Care Act Implementation and Risk
Overview of social care history and policy context
Description of the Dilnot Report and Recommendations
Overview of the Care Act 2014
The NW architecture
Exploring risk within Care Act implementation
Andrew Burridge, Policy Manager (Health)
GMIST
Complex legal framework
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1960s – series of scandals based around large psychiatric institution see a move to
community based care
Local Authority Social Services Act (1970) – establishing social services committees,
the formal role of Director, and the need to act under the general direction of the
Secretary of State.
Chronically Sick and Disabled Persons Act (1970) – introduced a duty on the LA to
assess the individual needs of adults who met the criteria within the National
Assistance Act
Disabled Persons Act 1986 – enabled individuals and carers to request an
assessment.
Social Security Act 1986 – replaced Supplementary Support with Income Support,
with a tighter financial criteria.
1988 Independent Living Fund introduced – small direct payments to people with
severely disability and low incomes
NHS and Community Care Act 1990 – established the duty to provide a service if
needs are established as eligible. New arrangements for assessment and care
management and individuals receiving individual tailored packages of care. As long
stay hospitals closed an assumption that people will receive care in their own homes.
Community Care and Direct Payments Act 1996 – local authorities enabled to provide
cash payments to people rather than provide a service.
Health and Social Care Act 2001 – mandatory to provide direct payments
Health and Social Care Act 2008
Health and Social Care Act 2012
Policy trends
Increasing focus upon well-being and prevention
Assumption of a person’s ability,
rather than disability
People receiving care seen as individuals
with unique needs
Local authorities to become commissioners
of care, rather than providers.
Increasing use of direct payments
and personalisation
Social workers to take on roles of assessment and
care management
Diverse market of providers developing –
private and third sector
Financial pressures
Councils are facing significant and increasing demand and financial pressure.
Adult social care spending has fallen by c8.5%
in real terms from 2011/12 to end of 2013/14
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(2013/14 prices)
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Since 2011/12 central revenue support for councils
has reduced by c10% each year (c39% by end of
2014/15). This is equivalent to a reduction in
spending power of c4-5%.
Impact varies locally – some councils have seen
spending power reduce by c7% each year.
Many councils have still given relative protection to
ASC compared to some other services.
Overall councils have reduced spending on ASC by
c8.5% in real terms over three years to end 2013/14,
consistent with 3% national efficiency assumption.
User numbers have also reduced significantly over
the SR period, particularly for +65s:
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19% fewer over-65s receiving community care
2% fewer over-65s receiving residential/nursing care
Reported outcomes and satisfaction have remained
stable, but data limited to people receiving care.
Overall councils have delivered savings whilst maintaining outcomes and satisfaction levels.
Within ten years local authority revenue budgets will be entirely taken up
by Adult SC expenditure, children’s services, and Council Tax Benefit
Background to the Dilnot
Recommendations
1. The current adult social care funding system in England is not fit for
purpose and needs urgent and lasting reform.
2. The current system is confusing, unfair and unsustainable. People are
unable to plan ahead to meet their future care needs.
3. A major problem is that people are unable to protect themselves
against very high care costs.
4. Most people are realistic about the need for individuals to make some
contribution to the costs of care in later life, but they want a fairer way
of sharing costs and responsibility between the state and individuals and
they want to be relieved of fear and worry. There is consensus on the need
for reform.
5. To support a strategic and cultural shift in care and support towards
wellbeing and prevention.
Background to the Dilnot
Recommendations
1. The current adult social care funding system in England is not fit for
purpose and needs urgent and lasting reform.
2. The current system is confusing, unfair and unsustainable. People are
unable to plan ahead to meet their future care needs.
3. A major problem is that people are unable to protect themselves
against very high care costs.
4. Most people are realistic about the need for individuals to make some
contribution to the costs of care in later life, but they want a fairer way
of sharing costs and responsibility between the state and individuals and
they want to be relieved of fear and worry. There is consensus on the need
for reform.
5. To support a strategic and cultural shift in care and support towards
wellbeing and prevention.
Dilnot Recommendation (2011)
Care Act (2014)
Cap lifetime contributions towards their social care
costs should be capped at £35,000
Cap set at £72,000 from April 2016 and lower for
working age adults.
Requires the introduction of Care Accounts.
People should contribute a standard amount to cover
their general living costs, such as food and
accommodation, in residential care - We believe a
figure in the range of £7,000 to £10,000 a year
A standard contribution to living costs of around
£12,000 a year will be set from April 2016 – this will
not count towards the cap.
The means tested threshold should be increased
from £23,250 to £100,000
The threshold for support is increased to
£118,000 in assets (including their home).
People should not have to immediately sell their
homes and therefore to introduce a national deferred
payment scheme.
People will the option to defer paying care home
fees from April 2015, so that people do not have to
sell their home in their lifetime to pay for residential
care
National eligibility and portable assessments
Introduced
To encourage people to plan in later life the
Government needs to plan a major communications
campaign and introduce an information and advice
strategy in partnership with the financial sector.
Public Health England to support local comms
and a national strategy in 15/16
Unclear picture regarding financial products
Care Act 2014:Headline reform on social care funding and
support
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Places well-being, and outcomes, is at the centre of every decision
Focus on prevention and delaying needs, and integration and partnership
working is reinforced
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Provides a single framework for social care addressing:
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Assessment (extending rights to self-funders)
Carers
Charging and financial assessment
Advocacy
Person centred care and support planning
Adult safeguarding
Integration and partnership working
Moving between areas (portability) and transitions
Delegating functions (third party assessments)
Prisons
Sight registers (visual impairment)
Managing provider failure
Presentation attempts to focus upon those areas with the most pressing risks.
Summer – Autumn
2013
2013 – 2014
April 2015
April 2016
• Formal consultation.
• Establish a partnership between Department of Health, LGA and ADASS and work
together on detailed implementation plans to ensure effective preparation for
and implementation of reforms.
• Government response to the consultation setting out more detailed plans.
• Continued engagement with local authorities, providers, voluntary and
community sector, financial services organisations and individuals and carers on
details including regulations and guidance.
• May 2014 Care Bill granted Royal Assent
• Introduction of a range of duties around assessment, charging, care planning and
review
• Introduction of deferred payments and preparation for introduction of cap using
the £335m allocated in the Spending Review.
• National minimum eligibility standard and fairer charging framework.
• Introduction of cap on care costs, care accounts and extended access to financial
support.
• An expectation that local authorities organise early assessments for self funders
from November 2015
Northwest Task & Finish Group
• Stuart Cowley (Director, Wigan Council) agreed to act as lead DAS.
• Representatives from all NW local authorities with links to NHS
England.
The Group is:
• Identifying the workstreams required to successfully implement the
Bill.
• Allocating tasks across the collective NW resource, and creating
new architecture where necessary.
• Agreeing use of regional funding allocations.
• Championing Northwest analysis and exploring lobbying
opportunities.
• Communicating across NW ADASS.
Risk assessment
• Suggestions taken
from:
– NW Task & Finish
Group
– NW Finances and
Resources Group
(developed a
submission into the
National Finance
Group)
– Local risk registers
Assessment and eligibility
• A new framework for assessment and eligibility
– based around wellbeing.
– A shift from duties to provide particular services, to the concept of
‘meeting need’.
– A requirement to consider prevention and independent living (pre-formal
assessment).
– Implications for local policy and capacity.
• New right for carers to request an assessment.
• A national eligibility criteria. Concern that the wording of the
legislation extends thresholds into ‘moderate’, not the ‘substantial’
levels that most NW Councils have set.
• Risks relating to consultation, process design, staff training,
increased costs to the local authority, availability of workforce.
Charging and financial assessment
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A new duty to provide an assessment to all people, regardless of finances or whether the LA
thinks they will be eligible.
Self funders will have a right to ask the local authority to arrange their care for them.
From April 2016 the local authority will need to maintain a Care Account for anyone that asks for
one.
Local authorities can currently charge for services. We retain the discretion to decide when to
charge. We will be allowed to charge admin fees to self funders when we arrange their care.
Local authority will be allowed to carry out ‘light touch financial assessments’ where thinks this is
appropriate.
We will need clear policies for charging, charging self-funders administration fees, and charging
carers and Deferred Payment Agreements – local consultation required?
If we want to carry out 'light touch assessments' – local policy needs to be agreed, unanswered
questions about proportionality and financial risk.
Increased requirement for financial assessments based on numbers of self funders.
New financial tools and training implications arising from Care Accounts and Deferred Payment
Agreements.
Risk around allowing rental income for properties that have a DPA.
Financial context places increased pressure upon the local authority to recoup costs.
Ongoing potential for legal challenge – legal literacy training to follow.
Increased activity and financial risk
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Two national models are being used to identify
costs.
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Lincolnshire Model (15/16)
Surrey Model (16/17 and beyond)
Lincolnshire model not yet reported. Surrey Model is
still not sufficiently robust to produce aggregated
results.
National collection of local data and results postponed
until January/February 2015
Joint ADASS/DoH/LGA advice for forward financial
planning is that the costs of funding reform will be
fully funded.
Extremely important that we influence and secure
appropriate funding of the reforms
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Understanding the number of self funders is
extremely hard 0  120-180k?
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There is also a similar but different gap regarding
carers - and how many additional assessments and
support will be required as a consequence of the
Care Act proposals. 350k  720k?
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How can we workforce plan and design processes
effectively without making assumptions?
Personalised care and support
planning
• Local authorities will have to provide individual support plans and
personal budgets.
• Individuals will have strengthened rights to ask for direct payments.
• The Local Authority must not stifle choice and innovation.
• The Local Authority must be satisfied that the direct payment is
being used to meet eligible care and support needs.
• Direct payments raise questions about fraud and error. 2012 Audit
Commission report looked at 102 cases totalling £2.2m.
• Reputational risks around the choices that services users make.
• Financial safeguards and political sensitivities need to be balanced
against transforming people’s lives by giving them control.
Workforce
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These changes have major implications for the social care workforce.
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Staff across the social care and health sector may not have the understanding to do the job
under the new legislation
– Capacity of staff to deal with new / additional demand driven by Care Act
– Impact of local restructure and authority wide financial pressure mean management and
leadership around Care Act implementation lose focus
It is important that Councils look to manage down this risk as far as possible:
– New joined up approaches to assessment
– ‘Proportionate or light touch’ assessment
– Third party assessment
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Some Councils are looking at workforce redesign so that higher paid qualified
social workers quality on DOLS, BIA, Continuing Healthcare and complex multiagency working.
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Process mapping has identified a range of simple ‘admin’ functions that unqualified social
workers can carry out.
NW Group looking at commissioning training at the NW or sub-regional level, and
focused work looking at the potential for ‘social care officer’ roles.
Financial risks and the costs of training, and implementation risks around scheduling
training and identifying the appropriate providers.
Market shaping
• A duty to support a market for adult social care that delivers a wide
range of care and support services.
• Risk of upward pressure on market fees in residential and nursing
care – particularly the ‘top-up’ subsidy issue.
• From April 2015 – the right of a self funder to request LA support in
arranging for needs to be met is likely to see transfer of private
payers to lower local authority fee levels.
• Duties on local authority to manage provider failure. Local
authorities would ultimately already by likely to step in and should
have contingency plans. The threshold is for large providers (1000+
beds) so large rural counties might need closer relationships with
small providers.
Safeguarding Adults
• A clear legal framework for how LAs
should protect vulnerable adults –
requirements for Adult Safeguarding
Boards.
• Systems should already be in place – not
featuring as a major risk, but could see
increased referrals.
• Advised that auditors need to be included
in safeguarding reviews.
Strategic risks
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Political and reputational
– Government creates unrealistic and unaffordable expectations of the offer
available from local councils, and the gap between expectations and reality
impacts on local citizens views of the county council.
– Other government reform programmes (eg Pensions, prisons, welfare reform)
make Care Act preparation and implementation hard to deliver effectively.
– Failure to deliver major elements of the requirements of the Care Act.
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Legal
– Litigation from individuals or groups dissatisfied with offer or process.
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Financial
– Magnitude of gap between Government funding and local expenditure related to
the Care Act is uncertain and / or significant.
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Care Act ICT
– Systems changes are not delivered in time (Care Accounts / Deferred
Payments).
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Partnership / relationship management
– Care Act implementation divorced from Better Care Fund and wider strategic
integration agenda.
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Project governance
– Project management and leadership capacity to deliver.
– Insufficient understanding of interdependencies and risks associated with other.
projects not hitting key milestones
Local risk registers?
Recommendations / implications
for audit
• Be aware of the Act and understand who
the local Care Act lead is
• Explore involvement in local programme
management teams
• Support the development of local risk
registers
• Representation on the NW Care Act Task
& Finish Group
Contacts
• a.burridge@agma.gov.uk
• http://www.local.gov.uk/care-supportreform
• Care and Support statutory guidance
(June 2014):
https://www.gov.uk/government/uploads/s
ystem/uploads/attachment_data/file/31599
3/Care-Act-Guidance.pdf