Charging with care

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