Charginmg 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

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