Promoting Independence in Vulnerable People
ITEM BV8
Review report and action plans
|Area under review |Promoting Independence in Older People |
|Core review team membership |Review Team Leader |
| |Neil Lawrence Performance Review Adviser |
| |Designated members |
| |Cllr Margaret Ferriman |
| |Cllr Lesley Legge |
| |Other core team members |
| |Natalia Lachkou Quality and Performance Officer (Supporting People), Social & Health Care, |
| |Oxfordshire County Council |
| |Eva Blacklock Chair of County Older People’s Panel |
| |Helen Scragg Anchor Staying Put |
| |Val Messenger Assistant Director for Public Health, SE & SW Primary Care Trust |
|Terms of reference (taken from the Scoping Report) |The Review will consider how Oxfordshire County Council can, working with its partners and |
| |key stakeholders, best enable older people to maximise their independence in terms of support|
| |to live in the community and access to and control over the services they receive. |
| |Key areas to be covered as part of the review are: |
| |How well the County Council is structured to promote independence, particularly in |
| |cross-departmental working and how its staff are trained and instructed |
| |How successful initiatives to promote independence have been, which are most effective, and |
| |how this is measured. |
| |How day services can contribute to better promoting independence for non-dependent older |
| |people, and how well they work with carers and voluntary groups |
| |How the County Council can increase the number of older people helped to live at home |
| |How NSF Standard 8, on the promotion of health and well-being for older people, can be |
| |implemented in Oxfordshire |
| |At its meeting on 18 September 2002, Best Value Committee also resolved; |
| |“to ask the officers to ensure co-ordination between the review and the Council’s Social |
| |Inclusion initiatives” |
Executive Summary
This Best Value Review has evaluated how well the County Council promotes the concept of independence. Older people as a client group have been used to test how effectively this is applied at various levels throughout the organisation, with a view to learning lessons that could apply to other client groups.
The Review has examined how promoting independence manifests itself in the plans and policies of the authority, and also how well it actions this operationally. Overall, it has found good work in hand but also the following key findings;
Strategies for Promoting Independence
No single definition of independence prevails within the authority. Each Directorate or individual within a Directorate has their own interpretation influenced by the position they occupy.
Responsibility for promoting independence crosses a number of Executive Member portfolios, and so no single Member is responsible for its promotion.
The Older Peoples Champion has no clear remit, and no formal reporting mechanisms exist between him and the Executive.
The Oxfordshire Plan does not reflect the joint working towards promoting independence in evidence across the authority, as its priorities are focused solely on Social & Health Care. As such it is not the best mechanism to deliver on this.
• Capacity issues within Social & Health Care, together with a priority on developing short-term intermediate care interventions, means that more preventative work needs to be developed outside of the Directorate as part of an overall corporate approach to promoting independence.
The experience of BGOP within Oxfordshire, together with the experience of top performing authorities, suggests that a shared vision together with an effective corporate strategy are the necessary tools to ensure that promoting independence is delivered successfully.
Good public transport is key to promoting the independence of older people. However, country strategy is at present focused on developing premium routes between major towns, which does not necessarily support this.
• Day Services have been described as the ‘main plank of promoting independence. Work on completing the draft day services strategy needs to set out a clear vision for how services should be developed. Special transport has been highlighted by the Review as a major restriction to access, and action on how to tackle this needs to be explicit within the completed strategy
Operational Activity to Promote Independence
• All Directorates can be shown to have a responsibility or remit for promoting independence to some degree, and good examples of work to promote independence can be found within each of them (as shown in Annex 1). Without linking this widespread activity together we miss the opportunity to align the Council in achieving this corporate priority.
• The majority of operational work relating to promoting independence focusing on older people lies within Social & Health Care. There is evidence of good work associated with intermediate care, in line with the Directorate’s strategy.
• The effectiveness of promoting independence is currently difficult to evaluate, either because of the nature of different activities, or because of a lack of performance targets. Social & Health Care performance against a key national indicator is currently poor, and measures to address this are uncertain to yield necessary improvements.
• Training and guidance given to care managers needs further development to ensure that promoting independence is given priority, and that good practice is maintained.
Care Planning and Promoting Independence
• Current practice does not fully meet with national guidance on how to record objectives in care plans, and this can inhibit the successful promotion of independence.
• The requirement to move to a Single Assessment Process provides an opportunity to address these problems and facilitate a more efficient transition to the new process
Direct Payments and Promoting Independence
• Direct payments are widely acknowledged as a means to empower people in receipt of care to become more independent.
• Oxfordshire has a good Direct Payments scheme, and performs well in promoting their use. However, in common with other local authorities, it has had difficulties in extending their use to greater numbers of older people.
• To maximise the potential for improving performance, more focused training and guidance is needed for staff, together with performance targets
Recommendations
Our aspiration must be to improve the quality of life for older people, and other vulnerable client groups, by better promoting their independence. This can be achieved through the following actions.
• Develop and adopt a single definition of independence for the Council to use in planning and assessing performance on its promotion based on the outline definition in Fair Access to Care guidance
• Introduce a mechanism to facilitate joint working across the authority on promoting independence, with a view to developing a clear strategy and action plan to guide the actions of all Directorates.
• Agree a clear local remit for the Older Peoples Champion, together with a mechanism for reporting to the Executive to ensure that this input is considered in planning and policy matters
• Complete the day services strategy with a view to creating an overall vision of day services for older people within Oxfordshire, and provide for better transport provision to day services by means of a extensive review of current provision
• Ensure all care plans for older people are outcome focused, setting clear objectives for clients in terms of promoting their independence. Monitor the progress of achievement of these objectives as an indication of how well independence is being promoted
• Introduce a Continuous Professional Development framework for care managers in adult services to ensure good practice is maintained with regard to promoting independence
• Aim to increase the number of older people receiving direct payments by means of a series of targeted team briefings and clear targets.
1. Introduction
This has not been a review of older people’s services. Instead, it has been an evaluation of how well the authority as a whole promotes the concept of independence by looking at older people as an indicative group. In doing so it has examined how promoting independence manifests itself in Oxfordshire’s policies, plans and actions, and how effective these are in achieving it. It has focused on work that prevents older people becoming clients and in how Social & Health Care can maximise the impact of their intervention.
The review has found that there is good work in hand to promote independence, particularly around supporting older people to live in the community and through a focus on rehabilitation. However, confusion sometimes exists about what we wish to achieve, what we are able to achieve, and how we measure our achievements. Some of these reflect philosophical issues of choice versus practicality and cost, but others reflect problems with current arrangements.
National Context
Older people remain a key governmental focus. An additional £1bn on social services for older people is planned nationally over the next three years, introduced through a package of reforms with six key features:
• faster assessment – by the end of 2004, first contact from Social Services following referral will be made within 48 hours, and an assessment completed within four weeks. Any equipment needed will be in place within 7 days
• stabilising care home sector – local authorities will be expected to pay higher fees to care homes, and have better training for social care staff
• expanded range of services – there will be double the number of intensive home care packages by 2005 compared to 1995, 70,000 more rehabilitation packages and a 50% increase in the number of extra care housing places
• easier access to community equipment – 500,000 more items of free community equipment will be made available, including handrails, hoists and ramps
• increased choices for older people – all councils will be obliged to offer direct payments to all older people allowing them to make their own decisions about the care they receive
• more support for carers – the carers’ grant will be doubled to £185m by 2006.
Requirements to increase the performance of Social Services departments to meet these reforms will be measured by new performance indicators introduced this year. This is also set against a raft of other initiatives, such as Supporting People, the National Service Framework for Older People and Fair Access to Care Services.
Local Context
The baseline report highlighted the demographic changes within Oxfordshire that show an increasingly aging population. According to the 2001 census, the number of people aged 65 or over has risen 10% compared to a 2% rise nationally. People are living for longer, and as a result they are placing increasing demands on Health and Social Care Services through increased levels of frailty over those experienced in the past. This is set against local pressures to remain within Social & Health Care budget resulting in eligibility criteria limiting services to those people with the highest needs.
Revised funding for Social & Health Care for 2003/4 will see an additional £1.7m made available specifically to improve access and systems capacity, which will be targeted at Home Support and intermediate care.
Areas of Research
The terms of reference from the Baseline report were initially used as the basis for five areas of research. However, as the review progressed these were amended to include issues arising from evidence obtained, and to target the efforts of the review on the most promising areas. Significant changes were:
• As day services, and particularly day centres, have already been the subject of a good deal of research, including a Scrutiny review in progress at the time of this review, it was agreed that it would be beneficial for this area of work to concentrate instead on reviewing the proposed Strategy for day services.
• Standard Eight of the National Service Framework, along with other elements of the NSF, is the subject of ongoing work by the Health Authority to meet an April 2003 milestone, and so this was not an appropriate area to concentrate on
• Information obtained during the review research indicated that particular work be carried out around care assessment, care management and direct payments.
The work of the review has been structured in six areas as shown below.
Area 1: How well the County Council is structured to promote independence
To establish the current structure and arrangements for the promotion of independence in Oxfordshire County Council, evaluate their effectiveness, particularly in comparison to best performing authorities, and make recommendations as to how this could be improved.
Area 2: How successful initiatives to promote independence have been, which are most effective, and how this is measured.
To identify the tools and strategies available to the Authority to promote independence, carry out an objective evaluation of their effectiveness and evaluate the appropriateness of current performance measures. To make recommendations on new performance measures where necessary, and on which tools and strategies should receive greatest focus to best promote independence.
This area of research also involved an evaluation of the success of the BGOP Action Plan since the end of the pilot. This has been presented as a separate report to the Social Inclusion Working Group on 28 February 2003.
Area 3: How day services can contribute to better promoting independence for non-dependent older people
To assess the proposed Day Services Strategy within a best value framework to evaluate how its proposed actions align to its aims and objectives and those national and local objectives for promoting independence.
Area 4: How the County Council can increase the number of older people helped to live at home
To identify factors across all services that help older people to live at home, and any services not currently offered that would further contribute to this. To make recommendations on means to achieve better performance.
Area 5: Care management and assessment for older people
To establish how independence for older people is promoted through the care planning process.
Area 6: Direct Payments for Older People
To evaluate Oxfordshire’s direct payments scheme in terms of its effectiveness for promoting independence, and the benefits it offers the Council and older people, and to look for ways in which it can be further promoted
Report Structure
This report has been structured into four main sections;
Strategies for Promoting Independence
Operational Activity to Promote Independence
Care Management and Promoting Independence
Direct Payments and Promoting Independence
The main headings within the report sections, and how they relate to the work areas described above are illustrated in the following diagram;
2. Strategies to Promote Independence
Definition of Independence
The baseline report highlighted the fact that no overall definition of independence exists within the Council, and questioned how this affected performance. As part of the research for this area of work, all interviewees were asked to define what they regarded as ‘independence’.
No single definition emerged from this work. Common themes are evident, particularly choice and control for individuals, living with a minimum of intervention and remaining at home. However, there is sufficient variation to question the how effective we can be in promoting independence without a single view.
Comparison with other Authorities in the BGOP Independent Living Network shows that of the 14 respondents, only three used a definition of independence. Of these three, Leeds (who achieved Beacon Status for Independent Living for Older People) uses the definition within Department of Health Fair Access to Care Services (FACS) guidance, which states;
..The following aspects…are central to an individual’s independence:
• Autonomy and freedom to make choices.
• Health and safety including freedom from harm, abuse and neglect, and taking wider issues of housing and community safety into account.
• The ability to manage personal and other daily routines.
• Involvement in family and wider community life, including leisure, hobbies, unpaid and paid work, learning, and volunteering.
This appears to be an attractive basis for a definition and Oxfordshire should consider using it. The four elements of this outline definition are used elsewhere in the report as a means to evaluate the promotion of independence.
The Oxfordshire Plan
The Oxfordshire Plan is the prime document in directing the organisation as a whole to achieve its strategic objectives. In common with other Authorities contacted as part of comparison work, promoting independence forms a sub-set of the strategic objectives of the Council.
The Plan agreed by full Council on 11 February 2003 identifies the priorities to promote independence as
• Increasing the number of older people using rehabilitation services.
• Enhancing day care facilities for older and disabled people to enable them to feel secure and remain independent.
• Developing services to help those who look after a relative or friend who need support because of age, disability or illness.
This places the emphasis for promoting independence firmly on Social & Health Care, and is disappointing as it does not reflect the contribution of other Directorates and will not lead to wider working. Managers spoken to in the course of the research did not feel that the Plan would encourage greater joint working to achieve overall objectives, as strategic priorities have been largely divided up between the different Directorates.
The conclusion is that the Oxfordshire Plan alone will not encourage a corporate approach to promoting independence and more is needed to help achieve this corporate priority.
Previous Strategies
Better Government for Older People
The effectiveness of BGOP as a vehicle for change in the authority was considered by the Best Value Review of Support for Older People. The final evaluation of BGOP reported to Strategy and Resources Committee in April 2001 stated that while the principles of BGOP were followed in a number of projects; "It does not seem that these have been brought together in a planned way to establish strategies for service development".
It was felt appropriate to revisit work done since the end of the BGOP pilot project in order to evaluate how Directorates had been able to sustain the momentum generated at the time.
The key findings of the review research are that there is a considerable amount of varied and interesting work ongoing across the Council that contributes positively to the independence of older people. Almost all actions outlined in the 1999 BGOP action plans have been successfully acted upon, and many continue to be ongoing. However, BGOP was seen to have had a limited impact on strategy or overall policy, and joint working was not widespread.
Prevention Strategy
The objectives of the Prevention Strategy, and the funding available to it through Government grants, were set out in the baseline report for this review. Initial funding came through the Prevention Grant, which later became integrated into the Promoting Independence Grant, and from March 2003 funding for this work will be mainstreamed into the baseline budget for Social & Health Care. No formal evaluation of the Strategy as a whole has been carried out since May 2001.
The overall aim of the strategy was to prevent dependency on services by fostering self-reliance and community support. Specific aims for older people were set out, but were not all reflected in the chosen projects. Other key findings are that it has been difficult to measure outputs in many cases, and the tangible outcomes for older people have been limited. The likely ongoing impact of the projects is variable, particularly without sustained funding. Limited engagement with other Directorates as part of the projects led to this being a largely Social & Health Care strategy.
Older People’s Champion
The NSF Champion’s toolkit comments on the role of the Champion as follows;
“They will be responsible for ensuring that older people become and remain a priority within their organisation and for supporting the implementation of the NSF specifically. They will present a progress report to..the scrutiny committee responsible for social services every six months. They will be a key player in the local programme to modernise health and social services.”
The Council has an Older People’s Champion, who is also the Chair of Social & Health Care Scrutiny Committee. He describes having inherited the role ‘by default’, but applies himself with commitment and enthusiasm. There is no agreed remit for the role and no clear reporting lines for the Champion to report back to the Council. Comparison with other Authorities in the BGOP Independent Living Network shows that of the 12 respondents with elected Members as Champions, nine had a clear remit for the role.
The conclusion is that the impact of our Champion is restricted by this lack of formal remit and reporting lines.
Strategy for Ethnic Minority Elders
Older people from ethnic minorities experience additional barriers to their independence. Research shows that elderly people from the Pakistani and Bangladeshi communities in Britain are far more likely to suffer from multiple deprivation than their Indian or white contemporaries.
An appreciation of these diverse cultural issues proves problematic for some public sector organisations. Overall, there is a risk that misunderstandings about these communities could have a detrimental effect on the choice and quality of services provided to them. With a voluntary sector more geared to the white community, it is important for public sector bodies to address these effectively when planning their services.
Following the Macpherson enquiry report, all public sector organisations have been required by the Race Relations (Amendment) Act 2000 to produce Racial Equality schemes. The NHS in London recently completed an audit of its individual schemes and produced a single scheme better linking to overall needs and allowing a more planned approach.
The plan of action associated with the Oxfordshire’s Racial Equality Scheme shows that older peoples services within Social & Health Care are to be examined as part of the work programme for 2003/04. For other Directorates, there is no similar distinction between age groups. An Equalities Officer is to be appointed in 2003/04 to help deliver the implementation of the Scheme, and also to carry out regular reviews of its performance
Social & Health Care
Promoting independence can be shown to lie at the heart of the Social & Health Care policies, and in the service plans of its teams. It further manifests itself in other key documents, such as the Better Care, Higher Standards Charter. Social & Health Care has traditionally been seen as the ‘home’ for promoting independence in vulnerable client groups.
Overall strategy and direction for promoting independence in older people is evidenced in Oxfordshire’s Delivery and Improvement Statement, made to the Department of Health in Autumn 2002. Emphasis in this is placed on supporting people at home and maximising their independence and social participation, supported in service terms by a network of day centres, the flexible care service, and phone link and visiting services. The emphasis for intervention is on short-term intensive services to return individuals to the maximum level of functioning, supported through the Community Rehabilitation Service and Rapid Response and Reablement teams.
Capacity issues have been a major influence on strategy. Priority in recent years has been given to aligning budget and operational activity, which has meant that preventative work has not been able to retain as high a profile within the Directorate as would have been desired. This is evidenced within team plans, which show an emphasis on budgetary control as a key objective. These capacity issues have been addressed, in part, by placing more preventative work with voluntary organisations, such as Age Concern. Guidance on Fair Access to Care Services requires local authorities to continue to provide preventative services and to publicise them.
There is also a strategy to move towards more creating more integrated services with PCTs, reflecting national and local priorities to improve coordination in delivery and achieve greater efficiencies.
The conclusion reached is that to ensure a greater emphasis on preventative services with the current capacity of Social & Health Care, it will be necessary for other Directorates to contribute towards an overall strategy for promoting independence.
Day Services Strategy
Day Services have been described as the ‘main plank of promoting independence’, and so an analysis of the draft strategy formed a specific area of work of this review. The strategy has been in draft form since May 2001, with work to complete it set to take place in 2003/04.
Many of the key findings of the analysis carried out are already recognised by Social & Health Care as needing to form part of the completed strategy. These are set out below;
• Development of services to date has been piecemeal by District rather than across the County as a whole. Although this approach has produced beneficial results, for the Strategy to be effective it needs to set a vision for services across the County and clear plans to deliver it.
• The need for greater partnership, the reliance on other stakeholders to develop or deliver the Strategy, and the need to tie in with District Council strategies for older people suggests that it should be a joint strategy with other agencies. This is not currently the case and further work is needed to consult and reach agreement with these partners and stakeholders.
• A key restriction to the greater use and effectiveness of day services is transport. This is addressed in the Strategy by a recommendation that ‘strategic and operational discussions take into account the need for a properly resourced transport service’ which does not appear to go far enough to resolve current problems. The restructuring of Social & Health Care to bring all day services under a single management structure provides an opportunity for a more comprehensive review of special transport across both older people and learning disability services to address the shortfalls identified.
• The strategy could be more explicit about how it is to be delivered, the resources available to achieve this, who will be responsible for individual actions, and also its performance monitoring and consultation arrangements.
Adult and Community Education
The overall aims of Adult and Community Education are to promote learning that will encourage people to play an active and creative part in society. Older people are a priority group for the Service in this work.
Senior managers within the Service recognise that potentially it can have a profound effect in terms of intellectual stimulus and social networking. An internal study, ‘Valuing the Arts’, showed that involvement in learning has a knock-on effect in maintaining independence, quoting participants as saying “it’s the reason I get up on a Friday”.
Strategies to widen participation in learning include increasing the number of local learning centres, and to secure equality of opportunity for specific groups of learners who are underrepresented in learning or experience particular disadvantages. For older people, there is a commitment to continue to provide programmes in residential homes, and an emphasis on increasing access to ICT through externally funded programmes.
There is a key objective to raise the proportion of older learners from 25% to 25.5% in 2002/03, which represents a large operational commitment. This also highlights a potential tension between locally developed plans to support existing priorities or even further growth in older learners and national objectives driven by the Learning and Skills Council, which now funds the large majority of Adult Education and has a particular emphasis on meeting targets in work related or accredited learning.
The conclusion reached is that Adult & Community Education has an important role to play in promoting independence in older people, which is recognised by managers in the Service. There is an issue around differences in local and national priorities for further education that could influence the Service’s ability to develop this.
Cultural Services
Cultural Services aims are to be socially inclusive, appropriate, effective and accessible to everyone in the county. The key aims of the Local Cultural Strategy are to contribute to the well being of people in Oxfordshire by helping them enjoy a rich, healthy and creative cultural life, to take positive action to exclude exclusion from cultural activity, and provide key choices and access to information about cultural opportunities.
Target audiences for social inclusion are; children in care, asylum seekers, people with disabilities and older people. The service is also targeting ethnic minorities as they are seen as not being sufficiently represented in its provision or its workforce. All aspects of the service are active in using volunteers as a means to consult with and deliver a range of services, and for the most part these are older people.
For Libraries, social inclusion is now the responsibility of a member of the Strategic Library Management Team, and is being pursued through developing policies and workplans for each target group. Targets and performance indicators are being developed to measure not only inputs and outputs, but also the impact of interventions developed.
For Museums and Heritage, there are a number of specific projects targeted at older people using short-term funding, such as ICT Heritage collections, the Culture Bus and reminiscence work, but this is not felt to allow for a consistent or coherent approach to promoting independence.
Arts funding is limited to £120,000 per annum, which does not allow for much direct provision of services. Instead, it is used to grant aid independent organisations, such as the Oxford Playhouse and Ithaca, to develop a range of activities that meet the overall social inclusion agenda.
The conclusion reached is that Cultural Services has an important role to play in promoting independence in older people, which is reflected in its policy on social inclusion. For Libraries, this forms part of day-to-day work, but for other parts of the Directorate this appears more limited due to capacity and funding issues.
Environmental Services
A theme that has emerged repeatedly during the review has been the importance of transport in promoting independence.
The broad vision for public transport in Oxfordshire is to create a more successful network on core routes and increase reliability/demand with a secondary network between towns and these premium routes. The 10-year programme is hoped to make certain successful routes self-sufficient so that resources can be released to support more unviable routes in other areas. This approach may reach more people through concentrating on people changing from cars to using buses, but it is felt to increase the inequalities experienced by older people and other socially isolated groups that rely on public transport outside of these premium routes.
The Best Value Review of Support for Older People recommended that the review of bus subsidy policy be used as an opportunity to investigate the effectiveness of current public transport policy in meeting the objective of the Local Transport Plan of addressing the transport needs of socially excluded groups, including older people. This Policy and Practice Review was carried out by Halcrows, and reported to Environment Scrutiny Committee on 18 December 2002.
A key recommendation of the Review was that bus subsidies should be used to meeting transport needs rather than concentrating on attracting more people to switch from cars to public transport. The justification for this being that this would maximise the coverage of the public transport network and provide vital transport links for those who are not able to use a car living in rural areas.
However, Scrutiny Committee has not adopted this recommendation, choosing instead to maintain the current policy of supporting the shift of people from cars to buses on key routes. This reflects a high degree of support for the current public transport policy found elsewhere as part of the review research, but which does not necessarily support the promotion of independence for older people through wider availability of public transport.
Through its Walking Strategy, Environmental Services is promoting a good quality walking infrastructure. It follows that improvements in pedestrian conditions may be particularly beneficial for older people as well as other groups including those on low incomes and younger people. A safer environment for walking will reassure older people that they can travel by foot and so walk between their home and services that they may need. A key objective of the Strategy is to devise a series of Core Pedestrian Routes Networks for the main towns in Oxfordshire. Included in this are improvements to address specific safety or environmental concerns, or to remove specific barriers to movement.
Trading Standards
The aim of the Service to “promote and maintain fair trading to protect customers and enable reputable businesses to thrive” may not appear at first to lend itself to the promotion of independence. However, its brief of consumer protection extends to protecting vulnerable consumers, of which older people are a significant group.
Specific objectives within the 2002/03 Service Plan that demonstrate a commitment to promoting independence are to;
• promote social inclusion by improving access to information and advice for older people via the Internet.
• pilot an Oxfordshire "Good Trader" scheme for the home maintenance and repair sector in partnership with other organisations to improve consumer confidence and protect reputable companies and those most vulnerable to the activities of rogue traders.
• increase availability of information on sales of mobility aids and products to assist the disabled.
• investigate trading practices associated with the advertising, marketing and supply of products for the disabled.
• in conjunction with partner organisations, explore the possibility of providing information to warn all households about rogue doorstep traders and distraction burglary.
Fire & Rescue Service
The overall mission statement of the Service is to secure a safer community. The Community Fire Strategy contained within the Service Plan 2002/03 sets out the Service’s aim “to identify, prioritise and target the most vulnerable groups within the community”. Beyond this, it has not been possible to identify the specific objectives of the strategy to achieve this aim.
Comparison with Top Performing Authorities
A comparison on structure for promoting independence was carried out with seven local authorities selected as being top performers, either because they had been awarded Beacon Council status for Promoting Independence in Older People, or because they achieve top quartile performance within a specific range of performance indicators.
In all cases, the ‘champion’ department for promoting independence was Social Services, although Nottingham City also had strong links with its Housing Department. In Liverpool, the Social Services Department has been renamed Supported Living. Northumberland have delegated many functions of adult services to a Care Trust within the health sector. Therefore, a single type of structure is not a key feature of success. It should be noted that many of these authorities are urban or unitary, and do not face the same challenges as a rural authority like Oxfordshire.
Success in promoting independence was more evident more due to the way these authorities work corporately and with their partners. For example, Manchester City’s Beacon Council application was judged as follows;
“There was a clear and corporately owned vision and strategies in place across a broad range of council services. The vision for older people included seeing them as a valuable resource, and entitled to a dignified lifestyle”
Conclusions
• There is a variation in how people define independence, which suggests that a common definition should be adopted. The definition used in Fair Access to Care Services is considered a good basis for developing this.
• Responsibility for promoting independence crosses a number of Executive Member portfolios, and so no single Member is responsible for its promotion.
• The current role of the Older People’s Champion is unsatisfactory and needs a clear remit and reporting lines to make the post more effective.
• There is no overwhelming case for a structural change to better promote independence. Top performing authorities all have a shared vision delivered effectively within a corporate strategy, but using a number of different delivery mechanisms.
• Capacity issues within Social & Health Care, together with a priority on developing short-term intermediate care interventions, means that more preventative work needs to be developed outside of the Directorate as part of an overall corporate approach to promoting independence.
The Oxfordshire Plan does not reflect the joint working towards promoting independence in evidence across the authority, as its priorities are focused solely on Social & Health Care. As such it is not the best mechanism to deliver on this.
• In completing work on the proposed Day Services Strategy, a vision for day services in Oxfordshire needs to be developed. Key areas in need of improvement are to set out clear areas of development by adopting a set of standards, developing the Strategy with Health and voluntary sector partners and ensuring action is taken to address problems with special transport provision.
Good public transport is key to promoting the independence of older people. However, country strategy is at present focused on developing premium routes between major towns, which does not necessarily support this.
3. Operational Activity to Promote Independence
The previous section of this report examined how policies and strategies within the authority compare to the overall corporate priority to promote independence. Within this section we examine how these policies and strategies translate into action, and attempt to evaluate how effective these activities are.
An overview of all operational activity has been analysed, and is attached as Annex 1. Performance against a key national indicator, and the training and guidance available to care managers is also examined as part of this section.
Overview of Operational Activity to Promote Independence
Annex 1 provides an overview of the activities current within Directorates that can be demonstrated as contributing towards promoting independence. For each activity, an evaluation has been made as to;
if the activity is aimed at older people specifically
any performance targets set for the activity
how the activity is performing (against targets where available)
what aspect of promoting independence the activity contributes towards
For the last part of the evaluation, the outline definition used in Fair Access to Care Services guidance has been used as a ‘yardstick’ to measure activity against. The key to the abbreviations used in the table is set out below;
|FACS Definition |Abbreviation |
|Autonomy & freedom to make choices |Autonomy |
|Health and safety, freedom from harm, abuse, neglect, inc housing and community safety |Safety |
|Ability to manage personal and other daily routines |Routines |
|Involvement in family and wider community life, inc. leisure, hobbies, unpaid/paid work, learning |Community |
|& volunteering | |
Key findings of the evaluation are set out below.
There is a wide range of activities across all Directorates that can be shown to make a positive contribution to the different aspects of promoting independence when evaluated against the outline definition.
Although much activity has been captured in terms of projects, there is much more in terms of day-to-day activity that is not as simple to capture or evaluate in such a way. For instance, the face-to-face work carried out by care managers with clients may have a significant influence on how well independence is promoted through improved morale or confidence, but it may be difficult to quantify this.
Much of the activity outside of Social & Health Care relates to Directorate agenda for social inclusion rather than specifically for promoting independence, and therefore the two initiatives can be shown to share certain core values.
A significant number of activities apply to more than one target group. For instance, older people and disabled people benefit from the intervention of Home Support. Similarly, social inclusion activity is often aimed at a range of target groups.
The greatest range of activities is, predictably, within Social & Health Care. Its emphasis on rehabilitative activities can be seen to be producing tangible benefits in promoting independence in terms of the proportion of care plans that cease or reduce after 12 weeks, as can its performance against delivery of community equipment.
Some activities can be shown to have better developed targets than others, with a focus on the measurement of their impact. Notable examples are those for;
16 Rehabilitative work within Social & Health Care
o Access to ICT within Cultural Services and Education
o Pedestrian crossings with disabled facilities within Environmental Services
There is not always a clear correlation between strategies and activity. The activities identified within Environmental Services are not apparent in the Directorate’s Performance or Service Plans. In contrast, Trading Standards activities can all be linked back to its Service Plan objectives.
The conclusions reached are that without linking this widespread activity together we miss the opportunity to align the whole of the authority and better promote independence, and also that clear objectives and targets need to be set to help us achieve this.
Helping Older People to Live at Home
PAF C32 is the national performance indicator measuring the number of older people helped to live at home per 1,000 of the population aged 65 and over. Helping people to remain living at home reflects both a national and local objective for promoting independence. Performance in Oxfordshire is currently judged to be poor, with estimates for 2002/03 as being 75.6 against a target performance of 85, which represents a moderate improvement over 2001/02. Top quartile performance is judged by the DoH to be between 100 and 140. A specific area of research was to examine ways performance against this indicator could be improved.
To be included in the return for the indicator, older people must be receiving at least one of eight specific services (e.g. day care, meals service) and to have been assessed for receiving these. Issues contributing to our poor performance are that Oxfordshire has encouraged a system of direct access to such services without the need for assessment, and current methods of collating statistics are largely manual. This illustrates the limitation of the performance indicator as a judgment on how effectively independence is promoted, which is a reason why it has not been used as a target within the Oxfordshire Plan for 2003/04.
However, the indicator forms part of an Oxfordshire PSA target 5 to ‘provide high quality pre-admission and rehabilitation care to older people to help them live as independently as possible’, and although the indicator definition is likely to change we will continue to be assessed on the current definition for PSA purposes. The target in the PSA is for performance to be at 90 by 2005/06. This represents around 8000 people receiving services, where currently we have around 6900.
Actions agreed to improve performance are to drive targets down to team level together with clear information for Care Managers on the range of services that can be counted towards the indicator, targeting more services at ethnic minority elders by redirecting existing resources, increasing the amount of community equipment provided to older people, including some services not currently counted, and ensuring all client data is entered on SWIFT.
Despite the limitations of the indicator as a representative picture of promoting independence in Oxfordshire, it is still relevant and important due to its inclusion in the PSA target. It is uncertain from the evidence gathered as part of the review if the proposed actions to improve performance will be sufficient to meet this target.
Training and Guidance for Social & Health Care Staff
Although a wide range of specific training courses are held within Social & Health Care that contribute towards preventative and/or rehabilitative services, there is no specific training towards promoting independence as it is seen as integral to overall social care training.
An analysis of internal training courses offered by the Directorate in 2002/03 revealed that of 30 training events aimed at service delivery, 24 could be shown to support services that are preventative, and a further 3 at services that are both preventative and rehabilitative.
The introduction of national care standards are currently focusing training activity on care assistants, as there are specific targets to be achieved in terms of percentages of staff trained to NVQ standard. In addition, care assistants have comprehensive guidance books that cover issues relating to the promotion of independence.
Care managers in adult services have no specific guidance currently in use, or formal system of continuous professional development (CPD) in operation. Occupational Therapists currently operate a CPD scheme, and Social Workers in Children and Families are required to attain a formal Child Care Award. This would suggest an inequality of provision. A post-qualifying award programme is being piloted within adult services in an effort to extend training opportunities to care managers, and it is intended to extend this in 2003/04
There is recognition within the Directorate of the need to better package existing training and guidance as part of a CPD framework in order to draw clearer links with the overall aim of promoting independence.
Conclusions
• There is a work ongoing within Directorates that contributes to the promotion of independence, and examples of where cross-Directorate working has produced benefits. Outside of Social & Health Care, this is largely centred on work to promote social inclusion.
• The effectiveness of promoting independence is often difficult to evaluate, either because of the nature of the different activities or because targets have not been set to measure performance against.
• Within Social & Health Care, success is evident in performance around reducing care packages by means of intermediate care and delivery of specialist equipment, which supports the current focus of the Directorate.
• A key national performance indicator is the number of older people helped to live at home. Oxfordshire’s performance is poor, and steps are in hand to improve this. However, this work is largely centred on improving activities to measure performance rather than increasing services, and it is uncertain if targets for increased performance can be met.
• Training and guidance for Care Managers in adult services does not match that for Children and Families, or the focus on independence given to Care Assistants. There is also a need for more guidance on Oxfordshire’s approach to care planning, which has been shown as key to effectively promoting independence.
4. Care Management and Promoting Independence
The number of older people dealt with as clients of Social & Health Care only represents around 10% of the older population, but the quality of this intervention is significant in terms of promoting independence. The process of care management can result in a number of conflicts;
• We actively seek to promote independence, but we restrict access to services to those with only the greatest need due to resource shortfalls. By doing so we miss the chance to reduce future demands on the service through more preventative work.
• By limiting access and the range of services available (i.e. care assistants not normally doing housework) we may expect clients to become more independent, or at least more dependent on those outside the Council (e.g. carers, relatives or private agencies). In addition, reducing care provision may have a profound effect on the morale and confidence of clients.
• Providing care may limit choice, i.e. a client can only have a bath if there is a medical reason. A client is restricted to going to bed to when the care assistant arrives to assist with undressing. Clients must go to day care, for instance, on a day when there is an available place.
• In contrast, providing support in this way may give structure to their day, and through social contact with home support we may stimulate clients more than they would have been otherwise.
• Promoting independence in one way may reduce it in another. The traditional ‘meals on wheels’ service did not promote independence well, but did provide some social contact.
• Client may exercise their right of choice and choose to neglect some aspects of their personal care. However, in the interests of hygiene or safety we choose to address these in the care plan. We may try to accommodate choice or control within the care planning process, but are constrained by questions of risk – some clients may have an unrealistic expectation of what they can achieve.
• In contrast, we may perceive that some clients can become more independent, but we may not allow them to pursue their choice to do less in the interests of our promoting their independence.
National Guidance
The NHS and Community Care Act 1990 first introduced the concept of care management. Guidance published by the DoH in 1991 states:
“The fundamental aim of community care is to promote the independence of individuals so they are able to live as normal lives as possible. Care management, as the process through which users gain access to services, should reinforce, not undermine, that aim”
The emphasis of care management, therefore, is to adapt services to need rather than fit people to existing services, thereby empowering users and carers rather than them being subordinate to service providers. The concept of ‘need’ is defined in the Guidance as “the requirements for individuals to enable them to achieve, maintain or restore an acceptable level of social independence or quality of life..” .
All users in receipt of a continuing service should have a care plan, which defines the users needs and objectives to be met by any service provided. By setting objectives, the success or otherwise of the care plan in promoting independence can best be measured. As the Guidance states;
“Objective setting is, therefore, the key to effective care management”
Analysis of Case Files
An analysis of 65 case files was undertaken as part of this research to see how well they met the principles outlined in this Guidance. The files were gathered from the three main teams covering older people;
|Team |No. of Plans |
|Community Rehabilitation Service (CRS) |17 |
|Specialist Teams for Older People (STOP) |19 |
|Adult Assessment Teams (AAT) |29 |
The findings from this research revealed that;
• A majority (55%) of intervention by Social & Health Care was due to people experiencing incidents such as falls or illness. The remainder of clients received intervention due to a steady decline in abilities.
• The majority of clients (89%) had some degree of physical disability, either temporary or permanent, with 23% of clients experiencing some loss of memory or cognitive ability.
• Overall, just 36% of case files showed evidence of having outcome-focused objectives. Of these, 91% involved intermediate care services, with most using rehabilitation plans.
• Nearly all rehabilitation plans produced by the Community Rehabilitation Service had clear objectives recorded, as expressed by the client, as to the degree of independence they wished to achieve. These objectives were further divided into discrete tasks that were relevant to independent living. For example “I want to be able to get out and about” would be translated into an objective to walk to the shops and back unaided, and progress against this objective measured regularly.
• In the majority of cases (96%), care plans produced by Adult Assessment Teams had no obvious objectives recorded, tending to concentrate instead in meeting a need with a service. For example, “Assistance with personal care” would be a typical expressed need, and would be met by “Carer support Monday to Friday”.
• Where clients expressed a clear wish or desire, these have usually been incorporated in care packages (e.g. “Mrs X feels she does need help, but wants to be independent again. She does not feel that getting dressed is important while in pain”). In some circumstances, staff have challenged such a desire where it was clear the client was able to become more independent (e.g. “Mrs Y is quite able to shop for herself”).
• Adult Assessment Teams are under a great deal of pressure, as much of their work involves dealing with crisis situations. It is common for Care Managers to be asked to arrange for care the same day, due to a critical life event or discharge from hospital.
• A differing approach to the care planning process was witnessed between teams as a result of this pressure. Some files had no care plans evident, as these were either with other agencies, or Care Managers had not yet written them up. One Care Manager mentioned she completed her care plans before writing up the client’s assessment, in an attempt to juggle available time with the need to agree care plans with the client.
• The views and attitudes of carers and relatives can be an important influence in successful care management. There is evidence of relatives being resistant to clients regaining some aspects of independence due to the risks that this can bring, and often they have expectations for rehabilitation that are much lower than may actually be possible.
• Similarly, the views and attitudes of clients themselves can be an important influence. The research shows that some are very forthcoming about the degree of independence that they wish to obtain, albeit on occasions unrealistic due to their physical or mental condition, and are reluctant to accept personal care. Others have the opposite view, and expect Social Services to provide for them.
The conclusion is that the way in which care planning is recorded in Oxfordshire does not fully meet the principles outlined in Community Care Act guidance. Care plans involving rehabilitation plans show clear evidence of objective setting, but other care plans suggest a tendency to fit people to services rather than set objectives for their care.
This contrasts with performance information from Adult Assessment Teams and Rapid Response and Reablement Teams showing a high proportion of care packages reducing or ceasing within 12 weeks. The implication is that the way in which plans are recorded does not necessarily reflect work carried out by these teams to promote independence.
Outcome- Focused Planning
Social & Health Care senior management are aware of the need to move to more outcome-focused care plans, and have been working to address this. The Service Plan for Older People 2002/03 contains two specific actions relating to this work;
Develop training for Care Managers on outcome focused Care Planning
Produce information for older people regarding options and goals / outcome setting in care plans and distribute it
A training event was organised in December 2002 for Unit Managers and Senior Practitioners to facilitate a move to this approach. The feedback received showed that the training was well received, but attendees were not confident that it could be integrated into practice owing to the inappropriate framework for recording assessments due to existing paperwork. Other feedback reflected concerns about the difficulty in promoting rehabilitation-focused care packages over a long term for clients whom are cognitive impaired or have dementia.
Single Assessment Process
As part of NSF Standard Two on person-centred care, a Single Assessment Process (SAP) has to be introduced by April 2004. This will involve coordinating the flow of information between different agencies to ensure that older people are only required to give information once in the overall assessment process.
SAP does not propose any fundamental changes to the care planning process, and builds on previous guidance on the need for objective setting. Its approach to improved coordination of assessment information presents the opportunity to achieve better outcomes for any objectives set through care planning. Without a move to embracing objective setting in care plans in advance of SAP, there is a risk in the transition being more difficult to implement.
As has been highlighted above, a barrier to care plans becoming more outcome-focused is the paperwork that is currently used to record assessments and care plans, as there is no obvious place for objectives to be recorded. The Single Assessment Summary example produced with the SAP guidance has a specific section for recording the objectives of the care plan. It is likely that revised paperwork introduced in Oxfordshire for recording assessments will reflect this guidance. A pilot scheme is planned to test the proposed assessment process.
As there will be changes needed in processes and paperwork as part of the SAP implementation, there is an understandable reluctance to make any changes to existing paperwork prior to its introduction, but this is considered necessary to promote the use of objective setting in care plans.
Conclusions
• The concept of providing care to promote independence is subject to a number of problems, centering on how well it allows choice and control for clients and how this conflicts with the provision of care services.
• Care planning in Oxfordshire does not fully meet the principles outlined in Community Care Act guidance due to the way plans are recorded. Care planning involving rehabilitation plans shows clear evidence of objective setting, but for other care plans it appears there is a tendency to fit people to services rather than set objectives for their care. Without objectives being set, it is not possible to evaluate how well independence is promoted.
• The requirement to move to Single Assessment provides an opportunity to address problems in recording objectives in care plans and facilitate a more efficient transition to the new process. However, problems with existing paperwork present a barrier to this change in advance of revised systems introduced under SAP.
• The possibility of a pilot for SAP should be used as an opportunity to introduce a revised approach to outcome focused care plans in line with the original Community Care Act guidance.
5. Direct Payments and Promoting Independence
Background
Direct Payments, introduced by the Community Care (Direct Payments) Act 1996, are cash payments made to a number of client groups in lieu of social care services. Local councils can offer some people money instead of arranging services for them. Direct payments are not a new service, just an alternative way of providing an existing service (through an assessed need.) They give clients the choice over who provides the assistance they need to live their daily lives, and when and how the assistance is given, although it is not possible to purchase care back from the local authority. This gives clients real control and independence in their lives.
An independent advisory service for Direct Payments is required by the legislation. In Oxfordshire this has been developed in partnership with Oxfordshire Council of Disabled People (OCDP), where other authorities have appointed in-house staff. The advantage of Oxfordshire’s approach is that the service is truly independent, developed and run by disabled people. The disadvantages are that much of the knowledge and expertise about the scheme rests outside of the Authority, and as OCDP also act as a pressure group there is a potential conflict of interest.
The service provided by OCDP costs £62,000 per annum which pays for two full-time advisors. They are tasked to deal with up to 50 referrals each year, but have capacity to deal with greater numbers. In addition to providing advice, the advisors give practical support in completing necessary paperwork, including financial returns and tax returns, and assisting with recruiting care assistants.
Advantages of Direct Payments
Independence
The biggest advantage of direct payments is that people are more independent as they choose and control the assistance they receive. Through direct payments they are empowered to take control. OCDP have anecdotal evidence of people stating they have been 'given their lives back' following a switch to direct payments.
Many of the conflicts between care management and promoting independence referred to elsewhere in this report can be resolved through the use of direct payments.
Cost
The hourly weekday rate given to recipients of direct payments is £9.15 as opposed to an internal provision cost of £14.40. This difference reflects the cost of purchasing care without management overheads, and so represents much better value for money for the authority. Anecdotal evidence is that Oxfordshire’s level of payment is higher than many other authorities.
Continuity of Care
As recipients can employ their own assistants this encourages good continuity of care, allowing relationship and understanding to be built up between the two parties, and an increased commitment on the part of the care assistant. If the quality of assistant is not to the older persons satisfaction, as an employer they are able to seek alternative arrangements.
Continuity of care is not exclusive to recipients of direct payments. A recent rise in numbers of recipients can be attributed to where external care agencies have become ‘de-accredited’ by Social & Health Care, and older people have then chosen to receive direct payments to ensure they can continue to use the care assistant they are comfortable with. However, care assistants employed through Social & Health Care are more likely to have more than one client.
Other advantages of continuity are that disabled people may have particular care needs that a care assistant needs to learn before they can effectively carry out their task. Continuity ensures that the level of re-learning is minimised, which can make care provision more effective, and reduce the need for, and cost of, training.
Recruitment
Social & Health Care experience difficulties in recruiting care assistants partly due to the low level of pay that can be offered. Direct payments allow the flexibility to spend a greater proportion of care money on wages - effectively following the ‘market rate’. The experience of OCDP is that of all people receiving direct payments, only one found problems with recruitment, and this was because nine assistants were needed in a week. Assistants are often recruited through a client’s existing network of support, or through limited local advertising.
Problems with recruitment of Home Support can contribute to issues around bed blocking if older people are unable to receive home support to enable their discharge. There are examples of where direct payments have helped resolve these issues.
Value
Agency staff used by the Council are paid for travelling to visit clients. In certain cases, the cost of this travel can be higher than the cost of care itself. Direct payment recipients are under no obligation to pay for travelling (care assistants are often recruited locally).
Cultural Diversity
There is a known issue with the provision of care to ethnic minority clients from home support staff outside their culture. With direct payments, a client is better able to secure the sort of care they want from within their own ethnic group, although restrictions on family members being employed as care assistants may inhibit this.
Barriers to Greater Use
If there are such clear benefits to greater use of direct payments, questions arise as to why they are not used to a much greater degree. Some of the barriers to their use, as identified through the research, are set out below.
Culture in Social & Health Care
The attitude of some care managers has been cited by OCDP, by Age Concern and also the Project Manager responsible for direct payments as the main reason for limited progress in this area. An example given to illustrate this was one care manager who had been 'chased' for 18 months to sign a client to direct payments after she had expressed a desire to do so. Only 30 older people have been referred to OCDP so far, and 5 of these have been from a single care manager. During interviews with key staff, one care manager commented that direct payments were a ‘good thing’, but are just not a priority given the volume of work she faced. It is recognised within the Directorate that a fresh approach to promoting direct payments is needed to maximise their potential, and this will need to await the publication of revised guidance from the DoH.
Training
Training for care managers in the relevant legislation and Oxfordshire scheme is provided by OCDP staff, whom are not professional trainers. Of the four courses arranged in 2002, two were cancelled due to lack of attendees. A further series of training courses is planned in 2003, with the format changing to encourage line managers to attend. The first of these took place in February 2003, and was received positively, although of the 7 people attended the course none were care managers. Attendance on this training, as for many courses in Social & Health Care, is not mandatory.
Care Planning
As part of research into care planning, unit managers in different teams were ask how they promoted the use of direct payments. In general, Adult Assessment Team managers felt that they were dealing with people at a time of crisis, where care packages were unstable, and so it was less appropriate for them to try and promote them. Managers in the Specialist Teams for Older People, looking after clients on a long-term basis with more stable care packages, said that most older people were simply not interested when the subject was discussed with them.
Paperwork
The freedoms offered by the scheme come at a price; financial returns are required from the recipient to demonstrate that money is being spent properly. Also, tax returns have to be completed. However, OCDP takes an active role in assisting with this, and considers Oxfordshire’s approach to necessary paperwork to be better than average in comparison with other authorities.
Information
A chief concern of OCDP is that incorrect messages about direct payments are often given, either through best intentions to help, or (it is suspected) by providers that could 'lose out' through their increased use. Discussions with the Age Concern City Older People’s Panel demonstrated that there is a good deal of misunderstanding or apprehension outside the authority to the use of direct payments, with most concern expressed about what happens when circumstances change, or if care breaks down.
Staff themselves appear to be unclear what the benefits are to older people, or believe that they may not be capable of managing their own finances. In conversations with some managers it was evident that there was confusion about how the scheme itself operates, with concern about what happens when a client’s needs change, or if self-purchased care breaks down.
Finance
The National Centre for Independent Living considers a major barrier is the amount of money received by a client with a small package of care, and out of which they may have to fund National Insurance contributions, insurance and holiday/maternity pay for assistants.
Capability
As the eligibility criteria has been raised to only include clients with high level needs, it could be argued that this means less people will be able to manage their own finances due to reduced cognitive function. However, with an estimated 2,000 older people receiving long term home support, the current number of recipients represents less than 1% of this total. Although it is accepted that direct payments will not be appropriate or possible for all these clients, it does illustrate there is great potential for improvement.
Structure
Social & Health Care have been encouraged by the Government to use block contracts to provide good value and promote a healthy local market. This has been done with great success in Oxfordshire. However, as recipients of direct payments cannot buy into these contracts, any drive toward their increased use threatens this approach. Social & Health Care are currently looking into how this issue can be addressed.
Performance Comparisons
Oxfordshire is regarded as a good performer for direct payments overall. At February 2003 there were 131 people in Oxfordshire receiving direct payments, of which 18 (13.7%) were older people. Of the referrals made to OCDP for further information on the scheme, only three older people (14%) have declined to take up direct payments. A target was set in the Older People Service Plan to increase the number of older people purchasing care through direct payments by 60%, which was achieved with relative ease, partly due to the low base figure.
The National Centre for Independent Living reported last year that the national average for older people using direct payments is about 10% of all recipients, which shows Oxfordshire as performing well, and that other local authorities have similar issues in promoting greater use amongst older people.
• West Sussex: had just over 11%. The key to success there seems to be sorting out the "assistance to manage" aspect, coupled with a management commitment to finding workable solutions. The West Sussex scheme is fairly well resourced in terms of staffing.
• Lincolnshire: had approximately 15%. This is a highly "managed" scheme, where users do not have to take on all the responsibility of being an employer.
• Barnet: had approximately 30%. This is quite a small scheme (under 70 users overall at the time of monitoring) with fairly individualised support for users.
Figures obtained from the SSI recently show Hampshire as performing significantly better than any other authority in the South East in terms of numbers, with over 90 older recipients. This equates to over 16% of their total recipients. The success of the scheme can be attributed to an informal scheme using indirect payments running since 1983 – well in advance of enabling legislation. Other factors contributing to success are the good reputation of the scheme amongst older people, and an emphasis on training Care Managers to better promote it.
Changes in Legislation and Monitoring
Revised guidance for Direct Payments is due to come into force in April 2003, which will require them to be offered to all individuals who are potentially eligible. The guidance also confirms that;
“..the Government’s aim, in promoting direct payments, is to increase users’ independence and choice by giving them control over the way the services they receive are delivered.”
The Government has stated clearly in the guidance that it expects to see a substantial increase in the number of people receiving direct payments, particularly older people. To monitor this, a new PAF indicator is being introduced during 2003/04. At the time of writing, performance bands for this indicator had not been published.
Conclusions
• Direct payments are widely acknowledged as empowering people in receipt of care to become more independent. The effective promotion of direct payments is an expression of the Authority’s commitment to promoting independence.
• The Government has made it clear that it expects more older people to receive direct payments, and will be monitoring this through performance indicators.
• Oxfordshire is a good performer in terms of providing direct payments overall, and also in the proportion of older people receiving them by national comparisons. However, it has the potential to perform even better, and in order to do so Social & Health Care staff need to present the option to older clients more strongly and positively.
• Oxfordshire’s Direct Payments scheme is well regarded, and the advisory and information service offered by OCDP goes well beyond its remit in ensuring that people are given sufficient advice and support to use direct payments. This provides an excellent basis for improving performance.
• Despite the financial and bureaucratic obstacles presented by the scheme there are clear benefits for some older people in receiving direct payments. However, these benefits are not yet being sufficiently explained to older people in order to increase the number of referrals to OCDP, where there is presently capacity to deal with them.
• Confusion exists amongst staff as to the precise operation of the scheme. Further, there is no clear recognition of who is responsible for promoting direct payments, and a resistance from staff to promoting the scheme more actively. Clear information, direction and targets for referrals would assist in producing improvements.
• Training provided for direct payments is not necessarily reaching the staff it needs to, and its reception to date has been mixed. Good training has been identified as a key success factor in Hampshire. There is a need to improve the quality and coverage of training if direct payments are to be expanded significantly.
6. Action Plan
|Service improvement 1 |Planning for Promoting Independence |
|Description |Develop a corporate vision and mechanism for joint working to plan and deliver the promotion of |
| |independence |
|Objectives |Create a corporate approach to the promotion of independence |
| |Revise the day services strategy to be more explicit about its vision |
| |Clarify the role and reporting lines of the Older People’s Champion |
| |Proposed service improvement targets |Completed by |
|1 |Agree and introduce a common definition of independence for the Council to work to use in planning|June 2003 |
| |for its promotion | |
|2 |Develop and introduce a revised model for the role and reporting mechanism for the Older People’s |July 2003 |
| |Champion | |
|3 |Revise and publish the day services strategy as a joint strategy with partners, including a key |August 2003 |
| |action to review special transport arrangements to address current deficiencies | |
| | | |
|4 |Develop and adopt an appropriate mechanism for corporate policy development on promoting |October 2003 |
| |independence | |
|5 |Develop and publish a joint vision and action plan for promoting independence, with key |April 2004 |
| |performance indicators generated to monitor performance | |
| | | |
|6 |All relevant team plans to use specific objectives and targets for promoting independence |April 2004 |
|Costs |
| |
|Risk assessment |
|Without a corporate mechanism or vision it will not be possible to coordinate the work of different directorates effectively |
|Without clear objectives and targets to measure against it will not be possible to measure the effectiveness of activities to promote |
|independence |
|Issues to consider – areas that will be affected by implementation |
| |
|Service improvement 2 |Care Management |
|Description |To bring current practice in care planning in line with national guidance to assist in the |
| |promotion of independence through the use of clear objectives for clients |
|Objective |All care plans in adult services to be outcome focused with clear objectives for promoting |
| |independence |
| |Training and guidance for care managers addresses key issues in promoting independence |
| |Proposed service improvement targets |Completed by |
|1 |Devise system to record objectives using current care planning paperwork, and test this as part of|August 2003 |
| |Single Assessment Process pilot work | |
| | | |
|2 |Carry out a series of targeted briefings with all care managers in adult services on the use of |October 2003 |
| |outcome focused care plans | |
|3 |Devise and introduce guidance on care planning, in line with national guidance for good practice, |October 2003 |
| |covering the use of outcome focused objectives | |
| | | |
|4 |Introduce a system of continuous professional development framework for care managers in adult |April 2004 |
| |services | |
|5 |Introduce revised care planning paperwork to all adult services as part of the Single Assessment |April 2004 |
| |Process roll-out | |
|6 |All care plans to contain outcome focused objectives for promoting independence |May 2005 |
|Costs |
| |
|Risk assessment |
|The current approach to recording care plans will inhibit the transition to new systems required under Fair Access to Care Services |
|Without clear objectives, it will be difficult to evaluate the success of care planning in promoting independence |
|The absence of a CPD framework for adult services training will maintain inequalities in provision and hinder a greater focus on promoting |
|independence |
|Issues to consider – areas that will be affected by implementation |
| |
|Service improvement 3 |Direct Payments |
|Description |Address the barriers preventing the Council from becoming more successful in promoting the use of|
| |direct payments for older people |
|Objective |Increase the number of older people receiving direct payments to at least top quartile |
| |performance |
| |Proposed service improvement targets |Completed by |
|1 |Carry out a series of targeted briefings with all care managers in adult services on the |July 2003 |
| |advantages of direct payments | |
|2 |Introduce clear guidance for care managers on the practice of using direct payments |July 2003 |
| | | |
|3 |Set targets for individual teams within adult services for increasing the number of older people | |
| |receiving direct payments by | |
| |At least a 100% increase in 2003/04 | |
| |Achieve top performance for PAF indicator when banding published |April 2004 |
| | |April 2005 |
|Costs |
| |
|Risk assessment |
|Failure to adopt revised training methods will restrict guidance to staff on the operation of the scheme, and therefore any significant |
|improvement in performance |
|The absence of clear targets for performance will inhibit improvements in performance |
|No increases in the number of older people receiving direct payments will reflect poorly on the authority’s commitment to promoting |
|independence, and performance against the new indicator |
|Issues to consider – areas that will be affected by implementation |
|Awaiting publication of revised guidance from DoH |
Glossary of Terms
|BGOP |Better Government for Older People |
|CPD |Continuous Professional Development |
|CRS |Community Rehabilitation Service |
|DoH |Department of Health |
|FACS |Fair Access to Care Services |
|ICSS |Intensive Community Support Services |
|LTP |Local Transport Plan |
|NSF |National Service Framework (for Older People) |
|OCDP |Oxfordshire Council of Disabled People |
|OT |Occupational Therapist |
|PAF |Performance Assessment Framework |
|PCT |Primary Care Trust |
|PSA |Public Service Agreement |
|RRR |Rapid Response and Reablement Service |
|SAP |Single Assessment Process |
|SSI |Social Services Inspectorate |
|STOP |Specialist Teams for Older People |
|SWIFT |Social & Health Care client database |
|WRVS |Women’s Royal Voluntary Service |
-----------------------
Work Area 5
Work Area 6
Work Area 4
Helping More Older People to Live at Home
Work Area 2
Work Area 1
Work Area 3
Training & Guidance for Care Managers
Overview of Operational Activity
Comparisons with Top Performers
Strategies for Promoting Independence in;
Social & Health Care
Adult & Community Education
Cultural Services
Environmental Services
Fire & Rescue Service
Trading Standards
Older Peoples Champion
Previous Strategies;
Better Government for Older People
Prevention Strategy
Oxfordshire Plan
Definition of Independence
Direct Payments and Promoting Independence
Care Planning and Promoting Independence
Day Services Strategy
Operational Activity to Promote Independence
Strategies for Promoting Independence
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