Dear Colleague

MONITORING/EVALUATION OF COMMUNITY CARE POLICY

Summary

1. This Circular advises local social work authorities, health boards, housing agencies and other interested parties of The Scottish Office's plans to monitor the implementation of the Government's community care reforms, the final part of which came into effect on 1 April 1993.

Previous Guidance

2. The new monitoring programme supersedes that set out in Circular SWSG21/91 dated 31 December 1991, (which was also issued as NHS SOHHD No 1991(GEN)33).

Action

3. This Circular sets out for all the agencies concerned with the planning or provision of community care services the shape of the Government's programme for monitoring/evaluation of its community care reforms. We would be grateful for the continued co-operation of social work authorities, Health Boards, housing authorities and others with the programme of monitoring and evaluation.

Introduction

4. Circular SWSG21/91 set out the context of The Scottish Office's monitoring programme, the methods to be adopted, the focus of the work and an outline programme for 1991-92 and 1992-93. That programme has been completed. A number of reports have been published drawing on the programme, which also informed implementation of the policy.

5. The new programme addresses implementation of the reforms and, particularly, attainment of the key objectives set out in the Governments White Paper "Caring for People" (Annex A). It embraces the activities of health boards, housing and other agencies as well as, obviously, social work authorities. On the housing front, Circular Env 12/93 introduced guidance on the new system of Housing Plans, Annual Policy Statements and Housing Capital Programmes. The guidance requires that local housing authorities should take the lead, in their strategic and enabling role in assessing overall housing needs and demand within their areas. It also emphasises that joint planning is needed with Social Work

Departments and Health Boards in relation to strategies for care in the community. In future Housing Plans will include quantified annual targets over the period of the plan for strategic priority issues such as community care, identified as part of the planning process, so that progress in the implementation of the strategy can be measured and reviewed annually in the Annual Policy Statement. Housing Plans should also take full account of the linkages between housing investment planning and housing management planning and in due course Housing Management Plans will become an integral part of Housing Plans as outlined in the guidance.

6. Scottish Homes Fourth Strategic Plan covering the period 1993 to 1996 recognises the need to take appropriate steps to support the objectives of the Government's Care in the Community policy and for a co-ordinated response involving other housing agencies. Scottish Homes is committed to introducing policies which will make a significant contribution to expanding the availability of high quality and sustainable projects providing community care. Through its Development Programme it will continue to fund the activities of housing associations and co-operatives in the provision of new build and improvement for special needs; use new grant giving powers to support voluntary organisations and encourage private sector involvement; and harness the potential of Scottish Homes own housing stock through the provision of special lets. Scottish Homes’ performance is also measured against a set of specific targets which are approved by the Secretary of State. Following the implementation of its care in the community policies in April 1993, Scottish Homes intends to monitor and adapt its policies in response to changing priorities within care in the community. General guidelines for the provision of housing for the main community care groups were set out in Circular Env 8/91, while Scottish Homes published in March 1993 a policy statement on community care and in May a discussion paper on "Housing for the Elderly in the 1990's". Circular Env 8/91 has been superceded by Circular ENV27/1994, which provides revised guidance on the important role of housing in community care. It replaces Circular Env 8/91, apart from the guidance in that circular on housing provision for community care group which is re-stated.

7. The main strands of the monitoring programme will be:

7.1 Analysis of community care and housing plans.

7.2 Statistical collection and analysis.

7.3 Social Work Services Inspectorate's (SWSI's) inspections and monitoring programme.

7.4 NHS Management Executive's accountability review programme

7.5 Research and evaluation projects.

Some of the elements are already in place.

General Approach

8. The basis for, the aims of and methods for monitoring remain as set out in Circular SWSG21/91. The programme previously concentrated on monitoring only but the emphasis has now shifted increasingly to the evaluation of the policy. Monitoring of subjects covered

by the previous programme, e.g. the complaints procedure, arm's length inspection units, the Mental Illness Specific Grant and community care plans (with particular emphasis on inter-agency action) will continue but the emphasis, as least as far as local authority social work departments are concerned, will, in future, be on:

8.1 The performance of their new responsibilities.

8.2 Measuring progress towards the wider community care goals.

8.3 Evaluation of progress towards the key objectives of the policy.

For housing, SOEnv will receive information on action being taken on housing provision for community care client groups through the new housing plan system for local authorities and Scottish Homes' programme and strategic plan. The main focus on the health side will increasingly be on health boards' performance in

- Improving health and outcomes of care.

- Improving people's satisfaction with services.

- Meeting assessed health care needs effectively.

9. The arrangements will draw mainly on the resources in Social Work Services Group, the Social Work Services Inspectorate, the NHS Management Executive and the Scottish Office Environment Department. The Scottish Office is also aware of the work of the Commission for Local Authority Accounts in Scotland. The Commission is, of course, an independent body which decides its own programme of work. Any work on value for money within community care services could prove useful and would be encouraged. The Accounts Commission’s report "Squaring the Circle: Managing Community Care Resources", dated September 1994, ISBN 0906206278, provides the Commission’s view of those areas where further attention is required in order to achieve an efficient and effective use of community care resources. Additionally, The Scottish Office has regular contact with local authorities, health boards, voluntary and private sector providers and, in prospect, users and carers. Those contacts will enhance the information gathered through formal monitoring arrangements.

The New Arrangements

10. The development of the policy and attainment of the White Paper's objectives will be evolutionary and inevitably take some time. That said, information on progress will be required quickly. The new monitoring arrangements have to have regard, therefore, to both the short-term and the medium to longer term needs.

Short-term Aspects

11. The Scottish Office needs to secure early knowledge of the way the new arrangements are operating, whether they accord with the Government's expectations and how they affect users of services. We will also wish to be aware of local authority social work departments' use of the substantial levels of new resources available to them under the DSS transfer and for implementation of the reforms generally. The short-term aspects of the monitoring programme are, therefore, expected to cover:

11.1 Local authority social work departments' performance of their new functions, in particular the key implementation tasks set out the Department's letter of 7 September 1992 at Annex B, (i.e. assessment, informing the public, purchasing residential and nursing home care, training, financial and management systems).

11.2 Progress on development of new approaches as part of the wider aims of the reforms as described in paragraph 14 of the above letter (i.e. the needs led approach, care management, purchaser/provider roles, promoting the independent sector, assessment of needs and joint information strategies.

11.3 Client related issues (eg. user satisfaction).

11.4 Local authority social work departments' financial disposition towards community care services.

11.5 Local authority social work departments' steps towards achieving the longer-term policy goals.

12. The focus will be on ensuring that the new systems are working well or are being refined; that assessment procedures are accessible and effective; that care management is developing or where in place being extended more widely; that satisfactory arrangements are in place for purchasing from the independent sector (with appropriate budgeting and monitoring systems); and that joint working is developing further. In terms of services, evidence will be sought of progress towards the needs-led approach and of the development of day/domiciliary services and support for carers, and if authorities are seeking to secure value for money.

13. This element of the programme will consist of examining authorities' budgets and their revised community care plans, inspections and a "snap-shot" survey or surveys (probably conducted by way of a questionnaire and site visits). The first such survey would take place very soon and may be followed up with a similar exercise or exercises later in the year. Further activity of this type would depend on the outcome of the initial work. There may also be information gathering about particular aspects, e.g. the level of occupancy in residential care and nursing homes and the exercise of choice in that field. Monitoring of measures to facilitate the policy, e.g. bridging finance, will be conducted separately. A more detailed statement of the coverage of this part of the monitoring programme is set out at Annex C.

Medium to Longer-term Arrangements

14. The programme for the medium/longer term will seek to establish continued progress towards the key objectives and will encompass in general terms:

14.1 Changes in the pattern of care and services, and support for carers.

14.2 On-going progress towards the objectives of the policy and, in particular, the specific objectives in the White Paper.

14.3 Client outcomes.

15. The policy is very much geared to change the balance of service provision, to develop areas where there are particular concerns, to improve the quality of services generally and to secure better value for money in the delivery of such services. Clients are at the centre of the policy and we wish to establish whether satisfactory arrangements exist for client involvement in processes (such as planning and assessment) and whether the policy has led to greater consumer satisfaction. The last of these is rather more difficult to quantify but we will aim to address in this context issues such as choice and consumer well-being. The work of the Steering Group on Community Care Information Requirements should help in this regard.

16. Apart from the specific objectives attaching to the community care reforms there are a number of policies in the health and housing fields which are an integral part of the Government's wider community care strategy. Without seeking to provide a comprehensive list these include, within the health service, the reduction of long-stay hospital provision and the transfer of services into the community and the prevention of unnecessary admission to hospitals; and, within housing, the greater availability of housing for community care client groups. Across the service providing spectrum the emphasis is on the provision of, wherever possible, care in the person's own home or otherwise in homely settings. The monitoring programme addresses these and other issues, either within the existing mechanisms in the health and housing sectors or otherwise. The outline in paragraphs 11 to 13 is developed more fully in Annex D.

Community Care Indicators

17. Through the Standing Group on Community Care Information Requirements, The Scottish Office is developing a common core of data about community care needs and services which can be shared by local agencies and which is required by The Scottish Office for monitoring purposes. This common core of data may be used to inform the development of performance indicators. In many cases, the key measures of successful care in the community are not yet recorded and much work will be needed to develop the necessary information collection systems. Annex E sets out measures that for the most part are currently available and which provide an overview of the progress of community care implementation. These will form part of the statistical data base to monitor the policy and act as a tool for inspection. Other sources of information will be used as appropriate. To steer investment in community care information systems, and to inform the Accountability Review process, the NHS Management Executive is currently developing a range of indicators to measure Health Boards' performance in purchasing community care.

18. The indicators in Annex E are associated with particular objectives of the policy. We recognise that they are only quantitative measures of the delivery of services and that measures of quality and effectiveness will be necessary to supplement them. These will be developed in due course (liaising with others with similar intentions) and tested through the inspection programme and longer-term research.

Monitoring and Research Programmes

19. Drawing on the scope of Annex C and D, the Social Work Services Inspectorate and the Central Research Unit have drawn up work programmes which will contribute to the monitoring and evaluation of community care. These are identified at Annexes F and G respectively, and will be subject to continuing review (with consultations as normal).

20. Enquiries about the content of this Circular should be addressed in the first instance to Mrs L Malcolm, Social Work Services Group, Room 48c, James Craig Walk

(telephone 0131 244 5424).

Yours sincerely

GAVIN ANDERSON JOHN ALDRIDGE DAVID MIDDLETON

Social Work Services Group NHS Management Executive Housing Group

ANNEX A

COMMUNITY CARE OBJECTIVES

Policy Objectives

The policy objectives for community care are set out in the Governments White Paper "Caring for People". They can be divided into three categories - aims, service principles, and specific objectives.

Aims

To enable people to live as normal a life as possible in their own homes or in homely environments in the local community.

To provide the right amount of care and support to help people achieve maximum possible independence.

To give people greater individual say in how they live their lives and the services they need to help them to do so.

Service Principles

Services should -

- respond flexibly and sensitively to the needs of individuals and their carers (i.e. the needs led approach)

- allow a range of options for consumers (i.e. choice)

- intervene no more than is necessary to foster independence

- concentrate on those with the greatest needs (targeting/resource management)

Specific Objectives

To promote the development of domiciliary day and respite services to enable people to live in their own homes wherever feasible and sensible.

To ensure that service providers make practical support for carers a high priority.

To make proper assessment of need and good care management the corner stone of high quality care.

To promote the development of a flourishing independent sector alongside good quality public services.

To clarify the responsibilities of agencies and make it easier to hold them to account for their performance.

To secure better value for money by introducing a new funding structure for social care.

ANNEX B

7 September 1992

IMPLEMENTING THE GOVERNMENT’S COMMUNITY CARE POLICIES

1. This letter informs the statutory sector - social work authorities, health boards, housing authorities - and the voluntary and private sectors of progress on implementing the NHS and Community Care Act 1990. It also sets out the key tasks which need to be addressed in the run up to full implementation on 1 April 1993 so that a smooth transition to the new arrangements can be achieved. It follows previous implementation letters which have been issued since the publication of the 1989 White Paper, ‘Caring for People’.

Progress to Date

2. All authorities have now set up complaints procedures and arm’s length inspection arrangements. The Mental Illness Specific Grant is now in its second year. In 1991-92 grant was paid in support of expenditure of £3 million on new facilities or services in the community. In the current year the figure is £6m. In the first year 85 projects were approved for grant, with a further 67 in the current year. The aim is to continue to develop facilities in the community for the mentally ill. The build up of the policy has been recognised in the provision for local authority expenditure.

3. All local authorities except one have now published their community care plans, as required under the NHS and Community Care Act 1990. All health boards except five have published their plans. The Scottish Office is currently examining the plans and will be writing to an discussing the plans with each local authority and health board. This examination will be against the stated aims of the policy as set out in the White Paper and circulars of guidance.

4. Six of the plans are joint: the remainder of the plans have been completed separately by local authorities and health boards. The joint plans show greater evidence of joint working but all local authorities and health boards have put considerable effort into the production of their plans. The initial picture is that progress has been made in developing the planning framework and infrastructure. However, in future, we expect local authorities and health boards to agree more clearly on long-term objectives and strategies for achieving them (including arrangements for joint purchasing), targets and monitoring mechanisms, and all the financial aspects. Local authorities and health boards should also work towards improving information systems.

5. Recent seminars and other sources suggest that local authorities and health boards need to do more to inform social work and health care professionals (and, in particular, general practitioners) and the independent sector about the reforms, their roles and the future provision of services. Local authorities and health boards should therefore ensure that such interests are closely involved in the consultation on the reforms and the planning of health and social care services. The other key message to emerge is the importance of securing inter-agency agreement and co-operation locally, particularly in regard to aspects such as care planning for individuals.

6. It is widely recognised that general practitioners in the primary health care team have a vital contribution to make to the planning, organisation and provision of community care services. For this to be effective local authorities and health boards should ensure that general practitioners or their representatives are fully consulted on and involved in the development of procedures and the planning and development of services. In particular, general practitioners would welcome being more closely involved in devising the arrangements for assessment of individuals (both to clarify their role and to ensure that they are not overburdened either administratively or in supporting people in a community setting), developing improved local discharge arrangements and training for the new community care arrangements generally. Local authorities and health boards should also recognise the value to general practitioners of speedy decision-making and effective communication of decisions to professionals in the field.

7. Alongside the main implementation programme, the Government have introduced a number of initiatives which form an integral part of the wider community care strategy. In addition to the Mental Illness Specific Grant the bridging finance scheme has been enlarged and extended to provide £33m of support over the years 1991-92 to 1994-95.

8. The local authority settlement for 1991-92 included allowance of £10m for implementing the first phase of the Government’s policies. A further £11m was provided in 1992-93 (making a total £21m) to allow authorities to prepare for full implementation on 1 April 1993. Resources were identified particularly for developing the framework for assessment and care management and purchasing and contracting, the development of information technology (particularly in the context of assessment) and the introduction of the Training Specific Grant (£2m of which is devoted to training on community care).

9. We plan to issue soon the guidance on the transfer of resources from health boards to local authorities as long-stay patients are discharged into the community. This will include guidance on joint purchasing and contracting, cash transfers and other inter-agency mechanisms.

10. The Scottish Office has recognised the importance of preparing effectively in the current year for the full implementation of the policy from April 1993 and has set up a Community Care Implementation Unit to assist in this regard. Its remit was sent to health boards, local authorities and others under cover of the joint letter of 7 April 1992 from Social Work Services Group and the NHS Management Executive. Its work on devising a national framework for the contraction of long stay hospitals is touched on later in this letter. The Scottish Office is also looking at the information needs in relation to community care.

Pre-Implementation Framework

11. In the period prior to full implementation it is important to focus on those aspects of the reforms which are required or implied by the legislation, and which must be in place by April 1993. Of greatest importance are:

a. establishing the arrangements for assessing care needs; and

b. securing the provision of care, including residential and nursing home care.

12. Within that framework a key feature will be assessing and arranging appropriate care for new clients who under the previous arrangements would have sought support through the system of DSS board and lodging allowances. We estimate that about 10,000 people (equivalent to 250 per 100,000 adult population) will come into this category during 1993-94, some of whom will be for short-stay admission.

Key Tasks

13. We believe that the tasks identified below represent those aspects to which local authorities, working closely with health boards and other agencies, should give priority in the run up to full implementation. The tasks are:

Agreeing procedures and systems for assessing individual needs.

Informing the public of the arrangements for assessment and provision of care and ensuring that they are fully informed of the choices they have in the field of care, particularly what is available in the voluntary and private sectors.

Clarifying and agreeing arrangements (including purchasing and charging) for the continuing care of new clients in residential care and nursing homes (including provision of respite care).

Ensuring that staff are fully aware of the new arrangements and are suitably trained, wherever possible on a joint basis.

Clarifying the roles of general practitioners and primary health care teams, especially in the assessment process.

Ensuring that financial and other management systems can meet the new demands after 1 April 1993.

14. Further information on these tasks is contained in the attached Annex. This also sets out our expectations of the progress required during the remainder of this year on aspects of the reforms which will require continuing and longer term development.

15. We also expect health boards, working in conjunction with local authorities and other agencies, to bring forward firm plans for the contraction of long-stay hospitals over the rest of this decade. These plans will inform the allocations of bridging finance. Discussions on the framework will be taking place with Boards and others in the coming months.

DSS Transfer

16. From 1 April 1993 the Government will start to transfer to local authorities the resources which DSS would otherwise have spent on the support of persons in independent residential care and nursing homes. The transfer will accordingly comprise DSS planned expenditure had the present arrangements continued less the resources necessarily retained to meet the cost of (a) existing cases and (b) ordinary income support and the residential allowance for new cases. The sum transferred will be transparent and separately identified within the distribution of Grant Aided Expenditure (GAE). Each social work authority will be told the sum which it has been allocated in respect of its new financial responsibilities.

17. Authorities are reminded that the transfer covers all adult client groups which have had recourse to the system of DSS board and lodging allowances for residential and nursing home care. It extends therefore to groups such as alcohol, drugs and solvent abusers, offenders and young adults as well as elderly and disabled people. It also covers respite admissions for all client groups to homes in the independent sector. The calculation of the transfer recognises that client groups have different lengths of stay. In the first year, many of the approaches to authorities may accordingly come from groups with traditionally short lengths of stay eg respite cases, addicts, substance abusers, offenders etc.

Housing Support for People in Residential or Nursing Home Care

18. The Government announced in March that its review of whether Housing Benefit should be paid to new residents in independent residential care and nursing homes after April 1993 had resulted in a decision to pay, instead, a residential allowance as part of the entitlement to Income Support. This will be related to rents typically paid by persons in sheltered housing: the expectation is that there will be 2 rates, one for Greater London and one for the rest of Great Britain. Information is currently being collected in order to determine these rates.

Training/Development Work

19. Investment in training for the reforms at both local and national levels has been significant. The Scottish Office attaches particular importance to identifying issues for which joint training of health and social work professionals is required. It is planned to assist the establishment of a Centre for Management Development in Health and Social Care which would provide quality training opportunities (including joint training) for senior management in the health and social care fields, and it is considering an initiative to extend the availability of joint training generally. SWSG is aiming to review in the autumn the training targets set out in Circular SWSG3/1992.

20. Local authorities plan to use the full £2m available for community care training through the Specific Grant. More generally, social work staff in local authorities and other agencies are making extensive use of the introductory module of the community care programme drawn up by the University of Dundee. A new edition (CCI), which takes account of nursing interests, became available in June. Large numbers of staff are now using the second module (CCII); and further modules will be developed in the coming year. Work on general learning packages is also progressing: the existing Level 1 package will be supplemented by a Level 2 by the end of the summer. These programmes, plus a Diploma in Community Care at Glasgow University, ensure the availability of relevant training from introductory to advanced levels.

21. More generally, social work authorities are now encouraged to produce formal training plans. SWSG will be considering later this year whether their submission should form part of the applications procedure under the Training Specific Grant.

Further legislative provisions

22. In order to complete the package of legislative provisions and related guidance to be issued under the 1990 Act The Scottish Office will be issuing in the coming months regulations on (a) the circumstances in which local authorities may assist persons resident in independent sector homes as at 31 March 1993 and (b) charging for accommodation provided in residential care and nursing homes. Consultations on the content of the regulations will take place soon.

Conclusion

23. The Government remain fully committed to the objectives of their community care policies and wish to ensure that the proper infrastructure and arrangements are in place for full implementation on 1 April 1993. The Annex to this letter identifies tasks which are central to a properly managed introduction of the new arrangements. Good preparation will enable the transition from the old to the new to be effected smoothly and with the optimum benefit to clients seeking services after 1 April 1993.

KEY TASKS FOR 1992-93

Assessment and Care Management

1. Local authorities should be making good progress with devising the organisation and operational strategies for their new assessment responsibilities. The recently published progress report on the pilot studies on care management and assessment - circulated under cover of the Chief Social Work Inspector’s letter of 29 May - identified the range of work taking place at the time of the study: we are aware that considerable progress has been made since then, particularly on aspects highlighted in the report.

2. Fundamental to this issue is that the assessment policies and practices must be jointly agreed by social work departments, health boards and housing agencies; and only through clearly defined roles and responsibilities will social care, health care and other staff have a full understanding of the arrangements as a whole and their respective contributions to them. Essential to this process will be establishing clear and straightforward criteria for priority setting and eligibility for services and the related systems for referrals, recording and communications. In taking forward their leading role in developing the communication between key staff are developed, principles, policies and procedures are mutually understood and discussions with professionals such as primary health care teams and GPs are taking place. Particular initiatives may be necessary where this is not the case.

3. The essence of the assessment arrangements should be a combination of effectiveness and simplicity. There is a considerable risk of devising procedures and systems which are over-elaborate: it is particularly important therefore to keep as clear and straightforward as possible the documentation for the assessment. The object should be to secure a well targeted, concise report on the client’s circumstances. Information on the assessment procedures, eligibility criteria and the result of assessments needs to be widely available.

4. The need for clarity of roles was one of the aspects highlighted at a recent Workshop on the role of GPs in the primary health care team. The Scottish Office will be issuing a report on the proceedings which will invite local authorities and health boards to address the issues raised in their respective fields. These include clarification of the role of the general practitioner in the primary health care team, assessment arrangements, communication, training and education, involvement in the planning process and the importance of local action. Further consideration is also being given to these matters centrally.

5. Many local authorities are making progress in developing arrangements for more effective care management. It is essential that the key elements of care management are addressed at this stage although full implementation should follow the establishment of the arrangements for assessment.

6. A further issue in the context is the need to have fast and effective mechanisms for decision taking, particularly on the provision of care services. The new arrangements for assessment are expected to improve the quality of decisions on the care needs of individuals. But the process must not become bogged down. Delegating to the lowest practicable level the power to commit resources is one way of ensuring that decisions are reached as expeditiously as possible. The Scottish Office’s monitoring of the new arrangements will seek to identify way in which decisions can be effectively and expeditiously secured: meanwhile, authorities should seek to ensure that the measures they introduce have regard to the need for fellow professionals, clients, carers and others with an interest to be made aware at an early date of the conclusions of the assessment process.

Continuing Care of New Clients in Residential Care and Nursing Homes

7. In making arrangements for the continuing care of new clients we expect local authorities and health boards to have a clear understanding of the current pattern of provision, the flows and movements of clients and of the resources committed to such continuing care. We do not expect their local authorities or health boards to change the current pattern of provision or the commitment each is making except on the basis of prior agreement properly reflected in either the community care plan or planning agreement.

8. Local authorities’ new responsibility to meet the care costs of persons in residential and nursing homes in the independent sector will require them to enter into contracts or other service agreements with providers. Health boards may also be contracting with nursing homes where the home provides continuing care and the residents’ care needs remain under the continuing management of a hospital consultant.

9. Local authorities’ contractual arrangements, as above, require to have the confidence of all parties. Home owners should have been consulted on their role as part of the preparation of the Community Care Plans. At a more detailed level, authorities management of their new responsibilities should have regard to the needs of residents, their wishes and those of carers, the concerns of home owners and a desire to secure value for money. Confidence in the arrangements will be helped considerably through authorities involving providers, users and others in determining the contractual framework.

Training

10. The covering letter identifies the main thrust of current training initiatives. Such are the changes of functions, roles and responsibilities under the reforms that training is a vital component of the implementation programme. Needs will vary considerably: all staff involved in community care should be informed of what the reforms mean for them and their patients or clients. Training should address changes of role or responsibility and for senior staff the development of new management skills. Local authorities and health boards require well-developed training plans based on an analysis of the training requirements of individual members of staff who have community care responsibilities. Without a systematic approach involving the staff concerned the capacity of local authorities and health boards to implement the reforms to the best effect will be severely limited. We will be considering specifically in the context of the Training Specific Grant what impetus can be provided to joint training.

Financial and Management Systems

11. Complementary to what is said above about training is the development of new financial and management systems to cope with the changes. Development work should already have begun, and in the initial phase it will be necessary to concentrate on the

requirements posted by the planning, assessment, purchasing and charging requirements. Considerable further development will, however, be necessary to deal with the continuing and longer-term aspects of the reforms.

Informing the Public

12. While there is considerable public awareness of the advent of the community care changes generally it will be necessary for, in particular, local authorities to inform clients and the public at large of the specific changes coming into effect on 1 April 1993. This would seem to call for publicity at an informative level for the general public, and at a more detailed level for clients or prospective clients of community care services. Some authorities have already produced useful summaries of their community care plans, for wide distribution, which is to be commended.

13. The Government attach considerable importance to clients in need of community care being able to make reasonable choices as to the care they receive. It will be particularly important, therefore, for authorities to provide to clients or their representatives information on the services available, particularly in the fields of residential and nursing home care where a number of providers operate.

Continuing and Long-term Developments

14. Some aspects of the reforms will require continuing work and development over the longer term. These include:

14.1 Continuing development of a needs-based approach to the provision of services and the proper involvement of users and carers in planning services and making arrangements for the care of individuals.

14.2 Further development of care management.

14.3 Further clarification of the purchaser and provider roles within Social Work Departments.

14.4 Continued promotion of a wider role for the independent sector.

14.5 Development of innovative purchasing and contracting arrangements, including joint commissioning.

14.6 Development of a joint assessment of population needs for planning purposes.

14.7 Development of joint Community Care Plans as purchasing strategies.

14.8 Development of joint information requirements and the systems to support these.

ANNEX C

MONITORING/EVALUATION: SHORT-TERM ASPECTS

1. Local Authorities' Performance of their New Functions

1.1 To find out whether suitable arrangements of the requisite quality are in place for:

1.1.1 Assessing individual need.

1.1.2 Informing the public of the community care changes.

1.1.3 Providing financial and management information.

1.1.4 The purchase of care from the independent sector.

1.2 To establish that:

1.2.1 Staff are and will continue to be properly trained.

1.2.2 Local authorities and health boards have an agreed strategy for the continuing care of elderly people.

1.2.3 Local authorities, health boards and housing authorities/agencies have agreed arrangements for hospital admission and discharge.

2. Continuing of Progress on Longer Term Developments

To establish progress on:

2.1 Needs-based approach to service provision.

2.2 Development of care management.

2.3 Further clarification of the purchaser and provider within social work departments and joint commissioning.

2.4 Development of community care plans as purchasing strategies.

2.5 Promoting wider role for the independent sector.

2.6 Joint assessing of local needs.

2.7 Joint information systems.

3. Client-related Issues

To find out whether suitable arrangements of the requisite quality are in place for:

3.1 Users'/carers' input to planning.

3.2 Users'/Carers' input to assessing of individual need.

3.3 Determining users'/carers' satisfaction with 3.2.

3.4 Continued support of small, at risk care groups such as drug/alcohol misusers etc.

3.5 Access to residential/nursing home care in the independent sector and exercise of choice.

4. Authorities' Financial Dispositions

4.1 To examine local authorities' planned expenditure in 1993-94, as compared with 1992-93, on:

4.1.1 Community care services.

4.1.2 Purchasing from the independent sector.

4.2 To examine shifts in the balance of care.

5. Progress on White Paper etc: Objectives

To establish early progress on:

5.1 Promoting day, domiciliary and respite services.

5.2 Giving priority to support for carers.

5.3 Ensuring clarity of agency roles and responsibilities.

5.4 Obtaining value for money.

5.5 Promoting choice and independence.

5.6 Effective assessment and care management.

6. Housing Issues

6.1 Effective inputs of housing agencies to community care planning.

6.2 Establish early progress on housing and community care towards:

6.2.1 Implementing guidelines for housing provision for community care client groups.

6.2.2 Effective housing management policies for each care group.

6.2.3 Inter-agency agreements on aids/adaptations/wardens.

6.2.4 Inter-agency agreement on standards for care housing.

7. Inter-Agency Issues

Monitor arrangements for:

7.1 Bridging finance.

7.2 Resource transfer.

7.3 Reduction in long-stay provision by the NHS.

7.4 Inter-action between social work professionals and primary

health care teams.

7.5 Role of community health services.

7.6 Training of NHS staff.

7.7 Care programme approach.

ANNEX D

MONITORING/EVALUATION: LONGER-TERM ASPECTS

1. Local Authorities' Performance of their New Functions

(Section 1 of Annex B)

Only as required.

2. Continuing (or Progress on) Longer-term Developments

(Section 2 of Annex B)

Maintain progress.

3. White Paper Objectives

(See Annex A)

4. Client Outcomes

To ascertain:

4.1 users'/carers' state of 'well-being'.

4.2 the degree of choice available to users/carers.

4.3 the effectiveness of the policy in terms of outcomes for clients eg. greater ingenuity, more appropriate and timely interventions, better quality of life etc.

5. Continuing of Existing Programme

5.1 To evaluate policy effectiveness of:

5.1.1 Arm's length inspection units

5.1.2 Complaints procedures.

5.1.3 Mental Illness Specific Grant.

5.2 To monitor the action contained in local authorities, health boards and housing agencies plans.

6. Housing

To establish that the planning, delivery and management of community care housing meets the objectives in the 1991 circular 'Housing and Community Care', as described in section 6 of Annex B.

7. Housing and Health/Social Work Issues

7.1 Evaluate effectiveness of bridging finance scheme.

7.2 Monitor reduction in long-stay hospital sector and effect on client outcomes.

7.3 Monitor resource transfer arrangements.

ANNEX E

COMMUNITY CARE INDICATORS

1. Assessment

Objective: to establish the pattern and mix of assessments:

Indicators

Number of referrals per 1,000 population.

Percentage of referrals proceeding to assessment.

Number of "simple" assessments.

Number of "complex" assessments.

Percentage current LA clients who have been assessed

Percentage of clients with individual care plans.

2. Inspection

Objective: to establish that inspections take place as required:

Indicators

Percentage of LA/Voluntary/Private Residential Homes on whom Inspection Reports have been completed (within 3 months of end of year).

3. Complaints

Objective: to provide an indication of the level of consumer satisfaction:

Indicators

3.1 Number of complaints per 1,000 population.

4. Care of Elderly People

Objective: to establish the extent to which people are supported at home, the mix of services for users and carers and the level of expenditure.

Indicators

4.1 Percentage of population 75+ living in own home/sheltered accommodation/residential home/nursing home/long-stay hospital.

4.2 Percentage of population 75+ receiving home help.

4.3 Number of home helps per thousand population 75+.

4.4 Number of home helps per client.

4.5 Number of day care places per thousand population of 75+.

4.6 Number of people attending day centres per 1,000 population 75+.

4.7 Number of designated respite care beds in residential homes per 1,000 population 75+.

4.8 Percentage population 75+ in local authority/voluntary/private residential homes.

4.9 Local authority expenditure per capita 75+ on services for the elderly.

4.10 Percentage population 75+ in long-stay hospitals/contracted nursing homes/other nursing homes.

4.11 NHS expenditure per capital 75+ on hospital services/community services for elderly people.

4.12 Average gross cost per place in local authority/voluntary/private residential homes.

4.13 Percentage population 75+ receiving Meals on Wheels.

4.14 Number of meals served in lunch clubs per 1,000 population 75+.

4.15 Number of Day Hospital places per 1,000 population 75+.

4.16 Number of people attending day hospitals per 1,000 population 75+.

4.17 Number of very sheltered dwellings per 1,000 population 65+.

4.18 Number of sheltered dwellings (including sheltered wheelchair) per 1,000 population 65+.

4.19 Number of amenity housing dwellings per 1,000 population 65+.

5. People with Mental Illness

Objective: to establish the extent to which people are supported at home, the mix of services for users and carers and the level of expenditure.

Indicators

5.1 Number of places in long-stay hospital/staffed homes/supported accommodation.

5.2 Number of people per thousand population aged 18-64 in long-stay mental illness hospitals/in staffed accommodation for people with mental illness/in unstaffed supported accommodation.

5.3 Number of admissions to mental illness hospital in year per thousand aged 18-64.

5.4 Number of day care places in the community per thousand population aged 18-64.

5.5 Number of day hospital places in the community per thousand population aged 18-64.

5.6 Local authority expenditure per capita on services for people with mental illness.

5.7 NHS expenditure per capita on hospital/community services for people with mental illness.

5.8 Ratio of places in local authority/voluntary/private staffed accommodation.

5.9 Ratio of places in local authority/voluntary/private day centres.

5.10 Number of respite care places in local authority/voluntary/private staffed accommodation.

5.11 Percentage of all projects/projects +£20,000 per annum funded by Mental Illness Specific Grant managed by voluntary bodies.

6. Number of dwellings provided for people with mental illness.

7. People with Mental Handicap

Objective: to establish the extent to which people are supported at home, the mix of services for users and carers and the level of expenditure.

Indicators

7.1 Number of places in long-stay mental handicap hospitals/staffed accommodation/unstaffed supported accommodation.

7.2 Number of people per thousand population aged 18-64 in long-stay mental handicap hospitals/staffed accommodation for people with mental handicaps/unstaffed independent accommodation/living with carers.

7.3 Ratio of places in LA/voluntary/private staffed accommodation.

7.4 Number of admissions to mental handicap hospital per thousand population aged 18-64.

7.5 Number of day care places per thousand population aged 18-64.

7.6 Ratio of places in LA/voluntary/private day centres.

7.7 Local authority expenditure per capita on services for people with mental handicap.

7.8 NHS expenditure per capita on hospital/community services for people with mental handicap.

7.9 Number of respite care places in hospital.

7.10 Number of respite care places in staffed accommodation in the community.

8. Number of dwellings provided for persons with a mental handicap.

9. People with Physical Disability

Objective: to establish the extent to which people are supported at home, the mix of services for users and carers and the level of expenditure.

Indicators

9.1 Number of staffed places per thousand population aged 18-64 in long-stay hospital/accommodation in the community for people with physical disability/independent accommodation receiving support.

9.2 Number of day care places per thousand population aged 18-64.

9.3 Ratio of places in LA/voluntary/private staffed accommodation.

9.4 Local authority's expenditure per capita on services for people with physical disability.

9.5 NHS expenditure per capita on hospital/community services for people with physical disability.

9.6 Number of aids issued per thousand population.

9.7 Number of adaptations made per thousand population.

9.8 Ratio of places in LA/voluntary/private staffed accommodation.

9.9 Percentage of population 75+ receiving Alarm Systems.

9.10 Number of Occupational Therapists/1,000 population.

9.11 Percentage of housing stock classified as "wheelchair housing".

9.12 Percentage of housing stock classified as "mobility housing".

10. People with Dementia

Objective: to establish the extent to which people are supported at home, the mix of services for users and carers and the level of expenditure.

Indicators

10.1 Number of long-stay hospital patients with dementia per thousand population 75+.

10.2 Number of people in residential homes with dementia per thousand population aged 75+.

10.3 Number of designated day care places for people with dementia in NHS/local authority homes/voluntary establishments.

11. Persons Suffering from Drug/Alcohol Problems

Indicators are currently being devised as a matter of urgency.

12. HIV/AIDS

Objective: to establish the relative level of expenditure on HIV/Aids:

Indicators

Expenditure on services on HIV+/per sufferer.

Expenditure on AIDS per sufferer.

13. Homeless Persons with Social Care Needs

Objective: to establish the level of assistance to and expenditure on homeless persons with social care needs:

Indicators

13.1 Number of homeless people with social care needs per 1,000 population given assistance by Social Work Department.

13.2 Local Authority Social Work Department expenditure per capita on services for homeless people with social care needs.

13.3 Number of homeless people with social care needs in LA/voluntary/private staffed accommodation.

ANNEX F

SWSI COMMUNITY CARE INSPECTION AND MONITORING PROGRAMMES

INSPECTION

1993/94

Inspection of Day Services for People with Mental Illness

This inspection will assess the extent to which projects funded by the Mental Illness Specific Grant are meeting the needs of people and helping them to avoid admission to hospital; will provide information about the effectiveness and quality of day services for people with mental illness; and will assist with the targeting of the Specific Grant in future.

Inspection of Home Care Services for Elderly People Living at Home

The inspection will focus on users' experience of home care services and will examine the extent to which services meet users' and carers' needs, how efficiently services are targeted, and how effective they are in helping people to remain at home with a good quality of life.

1994/95 and Beyond (Provisional)

The following subjects are SWSI's current priorities for inspection in future years.

- Effectiveness of support for carers

- Services for people with profound disabilities

- Effectiveness of assessment and care management

- Quality of services for people with dementia

- Performance of inspection units

MONITORING PROGRAMME 1993/94

SWSI will undertake six focused exercises during 1993/94 to monitor the implementation of Community Care. The first two exercises address a number of the key changes. Three others look in more depth at specific subjects and the final one will take an overview of the impact of new arrangements on service users and carers. The exercises will be as follows:

1/2. Performance of key functions.

- Assessment of Individual Needs (including carers', diversion to day/domiciliary services, small care groups and needs-based approach to service provision);

- collaboration, particularly between social work, GPs and primary health care teams and housing;

- purchase of residential and nursing home care;

- Information for the public and other agencies, including housing;

- Financial and management information and systems;

- Development of care management;

- Financial assessment and charging;

- User Choice;

- Processes for monitoring/evaluation and securing value for money;

- Training.

Timing - 2 phases (summer and end 1993). The exercises will involve questionnaires and meetings with staff in local authorities and other selected agencies and will seek to establish how effectively social work departments have carried out their new responsibilities.

3. Care Programme Approach

This exercise will collect information by questionnaire about the implementation of the care programme approach.

4. Hospital Discharge Arrangements for People in Acute Wards

This exercise will look at policies, protocols and procedures and their operation in practice. The study will be carried out with the help of medical officers and nursing officers from the Scottish Office and will include interviews with front line staff as well as questionnaires to relevant agencies. The exercise will give some indication of the effectiveness in practice of the new assessment arrangements and will identify whether people are being unnecessarily kept in hospital.

5. Contracting

This exercise will examine the experience of contracting from the perspectives of local authorities, voluntary organisations and the private sector. It will look at the purchasing arrangements, e.g. purchaser/provider split, the types of contracts and service specifications which have been established, how these have been developed and how well they operate in practice. It will also collect information about the arrangements with small care groups and prices in contracts generally. The exercise will provide information about the development of the mixed economy and the manner in which the quality of care is being addressed in contracts.

6. Impact on Users and Carers

This exercise will review the impact of the community care changes on users and carers. Relevant evidence will be obtained in a number of key subject areas, e.g. community care planning, assessment and care management, information, local inspection, complaints. The aim would be to report on the involvement of users and carers, highlight good practice and point to areas where improvements could be made.

ANNEX G

SWSG RESEARCH PROGRAMME

Current Programme

1. Evaluation of Efficiency and Effectiveness of Community Care

The research will evaluate a limited number of pilot projects on assessment and care management, study on a 'before' and 'after' basis service delivery to elderly people, and examine the operation of care management, the process of assessment and the pattern of service mix under the new community care arrangements introduced in April 1993. The work will have 3 phases. The preliminary phase will draw conclusions from the operation of the pilot projects, and present an overview of authorities' arrangements for assessment and care management (1992/93). The second phase will provide overviews of organisational mapping in local authorities and health board activity (1993). The third and final phase will provide a detailed analysis of the process, quality and costs of contrasting models of assessment and care management and of different packages of care for elderly people and those with mental health problems; analysis of the actual services provided to people in the selected areas and an assessment of their costs and impact on users and carers; and a commentary on the extent to which the pattern of service delivery has changed under the new policy (1995).

2. Mental Illness Specific Grant (MISG)

The research will assess the impact of MISG in generating new developments and in contributing to the policy overall.

3. Future Programme

1. Users' and Carers' Needs (including respite care and accessing of services).

2. Home Care Needs of Very Dependent Elderly People.

3. Younger Disabled People - Education and Social Work Planning of Services.