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Equipped for Inclusion: Report of the Strategy Forum: Equipment and Adaptations

Chapter 4
A joint future

The Joint Future Group was established to identify ways to make existing community care policies work better and to dismantle obstacles to effective services. It acknowledged that responsibility for the success of community care is shared between a range of agencies and interests, and that there are some critical interfaces that could work better.

4.1 Joint resourcing and joint management of services

Services that support 'independent living', including equipment and adaptations, do so across all age ranges and service categories. The 'joint pot' or 'envelope' for any client group or area of activity should therefore include resources for equipment and adaptations. There are some issues that require further clarification:

• at times of funding shortage or where organisational responsibility is contested, the legislative and regulatory framework can be used as an exhaustive list or to stipulate inflexible arrangements. Consideration of the usefulness of the guidance in the light of joint working is required. [See the companion report 'Using the law to develop and improve equipment and adaptation provision', paragraphs 2.1.16.1 to 2.1.18.3]
• joint decision-making in respect of a wider range of resources would be supported by consideration of the transfer of funds from national or regional level [e.g. for wheelchairs] to local joint 'envelopes'. Although traditional commissioning processes could inhibit the flexible use of resources, before transfer can be achieved consideration of some form of service level agreement with regional and national centres of expertise may be required.
• there are different charging regimes across organisational responsibilities, different VAT arrangements for health and local government, and limitations on the use of Direct Payments. Legislation and guidance relating to charging for equipment and adaptation provision, and to the use of Direct Payments, are detailed in the companion document 'Using the law to develop and improve equipment and adaptation provision'. The Department of Health, together with Customs and Excise issued guidance on VAT with regard to joint equipment services in June 2002. Clarification of accountability requirements where pooled budgets are in operation is required.
• the various anomalies and restrictions that exist in relation to the accessing of Scottish Healthcare Supplies safety information by local authorities, the independent sector and members of the public.
• the Home Improvement Task Force has recently reported on its comprehensive examination of the issues in improving quality in private housing, including assisting vulnerable, older and disabled people to improve, repair and adapt their homes. Whilst including Home Improvement Grant funding within the 'joint envelope' brings advantages to the individual, ensuring quality of work and maintaining links to the wider housing agenda are also important.

Recommendation 15: local partners should ensure that equipment and adaptations are integrated fully with one another, and as integral components in the planning and delivery of community care. The Scottish Executive should assist in establishing a 'Joint Future Equipment and Adaptation Network' to share promising practice, to address any difficulties that may arise and to work with the Implementation Steering Group to ensure the expectations of the agenda for equipment and adaptation services are being realised. Particular attention should be paid to any potential barriers to the effective pooling of resources.

4.2 Combined storage

The report of the Joint Future Group recommended that as agencies move towards joint resourcing and joint management of equipment and adaptation services they should "…consider the benefits of combined storage facilities…". Joint storage does not represent the 'joint envelope' for equipment and adaptation services, rather a delivery mechanism that is primarily for equipment.

One of the benefits of combined storage should be the ability to integrate delivery arrangements so that people receive fewer calls. There are other aspects of procurement, storage, delivery and installation where good practice could be developed and shared.

During the deliberations of the Joint Future Group the concept of a virtual store for Scotland was suggested. This was seen as a way of enabling one locality to help another with availability of equipment, particularly in cases of urgent or immediate need. It was also perceived as a way to achieve economy of effort across all local authority and health board areas. The potential benefits would appear to merit further exploration, so that some of the complex stock control issues, for example in rehabilitation technology, are adequately explored, together with the merits of moving towards a single purchasing framework.

Many localities have already made progress in the development of shared premises and support services for equipment [and some adaptation materials] from the local authority social work service and the community nursing service. However the agenda is much wider than these two areas, and the Joint Future Group recognised that whilst sharing physical premises may have financial and logistical impact, real change is about joint services that are modernised, simplified, and integrated with the rest of community care.

Recommendation 16: the Scottish Executive should evaluate progress to date on the sharing of storage premises, and advise the Implementation Steering Group on the benefits achieved and any issues raised. They should also commission a feasibility study on the concept of a Scotland wide store ['virtual' or otherwise], building on the achievements of the e-Care project in the Scottish Borders [see recommendation 11], and other alternative approaches that would deliver the same outcomes.

4.3 Local partnership agreements

Local partners should aim to strike a balance between the strategic vision and key milestones that are achievable and manageable locally. All localities are required to demonstrate clear programmes for local joint resourcing and joint management of community care services. These Local Partnership Agreements [LPA] provide action plans distilled from existing policy, and should be developed to include equipment and adaptation services.

Recommendation 17: Local Partnership Agreements should be developed to include specific information on the joint resourcing and joint management of equipment and adaptations services.

4.4 Single shared assessment

Together with joint resourcing and joint service management, single shared assessment [SSA] can help to break down the demarcations that have prevented equipment and adaptations being delivered as intrinsic components of, and alternatives to, community care services, and should produce quicker and easier access to services.

4.5 'Simple' equipment and adaptations

To reduce inefficiencies and improve choice the Joint Future Group recommended enabling people to identify their own need for 'simple' equipment and adaptations. Together with recommendations for information, advice and demonstration SSA provides the framework for this to happen. It supports the concept of people who are experts in their own situation and able to solve their own problems, and will help to promote equipment and adaptations as a central component of community based care. It also provides the framework for a wider range of assessors to access a variety of equipment and adaptations.

The Strategy Forum considered how best to define the concept of 'simple' equipment and adaptations referred to in the report of the Joint Future Group, and agreed that this should not be confined to a prescriptive list. Nor should it relate directly to cost, but rather to the person's individual circumstances and the simplicity with which a difficulty can be alleviated [rather than 'solved'].

It will be for local partners to consider the indicators that suggest when a situation is 'simple', so that they can publicise this to enable self-assessment and to include this in the training of all staff who will be completing simple assessments. There may be merit in considering this as part of a national exercise to share opinions and promising practice.

Recommendation 18: local partners should promote self-assessment and assessment by a wider range of assessors, for 'simple' equipment and adaptations. A national perspective should be encouraged through the 'Joint Future Equipment and Adaptation Network' [recommendation 15] where examples of promising practice can be shared and any concerns addressed.

4.6 Specialist assessment

Having a wider range of assessors with access to equipment and adaptations will release specialist expertise to support the training and provision of advice to others, and to focus limited specialist resources where they can make the most impact.

Specialist assessment is appropriate to specific needs or needs requiring more in-depth investigation, and should be available to all, regardless of whether an individual intends to acquire their own equipment and adaptations or is seeking public sector support.

Where a person has complex needs it may be necessary to consult with more than one expert. For example:

• developments in electronic assistive technology make it possible for some people with complex needs to have communication equipment [aids], environmental control and wheelchair control functions provided by a single system. Such systems may involve a variety of professional experts working together to achieve a package tailored to the needs of the person.
• the provision of equipment and adaptations is much more than assessment of the person. The built environment has major implications for the overall success, and the right technical support is essential.
• where equipment and adaptations are unable to enhance the relationship between the person and the environment in which they live, it may be appropriate to consider a change of accommodation. Assessment of accommodation and housing support needs is part of SSA. The role of housing professionals in SSA will be decided locally but with the expectation that assessors have an appropriate level of knowledge and skills.

Indicators and triggers for specific expertise in equipment and adaptations, and for other assessment inputs are critical to the appropriate involvement of different professionals.

Recommendation 19: the Scottish Executive should review the 'triggers' and indicators for professional expertise in specific areas of equipment and adaptations included within arrangements for Single Shared Assessment across Scotland, and work with the Implementation Steering Group to address any anomalies. This expertise should be made available to advice and demonstration services for people who wish to make their own purchases.

4.7 Access to resources

For SSA to be effective local partners are required to agree access to community care resources. Assessors therefore need to be competent in the selection of equipment and adaptations and the allocation of finite resources. This should include awareness and knowledge about what is available, its acceptability and effectiveness, and consideration of all the options available.

Training is required in the potential range of equipment and adaptations, and the networks of information, advice and demonstration, including specialist expertise available, so that the most appropriate selection can be made for each individual situation. Knowledge is also required of local eligibility criteria and priorities that have been established in consultation with relevant representatives of people who use services, together with levels and routes of authorisation required.

Some systems of eligibility have become dependent upon the opinion of the person’s General Practitioner [GP], and do not make best use of the specialist expertise available that would minimise, if not eliminate the need to do so. It should not be necessary routinely to seek confirmatory statements from GPs about the nature of an impairment or illness.

Recommendation 20: the Implementation Steering Group should commission a review of the training and resources available to assessors to assist them in the selection of equipment and adaptations, within a framework of finite resources.

4.8 Competency framework

Ensuring that the competencies and expertise required and achieved in the assessment for and provision of equipment and adaptations are clearly identified, agreed, in place and monitored is paramount.

A framework that acknowledges the competencies of assessors currently involved in provision is required before parameters are set for those who are new to this area of work. These parameters should facilitate movement of staff around Scotland and further afield, and ensure that principles of equality and social justice underpin the training of all staff involved in equipment and adaptation services.

Recommendation 21: the Implementation Steering Group should commission an audit of expertise in equipment and adaptation services, to inform an accreditation framework that ensures the competencies and expertise required in the assessment process leading to the provision of equipment and adaptations are clearly identified, agreed, and monitored.

4.9 Assessment tools

Tools to support the SSA process should be agreed and in place in accordance with Scottish Executive guidelines. The need for a subsidiary assessment tool to facilitate a wider range of assessors undertaking simple assessments and accessing equipment and adaptations should be based on the content of the local tool. This can be developed as the 'joint envelope' is widened to encompass a wider range of equipment and adaptations.

There are a few software packages available that link a person's abilities and potential home problems to possible products and ideas. 'Lifease' for example was developed from research evidence that many people whose lives could benefit from equipment and adaptations do not make the necessary changes in their homes or use appropriate products. A version of this for use in England [SARA: self-assessment and rapid access] is currently being developed by the Department of Health, in association with the work of the ICES [integrating community equipment services] team.

Recommendation 22: the Implementation Steering Group should commission a review of existing Single Shared Assessment tools to advise on a sub-set of information, and available software packages, to support assessment for and selection of equipment and adaptations, including self-assessment.

4.10 Care management

Care management is a complex activity that should be carried out by professionally qualified staff who have appropriate skills and experience. The Joint Future Group identified the need to redefine and reinvigorate care management to overcome lack of clarity of purpose and inconsistency in practice in many existing arrangements across Scotland.

Arrangements for care management should make efficient use of staff skills and experience. Skills and expertise in equipment and adaptations must be clearly documented, particularly in specialist areas, so that identification of the 'most appropriate' professional is a transparent and rational process, not biased by outdated and ill-informed attitudes.

Recommendation 23: local partners should ensure that care management is considered where individual circumstances suggest that a significant package of equipment and adaptations [and/or a change of accommodation] may be necessary to achieve an acceptable relationship between the person, their environment and their care needs.

4.11 Service redesign

The Joint Future agenda presents an unprecedented opportunity to review and challenge the people and processes involved in any service area. For example if a means of monitoring adherence to the comprehensive eligibility criteria available for accessing environmental control equipment was established, the process could be redesigned to reduce the number of professionals involved, and simplify the existing complicated medical pathway.

It also provides the opportunity to bring together environmental control equipment, rehabilitation technology, SMART, and Telecare. Many of the features found in demonstration SMART homes are very similar to environmental control systems supplied by the NHS and to those being incorporated into new, high priced home construction. The products and services being developed in each sector independently could be combined to provide a broad portfolio of products and services, alongside equipment and adaptations and other care services, to support independent living. [See recommendation 8]

Recommendation 24: the Scottish Executive should ensure that in determining the 'joint envelope' and developing Single Shared Assessment, local partners review the processes and procedures involved and challenge why they are there.

4.12 Measuring change

Community care services are traditionally provided by single agencies, and the current performance assessment frameworks reflect this. The Joint Future agenda is changing the way in which services are provided and requires new ways to monitor performance and gauge whether expectations are being realised.

The Joint Performance Information and Assessment Framework [JPIAF] is a high-level matrix approach to a consistent national and integrated picture. It seeks to measure whether integrated service provision achieves faster routes to services, less bureaucracy, and better use of resources. It begins with evaluation of two key elements of the Joint Future agenda: joint resourcing and management, and SSA. Equipment and adaptations are important sub-components of these two elements.

Recommendation 25: the Joint Performance Information and Assessment Framework should be developed to capture the effects of the integration of services on equipment and adaptation provision, and its contribution as a component of community care services.

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