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ITEM EX10

EXECUTIVE – 2 APRIL 2003

FAIR ACCESS TO CARE SERVICES

Report by Director for Social & Health Care

1. The Department of Health issued Fair Access to Care (FAC) Services Guidance in May 2002. The need for guidance was identified in the 1998 White Paper ’Modernising Social Services’. The aim is to ensure that councils deliver services fairly to adults in all client groups, irrespective of factors such as age, gender, race, living arrangements and location. It is part of the government drive to remove Age Discrimination and meets our requirements for National Service Framework for Older People Standard 1.
2. The guidance sets the eligibility framework for adult social care for councils to use when setting and applying their eligibility criteria. The eligibility criteria describe the eligible needs the council will meet. Councils have responsibility to determine the level of resources allocated to social care for adults. The right to set eligibility criteria in line with the resources allocated is retained. There is no intention that individuals with similar needs in different parts of the country should necessarily receive the same level of service.
3. Fair Access to Care Guidance must be implemented from 7 April 2003.

Principles of the Guidance

4. It is intended that implementation of the guidance will promote access to care services that is based on evaluation of individuals’ assessed needs and likely risks, including both immediate needs and needs which are likely to worsen for lack of timely help. Assessment of need should be in proportion to the individual’s need and within an appropriate assessment framework (such as the Single Assessment Process for older people for implementation from April 2004).
5. Councils should operate just one eligibility decision for adults seeking social care support - namely should people be helped or not? Services must be delivered to achieve similar care outcomes for people with similar needs. Councils must ensure that resources are used cost-effectively with due regard to the individual’s needs and agreed outcomes. Councils must continue to provide Prevention Services and publicise them.

Eligibility Criteria

6. The Guidance prescribes the framework for setting eligibility. The eligibility framework must be based on individuals’ needs and associated risks to independence and include four eligibility bands – "Critical", "Substantial", "Moderate" and "Low". These bands are described in detail in the guidance, and are reproduced at Annex 2. When placing people in these bands the authority should identify immediate needs but also needs that would worsen for lack of timely help. The threshold (as described by the eligibility criteria) at which services are provided is the decision of the council. The proposed eligibility criteria are described in detail in the Fair Access to Care Reference Document (see Annex 3) (download as .doc file). The proposal is that the "Critical" and "Substantial" bands will describe eligible needs in Oxfordshire. Discussion with other authorities indicates that this is in line with decisions being made elsewhere.

Procedural Changes

7. The guidance uses new language and concepts about a ‘contact’ with the department. There should be a low threshold for assessing if people have the need for community care services. At first contact with the department a person has ’presenting needs’. An assessment is made, in proportion to need, and a decision made if there are ‘eligible needs’. If there are no eligible needs, then there is a requirement to provide advice and information about other services, in particular about Prevention Services funded by the authority.
8. There can be only one eligibility decision. Once it has been agreed that there are ‘eligible needs’ then the department accepts responsibility for meeting them. Once the individual is through ‘the front door’, no further eligibility ‘hurdles’ can be put in place (unless there is a change of circumstance). Services provided or commissioned must have statements of purpose. These inform decisions about the suitability of a service to meet an individual’s needs.
9. A new requirement under the guidance is a face to face review of those receiving services, at a minimum interval of a year, by an ’appropriate council professional’. Reviews undertaken solely by providers of service are no longer acceptable. A review becomes the higher level activity and incorporates any reassessment of need against the eligibility criteria: this is a change of emphasis. There is particular mention of increased promotion of the use of Direct Payments.
10. The FAC guidelines are issued under section 7(1) of the Local Authorities Social Services Act 1970 which requires local authorities to "act under the general guidance of the Secretary of State." Legal advice is that the guidelines do not have the full force of the law but failure to comply with them may be cited in proceedings. The courts will look to see if the authority has good reason to depart from them.

Oxfordshire’s Position

11. Oxfordshire already has eligibility criteria which apply to all adults. The rigorous re-assessment of existing adult clients during 2002/3 had the effect of ensuring that existing criteria were applied to all equally. (Some authorities will need to reassess all clients against new criteria within the next year.)
12. As mentioned above, it is recommended that the Council should deliver services to those in the "Critical" and "Substantial" eligibility bands. As the revised criteria ( Annex 2) appropriate. However, the new criteria are written in terms prescribed by the government and are more comprehensive in expressing which factors we take into account when making decisions about eligibility. The intention is to improve transparency to the public about how decisions are made. The Oxfordshire criteria are produced with explanatory notes for reference and with a description of the process of care management.
13. The Directorate has set targets for performance for 2003/4 that mean at any one time it will support about 12,200 adults. This is made up of:

• 7,000 people over 65 helped to live in the community
• 1,400 people over 18-64 with physical disabilities helped to live in the community
• 1,000 people over 18-64 with learning disabilities helped to live in the community
• 700 people over 18-64 with mental health problems helped to live in the community
• 2,100 people in residential care.

14. Due to the new requirement that all adults receiving a service should receive a review by an "appropriate council professional", it is estimated that an additional 7,000 ‘face to face’ reviews per year must be achieved. The majority of additional service users requiring review are likely to be those using simple access services, such as Day Care, and economies can be achieved by ensuring that the review is proportionate to the level of need.
15. This change of practice is unlikely to be achieved within current staffing levels. However additional gains are:

1. tighter control of budget: as this year’s re-assessment process has shown, regular review will minimise the continued use of services by those no longer in need;
2. improvements for service users: their independence is promoted by provision of services which continue to meet their needs as individual circumstances change.
   
   

Training

16. The training currently provided for all staff working with adults contains an emphasis on promoting independence and anti-discriminatory practice. In view of the new criteria and guidance, however, there is an intention to work on reviewing and re-presenting the range of learning opportunities for care managers in a form which more explicitly puts both the fair access and promotion of independence agendas in centre focus.
17. This process will include consideration of gaps in existing provision, and will involve a new look at an induction pack and/or workbook for care managers, with an emphasis on anti-discrimination in all its forms, a person-centred approach and promoting independence and rehabilitation in the context of multi-disciplinary working.
18. The aim is to link programmes into a continuing professional development framework for care managers, so that competence in a person-centred approach, and in joint working to promote independence and assess risk, firmly rooted in anti-discriminatory values, can be demonstrated and accredited.

Financial Implications

19. The recommendation is that the eligibility criteria should be set at "Critical" and "Substantial", as described above. It is considered that this will allow for the same level of need to be deemed eligible as is currently the case. There should, therefore, be no resource implications in introducing the new eligibility framework with regard to the level of eligible need.
20. There is some risk attached to this as the description of need has changed considerably and the application of the criteria will need to be closely monitored to ensure that eligibility decisions remain appropriate.
21. There are, however, likely to be resource implications in respect of staffing. The requirement for all reviews to be "face to face" and be undertaken by an "appropriate council professional" is a significant shift from current practice.
22. Detailed work needs to be undertaken to determine the exact resource implications and how these will be met. There are no new resources to implement these requirements, which the Government considers have always been part of the Council’s responsibility, and was within the 2000 spending review

Process to Date

23. The eligibility criteria were initially developed by a group of representatives from across the department including Children and Families (because of the links with children with a disability reaching adulthood).
24. A number of stakeholders (see Annex 1 - A) were invited to a meeting in December to discuss the developing criteria. The option was given to contribute in writing or by the stakeholders’ preferred alternative method. The current draft criteria were subsequently presented at the County Older People’s Panel and an open meeting of the Age Concern Social & Health Care Panel. Views were used to develop the criteria further.
25. A later draft and invitation to comment was sent to an extended list of stakeholders (also Annex 1 - B) at the end of February. Any additional comments from this will be reported verbally.
26. Staff in Adult Care Management teams throughout the Directorate have had opportunity to discuss and comment on the criteria as they have developed.
27. There have been no formal opportunities to discuss the criteria at Government level or with other authorities. Unfortunately, promised informal regional meetings with other authorities did not materialise. However there has been an exchange of draft criteria and discussion about specific aspects with authorities such as Bristol, Devon, Berkshire Unitaries, Surrey, Essex and Buckinghamshire.
28. Amendments have been made to the criteria in accordance with advice from the Solicitor to the Council; he makes the point that the criteria can only be used as a guide as the authority may not ’fetter its discretion’ when making decisions about services to be provided to the individual.

Implementation Tasks

29. A revised version of the Department of Health FAC ‘Practice Guidance – Implementation Questions and Answers’ was issued on 6 March 2003. The implications will be analysed and any necessary changes to the criteria or notes of clarification recommended. Further work is also needed on the interface between the Children Act and FAC with regard to services provided to parents with a disability to enable them to care for their children.
30. The eligibility reference document (Annex 3) (download as .doc file) is to be produced in shortened and accessible formats, and publicised. Procedural changes are required within care management and briefing sessions for staff given. Commissioning and contracting changes will be made to ensure that services do not operate eligibility criteria but use descriptions of purpose to match eligible needs.
31. It is proposed that the FAC implementation be audited and reviewed in 6 months time (September 2003). This will be further opportunity for stakeholders to comment on content and presentation of criteria and the change of process.

RECOMMENDATIONS

32. The Executive is RECOMMENDED to:

1. approve the revised eligibility criteria for all adults as described in the report, for immediate implementation;
2. note the changes in practice, both in language and process, embodied in the guidance;
3. request the Director for Social & Health Care to report on the first six months of implementation to the Executive Members for Community Care & Health and Children & Young People.

CHARLES WADDICOR
Director for Social & Health Care

Background Papers: Fair Access to Care Services: Guidance on Eligibility Criteria for Adult Social Care

Contact Officers: Lorna Brown, Head of Adults and Carers, Tel 01865 815828
Jenny Lee, Service Manager, Tel 01865 221204

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