The Isle of Wight has improved the lives of older people by making home care free for many over-80s so they aren’t forced to go into residential homes. Natalie Valios reports
“Without social services I don’t know what we would do – we wouldn’t be together for a start,” says Pat Barnden.
It’s the sort of praise you don’t often hear about social services, but Pat, 87, and her husband, Barney, 92, can’t speak highly enough about adult social care on the Isle of Wight. For although free personal care on the English mainland is about as popular among local authorities as a coffee Revel, the Isle of Wight decided to introduce it in April 2007.
When Sarah Mitchell and Claire Foreman arrived on the island as director of community services and head of community care respectively they found existing services to be traditional and paternalistic. Older people were paying a high price for residential care and had little access to flexible and affordable domiciliary care.
Foreman says: “There was a historic trend on the island for residential solutions and the fees were among the highest in the southern region – between £500 and £900 a week.”
The island has one of the UK’s fastest growing ageing populations, so Mitchell and Foreman decided they needed to do something radical to keep older people out of institutional care when they shouldn’t be there and, more importantly, didn’t want to be there.
One challenge they faced was the number of self-funders on the island, says Mitchell: “We needed to reach them because they are most likely to go into residential care early and unnecessarily because they have no access to advice and support.”
The solution was to introduce free personal care was introduced for over-80s who met the eligibility criteria of critical or substantial need, although Foreman admits: “We don’t apply eligibility criteria as rigorously as local authorities on the mainland.”
The decision is based on self-assessment, which Foreman describes as “the starting point for personalisation”. She says prospective users welcome this less intrusive process.
“Older people don’t like to ask for help or the embarrassment of going through a funding assessment,” adds Mitchell. She also says that it hasn’t been overly costly: “Few people have over-assessed and that’s a good message for the future because everyone is worried that self-assessment will increase costs. In fact, we go out and review them and sometimes put in more care than they have asked for.
“Older people have told us that they no longer feel like a burden to the community. Instead they feel that the council is celebrating and supporting them rather than forcing them into a situation.”
The Barndens agree. Pat has had mobility problems since a knee replacement operation went wrong a couple of years ago and left her in hospital for a year.
When she was due to be discharged a case conference on the ward revealed that the plan was for Pat to go into nursing care, which the couple opposed. Care manager Avis Clift, who was in the case conference, stepped in to arrange personal care for Pat at home.
The couple are grateful that, against the odds, they have stayed together at their bungalow. There is evidence of the help from social services and the primary care trust in every room – a wheel-in chair into the bathroom, manual hoist in the dining room, hospital-type bed and other equipment in the bedroom, as well as a ramp in the garden. And the banter between the couple and Clift reflects the rapport and affection that has developed.
Clift says: “We have built up this relationship and, although it’s on a friendly basis, it’s a professional relationship and we have to be careful about boundaries. Every now and again we have to pull back a bit to our roles so they don’t get blurred.
“I commission the services and work with the providers at putting together a care package to meet Pat and Barney’s needs and not the needs of the agency or carers. We all work as part of a team here with the district nurses, caring agencies and social services.”
Two carers go in for three one-hour slots a day, though the lunchtime carer is usually unnecessary, says Barney, so they have the flexibility to decide daily at about 10am whether it is necessary to fill the slot.
“They do everything for me,” says Pat. “They are generally the same carers so we know them well. They are not only carers they are friends.”
Barney looks after Pat too, as well as doing all the cooking. At the last care package appraisal it was agreed that the care agency the council commissions, Wight Home Care, would train him in manual handling so that he could cope if something were to happen to Pat during the night.
Meanwhile, tomorrow Barney is going on holiday for a week to attend their granddaughter’s wedding in Sweden. But the couple aren’t worried about his trip because a carer will live with Pat for the week. Barney pays for his own respite care and the council funds Pat’s 24-hour care while he is away.
“I hate to think where we would be without this, it’s beyond thinking,” says Barney.
Pat chips in: “We’re not going down that road. We have to stay and celebrate our 70th wedding anniversary next year.”
Free home care is just one component of Mitchell and Foreman’s desire to bring about change. Alongside this, the council provides a lifeline service (the pendant that older people wear around their neck to press when in trouble) and linked to that is a mobile warden service.
The call centre decides the type of assistance required, which could be a warden or an ambulance. There is a reablement domiciliary care service and two short-term residential reablement units for older people “so that at every point they have the chance to have their independence maximised”, says Foreman.
In another break from the norm, older people with mental health problems will be able to access the same services as under-65s. And the council is developing an integrated dementia service across the island from diagnosis to end of life, because people with dementia are more likely to end up in institutional care. This multi-disciplinary approach will have a community-based focus.
More than 1,000 older people receive free personal care on the island and during the first year of the system there has been a 41% reduction in residential care – “how many of those would then have moved on to nursing care?”, says Mitchell. There has been a 28% increase in those supported by domiciliary care. These two figures have brought savings of £1.4m in the residential care budget and a corresponding investment in domiciliary care of £1.2m.
No wonder the Isle of Wight won the south central region service transformation award for its free home care in the 2008 DH/NHS health and social care awards.
“We have turned around a community dependent on residential care to become a community where the majority of older people stay in their own home, supported by domiciliary care and with enough money to purchase their own preventive services, such as cultural and leisure activities, gardening and housework support,” says Mitchell.
Foreman adds: “It’s about having a healthier, sustainable older persons community on the island.”
For couples like the Barndens it means they can stay together, reassured that Pat is in safe hands. As Barney says: “Carers have become like part of the family. They know Pat’s problems and needs and are geared up to them. In the background I hear shrieks of laughter and know all is well in here.”
How the change was made
Action was taken in five key areas to get the scheme up and running:
● Political sign-up: The cabinet lead and the director briefed the cabinet and members.
● Leadership: care managers were supported to change their behaviour to embrace self-funders and accept older people self-assessing.
● Cost allocation: the finances were remodelled to achieve a greater immediate saving on residential care placements. This meant a change of practice for all staff.
● Publicity: there are still people who do not know about or understand the scheme even though it was publicised widely. This confirms the view that older people and their families do not think about care and its cost until a crisis. Efforts have been made to improve communications and publications.
● Discrimination: there were suggestions that to offer the scheme to over-80s was discriminatory but this is the group that is most likely to be placed inappropriately in residential care.
Published in the 2 October 2008 issue of Community Care under the headline ‘Island of the free’