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CHAPTER SEVEN POTENTIAL BARRIERS TO THE SUCCESSFUL OPERATION OF FREE PERSONAL CARE

Evaluation objective

Identify barriers to the successful operation and continued sustainability of Free Personal Care

7.1 This report has identified a range of issues that should be considered to ensure the continued sustainability of FPC. In addition the evaluation has identified four major potential barriers to the successful operation and continued sustainability of FPC:

• Concerns about the guidance on FPC
• Staffing/ workforce issues
• Relationship with NHS
• Funding.

Guidance

7.2 Local authorities have found the Scottish Executive's Guidance on Free Personal and Nursing Care ⁴⁸ to be helpful in determining how FPC should be delivered. However, three key concerns about the guidance have been raised by local authorities and national stakeholders during the course of the evaluation:

• Food preparation
• Assistance with medication
• Lack of clarity about taking resources into account when providing services

Food preparation

7.3 The FPC legislation does not define what is meant or covered by 'assisting with the preparation of food'. The consolidated guidance on FPNC issued by the Scottish Executive in July 2003 did not accurately reflect the legislation, as the Executive acknowledged in a subsequent letter. The consolidated guidance stated that in respect of Food and Diet:

"Food preparation and provision of meals are not included. However, assistance with eating, assistance to manage special diets and the assistance with the preparation of specialist meals (e.g. pureed food) is included."

7.4 Despite clarification being issued by the Scottish Executive in September 2004 stating that the guidance was incorrect and that the legislation should be followed, local authorities continued to interpret the legislation and guidance in different ways.

7.5 The anomalies that have been created by the different ways in which the legislation and guidance have been interpreted by local authorities was one of the key issues raised by the Scottish Parliament Health Committee Care Inquiry.

7.6 The evaluation identified a range of different practices in relation to charging or not charging for food preparation. For example, Angus Council provides a subsidised meals on wheels service for people who receive a home care service where the charge covers the cost of the food but not the cost of preparing the meal, so in effect, the council does not charge for 'food preparation'. On the other hand other local authorities, including Argyll and Bute, Dumfries and Galloway and Stirling, interpreted the legislation and guidance in such a way that they charged for food preparation except when it is combined with assistance with eating or managing special diets (e.g. when food needs to be pureed). Some local authorities (e.g. City of Edinburgh) have issued several versions of guidance notes to staff to try to clarify their policy and bring it into line with the legislation and Scottish Executive guidance.

7.7 Local authorities have been challenged on their interpretation of the guidance and legislation, by users and carers, representative groups and, in some areas, MSPs. Some local authorities (e.g. West Lothian) have taken a policy decision to review all cases where charges have been made for food preparation whilst others have been reviewing care packages and charges on a case by case basis.

7.8 The Scottish Executive issued a letter in May 2006 which confirmed its 2004 guidance, but, according to council officials interviewed for the research ambiguity and uncertainty remain about what the legislation and guidance actually mean in practice.

7.9 Twenty five local authorities responding to the evaluation's local authority survey stated that the guidance on food preparation needs to be clarified. For example, the response from Comhairle nan Eilean Siar referring to the May 2006 letter expressed the view that: "Even the latest letter of guidance continues to have a conspicuous absence of clarity." Furthermore, several local authorities (e.g. City of Edinburgh Council) have sought a legal opinion on the legislation and guidance. ⁴⁹

Assistance with Medication

7.10 Several local authorities (including City of Edinburgh, East Lothian, and Aberdeen City) suggested that the guidance needs to be amended to provide further clarification in relation to 'assisting with medication'.

7.11 Evidence collected from the survey of local authorities suggests that local authorities are interpreting the meaning of 'assisting with medication' in a variety of ways. As with food preparation, differing interpretations can be placed on what is meant by the term 'assistance'. For example, some local authorities (e.g. Argyll and Bute) have interpreted this as 'prompting' the service user to take medication whilst others (e.g. Dumfries and Galloway) have interpreted it as meaning assisting with administering medication.

7.12 The guidance states in relation to 'simple treatments' that: "Assistance with tasks in this component will continue to be in line with any local agreements defining task responsibilities of health care and care at home staff." The evaluation found that there are significant variations in the medical treatments that care staff undertake and the level of training they have received, across, and in some cases within, local authorities. Local authorities (e.g. Argyll and Bute) suggested that there is ambiguity and uncertainty about what services should be provided by personal care staff and which services should be provided by community nurses.

7.13 Dumfries and Galloway Council and NHS Dumfries and Galloway attempted to clarify the guidance by issuing detailed guidelines for Home Care staff assisting older service users with medication in November 2006. This clearly details the level of support that care workers should provide depending on the needs and capabilities of the service user and explains the various tasks included within the definition of assisting with medication. A key aspect of the guidelines is the detailing of the level of training and competency staff require in order to undertake each task.

Lack of clarity about taking resources into account when providing services

7.14 Chapters 3 and 4 of this report have highlighted that there are people waiting for assessments and/ or the delivery of care services following an assessment in a significant number of local authorities and that some local authorities are operating waiting lists for assessments and services. Some local authorities are also using policies such as capping home care packages as a means of managing service provision.

7.15 The Guidance on Free Personal and Nursing Care states that:

" Following a needs assessment, payment towards personal care should commence when the authority is in a position to arrange or provide the required services. It is important that people receive services on the basis of prioritising the care needs of older people rather than on individuals' ability to pay." ⁵⁰

7.16 Local authority interviewees have suggested that the guidance is not explicit about, and does not provide detail on, the key issue of whether/ how and in what circumstances local authorities are able to take the availability of resources into account when determining access to FPC. The application of eligibility criteria and thresholds for services and the manner in which local authorities determine whether clients are waiting for a service differs widely across local authorities. The guidance clearly suggests that a local authority can take account of its available resources when arranging to provide services under FPC. However, it is not clear whether this would allow local authorities to delay payment of FPC/ FNC to self funders in care homes if funding is not available and how this relates to Lord Hardie's judgement that it is not an option for local authorities to do nothing if resources for providing the optimum care are not available (see para 3.30).

7.17 The guidance does not deal with the key issues of whether local authorities are able to operate waiting lists for people to receive personal care at home and whether they can operate a cap on the cost of home care packages. Both are practices that are followed by significant numbers of local authorities but which run counter to the broadly held public view, and expectation, that the provision of FPC services and payment of FPC should not be subject to financial constraints. (see Chapter 2)

Staffing/ Workforce Issues

7.18 The evaluation found that staff shortages have been, and continue to be, a major constraint on how some local authorities deliver FPC, contributing to delays in care needs assessments, reviews and the delivery of home care (see Chapters 3 and 4). Failure to address staffing shortages and broader workforce configuration issues can act as barriers to the effective delivery of FPC. Workforce issues need to be tackled to ensure the continued sustainability of FPC, including:

• Recruitment and retention of social workers, and the training of other staff to carry out assessments and co-ordinate or manage care packages
• Recruitment and retention of care staff to provide personal care for elderly people in care homes and at home and the training and upskilling of staff to provide personal care services
• Modernising the hours, pay and conditions of care staff to assist in providing client centred services. Home care staff in some local authorities (e.g. Argyll and Bute) still work old part-time shift patterns based on the provision of home help services rather than working full day shifts that allow for staff providing personal care services in the evenings and at weekends.

7.19 These issues are being addressed at a national level through the Scottish Executive's 21 ^st Century Social Work Review Implementation Plan ⁵¹ and the first report of the Range and Capacity Review Group ⁵² but they also need to be tackled at a local level through the development of local capacity plans and re-configuring services and staffing structures.

7.20 Evidence collected from national stakeholders and case study local authorities identified a number of workforce related issues that remain to be resolved either nationally or in individual local authorities, confirming the findings and recommendations of the 21 ^st Century Social Work Review ⁵³. The key staffing / workforce issues raised during the evaluation are summarised below.

Recruitment

7.21 Recruiting social work and care staff can be problematic particularly in rural and island areas and urban employment 'hot spots'. Recruitment and retention is likely to become increasingly difficult due to the demography of existing care staff (for example, around one in six of Angus Council's 600 care staff are aged 59 or over), the limited pool of possible recruits and competition to recruit staff.

Implications of upskilling the workforce

7.22 With the growing shift from providing non personal care to personal care, local authorities are having to provide and fund training programmes for domestic care staff to 'upskill' them to enable them to undertake personal care tasks (e.g. in relation to handling clients and assisting with medication and treatments). The possibility of losing some staff who do not want to go through the training will exacerbate existing recruitment problems. Another problem related to training is the difficulty in finding cover for staff who are undergoing training, especially in rural areas. Increasingly, there is a need to train staff to undertake assessments and use electronic data sharing systems.

Modernisation

7.23 The need to modernise working practices, hours and conditions to bring them into line with the demands of the person centred, choice led approach to providing personal care is also placing strain upon the service. Modernising services involves introducing shift patterns and longer, more flexible working hours for care staff. There are ongoing debates as to whether care staff should be brought under one grade covering both personal and non personal care tasks. There are salary implications in re-grading staff to allow for the additional duties and responsibilities involved in delivering personal care tasks.

Change management and service reconfiguration

7.24 All local authorities have gone through, or are still in the process of going through, major change management and service re-configuration in social work services. The introduction of FPC coincided in some areas with a major reorganisation of services into children's and adult services. Many are now reorganising again to integrate social services with Community Health Partnerships.

7.25 Some local authorities (e.g. Stirling and Angus) re-structured their home care staff around the time of the introduction of FPC to introduce new shift patterns to enable staff to provide personal care services in the early morning, evenings and weekends. Other local authorities are still attempting to re-structure their home care staff to introduce greater flexibility, new hours of working and shift patterns in order to provide more person centred services. For example, Argyll and Bute Council is still to complete a home care staff review that began in 2002.

7.26 City of Edinburgh Council restructured its adult services in Spring 2006. This major re-structuring included the creation of 'Home Care Direct' as a new central point for all enquiries and with a role to co-ordinate assessment and negotiating of care packages; the reorganisation of social work practice teams and Home Care into five teams (sectors); and giving Home Care Co-ordinators responsibility for undertaking simple assessments and reviews.

Relationship with the NHS

7.27 The continued sustainability of FPC has to be considered within the broader context of Community Care and the development of the Joint Future agenda. Therefore the relationship between local authorities and their NHS partners is a crucial determinant of how FPC operates now and in the future. Three key issues were raised by research participants:

• The interface between personal and nursing care
• The need to implement Single Shared Assessment ( SSA)
• Funding through resource transfer.

Interface between personal and nursing care

7.28 Local authority staff interviewed for the evaluation suggested that the interface between local authorities and the NHS (for example, different or conflicting practices in determining how personal and nursing care is provided by local authority or NHS staff) was a key factor in determining how community care in general and FPC operates. The Scottish Executive Review of Nursing in the Community in Scotland ⁵⁴ highlighted the important role that nursing services in the community play in supporting the broader health and community care agenda, including the need for full integration between all hospital and community services to facilitate the sharing of knowledge and skills.

7.29 Many of the Review's recommendations are relevant to the development of better relationships between the NHS and local authorities in relation to the delivery of Community Care in general and FPC in particular, including:

• nurses should ensure they incorporate the health care needs of unpaid carers into care plans and utilise single shared assessment tools effectively
• nurses must ensure that care plans identify the means by which nurses and care workers will communicate and share information. Care plans should include actions to ensure that common problems are anticipated before they arise
• a good practice framework to support service commissioners and providers to train and supervise paid personal care providers should be developed.

Implementation of SSA

7.30 Chapter 3 highlighted the important role that the assessment process and SSA plays in determining the care needs of elderly people and consequently their access to FPC. The evaluation found that there are major differences across Scotland, and even within local authority areas, in the level of integration of nurses and other NHS staff in the assessment process. Where integration is working effectively nurses are members of multi-disciplinary teams and contribute fully to the implementation of SSA, leading on assessments and taking on the role of care managers, usually within hospital based delayed discharge and intensive outreach teams (e.g. Argyll and Bute). However, nurses are not engaged in SSAs to the extent desired by all local authorities.

7.31 For example, in West Dunbartonshire, while nurses are full members of multi-disciplinary delayed discharge teams in hospitals, they are not taking the lead in SSAs in the community and local authority staff interviewed for the evaluation expressed concern at the lack of co-operation between nurses and local authority staff in carrying out assessments in care homes.

7.32 The increased involvement of nurses in taking the lead in SSAs in the community and care homes would help to reduce delays in assessments being completed and therefore speed up access to FPC services.

Resource Transfer

7.33 The third key element of the relationship between the NHS and local government that needs to be resolved to support the continued sustainability of FPC relates to funding via resource transfer.

7.34 The funds made available from NHS resource transfer and Scottish Executive funding for tackling Delayed Discharge have been a key source of additional funds which have supplemented the GAE allocations for FPC and other older people's services and provide specialist services that supplement personal care service provision.

7.35 For example, these sources have partly funded the Short Term Augmented Response ( STAR) teams in Dumfries and Galloway, the Prevention of Admissions scheme and Early Support Discharge Team in Angus, the Integrated and Intensive Outreach Teams in Argyll and Bute and the Step Up/ Step Down schemes in West Dunbartonshire and Stirling. These schemes provide personal care at home and rehabilitation for people who are being discharged from hospital or are at risk of requiring hospitalisation. The additional funding for these services from Delayed Discharge and NHS resource transfer supplements the local authorities' contribution, which comes from their FPC and older people's services budgets. Case study local authorities voiced concern that Delayed Discharge funds and NHS resource transfer need to be continued and become mainstreamed in order to ensure that such positive initiatives continue in the long term.

Funding

7.36 Although not explored in this research, funding was a key issue raised by the Scottish Parliament Health Committee Care Inquiry, which concluded that:

"Although significant issues have emerged with the delivery of free personal care the introduction of the system of free personal care across Scotland does seem to have gone smoothly. … It is in the funding of the policy that difficulties have emerged." ⁵⁵

7.37 Consideration of the funding and cost of FPC was not within the remit of this evaluation as the Scottish Executive has established a working group to analyse the cost of FPC and the wider costs of care for older people at a national level.

7.38 However, as with any other policy which involves public expenditure, the future sustainability of FPC depends on ensuring it is adequately funded to meet future demand. It is vital that agreement is reached between the Scottish Executive and local government as to the current costs of providing FPC and how future costs will be met.

Summary and Recommendations

Guidance

7.39 Despite attempts by the Scottish Executive to provide guidance on assisting with the preparation of food, most local authorities still believe there is ambiguity which has led to different interpretations about what services should be provided free. (7.2 - 7.9)

7.40 Assistance with medication is another area of the guidance that some local authorities have suggested should be clarified. Concerns are related to the definition of assisting with medication, the potential cross over with nursing care and the need to ensure that staff assisting with medication have the correct level of training and support (7.10 - 7.13)

7.41 The guidance on FPNC lacks clarity and transparency on the key issue of whether/ how local authorities are able to take resource issues into account in determining access to care services and FPC. (7.14 - 7.17)

Staffing/ Workforce issues

7.42 Staffing and workforce issues are a major constraint on how FPC is being delivered. Shortages of staff have contributed to delays in assessments and in the delivery of home care services. Inefficient working practices and staffing structures have restricted home care services' ability to meet demand for services. (7.18 - 7.26)

Relationship with NHS

7.43 The relationship between local authorities and their NHS partners is a crucial determinant of how FPC operates now and in the future. Three issues need to be considered: the interface between personal and nursing care; the need to implement Single Shared Assessment; and funding, principally 'resource transfer'. (7.27 - 7.35)

Funding

7.44 As with any other policy that involves public expenditure, the future sustainability of FPC depends on ensuring it is adequately funded. (7.36 - 7.38)

Recommendations

R7.1 The Scottish Executive should establish a short life working group with representatives from local government and other stakeholders to review and clarify the guidance on FPC especially in relation to 'assistance with food preparation', 'assistance with medication' and the extent to which local authorities can take resources into account when making decisions regarding the delivery of FPC.

R7.2 Local authorities should be asked to report to the Scottish Executive on how they have tackled, or are intending to tackle, the workforce issues that have constrained or may constrain their delivery of FPC.

R7.3 Joint Future Partnerships should report (to the Scottish Executive) on how they will support the implementation and operation of FPC with particular reference to the interface between personal and nursing care, the implementation of Single Shared Assessment (to reduce delays in assessments) and funding of care services through resource transfer and other joint funding initiatives.

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