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CHAPTER FOUR PROVISION

Evaluation objectives

• Identify, across all local authorities the number of people experiencing delays between having an assessment and receiving either personal care services at home or direct payments for these and personal and nursing care payments in care homes. Identify the length of these delays, how the delay differs for different types of services and reasons for this delay.
• Examine how local authorities manage their resources where they are required to deliver intensive packages of personal care to people who have been assessed as requiring a care home place but choose to live at home.
• Evaluate the extent to which the views of individuals and their families are taken into account when allocating care packages and the degree to which individuals are offered choice.
• Identify the processes by which Route 2 and Route 3 contractual arrangements are put in place when arranging care home places for self funders. Explore the advantages and disadvantages of different contractual arrangements from the perspective of service users, service providers and local authorities.

Managing Service Provision

4.1 The first two evaluation objectives will be considered within the broader heading of managing service provision. This section will consider:

• Prioritising service provision
• Numbers of people waiting for FPC
• Managing numbers of people waiting for FPC
• Limiting / 'capping' care packages
• Unmet need

Prioritising service provision

4.2 The requirement for local authorities to manage resources through prioritising and targeting services to those in greatest need was recognised in the Guidance on Free Personal and Nursing Care. This states that:

"Following a needs assessment, payment towards personal care should commence when the authority is in a position to arrange or provide the required services. It is important that people receive services on the basis of prioritising care needs of older people rather than on individuals' ability to pay." ²⁶

4.3 Access to personal care services is governed, not by the Community Care and Health (Scotland) Act 2002, but by previous legislation and associated guidance. Guidance on Assessment and Care Management ( SWSG 11/91) explicitly states that in drawing up the care plan following an assessment of need: " the availability of resources and services for meeting needs will have to be taken into account." The guidance reflects the reality that it may not always be possible to provide personal care services immediately following an assessment. In response, local authorities have implemented a range of approaches for managing resources to cope with pressure of demand for services.

4.4 Flowchart 2 below illustrates the typical process that a local authority will follow when deciding whether to arrange care services.

4.5 Although recognising the issue, the guidance on FPNC does not provide detail on the key issue of whether/ how local authorities are able to take resource issues into account in determining access to care services and FPC. There are no national guidelines for prioritising the delivery of care services or access to care homes. Each local authority will determine how it prioritises access to care services ²⁷.

4.6 As is shown in Table A6.2 (Appendix 6) most local authorities have three or four levels of priority which are the same as those used for prioritising the screening of referrals (see Chapter 3).

4.7 The definition of each level of priority will vary between local authorities but will be based on risks to the individual, their independence (whether the individual will be able to live in their own home) and quality of life. For example, East Lothian Council's four levels of priority are described as:

• Critical - risk of major harm/ danger to the person and/ or major risk to their independence
• Substantial - risk of significant impairment to the health and wellbeing of the person or significant risk to independence
• Moderate - some impairment and / or some risk to independence
• Low - promoting a person's quality of life and/ or low risk to independence.

4.8 The decision as to whether someone with assessed needs will have these needs met by the local authority will be determined by the level of risk / need identified by the community care assessment, the involvement of carers in providing services and the cost of meeting the need/ minimising risk by providing care at home, taking into account the resources available to the council.

4.9 The evaluation found that more than half of Scotland's local authorities have a threshold for determining whether an assessed need will be met by the provision of care services. Table A6.2 (Appendix 6) provides a summary of the processes followed by local authorities in determining whether assessed needs are met by the provision of services. Many local authorities do not provide, or guarantee to provide, services to people assessed as having low levels of need. Six local authorities reported that they will only guarantee to meet Emergency or High level needs and will only undertake to meet Medium level needs 'within available resources or when resources are available'. For example, East Lothian Council would not guarantee to provide a service for someone who did not meet the Council's eligibility criteria for critical or substantial need. In this situation the client's case would be reviewed if the individual, a carer or third party such as the GP or Day Care Centre alerted the council to a change in their situation which may affect their level of need.

Flowchart 2: Typical process followed by local authorities for prioritising service provision

4.10 Local authorities may also restrict the provision of services to people with personal care needs if these needs are being met by relatives/ informal carers or other service providers. For example, Argyll and Bute's policy summarises their approach to managing access to service provision in the following terms:

"The support given by partnership agencies is intended to:

• Retain, restore and promote maximum independence
• Intervene no more than is absolutely necessary
• Compensate for the absence of alternative support or complement existing supports including to enable carers who are already providing regular and substantive care to continue in their caring role
• Take full account of the risk to the individual if a service is not provided.

Consideration will therefore only be given to providing services when:

• The individuals are unable to meet their need themselves and
• They do not have access to adequate support from relatives, friends, neighbours and informal carers
• Failure to respond would place the individual at risk in a situation of unmanageable or unreasonable risk."

4.11 People with personal care needs, whose needs are not being addressed by informal carers or other service providers, will not be affected by the thresholds used by local authorities to prioritise access to services as their need for personal care will put them in a category above the threshold. For example, someone who needs assistance to get out of bed, dressed and washed every day will meet the criteria for a high or medium priority category. As East Renfrewshire Council reported to the evaluation:

"This council would never leave anyone in a situation where no-one was meeting their personal care needs; i.e. in a situation where they were not able to be fed, toileted etc. Such cases would always receive urgent priority to ensure these needs were met immediately."

4.12 However, situations were identified by a small number of local authorities where local authorities may not provide services to fully address an identified unmet need for personal care. Situations where a service may not be provided include the following:

4.13 In addition to the reasons outlined above, Midlothian, North Ayrshire and South Ayrshire Council also stated that situations may arise whereby the local authority might not immediately be in a position to address an individual's needs in full through the provision of FPC services due to a lack of available funding. In such situations the provision of services would be prioritised according to need. North Ayrshire Council stated that " If the resources were not available we would seek to address the needs in part while keeping the situation under review or we would seek to transfer resources from elsewhere if any free resources could be identified."

4.14 Some local authorities (including City of Edinburgh and Dumfries and Galloway - in both cases pre-dating the introduction of the FPC policy - and more recently, Argyll and Bute) have taken policy decisions to prioritise the funding of personal care services, and as a result do not provide domestic care services to new clients unless they form part of a comprehensive package of home care which includes personal care.

4.15 Most service users and carers interviewed for the evaluation across all six case study areas were unaware of the processes used by their local authority to determine access to services. However, users and carers in several case study areas commented that they felt there was a lack of transparency in decisions regarding the provision of personal care services and the decision to place or not to place someone in residential care.

Numbers of people waiting for FPC

4.16 During 2006 the Scottish Executive and the Scottish Parliament Health Committee attempted to gather data about the number of people waiting for home care services (February 2006) and the length of time people wait for services following their assessment of needs (April 2006). The data gathered from these exercises is presented in Table A6.3 (Appendix 6).

4.17 The February 2006 Scottish Executive survey found that 14 local authorities reported having a total of 426 people waiting at home (for any length of time) for services to be delivered following an assessment, and that there were 69 people waiting for a Direct Payment to be provided following an assessment. In addition, there were a total of 208 people waiting for payments for FPC / FNC following an assessment. Ten local authorities were not able to answer the Scottish Parliament Health Committee's FOI request for information about median waiting times. Of those that did provide the information, the median wait between assessment and provision of services ranged from 0 days to 67 days.

4.18 However, these survey results, especially those relating to median waiting times, need to be treated with caution because of definitional, data recording, and reporting issues (see paragraph 3.23). It should also be borne in mind that there will often be a delay between assessment and service provision, particularly in relation to delivering more complex/ intensive packages of FPC at home.

4.19 The evaluation sought to provide robust, up-to-date and detailed information about the number of people waiting for the provision of personal care services or FPC/ FNC payments through a supplementary survey issued to all local authorities in early December 2006. The survey asked local authorities to report on the number of people who have been waiting for six weeks or more ²⁸ for a service or payments following an assessment. All 32 local authorities responded to the survey, although some were unable to provide all the information requested. The full results of the survey are provided in Tables A6.4 - A6.6 (Appendix 6). The survey findings are summarised in Table 4.1.

4.20 Differences in eligibility criteria between local authorities mean that it is difficult to collect comparable data on the number of people waiting for local authority provided FPC services. As reported above local authorities have different threshold levels for determining whether they will provide care services or formally record people as waiting for a local authority provided service. This issue is particularly evident in relation to the number of people waiting 6 weeks or more at home for FPC services to be delivered. The figures reported in Table 4.1 (below) and in Appendix 6 should be read in that context. The impact of different approaches to meeting and recording assessed needs are discussed in further detail below. It should be noted that this survey provides a snapshot of people waiting for FPC services / payments at one moment in time.

Table 4.1: Number of people waiting 6 weeks or more for the provision of personal care services / payments following an assessment of need

* Three local authorities reported an additional 39 people whose financial assessment has not been completed and may be self funders who had been waiting 6 weeks or longer.
Source: Local Authority Survey; December/ January 2006
Waiting for FPC / FNC payments

4.21 Across Scotland there were 38 self funders spread across six local authorities who were already in care homes and who had been waiting six weeks or more for FPC / FNC payments to by provided following an assessment. Two councils, Dundee City and Inverclyde, reported that they have delayed FPC/ FNC payments to self funders in care homes in order to manage their budgets. However, Dundee City Council has since amended its policy and, as of January 2007, payment of FPC/ FNC for self funders in care homes will be made from the date the assessment is completed.

4.22 Ten local authorities reported a total of 53 people who had been assessed as self funders and had been waiting at home for six weeks or more to enter a care home and receive FPC/ FNC payments. People waiting at home for a care home placement were having their personal care needs met through a combination of local authority provided free personal care and informal care. Nine local authorities reported that people were waiting at home because they were awaiting a vacancy in a care home, either because of lack of vacancies in care homes or lack of vacancies specifically in their home of choice. Only one council, Argyll and Bute, reported that delays in placing people in care homes and paying FPC/ FNC payments were due to funding constraints.

4.23 One hundred and thirty nine people spread across 20 local authorities who had been assessed as self funders were waiting ready for discharge from hospital for six weeks or more. Three local authorities reported that they had a total of 39 additional people waiting for discharge from hospital who may also be self funders but were awaiting confirmation of their financial status. Six local authorities reported that the delays were caused by lack of vacancies in care homes. Fourteen local authorities reported that the delays were due to clients exercising their statutory right to choose their own care home and there being no vacancies in the clients' home/s of choice. A small number of local authorities also reported that some delays were caused by waiting for a resolution of legal or financial matters such as guardianship orders or disagreement with the family about the placement of the client.

Waiting for FPC Services

4.24 Thirty one people across 10 local authorities were ready for discharge from hospital for six weeks or more but were waiting for personal care services to be put in place at home. Six of these local authorities had only one or two people in this situation. Only Argyll and Bute Council reported that lack of funding was the main reason for the delay in care services being provided. Other local authorities reported that delays were caused by staff shortages and / or a lack of capacity to provide personal care services.

4.25 Nine local authorities reported a total of 391 people waiting at home for any personal care services to be provided. The main reasons given by local authorities for these people waiting for personal care services to be delivered related to lack of capacity (in-house or in the independent sector) to provide the service due either to staff shortages or to difficulty in sourcing a provider to deliver a service at the time required. Providing services in rural areas was noted as a particular difficulty by some local authorities. Only four local authorities - Argyll and Bute, Dundee, East Renfrewshire and Inverclyde - directly attributed delays in service provision at the time the latest survey was carried out to a lack of available funding.

4.26 All of those people waiting for personal care services were already receiving some level of care from the local authority and/ or informal carers and were waiting for either additional care following a review of their needs or for part of their care package to be put in place. Some local authorities specifically noted that most people in this category were in fact already receiving some services from the council (e.g. 89% of the people waiting for FPC services in Dundee were already receiving some FPC services from the local authority).

4.27 All nine local authorities reporting people waiting for six weeks or more for FPC services stated that any person assessed as being at risk would either be provided with a service or, if a service could not be provided, would be placed in a care home or, in an emergency situation, a hospital. Therefore, people classified as waiting for a service are people assessed as medium or low risk who have informal carers able to support them on a temporary basis at least. For example, Inverclyde Council reported:

"All five service users (awaiting services) were assessed as either medium or low risk and had informal carers able to support them on a temporary basis, if they had been assessed as high risk and had no other means of support we would have provided the care"

4.28 When an individual's personal care needs are being met by informal carers or other service providers local authorities typically take one of three approaches to keeping their cases under review:

4.29 The way in which local authorities respond to cases where an individual's personal care needs are currently being met by informal carers is largely related to the council's eligibility criteria. The majority of local authorities either ask clients to re-approach the local authority if their needs change or carry out reviews of peoples needs after set periods of time. Local authorities reported that people who were receiving other local authority services are more likely to have their needs kept under review than people who are not receiving any form of care provided through the local authority.

4.30 The figures reported by local authorities for the number of people waiting for personal care services to be provided (paragraph 4.25) may be partly attributable to differences in eligibility criteria across local authorities and the way in which local authorities provide services to (and record) those people assessed as requiring FPC, but who are currently having their needs met by informal carers and/or other service providers.

4.31 Local authorities with less strict or no eligibility criteria (e.g. East Renfrewshire) may record people who are currently having their personal care needs met by informal carers and/ or other service providers as waiting for services. However, local authorities with stricter eligibility criteria (e.g. East Lothian) may have nobody recorded as waiting for services because those in low priority categories who are having their needs met by informal carers and/ or other service providers are 'filtered out' of the system at an earlier stage and do not therefore show up as waiting for services.

4.32 This can lead to a picture whereby those local authorities that take a more proactive approach to meeting, recording and reviewing the needs of people assessed as having low levels of need and defined as being at low or medium risk have larger waiting lists. In responding to the evaluation East Renfrewshire Council stated:

'In keeping with many local authorities across Scotland we are considering the introduction of formal eligibility criteria which could remove such cases from the waiting list. We are very aware however that particularly in the interests of carer support, that these cases should not simply be considered as 'closed'. They need to be kept 'live' to ensure that they are appropriately reviewed while at the same time avoiding the negative connotations and possible public misinterpretation of the idea of a 'waiting list'. Given the wide variations across Scotland in how such cases are dealt with and defined, it may be helpful to consider a more detailed national look at the development of eligibility criteria and their impact on the delivery of home care services.'

4.33 Without national eligibility criteria, it may not be possible to collect comparable information on people waiting for local authority FPC services at a local authority level.

4.34 Four local authorities reported a total of 13 people who had been waiting six weeks or more for Direct Payments for personal care services. None of these reported that lack of funding was the cause of the delay in payment. The main reason for delay in payments was waiting for the client to put appropriate arrangements in place (e.g. contracts for Personal / Care Assistants or service providers).

4.35 Only five local authorities did not report anyone waiting for FPC payments or services. However, most local authorities reported only one or two people waiting in any category and only nine local authorities reported more than 12 people waiting for either FPC payments or services.

4.36 Whilst only four local authorities directly attributed delays in service provision / payment to a lack of available funding, several local authorities reported that they are only able to meet current demand for personal care by supplementing their budgets for FPC payments to self funders in care homes or for personal care services at home with funds from other budgets. For example, South Ayrshire Council reported that:

"The reason that we have no people who are in a care home and not being financed for free personal care is because we have supplemented this budget substantially from other areas within the council, this will not always be the case and we could see a substantial change in this information in the future. Also at this time we have no one waiting more than 6 weeks for personal care services at home, again this is because we have substantially supplemented the care at home budget from other areas within the council, this also is unlikely to be the situation in the future and will substantially change this position. The amount that these budgets have been added to this financial year is approximately £1million."

Managing numbers of people waiting for FPC

4.37 Local authorities that have people waiting for the provision of FPC manage this situation through regular (in some cases weekly) monitoring and review of the cases either by a council committee (e.g. Dundee City Council), the Head of Services or a senior manager (e.g. City of Edinburgh Council). Some local authorities have established council wide or area based groups to review waiting lists and the allocation of resources. For example, Argyll and Bute Council monitors the cases of people waiting for services or FPC payments through four multi-agency Local Resource Review Groups ( LRRGs) that meet weekly to review all cases to assess whether circumstances have changed. Recommendations made by the LRRGs for allocation of resources are considered by the Council's Head of Service; Integrated Care.

Limiting / 'capping' care packages

4.38 Faced with having to deliver intensive care packages that exceed the cost of a care home place, along with having to manage limited resources for providing home care services, some local authorities have chosen to try to limit care packages.

4.39 The local authority survey and case studies undertaken for the evaluation found that 14 local authorities operate some process to attempt to limit or control the cost of home care packages.

4.40 Nine local authorities reported operating some form of cap or limit on care packages, expressed either in monetary terms - usually about the cost of a care home place (£410 a week) - or in the number of hours of care provided per week (between 25 - 35 hours a week) (Table 4.2).

Table 4.2: Home Care Package Capping Limits

Sources: Local Authority Survey (May 2006) and Case Study Councils

4.41 Another five local authorities reported that they do not have a formal cap, but any care packages above a certain level (usually around the cost of a care home place) have to be reviewed and approved by a senior manager or panel. For example, City of Edinburgh Council does not operate a cap on care packages, but high cost packages (around £500 a week) go before a panel for authorisation. The panel scrutinises the assessment and proposed care package to assess whether the client's needs meet the council's criteria for high level care. If, at the time of a review, additional services are required which would make the new package more expensive than a care home place, then the client is asked to consider a care home place.

4.42 Two of the case study local authorities (Angus and West Dunbartonshire) reported that they do not operate any form of capping or limit on home care packages and, as outlined above, City of Edinburgh Council has no formal cap but has a process for reviewing the cost of home care packages that exceed the cost of a care home place. Three of the case study local authorities operate capping limits: Argyll and Bute, Dumfries and Galloway and Stirling.

4.43 The operation of the capping limit varies across all local authorities but there are certain common features. If a home care package is going to be higher than the capping limit (in financial terms or in hours of care provided) the care manager undertaking the assessment will discuss with the client and family alternative forms of (unpaid) care or support from the voluntary sector. If appropriate, Direct Payments might also be discussed as an option. If the client meets the criteria for a care home placement this would also be discussed as an option.

4.44 Whilst local authorities cannot charge for personal care services they provide, service users can purchase additional services from other service providers. Dumfries and Galloway Council reported that they ask clients and their family to consider purchasing additional personal care from their own resources to supplement the council's provision of FPC if the care package exceeds the £410 per week capping limit.

4.45 Each council's process has a degree of flexibility, with discretion being used to try to accommodate the wishes of the client and family. However, if the care package required to keep the client at home is thought to be unsustainable either in financial terms or in relation to the amount of support required (for example the unpredictability of the client's needs or the requirement for care to be provided at night) then the option of a care home placement will be presented to the family with a view to their agreeing to the placement.

4.46 If, following discussions with the client and family, the care manager proposes to provide a home care package that exceeds the financial cap or limit on hours a recommendation will go forward to the Head of Service or Operational Manager. In Argyll and Bute the Local Resource Review Group would consider the care and funding request in the first instance and, if it agreed with the recommendation, would refer the case to the Head of Service for approval.

4.47 In each council, cases are dealt with on their own merits in the context of safety, sustainability, client/family preference, prognosis and potential for higher expenditure in the future. Any packages to continue supporting the client at home must be assessed as safe and sustainable.

4.48 Local authorities do not monitor the number of cases where clients have been placed in a care home because the alternative package of care at home would exceed the capping limit. However, the number of cases that breach the capping limit in the case study local authorities that operate caps is relatively small. Argyll and Bute reported that in the last 12 months only four cases have been subject to review because they exceeded the £20,000 threshold. All four have resulted in additional expenditure being approved by the council to allow the client to remain at home. Stirling Council reported that 11 people aged over 65 have had care packages exceeding the 25 hours limit. Dumfries and Galloway Council does not record the number of care packages that exceed the capping limit.

4.49 The setting of caps on the size of care packages goes against the public's view, as evidenced from the evaluation's Public Attitudes Surveys, that people should be assisted to live in their own homes no matter the cost to the public purse (see Chapter 2) and the Care Development Group's view "that where practical and reasonable frail older people should be supported to live in their own homes for a long as possible and certainly should be helped to do so, where they want to." ²⁹ However, it is in line with the Guidance on Assessment and Care Management ( SWSG 11/91) which states that local authorities have to take into account " the availability of resources and services for meeting needs" when drawing up the care plan.

Unmet Need

4.50 Unmet need in relation to care service provision following an assessment can be the result of a wide range of factors including:

• Service not provided due to service shortage (e.g. lack of staff or funds to provide the service)
• Service not available locally (e.g. specialist equipment or staff required)
• Service offered but declined due to timing (e.g. client and council cannot agree a time at which a service should be provided)
• Service offered but declined due to charging policy (e.g. non-personal care services)
• Service provided but not to level required (e.g. bathing service provided only during week days rather than seven days a week).

4.51 The recording of unmet need is the final stage of the assessment process. Tools such as CarenapE and Carefirst include the facility for detailing what services (personal care, non personal care, housing support, equipment and adaptations) are not being provided and how and when the unmet need will be reviewed.

4.52 Where care needs are not being met by the council and the assessment records this as an unmet need the assessment should flag up the need for a future review of the case; the timing and frequency being determined by the level of risk to the client. In such cases the client and unpaid carer/ relative and other professionals that may be involved in the case (e.g. GP or Community Nurse) would be informed of the need to review the client's situation and report any significant changes that may prompt the need for an urgent review.

4.53 The Audit Scotland report, ' Commissioning Community Care Services for Older People' ³⁰ showed that in 2004 two thirds of local authorities collected information about unmet need. However, the majority of those lacked the IT system to enable them to systematically collate and analyse the information recorded in care plans about individual service users, including their unmet needs.

4.54 The position in 2006 with regards to recording and analysing data on unmet need has not improved since 2004. All six case study local authorities reported that their assessment process records unmet need. However, only two of these local authorities reported that they have been collating and analysing the information recorded in order to inform strategic decisions about planning services. (Table A6.8 in Appendix 6)

4.55 For example, Stirling Council collates information about broad areas of unmet need relating to home care, respite care and day care places. This information is used at a strategic level to inform the configuration of services to address unmet need through deploying care workers more effectively to provide a higher level of service with the same resource, and developing and extending Older People's Day Care. The council is also piloting a different way to deploy Occupational Therapists to meet demand for their services. Information about local strategic level needs and unmet need has also been analysed in specific service reviews such as Learning Disabilities, Day Care and Residential Care Homes. At a wider strategic level, data has been collated for specific work, undertaken in 2006 with neighbouring local authorities and the NHS, and has assisted in developing JPIAF Local Improvement Targets and the development of a joint commissioning strategy.

Involving Carers and Offering Choice

Involving Carers

4.56 The role of carers is central to the provision of community care to older people living in their own homes. 'The Future of Unpaid Care in Scotland' report for the Care 21 Unit of the Scottish Executive noted that " unpaid carers are the largest group of care providers, and as such, the largest component of the Scottish care 'workforce', making an enormous contribution to society." ³¹

4.57 The Community Care and Health (Scotland) Act 2002 requires local authorities, following an assessment of need, to take account of the views of the individual and their carer, as well as the care the carer is willing and able to provide, before deciding what services to provide to the individual. In addition, the Act gives all carers an entitlement to have an assessment of their own need (a Carer's Assessment) undertaken at the same time.

4.58 However, few formal Carers' Assessments are being undertaken. Local authorities have reported that, whilst they do offer Carer's Assessments, many carers decline the offer for a variety of reasons including the following:

• Carers want to concentrate on the needs of the person they are caring for
• Carers are unwilling to reveal personal details or support needs to the social worker or person they are caring for
• The language used around carers' 'needs' is viewed as a barrier in that carers do not want to be viewed as people who 'need' a service.

4.59 At least three of the social service inspection reports that have been published by the Social Work Inspection Agency to date - Inverclyde, South Lanarkshire and Dumfries and Galloway - have concluded that carer assessments are an area where improvement is required, both in terms of the number of assessment carried out and in the outcomes for carers which result from these assessments.

4.60 As a way of trying to improve the formal recording of carers' needs, some local authorities have begun to use self assessment forms to support carers to assess their needs. For example, Stirling Council is working with the Princess Royal Trust for Carers to develop self assessment forms for carers.

4.61 All six case study councils reported that their policy is to involve carers as well as the person being assessed in the assessment, care planning and review process. The assessment tools used by these councils require the individual and his/ her carer's views to be sought and noted, including any disagreements about the assessment or its outcome. Carers' views on the existing level of service and whether it needs to be revised will also be sought as a formal part of the review of cases.

4.62 The qualitative research undertaken for the evaluation found that users and carers had mixed experiences of the assessment, care planning and review process. Some users and carers felt that their views and needs had been taken into account when their care package was being assessed and drawn up and were happy with the resulting care package. However, a small number of carers expressed dissatisfaction with the assessment process itself (for example, several interviewees complained about a lack of contact with their social worker). Others felt that their views about the type, level and timing of service were not fully taken into account in the assessment and the resulting care package. Carers in Argyll and Bute were particularly negative about the outcome of assessments due to the impact of the moratorium on funding of new care packages or FPC payments for self funders in care homes.

4.63 A small number of carers expressed dissatisfaction with the outcome of assessments that either resulted in home care packages when the carers felt that a care home placement was required or, alternatively, resulted in a care home placement when the carer and client would have preferred a package of home care.

Offering Choice

4.64 Local authorities are not required to provide choice to service users and carers and the extent to which service users are offered choice is limited. All local authorities have to take resources into account when drawing up care plans and they may not always be able to provide the level, type and timing of service that is sought by service users and carers. For example, Highland Council's eligibility criteria includes the statement:

"We will respect your choice and preferences for services appropriate to your priority group. However, it may not always be possible to do this because our resources are limited and the Council has to demonstrate best value and equity in how we use our funds."

4.65 Interviews with users, carers and local authority staff found little evidence to suggest that service users and carers are offered choice about the type of service they receive or about who delivers their care service.

4.66 Even in local authority areas with a mixed market of care provision with relatively high levels of care provided by voluntary or private sector providers, the decision about who will provide the service is driven more by factors such as capacity, availability and cost rather than user choice. Only one carer reported that they had been able to persuade the council to change the service provider.

Mr E (Dumfries and Galloway) receives FPC in his own home and home care for which he pays. He is in his late 80s and, following a fall, he has recently been discharged from hospital. His daughter felt he needed overnight care. Social work would not cover this so she paid £70 per night for this additional care until she could get respite arranged for him.

Mr E and his daughter wanted the same provider to be giving the care at night as during the day. The company contracted by the social work department for the FPC element did not do overnight care. The social work department refused to consider another care company and the daughter filed a complaint following which the council agreed to change the day care provider. All Mr E's personal care is now provided by the same company.

4.67 In relation to carer involvement and choice, of note from the interviews conducted for the evaluation were:

• a desire for practitioners to be more proactive in giving information about people's entitlement to care in general and FPC specifically
• complaints from some carers at the length of time and effort that might be involved in negotiating with the care manager over the details of the care package
• an appreciation of the value of advocacy groups and groups such as Alzheimer's Scotland in providing information and support.

4.68 Direct Payments for self-directed care can give service users greater choice, control and flexibility over their support. Uptake is steadily building across Scotland. Direct Payments have been available to disabled people aged 65 and over since July 2000. Four hundred and eighty four people in this age group received Direct Payments in 2006.

4.69 It is mandatory for local authorities to offer eligible people Direct Payments instead of arranged local authority services, but, as has been documented elsewhere (the Baseline Study ³² and research undertaken for the Scottish Parliament Health Committee Care Inquiry ³³), there is still some way to go before they are fully part of mainstream service provision in most areas of Scotland.

4.70 The evaluation's public attitudes surveys show that a significant proportion of people, including elderly people (just under 40%), would prefer to receive direct cash payments rather than have help arranged for them, reflecting the potential key role of Direct Payments as part of mainstream support. (Table 4.3)

4.71 Direct Payments may not necessarily improve choice for service users in remote and rural areas where there are fewer care/ personal assistants and service providers available. However, in some cases, they may be able to improve flexibility for service users; for example, a mixed package of provided care and direct payments may allow an individual to purchase support at times that better suit them or better reflect their personal priorities.

Table 4.3: Support for Direct Payments

(a) Base = 1,005 general population; (b) Base = 1,327 people aged 65 + and carers
Sources: Scottish Opinion Omnibus Survey, July 2006; Postal Survey, July 2006.

Contractual Arrangements for Self Funders in Care Homes

4.72 When a person enters a care home there are three possible contractual routes for individuals, local authorities and care homes.

Route 1 - Self Determined

This route applies to those arranging their own care without a social work assessment or to those who have been assessed as not having a level of need which makes them eligible for local authority funded residential care. In these cases the charges and contractual arrangements are a matter between the individual and the care home manager.

Route 2 - The Mutual Route

This route covers those assessed as needing residential care where the individual negotiates and purchases a place in a care home of their choosing and to their specification. The local authority will contract with that home for the provision of the free personal and nursing care component of the package only (£145/ £65). The contract for the remaining services, i.e. the hotel/accommodation/living costs, will be between the individual and the care provider and, as for the self determined route, the amount paid is a matter between the individual and the care home.

Route 3 - The Integrated Route

This route applies where the individual is assessed as needing residential care and the local authority manages all the contractual arrangements on their behalf. The resident's contribution should normally only be that calculated by the local authority in the statutory financial assessment. Any fees in addition to the standard fees normally paid by the local authority for the relevant care package should only arise where services additional to the assessed package are requested. A national contract has been developed for Route 3 contracts and it stresses that additional charges (top ups) are only allowed if a significant and demonstrably higher level of facilities or service is provided over and above that required by the contract.

4.73 The Guidance on FPNC suggests that with the Route 2 contract the individual benefits by having more control over the contract that they have with the care home and not involving the local authority in their contractual arrangements for accommodation and living costs. From the perspective of the care home, the benefit of this form of contract is that they retain flexibility and control over the contract with the individual for accommodation and livings costs.

4.74 Case study local authorities suggested that the Route 2 contract has advantages for them in that it is simple to administer, involving a contract with the care home only for the FPC/ FNC element. As the service user contracts with the care home for the remaining services, this also avoids any possible disputes between the home and the local authority and means that the local authority is not reliant on the service user reimbursing the local authority with their assessed contribution, with the possibility that debts might be accrued by the council as a result of non-payment by the resident.

4.75 From the care homes' perspective, Route 2 contracts have the disadvantages that they require two contracts to be made - one with the council and one with the resident - and they are liable for any debts accrued if residents fail to make their payments. These disadvantages are outweighed by the benefit of not being bound to the nationally agreed local authority rate which, in almost all cases, is lower than the standard rate.

4.76 For the Route 3 contract, the Guidance suggests that the client benefits from key aspects of the normal local authority contract with care homes including elements such as restrictions on the level of increases of fees, agreements on when fees can be increased and an over-arching quality assurance and monitoring framework in respect of the particular needs of the local authority clients. However, Route 3 contracts are unpopular with care homes since they limit their ability to set and increase fees.

4.77 All case study local authorities reported that some care homes in their area will not accept self funders on Route 3 contracts or, at best, are very reluctant to do so. For example, Angus Council reported that care homes in the area only offer Route 2 contracts "so in reality there is not a choice for people going into care homes in the independent sector."

4.78 Three of the case study local authorities (Argyll and Bute, Stirling and West Dunbartonshire) reported that all self funders in receipt of FPNC are on Route 2 contracts (274, 230 and 74 respectively).

4.79 Angus and City of Edinburgh Councils reported that all but a small number of self funders are on Route 2 contracts. In Angus, only 12 out of almost 300 self funders are on Route 3 contracts (10 of these are in local authority care homes). In Edinburgh, Route 3 contracts for self funders are used solely for people who have a deferred payment agreement ³⁴. There are currently 3 people with such agreements.

4.80 Dumfries and Galloway is the only one of the six case study councils that reported placing a significant proportion of self funders on Route 3 contracts (176 are on Route 3 contracts and 129 are on Route 2 contracts).

"We always offer self funders the option of contracting through the local authority. This means they get the benefit of the local authority price. This has been unpopular with some local homes because they are unable to charge a higher price."

4.81 The evaluation found that users and relatives/ carers may not be being provided with sufficient information to make an informed choice about contractual routes. The case study councils reported that they will advise clients about contractual matters and some have produced their own explanatory leaflets. However, most local authorities' preferred option is the Route 2 contract. For example, one case study council official reported:

"As far as I can ascertain there is little discussion about whether or not the resident/families wish to go down the Route 2 or 3 option. This Council would set in place a Route 2 contract to confirm that the FPC/ FPNC contribution would be payable direct to the care home and that this sum should be deducted from the total gross rate."

4.82 Many of the care home residents and their relatives who were interviewed for the evaluation commented favourably on the financial benefits of FPC/ FNC, in particular in relation to giving them more disposable income and allowing them to maintain their savings longer. However, most care home residents were unaware of the detail of the contractual arrangements since financial matters are often dealt with by a relative or friend.

4.83 None of the care home residents or their relatives interviewed for the evaluation reported that they had been assisted in making an informed choice about the various contractual routes. Several relatives commented that the process of agreeing the financial aspects of the care home place was the most stressful part of the process and they felt that they had too little guidance.

4.84 Local authorities, both individually and collectively through COSLA, have raised concerns about 'Top Up' fees charged by care homes to self funders opting for the Route 3 contract. 'Top Up' charges are meant to cover additional services or higher quality services not covered by the basic fee. The practice of 'Top Up' charging varies across the country and between care homes within local authorities, largely dependent on the local care home market. 'Top Up' charges are less of an issue in areas where there are higher levels of vacancies in care homes and less demand for care home places from self funders.

4.85 The latest national contract agreed between COSLA and the independent care home sector for 2006 included an agreement to tighten up on 'Top Up' charges. The new rates of £410 (residential home) and £471 (nursing home) for 2006/07 were accepted by the sector as being closer to the true cost of delivering the service and consequently care homes should not charge a 'Top Up' above these levels unless it can be justified by the provision of an additional level of service and clearly demonstrated and specified in the contract.

4.86 The fundamental issue with regards to whether care homes refuse to accept Route 3 contracts, or charge residents a 'Top Up' charge, is that there are no sanctions against such practices. Independent care homes operate in the market and can contract with whom they like and on whatever terms they choose and to which their clients agree.

4.87 The Care Commission, which regulates the care home sector, has no regulatory role in relation to charging. However, it is currently gathering information on how 'Top Up' charges are levied and the extent to which they are reflected in the level of service.

Summary and Recommendations

Prioritising Service Provision

4.88 Although recognising the issue, the guidance on FPNC does not provide detail on the key issue of whether/ how local authorities are able to take resource issues into account in determining access to care services and FPC. (4.5)

4.89 More than half of Scotland's local authorities have a threshold for determining whether an assessed need will be met by the provision of care services. In most local authorities that operate thresholds, people with personal care needs will be in priority categories and will receive access to services. However, some local authorities may restrict access to FPC services for people if their personal care needs can be (and are being) be met by unpaid carers or other service providers. (4.7 - 4.15)

Delays in delivering Free Personal Care

4.90 Differences in eligibility criteria between local authorities mean that it is difficult to collect comparable data on the number of people waiting for local authority provided FPC services. A survey of local authorities carried out in December 2006 found the following totals of people waiting six weeks or more for the delivery of FPC services / payments following an assessment of need:

• 38 self funders in care homes (in six local authorities) waiting for FPC/ FNC payments to be provided
• 192 self funders (in 20 local authorities) requiring FPC/ FNC in a care home waiting for a care home place and the payments to begin
• 31 people ready for discharge from hospital (in 10 local authorities) waiting for personal care services to be put in place at home
• 391 people (in nine local authorities) waiting for any personal care services to be delivered at home
• 13 people (in four local authorities) waiting for Direct Payments for personal care services.

However, it should be noted that this survey only provides a snapshot of people waiting for FPC services / payments at one moment in time. (4.19 - 4.20)

4.91 Lack of vacancies in care homes is the main reason reported by local authorities for people having to wait for a care home placement following an assessment. (4.21 - 4.23)

4.92 Lack of capacity to provide personal care services at home, either in the location or at the specific time of day requested, was reported as the biggest factor contributing to people having to wait for all or part of their care package to be delivered. People waiting for local authority FPC services were having their personal care needs met by informal carers and other service providers. The majority of people waiting for services were already receiving some personal care services from the local authority. (4.24 - 4.27)

4.93 Four local authorities directly attributed delays in service provision/ payments at the time the latest survey was carried out to a lack of available funding. (4.28 - 4.36)

4.94 Only five local authorities did not report anyone waiting for FPC payments or services. However, most local authorities reported only one or two people waiting in any category and only nine reported more than 12 people waiting for either FPC payments or services. (4.28 - 4.36)

Limiting or 'capping' care packages

4.95 Nine local authorities operate a 'cap' or limit on home care packages and a further five local authorities operate a formal review process to review the cost of home care packages that reach a threshold level. The cap on home care packages is usually set at around the gross cost of a care home place. Local authorities that operate a cap on care packages apply these flexibly, reviewing each case on its merits and trying to accommodate the needs and wishes of the client and family. (4.38 - 4.48)

4.96 Although operating caps on home care packages goes against the view that frail older people should be supported to live in their own homes for as long as possible, it is in line with guidance that local authorities have to take account of " the availability of resources and services for meeting needs" when drawing up care packages. (4.49)

Unmet need

4.97 Few local authorities currently collect and analyse information about unmet need arising from assessed needs not being met in full. However, such information can be used to identify and address areas of unmet need in home care, respite care and day care places and at a more strategic level to develop Local Improvement Targets and in developing joint commissioning strategies. (4.53 - 4.55)

Involving carers and offering choice

4.98 Unpaid carers are crucial to the effective delivery of community care. Whilst carers are being involved in the assessment process, few have a formal Carer's Assessment carried out. Some carers and users voiced concern that their views and needs were not reflected in resulting care plans. (4.56 - 4.63)

4.99 Local authorities are not required to offer choice to users and carers and offer limited choice about the type and level of service and who will deliver it. However, the level of choice that can be offered is often constrained by lack of service capacity. This is particularly the case in more rural areas and at peak demand periods. (4.56 - 4.63)

4.100 Just under 40% of respondents to the Public Attitudes Survey said they would prefer to receive cash payments (Direct Payments) rather than have help arranged for them. However, less than 500 disabled older people currently receive Direct Payments. (4.69 - 4.71)

Contractual arrangements for self funders in care homes

4.101 The majority of self funders in care homes are on Route 2 contracts. Local authorities prefer the Route 2 contract since it reduces their liability and is simpler for them to administer. Care homes prefer the Route 2 contract since it gives them greater flexibility in setting charges. Care homes are reluctant to accept Route 3 contracts for self funders. (4.73 - 4.80)

4.102 Self funders and their relatives were unclear about the different contractual options and may not have been given sufficient information to allow them to make an informed choice. (4.81 - 4.83)

Recommendations

R4.1 All local authorities should publish easily understood statements of their policies and their processes for prioritising access to services and ensure that users and carers are made aware of them.

R4.2 Local authorities should be open and transparent about waiting times for care services and payments following assessment. Local authorities should provide information to people who are waiting for services/ payments on the reason for the wait and an indication of the timescale before the service will be delivered.

R4.3 The guidance on Free Personal and Nursing Care should be reviewed and revised to clarify the basis on which local authorities can legitimately operate waiting lists for personal care, and whether/ in what circumstances local authorities can adopt and operate a cap on the size of personal care packages delivered at home.

R4.4 Local authorities should have systems in place to record, monitor and analyse unmet need and use the information to develop strategies for reducing unmet need. This should be reported either through the JPIAF or in annual reporting on FPC to the Scottish Executive.

R4.5 The Scottish Executive should consider producing an accessible, easily understood explanatory leaflet on the advantages and disadvantages of the various care home contractual arrangements for self funders. Local authorities should ensure that all self funders and their relatives receive adequate information on the contractual options to enable them to make an informed choice.

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