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Report of the Joint Future Group

CHAPTER 7 CHARGING FOR HOME CARE SERVICES

7.1 We were invited to offer advice on charging for home care services. Local authorities have considerable discretion on what charges, if any, they make and on how they set these charges.

7.2 The task had two elements. The first was to consider steps to reduce the inconsistency in charging for home care services between areas of Scotland. Our proposals are set out below in paragraphs 7.3 to 7.5. The second was to consider any new policy on charging in the light of, amongst other things, the Royal Commission on Long Term Care’s8 recommendations on free personal care. While recognising the principles which underpinned the Royal Commission’s recommendations, we preferred approaches to charging that not only helped older people financially, but also supported community care more directly. Our proposals are set out below from paragraph 7.6 onwards.

Improving Consistency

7.3 Charging for services is an integral part of the funding of social care. Practice has evolved often as a consequence of financial pressures. As a result, the levels of charge and charge construction vary considerably from authority to authority. Greater consistency is clearly required. The Convention of Scottish Local Authorities (COSLA) has been looking at this since before the JFG was set up. We support their initiative.

7.4 We recommend therefore:

COSLA should develop guidance on charging policies to reduce the inconsistencies in home care charging.

7.5 COSLA is now consulting on a number of approaches authorities might adopt to improve consistency. These include setting common income thresholds above which charges would apply; an agreed minimum for the treatment of capital, with no maximum; housing, mortgage and council tax payments to be disregarded; and a standard disregard for dependent children. The objective is that local authorities should take a more strategic view of charging policy and its relationship to overall plans and objectives. The desired effect is greater consistency in charge construction, and users of services being left with sufficient money to have a reasonable quality of life. The role of benefits is obviously pivotal. COSLA’s proposals include a benefits check as part of any proposal to charge and, secondly, that an individual’s resources left after any charge should exceed the level of Income Support and any premiums.

Charging Policy

7.6 Our starting point was to consider whether home care services should be provided free of charge. We concluded that providing free home care services as a whole would be unaffordable, would give rise to inconsistencies with the benefits system and would do nothing to develop better community care services. We explored a number of options and focused on two:

• free home care for older people for up to the first 4 weeks after hospitalisation; and
• free personal care for those older people receiving most care, who might otherwise be in residential, nursing home or hospital care. (For reference purposes, this group of people are described as requiring "extended home care").

Up to 4 Weeks Post Hospital Care for Older People

7.7 Our proposals aim to facilitate an individual’s discharge/ resettlement and to benefit them financially, for a limited period. They also support both rehabilitation and the initiatives to speed up discharge. We want older people to receive care at a critical time, possibly more intensively than needed for the longer term, and get back on their feet without worrying about the cost of their care.

7.8 For these purposes we define older people, as men over 65 and women over 60. The extension would follow discharge from in-patient acute hospital care. It should be limited to a maximum of 4 weeks in each case. For these purposes home care means personal care or other social work services, including equipment, provided in the home within the maximum 4 week period.

7.9 Local authorities will therefore have to decide, just as they do at present, how long a person needs support following discharge. Four weeks is not a norm. It is a maximum, only for charging. We recognise some people will not need 4 weeks, but others may need more. The limit will cover the vast majority of cases. Setting a time limit gives a clear message about duration, and reduces incentives to prolong the initial level of care unnecessarily.

7.10 We also considered - but rejected on practical grounds - offering relief from charges to stop people going into hospital in the first place. It has been suggested that under our proposals professionals and users could collude to engineer a stay in hospital so as to secure free post hospital care. But we do not believe that is realistic.

7.11 Some councils already operate "home from hospital" schemes. Some charge, some do not. Our proposals would mean that all older people would get a free service for up to 4 weeks.

7.12 We recommend therefore:

free home care for older people for up to 4 weeks after leaving hospital.

Extended Home Care

7.13 We recognise that a small number of home care users receive very high levels of home care, usually provided by both health and social care services to sustain them at home. Without that level of help, these people would almost certainly be in residential, nursing home or even hospital care. This is therefore effective community care.

7.14 Charging for these services is a recognised part of the financing of local authority services. Moreover, the benefit system provides resources, with a dependency differential, to help individuals meet the added cost of frailty or disability, including paying for care.

7.15 We believe that people who need substantial levels of care should not have to pay a premium, just because they are more infirm than others. In hospital, they would not pay at all, and in residential or nursing home care their care costs would be met wholly by the state if they had limited resources; partly by the state if they had modest resources; and if they were better off they would have to pay the whole cost themselves. Because of local authorities’ discretion, people paying for home care are currently treated differently from area to area, though only a few pay the full costs. Nevertheless this can, depending on the levels of local disregards, make care at home financially unattractive.

7.16 We are told that charging for social care can be an impediment to developing joint packages of care, especially where agencies are working towards or already have generic workers or other blurring of professional roles. We would want charging to support joint working wherever possible.

7.17 Our approach aims to support joint working, and the home care policy generally. It also recognises the contribution which benefits can make to an individual’s ability to pay for care. Moreover we believe that people who use services will understand that getting greater levels of care should not necessarily result in a greater charge.

7.18 We propose to provide relief for the additional cost of care of those people who receive ‘extended home care’. ‘Extended home care’ means a range of specific tasks to be defined, provided by both health and social care staff. The crux, however, is their intensity. To secure relief from the charge would require at least 4 such interventions a day. To maintain a link with the benefits system, the person would, however, continue to pay for ‘ordinary’ home care or other services. How to measure both ‘extended home care’ and ‘ordinary’ services will be discussed with COSLA.

7.19 We recommend therefore:

Free home care for older people receiving "extended home care", (though they would still pay for ‘ordinary’ services).

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