Scottish Government

APPENDIX FIVE STAKEHOLDER WORKSHOP

Introduction

The Stakeholder Workshop, held on 26 ^th September 2006, provided an opportunity to engage with key national and local stakeholders at an important stage of the project. The workshop took place following conclusion of the fieldwork and an initial analysis of the data..

The workshop considered an early findings paper and key questions and challenges based on emerging findings from the primary research undertaken for the evaluation.

Around 40 people from 20 local authorities and a range of national organisations including the Scottish Executive, COSLA, the Care Commission and voluntary organisations such as Alzheimer Scotland and Capability Scotland attended the workshop.

The workshop provided an opportunity for stakeholders to comment on key findings to date, consider the challenges and questions posed by the findings and contribute to the thinking about emerging conclusions and recommendations.

Following a presentation which summarised the early findings paper and outlined the challenges and questions to be discussed in discussion groups, delegates were divided into four groups.

The morning discussion session was based around a set of core common questions relating to the objectives of Free Personal Care, how it can be monitored and evaluated and whether it is sustainable. The afternoon discussion sessions were based on three different themes:

• Assessment, Unmet Need and Eligibility
• Provision of services and Capping
• Public Awareness, Care Homes and Quality of Services.

Each of the groups was facilitated by a member of the project team and summaries of group discussions and conclusions were fed back to plenary sessions of the workshop and then in writing for this report.

The following report of the workshop presents the main points and conclusions of the discussion groups. The views reported are those of the people who took part in the discussion groups.

The comments from the workshop were fed into the overall qualitative analysis that has informed this evaluation.

Summary of Key Points from Discussion Groups

Morning Discussion Groups

Is there agreement and certainty as to the aims and objectives of FPC? Are these aims fully compatible? Can the impact of FPC be measured against these objectives or are they indistinguishable from the objectives of Community Care?

• It is very hard / impossible to separate FPC and its objectives from Community Care and its objectives. FPC is essentially a part of Community Care - a funding stream/ means of paying for personal care services.
• The original aim of FPC was to end the discrimination faced by older people suffering from chronic and deteriorating illnesses, notably dementia, whose care needs are classed as non-medical but who require nursing and personal care in the community, having to pay for this whilst people in hospital receiving the same services are not charged. FPC also aims to end the discrimination caused by means testing for personal care.
• FPC could be seen as having two main aims - for people in residential care and for people in their own homes. But these different aims may not be compatible. The £210 payment for FPC/ FNC in care homes can be an incentive for people to go into care homes (making care home places more affordable for self funders), defeating the aim of keeping people at home longer.
• In practice, FPC benefits the better off and so turns fundamental community care principles on their head. Less well off people were getting free personal care previously under the means tested scheme. Less home care is now available as a consequence of local authorities paying for FPC and so some people may be experiencing a reduction in home care.

The increase in free personal care has been accompanied by a reduction in the level of non-personal care services provided for frail older people. What are the likely consequences of this reduction in 'lower level' care?

• It has been necessary to concentrate resources at the intensive support end of services and away from the preventative, early intervention end - provided by non-personal care. Many local authorities no longer provide non-personal care unless it is part of a more comprehensive care package.
• There has been an increase in the incidence of depression amongst older people who would have been receiving home care but are now isolated. This can have a subsequent knock on effect in increasing the need for personal care services as a result of their depression.
• There has been an increase in the demand for day care services and increasing demands on unpaid carers to do domestic care tasks. This is not necessarily seen as negative as these tasks are a day to day part of family life. It can be difficult, however, when carers are elderly themselves.

Given the significant variations in practice in areas such as eligibility criteria, waiting lists and capping, is the objective of having the same range and standards across Scotland reasonable and achievable?

• Equity is the aspiration but full scale national consistency would defeat local democracy. Local discretion has enabled local authorities to implement FPC, by allowing money to be transferred from other budgets. Equity has to take account of many individual factors - broad based guidance aiming to promote consistency does not necessarily lead to equity.
• Local differences will remain because of different social and geographic conditions and differing capacity to fund services to meet identified need. If FPC remains as it is then it will always be open to local interpretation with the flexibility in budgeting this allows to meet local and national priorities.
• Greater consistency and clearer understanding of eligibility criteria would help in promoting similar expectations amongst users and carers across Scootland.

Should there be some form of explicit annual report evaluating how FPC is being implemented? Is JPIAF sufficiently robust to allow it to be used to monitor how FPC is being delivered?

• Monitoring and reporting requirements on Local authorities are already onerous, time consuming and often focus on the wrong things. FPC should not add more problems. There is a need to move to a simpler system that is based on key outcomes.
• There is a need for a robust monitoring system across Community Care and FPC should be one part of that - it would be difficult to separate it out for monitoring purposes.

Apart from food preparation, are there other parts of the guidance on FPC that need to be revised and re-issued?

• There is a need for greater clarity about the definition of nursing care and, in particular, "Simple treatments".
• Official guidance states that there are three types of contract but private care homes are ignoring this and not accepting people on Route 3 contracts.
• Clarification of the rules about backdating FPC payments is needed. Guidance states that payment should only be made once the service commences but there are situations where people have had to pay for care whilst waiting for local authority services.

Is funding the most important determinant of whether FPC can be implemented successfully?

• Funding is fundamental to the success of FPC. But it is not the only consideration.
• The relationship with the NHS is a key issue:
• Resource transfer and the lack of it; local authorities are not always successful in their negotiations with the NHS
• NHS services disengaging from personal care
• Local authority initiatives save the NHS money that is then used in acute services
• Limited use of pooled budgets

Is enough being done at national and local levels to plan to meet the community care needs of an aging population within the wider demands on care provision?

• There are major challenges of which FPC is a part. The complexity of the issues involved and uncertainty about demographics and other societal changes mean that planning has become almost impossible.
• Staffing is a key issue. Many areas have "run out of recruitable workforce" to provide care services.
• There is definitely a need for local capacity planning in addition to national work.

Afternoon Discussion Groups

Group A Assessment, Unmet Need and Eligibility

Waiting for assessments

• It was felt that, taken from the service users' viewpoint, the concept of "waiting" is the time between asking for help and the delivery of that help. Waiting in any part of the system could constitute delay.
• No area deliberately keeps people waiting. It is a question of resources and the impact of other areas of policy that can impact on the assessment process, including: staff shortages, questions about who does the assessment, and national and local priorities around delayed discharge.

Should FPC for people in care homes be backdated from the date at which it is applied for rather than from the date at which the assessment has been completed?

• Not under the current legislation and assessment system - if an older person goes into a care home privately and bypasses the system then they should be prioritised in the same way as anyone who had not taken that action. It is usually people who can afford to self-fund who take this step. If additional money was made available for this purpose then backdated payments could be made.

Carers' assessments

• Single Shared Assessment ( SSA) is the route most areas are using for carers' assessments, with carers' needs recorded as part of the overall SSA. However, since this is not recorded as a carers' assessment, local authorities' performance indicator figures under-record assessments. A better way of recording the assessment of carers' needs in SSA would be helpful.
• Some local authorities have self assessment forms for carers and have tried different ways of supporting carers to assess their needs. But these are not always successful. For example, in an area with an agreement with the local Princess Royal Trust to support carers in filling in the self assessment form, only two carers have taken up the offer.

Are eligibility criteria a legitimate way of 'rationing' access to care services? Should there be nationally agreed eligibility criteria?

• Eligibility criteria are a legitimate way of 'rationing' services.
• There is an uncomfortable mix between national and local governance of FPC. National eligibility criteria would provide clarity, but there would be less local flexibility to provide solutions that fit local need and person centred care.

Group B: Provision of Care Services: Waiting for Services and Capping

Are waiting lists for the provision of care services a legitimate way in which local authorities manage their resources?

• There needs to be greater clarity about terminology to allow comparability; e.g. what is meant by waiting, waiting lists, target times, waiting times and eligibility criteria.
• 'Waiting' for residential care and personal care at home is unavoidable in practice and can be due to one or more of a wide range of factors. Participants would welcome a closer examination of waiting and reasons for waiting in this evaluation.

Are local authorities doing enough to resolve staffing issues - creating the capacity to provide personal care services in the right place and at the right time

• Recruitment and retention of staff is a major issue. Local authorities have tried a wide range of mechanisms. Some think the situation has worsened significantly over the last couple of years. It is not yet clear what impact recent recruitment campaigns have had. New sources of staff need to be explored.
• The evaluation has to unpick the different areas of staffing recruitment and retention issues. There are differences in relation to recruiting assessors (qualified social workers) and care workers; travel issues in rural areas; terms and conditions for care workers.
• There would be benefit in more sharing of 'good practice' between local authorities.

Is the capping of care packages an acceptable way of managing resources? Should there be Scottish Executive guidance either prohibiting capping or setting the level of permissible capping?

• Capping should not be prohibited nor should a limit on care packages be set by the Executive. It is one mechanism of limiting expenditure. Authorities will always have to find ways of doing so.
• Currently a number of different systems of capping and gatekeeping are in use. Authorities operate these flexibly whenever possible. They need to retain this flexibility/ discretion. Some local authorities 'embrace' capping whilst others are actively opposed.

Group C Public Awareness and Care Homes

How can we increase public awareness and understanding of FPC and better inform users of services, their carers and families of how FPC impacts on them?

• The difficulty in raising public awareness is that it is not clear what outcome was expected from the policy. It is not clear what needs to be put across to the public or what rights people do have.
• There needs to be more openness with the public about what is available, how needs are assessed and what the choices and limitations are.
• For people transferring to care homes there needs to be better information about all the implications of FPC and care home charging.

Care Homes

• The Care Commission has no regulatory role in relation to charging. It is currently gathering information on how top up charges are levied and the extent to which charging levels are reflected in level of service. The Care Commission would question whether monitoring charges more generally would be a good use of its time.
• Specialist staff are needed to provide augmented care - in Glasgow there is specialist health care provision for people in care homes to reduce hospital admissions. Some local authorities treat augmented care needs as qualifying for FNC. The criteria for FNC are not specified and so there are anomalies.