Can the government deliver on its ambitions for older people’s services?

A slice of the pie is nice, but if it’s well-baked more than a
slice is better. Last week health secretary Alan Milburn gave older
people a fair-sized portion when he announced that they would be
the “principal beneficiaries” of the extra social services
resources he promised in April.

He declared that, by 2006, older people’s social services would
receive an extra £1bn a year in real terms – almost a third of
the extra £3.2bn social services is to gain by 2005-6.

Milburn outlined an ambitious programme of reforms aimed at
guaranteeing older people “not more of the same but faster access
to a wider range of services, offering them greater choice”. These
include faster assessments followed by quicker delivery of services
and equipment, more places in very sheltered accommodation, a
greater number of intensive home care packages and a requirement
for councils to offer older people direct payments. In addition he
promised an increase in care home places, more money for local
authorities to pay their fees and, most significantly, an amended
set of the environmental standards that were behind so many home
closures.

For the first time local authorities will be obliged to offer
older people access to direct payments. It will be up to the
individual councils how they pay the money, whether weekly or over
longer periods. Older people have been able to claim direct
payments since 2000, but figures from the Department of Health show
that between April 2000 and March 2001, of the 5,000 people
receiving direct payments, 88 per cent were aged between 18 and 64,
with only 500 over-65s receiving them. While the charity welcomes
any extension of direct payments it stresses that they must not
replace residential support or hospital care where it is
necessary.

Age Concern’s community care policy officer, Stephen Lowe,
anticipates that the number of older people wanting direct payments
will increase as people get used to the idea but questions whether
it will lead to tens of thousands taking them up.

“I think the number of older people who are going to want direct
payments will always be quite limited as they don’t want the effort
of managing them,” he explains.

He also doubts whether offering direct payments will have much
of an effect on delayed discharges. “People in that situation who
are in hospital and are not very well – I can’t see them wanting to
think about the issues of becoming an employer and paying direct
payments.”

But Lowe does think that direct payments offer an additional
choice to older people and allows them more control over their
care. The care provided by local authorities is often not enough
and too rigid, he says.

“I often come across the situation where a local authority has a
limit on how much care it will provide at home and, if it costs
more, the person is expected to go into residential care.”

In his announcement Milburn said that, by 2005, twice as many
older people will receive intensive home care compared with the
number in 1995. Depending on the intensity of care required, home
care can prove expensive for local authorities, costing an average
of £10 an hour compared with £280 a week for residential
care.

Lowe welcomes the aim to increase home care, but adds: “I am
worried that it would result in the continuation of the current
trend where local authorities are concentrating on people with
higher needs and those with lower needs find it hard to get
care.”

Few people would criticise the government’s aim to increase the
number of older people who receive help at home but the home care
market has its own problems, particularly with staffing. Without
some way of addressing the recruitment and retention problems of
home carers the government’s intentions seem unattainable.

The UK Home Care Association’s president, Lucianne Sawyer, says
that in order to recruit and retain carers the work needs to be
more satisfying. “It’s about the ability of the person providing
the care to use their initiative and respond, but the way contracts
are written means they can’t do that,” she says. “Many local
authority contracts are restrictive and prescriptive.”

The service is focused on the local authority rather than on the
user, she says. “Organisations that provide home care are
contracted by the local authority. Therefore, who is the client,
the person getting the service or the local authority, as home care
providers are having to please the local authority to keep the
contract?”

She feels that direct payments would help solve this triangular
relationship, as it would allow the user to negotiate directly with
the provider, choosing to go elsewhere should they be
dissatisfied.

The commissioning of services could also become an issue should
a large number of older people choose to take up direct payments.
Local Government Association programme manager Jeni Bremner warns
that there could be an overlap resulting in the double running of
services.

During the transition period there would still be a need to
maintain the current local authority commissioned services, as they
are gradually decommissioned. Commissioning could also become more
difficult, she says.

“At a time when providers want to move towards block
contracting, direct payments pull towards spot contracting.”

In his announcement, Milburn, for the first time, set out
targets for the maximum length of time taken to carry out client
assessments. He promised that by the end of 2004 assessments would
begin within 48 hours and be completed within one month.

While Bremner has no argument over this intention, she is
concerned that lack of resources and the quantity of experienced
assessors could undermine it.

Despite initial opposition to levy fines against local
authorities for delayed discharges, Milburn last week confirmed
that he intends to introduce the reform by next April.

The LGA remains “completely opposed” to the idea. Bremner says:
“The reasons for delayed discharges are complex and not the fault
of one particular bit of the system. Imposing a charge on one part
of the system is inappropriate.”

There are further concerns that fining social services and not
health providers will have a negative impact on partnership
working. Glenys Jones, social services director at Middlesbrough
and chairperson of the Association of Directors of Social Services
older people’s committee, believes that health and social services
have been working together and that fining local authorities could
“drive a wedge” into the partnership.

She is concerned that targets for faster assessment could be
linked with the fines for delayed discharges, an approach, she
regards as too crude.

“In the single assessment process critical information may be
required from the GP to complete the assessment or from the
occupational therapist or housing if there is a need for
adaptations. Sometimes you are not in control,” she says.

She believes it is critical for all the agencies that contribute
to the assessment to work within a clear “fast-track scale”
protocol.

In addition to his pledge to provide equipment within a week to
help people live in their own homes, Milburn also set out his
intention to legislate to remove the charges for equipment such as
handrails and hoists from April. Through ring-fenced funding, up to
half a million extra pieces will be provided to about 250,000 more
older people.

The British Healthcare Trades Association, which represents
equipment suppliers, welcomes the ring-fenced money but describes
the proposed timescale targets as “unachievable” without
“appropriate tracking and recycling of equipment”.

No one can deny that Milburn’s proposals are admirable, although
some would argue that they are overly ambitious. By promising so
much for older people the government could be shooting itself in
the foot unless it delivers on its promises.

Expectations will now be high, and managing them is likely to
pose challenges to all those involved in providing services.