Eligibility criteria depriving older people of gain services: thresholds on the rise

Sometimes referred to as the “care gap”, the difference between the needs of older people and the public money to pay for them is in reality an ever-widening gulf. The number of over-85s is rising at 2.5% a year, yet the social care funding shortfall is already running at £1.7bn and on current projections everyone whose needs are less than “substantial” will be denied a local authority service within three years.

More than a year after Sir Derek Wanless’s report, Securing Good Care for Older People, showed that spending on social care would have to more than double by 2026 just to keep pace with demand, there is little to suggest that the issue has caused more than a ripple on the political seismograph. The Treasury has been notably tongue-tied, Gordon Brown all but ignored it as he set out his credentials for Number 10, and none of the six contenders for Labour’s deputy leadership gave it much air time.

The size of the problem is clear from our survey (see “Councils feel the pressure”, below) of eligibility criteria, which shows nearly one-fifth of local authorities in the past 18 months making it more difficult for older people in need to get services. A similar survey published by older people’s charity Counsel and Care earlier this month found more than 70% of councils just providing services for people with high needs (defined as “substantial” or “critical”) and, worse, 12% only supporting older people with the most acute, critical needs.

Voluntary sector alternatives

While simple, low-level services which help older people to maintain their independence have now almost disappeared from local authorities, some councils are better than they were at flagging up voluntary sector alternatives. But even these services, intervening early to prevent further decline into acute need and institutional care, are usually under-resourced and overstretched.

According to Annie Stevenson, senior policy adviser at Help the Aged and member of the Caring Choices coalition set up to stimulate debate on the funding of long-term care, the poor law lives on. “What we have now is the cumulative effect of gross under-investment over many years which has simply entrenched the poor law mentality,” Stevenson says. “Ageism is the root of it, but one test of a civilised society is how we treat our older people.”

Lobby for Reform

As the crisis deepens, the lobby for fundamental reform grows. Care services minister Ivan Lewis, the one politician who cannot dodge the issue, writing in The Observer in June, called for a single health and well-being service in each locality, in which older people with individual budgets controlled their own services supported by social workers, acting as facilitators and advocates, and strong community networks. These networks depend on a range of preventive provision, from good-natured neighbourliness, easily accessible buildings and shops, to services such as gardening, cleaning, transport, education and leisure, through to relatively sophisticated ideas like telecare and timebanks. If all this is in the spirit of last year’s white paper, Our Health, Our Care, Our Say, it is often honoured in the breach.

Many pundits think it makes good economic sense to reconfigure social care rather than hope for vast sums of extra cash to shore up a system of intensive support presided over by a discredited set of Fair Access to Care Services (FACS) eligibility criteria. The new approach depends on diverse ­agencies coming together, for example in local area agreements, to plan and implement a preventive strategy.

“This is much bigger than social care,” says Counsel and Care chief executive Stephen Burke, “but it depends on your definition. You have to look at things like health, housing and social care together without drawing an arbitrary dividing line between them.”

Telecare benefits

Institutional care, Burke argues, is inefficient and encourages dependency, citing evidence that telecare technology in people’s own homes not only delays their admission to hospitals and nursing homes but, if they do eventually arrive there, it reduces their average stay from three years to one year. “While it is true that more evidence is needed about the impact of early intervention and prevention, I think government should take a leap of faith as it did with Sure Start.”

Proponents of what has been grandly described as a fresh “constitutional settlement” for social care argue that new partners will bring new money with them, welcome news for practitioners wishing to escape the routine of assessment and ­rationing they have become used to. The white paper called for 5% of hospital ­budgets to be moved into community services by 2014.

At the heart of the new settlement is personalisation, in which choice and control pass from professionals to service users. It is a giddy prospect for practitioners who wonder about the impact on their own job descriptions, but the proposed shift from assessment to self-assessment could free up more time and resources for the kind of empowering work with users they came into the profession for in the first place.

As personalisation catches on, it may help social care finally to shrug off the poor law. Association of Directors of Adult Social Services vice president John Dixon likes to stress diversion rather than prevention, having discovered two significant benefits, financial and social, in providing advice and support to the many well-to-do people who pay for their own care in West Sussex where he runs the department.

Having needlessly admitted themselves to residential care in the past, they can now be steered towards cheaper community-based options with far fewer later turning up on the council’s doorstep, having run out of money. And, combined with individual budgets for the less well-off, it could create a single system of expert self-funders in which everyone has a stake.

Even so, Dixon is cautious about the economic case for personalisation, which has been put to the test in Partnerships for Older People Projects (Popps) and individual budget pilots. For example, individual budgets are cheaper for high-cost, low-volume services for people with learning disabilities, say, but the scope for savings is less clear when it comes to the high-volume, relatively low-cost services for older people that account for the bulk of public spending. “After all,” Dixon says, “the emphasis of procurement over the past 15 years has already been on reducing costs and individual budgets are not a magic wand.

“They might lead to a vastly better service in the eyes of the individuals who receive them, but they’re not a way out of the funding problem. Funding will have to be faced up to sooner or later.”

‘A daily shower for 15 minutes would improve my life’

Valerie Tugwell is 72 and lives in a bungalow in Essex. She is doubly incontinent but since 2004 she has been given just one shower a week by a home carer. She would like a shower every day and a half-hour dinner call instead of meals on wheels because she has diabetes and an intolerance to dairy products, which means she is unable to eat many of the meals.

On days when she cannot eat the food she makes herself a sandwich. Eating food she is intolerant of causes bouts of diarrhoea. “Once I had my sheets changed at 8.30am and my home carer had to come back two hours later to change them again,” says Tugwell. “I get washed down every day but it’s not the same as having a shower and it only takes an extra 15 minutes.”

Age Concern helps Tugwell with her shopping but every three weeks a relative travels to Essex from their home in Norfolk to take her shopping and she pays their travel expenses.

Tugwell has lived in her bungalow for 14 years but has requested a transfer because her physical disabilities make it unsuitable. She is awaiting a transfer to warden-assisted accommodation but few places will accept animals, a problem given Tugwell has a 16-year-old cat, Twinkle. “She is all I’ve got in life,” she says.

Jenny Owen is director of adult community health and well-being at Essex Council and she has recently visited Tugwell at home.

“We are in complete agreement about the fact we need to be campaigning about resources,” she says. “I understand her points about bathing but I calculate that in order to give everyone who is doubly incontinent daily baths I would need an extra £1m. That’s a huge pressure on the budget.

“Demographic pressures and inflation on care costs means the budget is under a lot of pressure. By 2025 we will have 63,000 people aged over 85 that we will need to provide services for. “

Making the grade: how needs are assessed

Under government guidance Fair Access to Care Services, councils are required to assess needs according to four bands: low, moderate, substantial or critical.

Critical is when:

● Life is/or will be threatened and/or significant health problems have developed or will develop
● and/or there is, or will be, little or no choice and control over vital aspects of the immediate environment
● and/or serious abuse or neglect has occurred or will occur
● and/or there is, or will be, an inability to carry out vital personal care or domestic routines and/or vital involvement in work, education, or learning cannot or will not be sustained
● and/or vital family and other social roles and responsibilities cannot or will not be undertaken.

Substantial is when:

● There is, or will be, only partial choice and control over the immediate environment and/or abuse or neglect has occurred or will occur
● and/or there is, or will be, an inability to carry out the majority of personal care or domestic routines
● and/or involvement in many aspects of work, education and learning cannot or will not be sustained
● and/or the majority of family and other social roles and responsibilities cannot or will not be undertaken.

Moderate is when:

● There is, or will be, an inability to carry out several personal care or domestic routines
● and/or involvement in several aspects of work, education or learning cannot or will not be sustained
● and/or several social support systems and relationships cannot or will not be sustained
● and/or several family and other social roles and responsibilities cannot or will not be undertaken.

Low is when:

● There is, or will be, an inability to carry out one or two personal care domestic routines and/or involvement in one or two aspects of work, education or learning cannot or will not be sustained
● and/or one or two social support systems and relationships cannot or will not be sustained
● and/or one or two family and other social roles or responsibilities cannot or will not be undertaken.

Councils feel the pressure

Across England evidence is emerging that cash-strapped councils are being forced to restrict access to adult care services, writes Sally Gillen.

An ageing population and a huge increase in the number of children with learning disabilities with complex needs, who are becoming the responsibility of adult social services, are straining budgets.

But just how bad is the problem? Community Care surveyed half the country’s 150 councils that provide adult social care to form a national picture of how local authorities are responding to financial pressures.

Our research shows that only four of the 75 councils provide services to people who fall in all bands: critical, substantial, moderate and low. Fifty-four of the 75 councils (72%) have set their threshold at substantial. Fourteen provide services for moderate need (19%) and four for those with low need (5%). Three councils provide services for those in critical need only (4%).

So, although the figures may allay fears of a looming crisis, the research does show that across the country eligibility criteria for services are becoming tighter.

Fourteen of the 75 councils have raised their threshold in the past 18 months, 10 of them from moderate to substantial, two of them to critical and two more from low to moderate.

A further nine councils are reviewing their thresholds with a view to raising them. If they go ahead it will mean that 30% have raised their threshold in the past three years.

Further information

Contact the authors
 Mark Ivory and Sally Gillen

This article appeared in the 19 July issue under the headline “Where the poor law lives on”

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