news analysis of expected new guidance on access to care services

English local authorities are still waiting for new
guidance on access to care services and are fearful of the
rationing decisions that it may well bring. Lauren Revans
reports.

There were two noticeable absences at the conference on Fair
Access to Care Services (FACS) in London last week. The first was
the FACS guidance. The second was the Department of Health’s senior
civil servant who had been due to explain the yet to be published
guidance to conference delegates.

The guidance was first promised in the 1998 white paper
Modernising Social Services in response to a widespread
lack of understanding about which services are or should be
provided, and to what standard.

At the launch of the draft guidance in July 2001, health
minister Jacqui Smith said it would “help to achieve national
consistency for adults of all ages” (News, page 4, 26 July). She
added: “In particular, the guidance will emphasise that when making
decisions about access to services, local authorities should place
importance on helping individuals to retain their independence as
much as possible.”

Consultation on the draft guidance finished in October 2001 and
the government set itself a provisional autumn deadline for
publication of the final version. Local authorities were told they
would need to revise their eligibility criteria, using the FACS
guidance, by April 2002.

It was with some surprise then that conference organisers
Harrogate Centre for Excellence found themselves last week running
a conference on guidance that had not yet been published.

But despite all the uncertainty around its arrival, the guidance
is unlikely to contain too many surprises. Social Services
Inspectorate assistant chief inspector and conference chairperson
John Fraser says feedback on the draft has been “quite
constructive” and he does not expect the final version to differ
too much.

That school of thought is supported by evidence from Wales,
which published its own version of the FACS guidance last
month.

The chapter on setting eligibility criteria in the Welsh
assembly’s Health and Social Care for Adults: Creating a
Unified and Fair System for Accessing and Managing Care bares
striking similarities to the English draft guidance.

“There is good reason to believe that the Welsh guidance will be
a reasonable basis on which to make assumptions about the English
guidance,” director general of Age Concern Gordon Lishman told
conference delegates.

Top on the list of those assumptions is that FACS is, to all
intents and purposes, about rationing services. Disability manager
at Bradford social services department Jim Ledwidge explains: “The
demand for social care is greater than the supply. The number of
potential services users who feel they are not getting enough
support is far greater than the number who think they are getting
enough. The cost of services is increasing. And as far as I’m
aware, the government isn’t talking about a huge injection of
resources alongside FACS. So, we are talking about rationing.”

Ledwidge says publication of FACS guidance will raise
expectations still further and he anticipates decisions being
challenged.

“If we are talking about increasing services for some, then we
are inevitably talking about reducing services for others,”
Ledwidge says.

The eligibility framework is graded into four bands – critical,
substantial, moderate, and low – based on the seriousness of the
risk to independence if problems and issues are not addressed.

The Welsh guidance suggests that some local authorities might
draw the line of eligibility between these four bands, for example
deciding that all needs that fall within the substantial and
critical bands are eligible, while others might choose to draw the
line within all four bands.

The Welsh guidance adds: “In the past, the imperative to target
those in immediate need has, to some extent, resulted in people
with low level needs not receiving appropriate or timely responses.
It is a challenge to get the right balance between responding to
immediate and high level needs on the one hand, and low level
needs, which nonetheless may require a speedy response to prevent
deterioration or to enhance individual quality of life, on the
other.”

The focus on prevention is a theme throughout the Welsh and the
draft guidance and is likely to remain a high priority in the final
version of the English FACS too.

The Welsh guidance goes as far as warning local authorities
which have stopped providing certain low-level preventive services
altogether – such as shopping only, cleaning only, the provision of
bathing equipment only – to “review their positions”.

“Such services, if targeted purposefully, can have an
appreciable cost-effective impact on promoting independence and
preventing deterioration in an adult’s personal circumstances,” it
says.

But many remain sceptical about turning the rhetoric on
prevention and independence into reality, given the finite
resources available.

The Welsh guidance, for example, qualifies all its good
intentions by stating that, in setting their eligibility criteria,
local authorities will need to take account of their resources,
local expectations, and local costs.

“It is recognised that in order to manage these resources, local
authorities will continue to have to decide those they are able to
help and those they are not,” it states.

But Age Concern has a secret weapon when it comes to ensuring
that people’s rights to social relationships are recognised and
assessed, and are not automatically deemed dispensable by those
judging eligibility and rationing services.

In a recent case at the European Court in Strasbourg (Botta vs
Italian state), the judge ruled that the right to private and
family life under article 8 of the European Convention on Human
Rights included a right to the development of the personality of
each individual in relation to other people.

“The general import of that case is if you take action which
would lead to the denial of the right to development of personality
you are in contravention of the Human Rights Act,” Gordan Lishman
says. “That means assessments can not disregard the right to access
to social relationships. If that right or need is not recognised as
part of the assessment process, it will be actionable.”

As well as reminding local authorities to ensure their revised
eligibility criteria take account of the implications of the Human
Rights Act and the Race Relations Amendment Act as well as case
law, the final guidance is expected to make recommendations about
joint training in FACS, risk assessment, and anti-discriminatory
practice with staff from other agencies who may also be involved in
social care assessments and may contribute to eligibility
decisions.

The Welsh guidance goes further than this, calling on local
authorities to develop joint eligibility criteria with their health
partners wherever pooled budgets are involved, and to ensure that
health agencies clearly understand social care eligibility criteria
where other joint commissioning and integrated working arrangements
are in place.

According to the draft guidance, local authorities have until
the end of March 2003 to complete a review of all those using
services at the start of April 2002, using the FACS guidance. But
with the deadline in Wales set for October 2003, it seems likely
the goalposts in England will move too to take account of the
delays in publishing the guidance.

The SSI’s John Fraser told the conference he would be
“staggered” if the guidance came out without a reviewed timetable
for implementation. He also suggested delegates asked about
resources, particularly for rolling FACS out, at a workshop to
which they would all be invited once the guidance was
published.

But Ledwidge and others are not holding their breath, despite a
hint from Fraser that the publication of FACS might be tied to some
new money: “The reality is that most, if not all, social services
departments face huge financial pressures. We are looking at ways
of spending less on social services, not more. Fair access does
entail some fair rationing. We have got to be honest about
that.”

Draft English guidance www.doh.gov.uk/scg/facs/policyguidance.htm

Welsh guidance
www.wales.gov.uk/subisocialpolicysocialservices/content/managingcare.pdf

Eligibility criteria

Individual eligibility is measured in both the draft guidance
and the Welsh guidance against four factors judged to be key to
maintaining an individual’s independence:

– Autonomy.

– Health and safety.

– Ability to manage daily routines.

– Involvement in family and wider community life.