Maintaining independence

Good practice examples

Intermediate care and rehabilitation

Train and Support Staff

Supporting carers and getting a break

Direct payments and vouchers

Equipment and adaptations

Overview

Shifting the balance of services to focus on prevention and independence requires an understanding of the relationship between demand and supply. Changes to the supply side which are not linked with shifts in care management practice are not going to work (See Exhibit 8)

The current challenge for social care commissioners is to maximise the services available at the lower tiers to minimise demand for residential and nursing care. Even with good local social inclusion policies there will still be a need for some community based specialist services. This section looks at some of the main practical ways in which councils have managed to provide cost effective and flexible services that give users control over their lives.

Milton Keynes - Budget efficiencies in homecare

Salford - assessment and equipment for people with physical disability

Hartlepool - multi-agency link team

Surrey - Direct Payments

Surrey - Using vouchers for carers' breaks

Surrey - user involvement in commissioning

Blackpool - care and repair

Intermediate care and rehabilitation

Whilst in the past many specialist services in the community have focused on maintenance, not rehabilitation, this is shifting with an acknowledgement that a different and possibly more intensive intervention at the beginning of a care plan may reduce overall costs in the long run if new skills can be learnt or relearnt.

Intermediate Care is a whole system approach to a range of multidisciplinary, multi-agency services designed to promote independence. For more information about Intermediate Care go to the DOH website

Whilst the principles were developed around older people they provide a good foundation for thinking about work with other groups too.

It illustrates the close relationship between demand and supply :

Manage demand by…

• Reducing avoidable admissions to acute hospitals
• Facilitating timely discharge from acute hospital and promoting effective rehabilitation
• Minimising premature or avoidable dependence on long term care in institutional settings

…through the provision of

• Rapid response/ emergency response teams / Hospital at home schemes
• Supported discharge teams
• Nurse led facilities in acute or community settings
• Council-run/independent residential rehabilitation

See Good Practice: Hartlepool for some ideas about putting together a range of intermediate care services

See Wokingham Preventative service for ideas about how an authority tried to reduce falls and increase mobility through very early intervention preventative services.

Others authorities are finding that by developing more specialist services for particular types of need they can provide a better service and improve staff job satisfaction.

See putting the full range of services into place for what this means for day care

Train and support staff

• Domiciliary care services are developing to provide a much wider range of support in users own homes. Many authorities such as Milton Keynes (some in conjunction with independent providers) are offering additional training to domiciliary care staff who then become part of a team who work with particular groups with specialist needs, obvious specialisms are EMI, mental health, and intensive rehabilitation after discharge from hospital. This can provide a career route for staff who wish to remain in the sector but want development opportunities, and can be a cost effective way of providing skilled support to users with complex needs.
• Some departments are working closely with health colleagues to provide shared career paths, training opportunities and recruitment drives for unqualified care staff as a way of maximising the number and quality of staff, and getting away from competing for the same group of recruits.
• The Joint Review Team continue to find examples where care staff are not encouraging users to do as much for themselves as they are able, promoting a culture of dependence not one of self sufficiency. Helping someone to do something for themselves is not necessarily the same as doing it for them, domiciliary staff need training in developing these skills and support from care managers and occupational therapists in identifying where there is potential for improvement. Some authorities involve occupational therapists and physiotherapists in training domiciliary care staff.
• Very short visits are also unlikely to promote learning, so make sure your purchasing policy does not promote dependence through insistence on minimal lengths of visit in all instances

Supporting Carers and getting a Break

Sustaining carers in the community will reduce the demand for residential care, a small sum invested now in respite and carer support will build confidence and keep carers going. For more information about carers and their role see Putting the full range of services in place.

In A guidebook for good practice in the provision of short-term breaks as a support for care in the community the view is expressed that the term "respite", suggests escape from something disagreeable or burdensome and should now be replaced "short-term breaks" as this has no bias, and implies that there is benefit to both the carer and user.

Short breaks may be intermittent or ad hoc in response to a specific need or a crisis in the family. They may be regular breaks on a monthly, weekly or other timescale The break may be provided at the persons home by a volunteer or paid carer to enable the regular carer time away from home or to enable the cared for person to be involved in a specific activity or visit.

The 1999 Department of Health publication A Real Break provides a Good Practice Checklist and a number of Good Practice Examples.

Direct Payments and Vouchers

Direct payments and voucher schemes give more control to the user in putting together a package to meet their needs. Direct payments schemes are now mandatory for all authorities in England so it is in every authority's interest to develop a scheme which is efficient. Mandatory direct payment and voucher schemes are proposed to be introduced in Wales during 2004. Surrey County Council have developed a particularly good one. Voucher schemes are voluntary but those who have tried them are already commenting on their potential simplicity and therefore should prove an inexpensive, but effective way of giving more control to users and carers

This section looks at how authorities who have not yet set up direct payment or voucher schemes, or who wish to grow the schemes they already have, might set about doing so.

Direct payment schemes across the country have had a mixed start. Some councils like Surrey have succeeded in recruiting several hundred people onto their schemes; others have stuck in single figures

For factsheets and guidance from national voluntary organisations see National Centre for Independent Living and British Institute of Learning Disabilities

What gets in the way of developing a good direct payments scheme?

• User and carer fears that they will not be able to put together and sustain the level and quality of service they need
• Social workers have the same fears about competence, and about what happens if the arrangements go wrong
• Senior officers and councillors don't realise that to run a good scheme they need to fund the infrastructure that will enable users and carers to do it well, so it is not necessarily the cheapest option

Why are direct payments valued by users?

• Users realise they can do things for themselves, and don't need to be dependant
• In reality the number of occasions where something goes wrong is no more than the normal crises that happen for everyone in receipt of a service
• Users get innovative, often cost effective, packages of care which meet their needs.
• User and carer organisations get the opportunity to work in partnership with the council

To make direct payments schemes work, don't treat them as something you have to do, if you can get it right there will be long term benefits for the council as well as for the users.

Getting users and carers signed up to the concept

• Involve users, carers and the voluntary sector in developing and growing schemes
• Recognise that there will be a cost element for all these groups in being involved
• Introduce users to champions who have made direct payments work for them
• Successful direct payment schemes such as Surrey fund user organisations to act as advocates and advisers on recruitment, employment, dealing with national insurance etc
• As schemes expand to cover the full spectrum of client need you may need to involve more than one user organisation or encourage groups to work in partnership
• Ensure that user groups who enter partnerships are committed to including all potential users and can accommodate the needs of those with limited communication skills and those from black and ethnic minority communities

Getting members and officers signed up to the concept

Common concerns include, equity, costs, covering emergencies and holidays, users spending the payment on other things and then coming back for more, and getting the process right.

• The unit costs of running a small scheme, particularly one that involves funding a user organisation, are likely to be higher than those of a large scheme, so set yourself a target to grow to a size that is going to be cost effective
• Consider how much should be invested in support services
• Accept that it will take time to build up a reasonable sized scheme, but set medium term targets and recognise that you may need to put in extra investment in the first few years to develop the expertise and user confidence.
• Smaller authorities may wish to consider partnership with other authorities to reduce costs particularly when developing schemes for more specialist groups.
• When calculating unit costs of direct payments don't forget the costs of the payment process and the support structure. At the same time , when making comparisons with other ways of providing a service don't forget the costs of your normal infrastructure like; staff recruitment, supervision and other on costs; and contracting with, monitoring and paying independent providers etc.
• Get your auditors involved at an early stage to ensure that you develop good monitoring processes which support flexible packages
• Use standard assessment, review and charging processes for those on direct payments
• Regularly recost and review Direct Payments
• Latest regulations (in England) mean that payments must be made gross, i.e. without deducting assessed charges, then charges collected in the same way as for all other services
• Develop a finance system that monitors how payments are used and link this in with the review system. If needs are not being met bring forward the review as you would do with any other user.
• Experience has shown that users who drop out from schemes are more likely to have experienced problems in setting up reliable support or suffered deteriorating health.

Innovation through direct payments

Some authorities are using direct payments to meet the needs of black and minority ethnic communities particularly where ethnic groups are small and communities already have an infrastructure that provides informal support. This can be more cost effective at the same time as being more responsive to user need than setting up specialist services of your own for these communities

Setting up and administering a user led organisation to support direct payments will develop user empowerment in your area, and give you a forum of users who are developing an understanding of user need and the type of services they purchase, this will help inform your own commissioning.

Voucher schemes

As a halfway house between local authority managed care packages and direct payments, voucher schemes are ideal for some users and carers, who want to control when they access services without the responsibilities of employing their own staff. Surrey County Council have recently introduced a successful voucher scheme.

For more information about the act and guidance on its use, in England, see www.carers.gov.uk/voucherstb.htm

Vouchers can be issued in two ways, as money value vouchers, or as time value vouchers.

Why develop a voucher scheme?

• There are a number of users and carers who want more control over their care packages but don't want to go as far as direct payments.
• Costs of providing a voucher service over and above normal care management should not be significant (care managers issue vouchers post assessment/review, carers give them to providers who submit them with normal invoices for payment), and it takes the hassle of sorting bookings away from busy care managers. Surrey County council staff were surprised at the simplicity of their newly introduced voucher scheme.
• Simplicity of process means that it is should not take a long time to develop. Surrey got their scheme off the ground within 3 months of funding allocations being finalised, and already within 3 months of its start users of the scheme were very pleased with the service.
• Carers generally want to be able to negotiate dates and which service to use and it will be they who have to work with providers around bookings at short notice, high demand dates etc.

What sort of services are vouchers being used for?

• Some authorities are using them for overnight respite care packages for adults and/or children, giving carers control over when they take their breaks.
• Others are using them for shorter respite breaks with agencies providing care in users' own homes. Surrey County Council are using them for short and overnight respite.
• Authorities can let voucher holders use them with in house providers and for services purchased as part of a block contract as well as purchasing in the open market.
• It is important to get the commitment of local providers at an early stage as the authority will generally need to negotiate with providers to get them to agree to take vouchers, and attached fee levels. Vouchers are likely to be most effective where there are several potential providers available.
• Where several councils use the same providers it may be worth developing your voucher schemes together, economising on some of the development costs. This may also attract more providers to welcome vouchers as they are not having to work to several very different schemes
• One question that may arise is should carers/users be able to top up the value of vouchers to purchase a service that is above the level of fee the authority is prepared to pay? The legislation allows for this, seeing it as a way of accessing better quality rooms, or adding extra value to a money voucher that has little left on it. See the doh site for more information, on the position in England, at www.carers.gov.uk/voucherstb.htm

Time Value Vouchers

• These state the number of hours respite that will be provided
• They will also specify what type of service will be offered, e.g. overnight accommodation, respite in the home etc.
• These will be ideal for the user and carer who have a clear sense of what type of respite works best for them
• Users/carers can be assessed for charges for this service in the same way as they would be for any other relevant service provision
• You will need to link the issuing of vouchers in with appropriate guidance, the DOH site gives a more detailed explanation www.carers.gov.uk/voucherstb.htm

Money Value Vouchers

• Each voucher has a monetary value which can be redeemed against any service provider who is part of the scheme
• Again the amount of money included in the voucher will need to be linked with assessed charges
• Users have flexibility in whether they choose a small number of overnight stays or more frequent short breaks or a combination

Equipment and adaptations

Many authorities have real difficulties in getting equipment and adaptations to disabled service users quickly. Blocks occur at all stages in the process from assessment, through to the issuing of equipment, onto small adaptations and through to major building works. Experience within Joint Reviews demonstrates that a culmination of delays at each stage of the process can mean that significant numbers of users are waiting unacceptable periods of time for what are sometimes very basic pieces of equipment. The absence of equipment or adaptations to support mobility can precipitate falls or carer breakdown, with the final outcome of placement in costly residential or nursing care.

Equipment

The Audit Commission report in March 2000 "Fully Equipped" painted a largely negative picture of the state of equipment services across the country. In response the government provided new money to English authorities for the development of fully integrated equipment services across health and social care and linked this with significant service targets

For more information about these, see www.doh.gov.uk/pdfs/cesguidance.pdf

Guidance and support Is available through a support team set up to provide advice and support to managers who are introducing the new joint services.

The National Integration of Community Equipment Service Team (Ices) monitors progress and shares examples of good practice. They can be accessed through their website on www.icesdoh.org

Topics covered in this site include advice on;

• Involving users
• IT Systems
• Finance information on purchasing and supply, community equipment service funding, indicative monies, pooled funding and VAT.
• Health and Safety
• Performance Indicators
• Equipment for Children
• Management Boards
• Sensory
• Telecare
• Boundaries
• Self Assessment
• 50 per cent Benefit
• Community Equipment Services and the wider health agenda
• Environmental control systems
• Legal advice on bathing equipment and self assessment
• Contracting and outsourcing services

Getting the best out of your equipment

• Involve users in developing and improving your equipment services. Surrey County Council have included users as a major player in developing their joint equipment service, for more information see Good practice Box Surrey County Council User Involvement
• Assessment
  • Maximise the use of your professional occupational therapy staff; getting equipment issued quickly without sorting waiting times for assessment will not significantly improve user satisfaction.
  • Analyse the nature and pattern of demand for OT assessment and ensure the skill mix, particularly of qualified and unqualified staff within the service, reflects this
  • Reduce the numbers of assessments you need to do using self-assessment and assessments done by other professionals for less complex or low risk equipment. For more information see www.icesdoh.org/article.asp?Topic=28
• Equipment services
  • Collect redundant equipment promptly; users are often distressed that equipment no longer needed is not collected, some authorities have built in a collection service with tight time targets to their new joint equipment services
  • Link this with effective recycling with good cleaning facilities and staff who can carry out basic repairs.
  • Use shop front type facilities where users can try out a range of equipment and purchase small items directly with the benefit of advice from staff. Some authorities are doing this in partnership with voluntary sector organisations
  • Get the balance right between what you hold in stock and what you order from suppliers only when it is required.
  • Develop good electronic stocktaking systems linked with good professional knowledge about the sort of equipment that is likely to be needed at short notice, enabling you to minimise the amount of equipment that sits on shelves unused for months.
  • Get your contracts with regular suppliers sorted so that you can ensure prompt delivery of equipment you do not retain in stock.
  • Think creatively about the sort of equipment that you supply, telecare equipment can reduce the need for high levels of visits for those who need regular monitoring. See www.icesdoh.org/article.asp?printer=1&TopicCol=10 for some ideas of the sort of equipment that is currently available.

Major Adaptations

The adaptation of a property to enable the service user to remain at their home address has been an established service for many years.

Some authorities have formed joint housing and social services units which specialise in adaptations and increasingly Health partners are being engaged so that an OT in a health setting can authorise an adaptation without a second assessment from a local authority OT.

The Disabled Facility Grants (DFG) are administered by local authorities, usually by a Housing Grants Team. Applications for a DFG have to be approved by an occupational therapist and the work is inspected by a surveyor within the Housing Grants team. The DFG is means tested and has an upper limit of £25,000 (£30,000 in Wales). In England the grant is paid by the Office of the Deputy Prime Minister, via the Local Authority. In Wales funding is provided by the Welsh Assembly Government to the local authority. From July 2002 Councils have been given a general power to award discretionary assistance, This can take any form, e.g. a grant or a loan and can be for any amount. Circumstances where discretionary payments may be made include:

• Grant to assist moving rather than adaptation
• access to gardens
• provide safe play area for a disabled child
• or to improve the quality of an adaptation by topping up the money available under the grant.

In England Council tenants can often access a separate fund. It is usual (but not required) for Councils to set aside a specific budget, usually from the capital programme for adaptations to Council property. This budget means that the DFG process is not needed for Council tenants.

In Wales, council tenants, tenants of private landlords and owner occupiers can all apply for DFGs. Tenants of private landlords and owner occupiers are required to access DFGs.
Housing associations can fund adaptations in the same way as Councils, however they are under no legal obligation to do so. In England, some tenants of Housing associations can find themselves facing delays whilst the Housing association decides whether to fund or not and sometimes whether they will consent to the work.

Construction issues

Quality issues are significant in any building project and especially so as disabled people may have to live in the property while it is adapted. Most Councils will have a list of approved contractors but they are not able to advise people in other forms of tenancy who to employ. Some authorities have a Home Improvement Agency or Care and Repair agencies in Wales (usually a voluntary sector organisation) which can organise such work on behalf of the tenant

There is no requirement for a register of adapted property, but the local authority will usually keep a record of its own adapted stock. Increasingly the Homes for Life (or Lifetime homes in Wales) standard is applied to all new building. This will eventually reduce the extent of adaptations however not all local authorities require this standard when commissioning new build dwellings.

Minor Adaptations

Home improvement agencies (HIAs)(Care and Repair Agencies in Wales).

HIA's or Care and Repair Agencies are generally small non-profit-making bodies managed locally by housing associations, local authorities, independent management committees or charitable organisations, such as Age Concern. Their main functions are:

• to help older, disabled, and vulnerable people to remain independent in their chosen home by identifying necessary repairs and improvements, finding suitable contractors and ensuring the work is properly carried out;
• to help people to access public resources for housing renewal, including disabled facilities grants, where available;
• to help make use of other sources of funding through information on loans, insurance, charitable finance and equity release.

They can assist service users in various ways including:

• Repairs/maintenance and handypersons schemes
• Financial advice/advocacy
• Home security and safety
• Hospital discharge schemes

If you are interested in more information about an award winning HIA see Good Practice: Blackpool.

A major advantage of HIAs is their perceived independence from any statutory body and their sole focus on meeting the needs and aspirations of their client groups. It is this strength that allows them to diversify into the provision of other complementary services and address the housing, social care and health needs of their clients. There is a national coordinating body, Foundations - www.foundations.uk.com or in Wales email enquiries@careandrepair.org.uk.