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Independence, Wellbeing and Choice, a Green paper on Adult Social
Care.
Consultation response from Hertfordshire County Council.
This response will broadly follow the format set out in the on-line questionnaire but is
submitted in this form to allow for additional comments where only tick boxes are
offered and to ensure we comment on important issues not addressed in the
questionnaire.
Question 1: Does the vision for adult social care summarise what social care for
adults should be trying to achieve in 21st Century?
The vision is a good one and accords with our own current aspirations for adult social
care in Hertfordshire. However, the ambitions of the Green Paper need to go beyond
social care to the wider support which is needed to ensure that vulnerable adults are
supported to live independently, to access mainstream universal services and to
participate in the communities they live in. Later on the Green Paper acknowledges
some of these points but what this means is that this is not just a vision for social care
for adults but must encompass the way in which any other identified needs are met if
we are to have a truly person centred and holistic service. Good health is clearly on
enabler to independence and, even with single assessment and some integrated
commissioning, issues such as charging and direct payments as well as conflicting
priorities act as barriers to getting the best possible arrangement for people who need
support. The Government needs to be clear whether this is a vision for Social care or a
vision for meeting the needs of vulnerable adults. At the moment it comes across as a
mix between the two.
Question 2: Independence , Wellbeing and Choice sets out seven outcomes for
social care :
Improved health
Improved Quality of Life
Making a positive contribution
Exercise of Choice and control
Freedom from discrimination or harassment
Economic well-being
Personal Dignity
Are these the right outcomes for social care?
The proposed outcomes are fine but again go beyond pure social care. Perhaps there
are too many – Quality of life seems to be more of an overarching aim which we will
deliver if the other outcomes are achieved. If we think about the aspirations for all
adults what most of use aspire to is the following:
Good health
Employment/Economic well being
Housing
Access to learning/training
Independence and inclusion
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More vulnerable adults only differ in the amount of support they need to achieve these
outcomes. Some will need help in achieving all of these outcomes most of the time
but some with only one and maybe only once. If we take this view we really do start
to look at things in a cross cutting way and get away from just the social care agenda.
For example, some adults will need support to get into or return to employment form
time to time – some of these adults will have social care needs as well and some will
not but all need access to services specifically designed to advise and help them into
employment.
Question 3: What are your views about how we can strike an appropriate
balance in managing risks between individuals, the community and the social
care worker?
The key thing about risks is that they are identified and the likelihood and
implications are assessed. The balance of responsibility for risks needs to depend to
some extent on who the risk is to. If an individual wants to take a course of action
which may pose a risk to themselves fully in the knowledge of the risks and
implications then we should respect their right to take that risk. Where the risk is
potentially to a third party or parties then, where possible the third parties need to
understand and agree to any risk before a particular course of action is taken and
where this is not possible, for example the risk is to the wider community it should
fall back to professionals to ensure the risk is at an acceptable level. Where
professionals do need to make such judgements they will not only be social care
workers but also health professionals, housing officers, probation officers etc – and
often an interagency view will be needed.
We do need to be willing to allow people to take some risks full in the knowledge that
they are doing so and we may need to work with some professional bodies to make
that acceptable professional practice. At the moment, vulnerable adults are able to
take great risks and exercise very damaging choices when they self-neglect, abuse
alcohol, live in squalor and refuse all support and yet, once they are in touch with and
seeking support from statutory services we sometimes are so anxious about risk and
professional responsibilities that we rule out taking much smaller risks which service
users themselves are willing to accept. An example would be ruling out offering a
stair lift, as there had been instances of someone with a similar condition injuring
themself during use, when the service user and family had an express desire to use a
stair lift and were willing to accept the risks. Where people use direct payments and
arrange their own care by employing a personal assistant there will be a risk if such
employees are not trained or police checked. The role for the local authority and
support agencies is to ensure service users are aware of the risks and perhaps to offer
training, support and CRB check services which people can then choose whether to
use or not.
Question 4: Should we take forward proposals to minimise the need for people to
provide broadly the same information, for instance by sharing information
between agencies such as the local authority and the department for work and
pensions?
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Yes – and we should look together at the most practical ways to achieve this. This
may or may not be through joint teams. We need to consider the full range of agencies
where there may be benefits if information is shared.
Question 5:We welcome views on modernising assessment and putting
individuals at its centre. We are particularly interested in the practicalities of self
assessment. Do you think there should be professional social work involvement
in some or all assessments?
Professional social work involvement is not needed in all assessments. The important
thing here is fitness for purpose. Our aim should be to allow a person’s needs to be
met, in accordance with their wishes, at the earliest possible point and we should use
skills appropriate to assessing the needs in question. Some people are very clear what
their need is and what they need to help them and simply want us to facilitate the
solution. Self assessment with service signposts may well be a way forward in such
cases. There is certainly a case for a degree of self assessment so that people or their
friends/relatives can check whether eligibility criteria are likely to be met or access
targeted information and advice by completing a basic assessment from online.
Professional social workers and Occupational Therapists are in short supply and we
must use their skills to best effect in dealing with complex cases that cannot be dealt
with by self assessment or trained community care support staff. A significant amount
of work has been done in Hertfordshire to ensure that we have staff doing work
appropriate to their qualifications and which uses skills to best effect. On line
referrals will go live in Hertfordshire in the next few months as part of a move
towards enabling self assessment.
Question 6:Do you have views on whether the Single Assessment Process (SAP),
the Care Programme Approach (CPA) and person Centred Planning (PCP)
should be further developed to provide a tool to use for all people with complex
needs?
There should be a single but flexible process for assessing the needs of all people
regardless of their age or the nature of their disability, vulnerability or mental illness.
In Hertfordshire, the Single Assessment process has been implemented for all older
people and adults with physical disabilities. There are issues about what process
should be used for older people with mental health problems – SAP or CPA – yet the
core information needs will be the same. It seems sensible to build on single
assessment and use the specialist assessment part of the process to deal with needs
which are specific to particular care groups, illnesses or needs. It also makes sense for
service providers in the independent and voluntary sector, when proving services
following an assessment by adult social services, to continue the single assessment
process – again using the specialist assessment part to do the assessment they need to
deliver high quality, person centred services to meet the service user’s care plan.
Question 7:How can we encourage greater take-up of direct payments in underrepresented groups such as older people and people with mental health
problems?
Clearly we should do everything we can to ensure that people in need of support are
aware that they can opt to organise their own care and support using direct payments
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and that there is support available ( often through services commissioned from the
voluntary sector) to help them manage money received through a direct payment and
how they arrange services. However, it may be that this is the wrong question. If we
genuinely want to offer real choice and a person centred service then we should only
encourage take up of direct payments in these groups if there is evidence that this is
the approach service users want to take. Direct payments is one choice not the only
way to deliver choice which can also be achieved through individual budgets( to be
commented on below) and through good person centred planning where access to a
wide range of services is available.
Question 8. Extending the scope of Direct Payments. Do you think we should
review the exclusions under the direct payments regulations?
Do you think that extending direct payments should initially be a power or a
duty for local councils?
What do you think about the proposal to extend direct payments via an agent to
groups currently excluded, namely those unable to give consent or manage a
payment even with assistance?
Direct payments should be available wherever this seems to be the best way of
meeting needs. However, where service users are not in a position to consent to or
manage payments then carers should not have a right to manage direct payments on
behalf of the service user, rather authorities should have the power to offer direct
payments where this seems to offer the best outcomes for the service user. If there is
to be a duty of local councils it should be to have a scheme in place that allows the
granting of direct payments to a wider group but it should not offer carers a right to
such payments. This is in order to protect service users in cases where carers may not
act in their best interests.
We should also enable groups of service users to “pool” direct payments if this offers
a cost effective means of meeting needs. Such an arrangement would be likely to
require extensive support, probably from the voluntary sector and possibly access to
legal support. An example of where such an arrangement could be useful would be
where there are a number of younger physically disabled people coming out of
education and wanting to live independently yet requiring imtensive support. Pooling
of direct payments alongside accomodation provision commissioned or enabled by the
council could offer a viable means of independent living. We are actively considering
whether we can use such an arrangement in Hertfordshire for a number of young
people whose carers have identified this as a possible option.
A practical issue that needs to be considered for the future of direct payments as well
as for individual budgets ( to be discussed further below) is how to determine how
much to offer as a payment. At present in Hertfordshire we offer what it would have
cost us to pay for the package of care we would have offered had direct payments not
been the chosen solution. To date this has largely meant costing home care, day care
& respite care. However, the more flexible we become with service solutions, the
more difficult it will become to determine and cost what we would otherwise have
offered. It will be important that the principle of equity is retained so that people
arranging their own services have no greater or lesser quality of care or access to
resource as a result of the way they choose to have their needs met.
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We would like consideration to be given to offering direct payments to meet health
needs. As we move towards ever closer working, service integration and joint care
plans and claiming a person centred approach, it is illogical to be able to offer direct
payments to meet some of a person’s needs but not he remainder. This seems
particularly pertinent in the case of people with long term conditions where an
integrated, preventative approach is needed and self-care is being promoted.
Question 9:Changing the name of Direct payments. Which name for direct
payments is most appropriate? Are there any others?
Individual service payments would seem to describe best what is on offer and there is
a fit with the concept of individual budgets – the former being where money actually
changes hands and the latter where a notional budget is allocated – but both very
much focused on meeting an individual’s particular needs – not on a kind of benefits
entitlement model. An alternative would be (Individual) Care and Support payments
and (Individual) Care and Support budgets.
Question 10:We are committed to the introduction of Individual budgets to give
people greater control over their lives. We would welcome views on the proposals
to pilot individual budgets.
We are interested in the concept of individual budgets which would seem to offer
many of the benefits of direct payments without passing an organisational burden to
service users. However there are some very practical questions that need to be
answered before consideration could be given to making this the norm. There is the
same question as with direct payments of how you decide how much the budget will
be. If all clients were either in receipt of a direct payment or working to an individual
budget this would be even harder. The question also arises as to the point at which
you agree the available budget with the service user: too early and you may commit
more budget than is necessary , too late and the information will not inform client
choice. A further and more fundamental question is whether individual budgets offer
any more for a service user than good person centred planning where access to a wide
and flexible range of services is available.
The Green paper talks about an end to the role of social workers and social care
professionals as rationers or gatekeepers of services but whether we offer services,
direct payments or individual budgets we will continue to work to finite budgets and
will have to make judgements about priorities and levels of support for individuals as
well as about the balance of investment between early intervention/ prevention and
meeting the needs of the most vulnerable. There is some evidence, from the in control
pilots and from individual casework elsewhere that for people with very high levels of
need for whom very expensive residential placements are being considered, it is
sometimes possible to work with families to achieve a more cost effective solution
which also potentially better meets identified needs. Individual budgets may have that
impact for cases costing tens of thousands of pounds or more - if sufficient time and
effort is given to negotiation and research and discussion abut possible alternatives.
However for the majority of people in receipt of a few hours of homecare or perhaps
some form of daycare , the introduction of individual budgets will not reduce costs.
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There is a worry, following on from the above, that the only way to meet Green Paper
stated aims both in terms of new models of working and of working from the same
budget envelope i.e. no increase in resources, would be to introduce banded payments
for different levels of need. It would be extremely difficult to do this in a way that
reflected both levels of need and circumstances and which offered demonstrable
improvements in wellbeing, independence and choice while keeping to current
planned resourcing levels. The fear is that banded budget allocations, far from
stopping a rationing or gatekeeping culture, would become an easy means to limit
expenditure or an automatic rationing device.
There is a further complexity that arises where authorities have been active in
commissioning or funding services run by the voluntary sector – which may be
accessed either directly by a person in need of support or following an assessment.
Would someone have to allocate part of their individual budget to access such
services when others access them direct? Or should we assume such service can be
accessed when setting the budget? How would we take into account different
availability of such services in different areas and avoid making assumptions about
what choices people will make before setting the budget? All of these issues arise if
we want to offer a fixed budget up front… good person centred planning would allow
discussion of all the options – including letting people know how much certain
services cost so they can consider whether they might get better value from a different
set of services.
Individual budgets should be tried but, like direct payments, may not be the solution
for everyone. Good person centred planning including discussions about relative costs
may prove to be more practical. Hertfordshire would be pleased to be included in pilot
work in this area.
Question 11. We are proposing a care navigator/broker model and would
welcome views on these proposals.
What are your views on the skills needed to perform the function and whether
such a model might free social worker expertise to deal with the most complex
cases?
In Hertfordshire we have, this year, restructured our assessment and care management
teams that deal with older people and people with a physical disability. One of the
drivers to this was to ensure we make the best use of the skills of scare staff such as
experienced social workers and occupational therapists. Another was the fact that as
we aim to offer or enable people to access an ever wider spectrum of services, it is too
much to ask that all staff become experts in how to access all forms of care from all
manner of providers. There would be a danger that staff spend a disproportionate
amount of time trying to arrange care, without sufficient knowledge, and this taking
valuable client contact time. To tackle these issues we have introduced “Service
Solutions” teams. These teams will take over the arrangement of a care package once
the assessment is complete and care plan in place. They will also ensure financial
assessments are completed. Over time these teams will build up market contacts and
knowledge in their locality across the broad spectrum of services and will develop
relationships with local providers. They will also identify gaps in provision and link to
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strategic commissioning staff to flag up requirements and influence commissioning
strategies and plans.
We see these staff as akin to the “brokers” identified in the Green paper and support
the consideration of using staff in his way. It does not seem necessary to actually have
staff called navigators or brokers – we tried to use the name of our teams to explain
what they were there to do – find service solutions.
Consideration should be given to whether this kind of division of roles would work in
all sizes of authorities and the size of he cultural change required to make such
changes should not be underestimated.
Question 12 What do you think will be he impact of shifting the balance of
services from high level need to earlier, preventative interventions on the
eligibility criteria and what might this mean for Fair Access Care Services
(FACS)?
In many cases preventative services are provided by the voluntary sector using
funding from local authorities. By their nature they should be accessible to people
who do not currently meet eligibility criteria and, in many cases access to such
services prevents a need for statutory assessment or intervention. Even where FACS
is applicable, the interpretation of the clause about “risk to loss of independence”
allows us to offer access to preventative services – even where the threshold for
eligibility is relatively high e.g. substantial or critical risk (now.. or that independence
might be lost).
A relative shift to preventative services need not require a change to FACS.
Question 13 What is the best approach to strengthening leadership at council
member level?
Requiring a member lead for adult care and placing the same degree of importance on
that role as for the lead member for Children’s Services.
Question 14: Do you support the introduction of a strategic needs assessment to
inform the development of the social care market?
Yes and we have done a significant amount of work on his in Hertfordshire,
particularly in respect of home care and care home/extra care housing provision.
Question 15: How can local authorities stimulate the market to offer a range and
diversity of provision which meets the outcome demanded by the vision?
By being clear about demand and supply and gaps in provision and listening to users
and carers when they identify alternative means of support they would like to access
but which may not currently be available. Then, equipped with this information
working with providers in mature relationships and using flexible contracting
frameworks to develop and diversify the services available. There may also be a need
to capacity build , for example , in the voluntary sector or to stimulate or incentivise,
for example where land prices prohibit development, or to actively trigger new types
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of service through assisting in the set up of social enterprise, for example. Skilled and
experienced commissioning and contacting staff are essential to this as is the
commitment of senior managers to developing strategic relationships with providers.
In Hertfordshire we can offer examples of effective work in this area.
Question 16.
Do you support the proposal to develop a strategic commissioning framework?
Yes. For this to succeed there would need to be positive incentives for partner
agencies to participate in developing the framework and something to motivate them
to play their part in delivery. Too often strategic objectives are not aligned and
differing organisational priorities undermine well laid plans and good intentions.
Question 17 : Is the proposed shift to a preventative model of care the right
approach?
This council fully supports the provision of preventative services and has increased its
investment in the voluntary sector in the last 2 years focusing on preventative services
for older people as well as developing enabling homecare services and intermediate
care services all aimed and preventing or delaying the requirement for more intensive
services. Preventative services may prevent some people from needing our services at
all and make delay or reduce the intensity of services needed by some others.
However it is more accurate to describe a shift in the balance between preventative
services and more intensive services than to say there can be a shift per se. There are a
whole range of disabilities and conditions that we cannot prevent through services we
might offer or actions we might take. We can take new and innovative approaches to
helping people live with these conditions but this is to offer new service solutions not
prevent needs. For example, we cannot, at present, prevent the onset of dementia. In
some cases, medication will slow its progress and assistive technology may allow
people to remain in their own homes for longer but for many, more intensive services
– sometimes in care homes, will eventually be needed. Nor can we prevent learning
disabilities, physical disabilities or sensory loss and people with these kinds of needs
often need very intensive and costly care packages throughout their lives. Preventative
and public health activity may have some impact to reduce mental health problems
but this is likely to be marginal when compared to the cost of supporting people with
complex mental health conditions.
In Hertfordshire x% or £m of our budget for adult social care is spent on services for
people with learning disabilities or physical disabilities. We know that the numbers of
people with learning disabilities requiring accommodation and support is rising and
the County Council is having to increase its investment in these services substantially
every year. The rising numbers and needs of people with learning disabilities are
widespread issues affecting most authorities. The Green Paper refers to these trends
on page 22 but the document is silent on how we can meet these rising demands. In
Hertfordshire, services for people with learning disabilites are already being remodelled to offer independence, well being and choice and person centred planning
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and user and carer involvement are well advanced. All of this is in line with the Green
Paper vision but continued delivery will need resources and these resources will have
to grow to meet rising demand. Preventative services will not provide a quick fix to
this challenge.
Question 18: What are your views on approaches to promoting and developing
partnership working across agencies and effective models for so doing?
Where strategic objectives coincide, excellent models of partnership working can be
developed which can offer added value solutions. There are a number of such
examples in Hertfordshire, one of which is quoted in the Green paper. Good
partnership working can deliver excellent solutions but it requires a huge degree of
commitment, effort and trust. At times a great deal of effort is expended only to find
that partner objectives, directives or targets change and projects and agreements fall
by the wayside. Local Area Agreements may offer a framework within which
partnership working can mature, but that is yet to be tested in Hertfordshire.
Question 19: What help and support is needed to help local authorities and other
social care providers to work with people using services and carers to transform
services?
There are many examples of excellent practice in working with service users and
carers across the social care sector and sharing best practice is always good support.
Question 20: Do you have innovative models of provision which support the
outcomes of our vision?
Yes, we have a wide range of innovative models of provision, of partnership working
and of working with the market to reshape services. We are happy to share
information about these developments which include:

Working with independent sector homecare agencies to develop and enabling
homecare services and a new intake and assessment model which will help
identify those that will benefit from an enabling service.

Development of an intermediate care unit in an independent sector residential
care home in partnership with the provider and the PCT.

A tender for the development of a care home to replace a community hospital .
This a joint PCT and Council tender with pooled purchasing budgets and lead
commissioning. The home will offer 20 continuing care beds – to replace the
hospital beds, 20 intermediate care beds, 20 nursing care beds and further
nursing dementia beds some to be bought through the contract and some sold
privately.

Handy person schemes incorporating home security services – available to
support elderly people across almost the whole county and funded and
commissioned in partnerships between the county council, district councils,
PCTs the voluntary sector, police and others.
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Question 21: Do you have views on appropriate performance measures to
encourage the implementation of the vision?
We are currently in a situation where, in many cases, the Performance indicators used
to judge our services do not truly reflect the outcomes we aspire to achieve and which
we are nationally expected to deliver. Many of these aspirations are endorsed in the
Green paper. For example, if there is to be a shift towards more prevention and
partnership with the voluntary sector to deliver this, then these services are likely to
be direct access in many cases and will not require someone to have a social care
assessment on meet FACS eligibility criteria. If this is the case then we must be able
to count services delivered through this route in our performance. Hertfordshire has
done a great deal of development work in this territory and several thousand people
benefit – we are able to monitor this but it is not counted in any way in our
performance indicators as we can only count services that are provided post
assessment. This applies to all the helped to live at home indicators and to the new
carers indicator.
In addition to this issue we must have indicators that consider successful rehabilitation
through intermediate care and which acknowledge the development of extra care
housing services for example. Under the LPSA Hertfordshire had to devise its own
local targets as none of the national indicators reflected what we were aspiring to
achieve.
Many indicators are restrictive in a way which does not allow best practice to come
through. For example, direct payments only count if they are on-going when a one-off
direct payment may offer something which allows a carers to continue in their role on
an on-gong basis or someone to maintain their independence. Such cost-effective and
person centred solutions should be counted. Similarly, one off interventions whether
via direct payments or provision of equipments are not countable against the helped to
live at home or carers indicators.
More flexible and creative service solutions and good practice need to be picked up
and reflected in new performance measures. Greater use of user/carer feedback may
be a useful supplement to enhanced and re-defined statistical indicators.
Question 22: How can the Government best enable Local Strategic Partnerships
develop and monitor progress on cross-cutting issues?
Local area agreements may offer an opportunity to progress in this area. There does
need to be recognition of the different dynamics in 2 tier, multiple PCT areas where
there will be district and county level LSPs.
Question 23: Do you think the direction proposed for strengthening and
developing the skills of he workforce is right? And
Question 24 How can we improve and better integrate local workforce planning?
The Workforce is key to the vision and yet the Workforce chapter is light. Although
some key areas of activity are discussed e.g recruitment & retention, reward &
training there is no clear direction of travel that sets out how we might go about
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transforming the workforce. To deliver the vision we will need a systems wide
workforce strategy and a means of delivering the actions identified. At the moment
there is a lack of clarity about responsibility and funding of learning and development
of the social care workforce. The Learning and Skills Council has social care as a
priority but seems to have fairly rigid, nationally set targets which can only be
influenced in a limited way by local commissioners of services ( largely local
authorities) and employers ( largely independent sector). Consultation on strategies is
mainly through employers and yet it is be local adult care departments, through
commissioning that are tasked with reshaping and refocusing what is delivered. Links
between and respective roles of the LSC, Skills for Care, SHA Workforce
development directorates, employers and local councils are not clear. There is an
opportunity to use the newly established Learning Resource Centre Networks to bring
together funding and commissioning of learning & development for the social care
workforce and deliver a cross sector Workforce plan.
Question 25. What actions are needed by Government and others to assist
employers in recruiting , retaining and developing the workforce?
See above. In addition positive profile campaigns & good news stories can help –
though these largely need to be locally driven. There is also a funding issue. If we
cannot afford to pay a price for care that enables a reasonable wage to be paid then
care providers will be unable to recruit or quality standards will drop.
Question 26. How can we strengthen the links with the voluntary and community
sector, and increase community capacity?
By building relationships through close involvement in service planning and
consultation and by resourcing and supporting the sector appropriately to fulfil the
roles we would like them to play. Although there is still a volunteer component to the
services provide to the voluntary sector, increasingly they are provided on a
contractual or service agreement basis with funding for staff as well as other costs.
These services can still offer excellent value for money but we cannot expect to get
something for nothing. Whilst local authorities might want to support voluntary sector
campaigns for volunteers & might be able to assist with this through awareness
raising in its own workforce, in schools etc. , it is better if the lead remains with the
voluntary sector so we do not increase the perception that we are trying to get
volunteers to take on statutory roles. It is possible that the rising number of older
people could have a positive impact on community capacity as well as increasing
demands on he system. However, expectations have changed and it remains to be seen
how many active older people will be willing to offer time as volunteers in the future.
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