining the level of local council tax, which would be something of a mockery. That, furthermore, would also unbalance the national system of finance, in that the non-council tax funds available might not meet the specific spending needing to be supported through ring-fenced arrangements.

4.11 We support the Government's localist approach emanating from the Department for Communities and Local Government, for example, through the Local Democracy, Economic Development and Construction Bill and the consultation on Strengthening Local Democracy as we believe that greater local involvement in decision-making and in the shaping of public services is crucial and this applies to social care more than any other service, given how personal to the individual all care and support services by their very nature must be.

4.12 The oft-cited fear of a "postcode lottery" in local systems largely depends in practice on the actual extent of movement between local authorities of the potentially affected individuals. That is what may expose the difference between one authority's policies and another's (whether or not those differences are justified by local circumstances). The Council believes that such movement is likely to be limited. The potential individuals affected are:

      · Those in older persons residential care, who are already covered by a national assessment system.

      · Those in adult residential care who, if they move between authorities, are already covered by the ordinary residence rules.

      · Recipients of non-residential care who move between authorities. Research would be required, but it seems likely that those over 65 quite rarely move their home from one authority to another, that being the circumstance in which their needs would fall to be re-assessed under new arrangements which might provide a different outcome from their former arrangements. (However, younger people with disabilities or mental health issues would certainly welcome greater flexibility; also older people might move more readily (eg to be closer to family or friends) if they were able to take their needs assessment with them.)

4.13 Furthermore, although the NHS is held up as a national service, it is worth pointing out the perception that a postcode lottery can exist within a national service too. Primary Care Trusts, for example, do not receive budgets based on individuals' needs but based on the population's needs and they, not central Government, then determine how funding should be allocated locally for treatments and services. We are concerned that a national system of allocating funding will mean inequality for users, and a lack of flexibility in services that must be designed around the needs of each individual. A national system could potentially struggle to cope with the huge demographic variations across the country which will affect how much people can purchase for their individual budget. Managing issues such as the availability of care, the widely varying costs of care, the potential premium in providing services in a very rural area, and meeting the needs of BME communities, for example, are all much easier to moderate for and manage in a locally administered funding system. Hampshire's experience of implementing our Resource Allocation System for personalisation has shown that moderation can be necessary to ensure that the money an individual receives is sufficient to meet the needs identified in their support plan. Even within one county area, prices for services in different areas, and issues such as rurality, are impacting on how much care people can buy with their budget.

4.14 The Council would suggest that in this context, there is no need for a fully national system of funding in order to avoid specific cases being seen as illustrating a `postcode lottery'. As mentioned in the response to Q2, we do believe however that there is merit in a national Resource Allocation System, whereby people across the country are asked the same questions and their needs are assessed in the same way. Such a system would also make it easier to enable national and more efficient dissemination of relevant information.

5. Conclusion

      The funding of adult social care is extremely complex and much more work is needed by Government to test the financial models put forward in this Green Paper. However, regardless of the resources directed in future towards social care, what is more fundamental is the transformation of services through personalisation. Without this whole systems reform, which is the focus of our Hampshire Model transformation programme, the necessary improvements in outcomes for users and carers will not be possible.