With long-term care becoming a high-profile issue, the need for fair financial assessments and charging has been thrown into sharp relief. Here, Greta Bradley and Jill Manthorpe report on a recent study of charging systems.
Whatever the results of the political debate about the funding of long-term care for older people, someone, somewhere is likely to be involved in means testing. Social workers, care managers and finance officers are responsible for the financial assessment of people entering long-term care. Any new system should take account of their experiences.
The study, funded by the Nuffield Foundation,1 found a variety of practices under the name of financial assessment. The research, gathered from five English social services departments, collected information from 177 care managers.
The study finds that many care managers feel that they do not have a clear practice or policy steer on how the work should be done. There is also diversity of practice within authorities and significant differences between councils, and there are several key areas where social workers experienced particular uncertainty.
Care managers appear split in their views of whether to suggest that older people or their relatives, or both, seek independent advice about the financial implications of entering a nursing or residential home. Half say that it is not their role, half say that it is.
Similarly, they are divided on whether they should give written information on how an older person may protect their assets. In some cases the approach taken has little in common with the official steer of their department. Some care managers feel confident in giving older people leaflets from, for example, Age Concern, spelling out how older people can "put their house in order" and the legal context to "divesting" themselves of assets. Others, the study reveals, are unclear about their role or the stated view of their department. Not surprisingly, the care managers who are most uncertain about giving advice are the ones who have received the least training.
While 51 per cent of care managers agree that residential care should be means tested, many do not feel comfortable when checking bank accounts. Indeed, nearly a quarter of those care managers who are specifically required to verify evidence in this way avoid this activity. In one authority a manager informed us that "jobs would be on the line" if staff did not follow through the directive. Nonetheless, we interviewed staff in the same section who said that sometimes they would not engage in "intrusive activity" which undermined their relationship with the older person.
Many care managers based in hospitals find this aspect of the work problematic. Frequently, they are reliant on next of kin to produce financial information on behalf of the older person; the very people for whom there may be a conflict of interest. Finding privacy to discuss sensitive matters such as money is also difficult.
Care managers are concerned about charge avoidance and ways in which this is identified and reported on. The study unearthed evidence of some guidance and procedures, but these are inconsistently acted on. When care managers report suspicious cases, many feel let down by their department and believe even the most blatant cases of charge avoidance are likely not to end up in court. They also feel unclear about how these matters are resolved, which leads to frustration with the task. As one care manager states: "If you go part way to question clients and challenge them, which can result in you getting flak, then the local authority should pursue the case. I am likely not to refer a case on, as I may end up looking incompetent when nothing happens."
Many staff feel ambivalent about reporting cases of charge avoidance because they feel the charging policy is unfair, open to interpretation and full of "loopholes" that enable people in the know to avoid charges.
There is also a feeling of frustration among legal staff that local authorities were not given sufficient powers to uncover evidence. As one local authority legal adviser stated: "The onus is on the local authority to show there was intention to deprive and that's where the legislation falls down...if relatives say 'we didn't know mum was going into care' that's enough...it [the Health and Social Services and Social Security Adjudications Act 1983] is a useless piece of legislation."
A further sensitivity found by the study concerns the political will to recover charges. Senior managers and chairpersons of social services committees hold that it is unlikely to be in their interest to be seen to tackle a vulnerable older person. One manager reflected: "Taking people to court is not what a politician wants to do...we point out to clients that they should pay and that is enough."
If charges had been avoided the view was that it was the relatives or beneficiaries and not the older person who should be pursued to court. This sympathetic view towards older people was summed up by a senior manager: "We need a system where the relatives are pursued, as they are the ones who benefit. I would pursue them to court - no hesitation. But not the older person... you can't provide care for older people then hound them."
A considerable number of care managers referred in the study to problems of financial abuse. They gave examples of relatives exercising undue influence on older people when disposing of property, of relatives actively preventing admissions to care in order to preserve family assets, and of the systematic abuse of power of attorney. However, proving financial abuse is seen to be problematic. Some care managers say they are reluctant to report it; their perception is that they lacked statutory powers. They are also uncertain of their ground and the extent to which the department would protect them. One care manager describes her dilemma as follows: "I can't tell the client that abuse has happened as it is a breach of my role, it could be construed as slander, and we can't prove it...the department doesn't legally protect me."
Care managers speak of their need for clear guidance in financial assessments. This will need to incorporate links with other policies and practice guidance, such as the vulnerable adults procedures and policies in respect of intermediate care. It will also need to key into DoH updating of Crag (charging for residential accommodation guide). Guidance should also be embedded into training at pre- and post-qualifying levels. The range of ethical dilemmas identified by care managers should inform training. Good quality and consistent information on the charging policy and its implications in practice are crucial for all parties. Information available to care managers should be reliable, accessible and transparent. It should enable care managers to feel confident that they are operating a system which is equitable and nationally driven. It is our view that it is not the role of care managers to point to loopholes but to operate the policy fairly and systematically. Standardising written information given to older people would also help promote administrative justice, as would a clear steer on how they and their relatives should be informed about obtaining independent legal and expert advice.
We found that supervision was an important opportunity for care managers to discuss particular cases. Many reported instances where they had suspicions that all was not well within a family, but perceived there was little they could do. Supervision could help them identify their particular concerns and the basis for action or otherwise, and also support them in their task to operate within the law, humanely and with sensitivity.
Finally, local politicians raised most clearly the issues of political sensitivities in dealing with people who avoid charges. We know that few cases are taken to court; cases are often settled out of court. In this contentious area, local understandings are reached. How cases are handled can be a learning point for all, but rarely does the training of practitioners extend to these particular lessons learned. Without a feedback loop to practitioners, a culture of conspiracy can emerge, helping to feed ambivalence throughout the organisation and encourage practitioners to operate outside the law. A more open discussion of discretion is likely to allay disquiet among staff and also encourage more accountability and openness within the system. It is likely that we will see an increasing requirement placed on local authorities to operate with less discretion and perform more mandatory tasks.
This research extends our knowledge of charging systems, already heavily criticised in respect of home care charges for being inequitable and insensitive.2 It reflects care managers' ambivalence, noting that while they are often able to identify problems in the system, they are generally able to communicate sensitively about such matters, could recognise the issues of loss involved and are alert to the possibilities of mistreatment. Care managers involved in assessments are well placed to deal with financial assessments in close partnership with local authority finance officers and legal advisers.
In what can be difficult times for older people, the impact of financial assessment upon them can be ameliorated by skilled, fair and respectful processes. Care managers' experience will be vital in the construction of guidance on financial assessment. The next part of this research will involve them in this important task.
1 Bradley G et al, Ethical Dilemmas and Administrative Justice: Perceptions of Social and Legal Professionals Towards Charging for Residential and Nursing Home Care, 2000.
2 Audit Commission, Charging with Care, The Stationery Office, London 2000.
If you have views on the type of guidance on financial assessment, which would be helpful to care managers and local authorities, we would like to hear from you. Contact Greta Bradley at M.E.Bradley@comhealth.hull.ac.uk
Greta Bradley is senior lecturer in social work at University of Hull. Jill Manthorpe is a reader in community care at the University of Hull.
Have your say – Are you involved in means testing? Do you find making fionancial assessments of people stressful, and if so what changes would you like to see? Have your say by joining the debate. E-mail your views to us at comcare.haveyoursay@rbi.co.uk
