TAKING CARE OF WALES

Care Forum Wales Manifesto

The Care Forum Wales manifesto was launched in April 2003 and outlines the organisations objectives for the care sector in Wales.

Consolidating Community Care in Wales »
1. Equality in Assessment »
2. Consistent Pricing Policy for all Community Health and Social Care Services »
3. Equity of Eligibility and Access to Services »
4. The Development of “Smart” Commissioning and Contracting Arrangements »
5 Regulation of Care Services and Review and Revision of National Minimum Standards »
6. Workforce Training Strategies Linked to Funding »
7. Consolidated and Co-ordinated Community Care Funding and Purchasing »
8. Consistent Funding Formula for Community Care Services »
9. Commitment to a Mixed Economy of Community Health and Social Care Provision »
10. Coordinated Arrangements at Local, Regional and
National Level for all Organisations and Agencies »
Summary »

Consolidating Community Care in Wales

Putting service users and their carers first should be the key principle underlying all community care services. Service users need to know that their assessed care needs can be met consistently and for as long as necessary. For most dependent adults, their future has a degree of uncertainty. Service commissioners and providers need to ensure that the arrangements for long term care services – whether they are domiciliary services, day care or care homes, offer quality, comfort, and continuity for those who rely on them.

The promotion of independence, self-esteem and social inclusion depend on service users and their carers having confidence in the care with which they are provided. They need to feel that their views and wishes are taken into account in all aspects of service commissioning. They also need the assurance, that when they need to live in a care home, they have a home with care provided for the rest of their life. This requires not only joint planning with flexibility in joint working between all agencies involved, but also sufficient resources to enable the principles underpinning the Welsh Assembly Government’s health and social policies to be achieved.

The Welsh Assembly Government has put in place sound policies for health and social care services. Those policies must be supported by the political will, at all levels in all organs of government – national, local and the related Quangos – to make them a reality for those people who are the intended beneficiaries. Performance in putting policy into practice is patchy at best and poor overall when compared with the aspirations in documents such as The Strategy for Older People and Promoting Partnership in Care – commissioning across health and social care.
Care Forum Wales stated in its Manifesto in May 2001: “service users and carers judge political success in community care by the availability of quality services, equality of assessment, eligibility and funding, access, choice and timing”.

This is even more important in 2003 as the uncertainty amongst community care providers in all sectors has increased. Instability in care homes and amongst small domiciliary care providers derives mainly from difficulties in maintaining financial viability. The lack of a coherent strategy and effective action to fund public services to meet assessed care needs has resulted in continuing loss of business confidence and loss of provision. This situation will continue until the nettle is grasped and strategic funding arrangements are put in place. The National Assembly needs to take effective action to ensure that its policies are implemented in practice by all organisations and agencies to avoid giving the impression that window dressing is more important than actually ensuring the services required are delivered.

Service users and carers are not concerned with the political niceties of structures, organisations and boundaries. They want, and have been led to expect, improvements in health and social care services to meet their individual assessed needs. It’s time to turn the rhetoric into reality, cut through the bureaucracy and really put service users and carers first.

On average, more than 70% of all independent sector provided social care services are purchased by local authorities or health authorities. In some parts of Wales, especially remote rural areas and small population centres with high levels of social deprivation, 95% of services are publicly purchased. The independent health and social care sector is a major part of public service provision. The majority of the independent sector care homes and domiciliary care services are owner run and managed and if they close they are most unlikely to be replaced by new provision on such a small scale and serving local communities.

Service users and carers, who are generally the neediest members of society in terms of disability, health, housing, income and capital, deserve much better treatment than they get at present. They are disempowered by their personal circumstances and the conditions making care necessary. They are mostly unable to speak out effectively against the discrimination they face as a result of having disabilities or being old, ill and poor. It is those who care for them – whether they are relatives and friends at home, domiciliary carers or care home staff – who are truly aware of the indignities and uncertainties experienced by the many people who need care services they are unable to afford to purchase themselves. Service users are still subject to the vagaries of local political and professional views - rather than being able to have confidence that the care arrangements in place today will still be there tomorrow.

There is a need for better targeting of existing resources across health and social services, to ensure best value for money, as well as increased resources being made available to ensure continuity of care in the future for an increasingly ageing population. Resources must be directed to the achievement of National Assembly policies so that priorities do not continue to be distorted by local political and managerial decisions.
Care Forum Wales identifies the following ten point plan for action to improve performance by implementing the policies and strategies already adopted by the Welsh Assembly Government.

• Equality and consistency in assessments of individual care needs and care costs, building on the WORD funded pilot projects, on the use of the Minimum Data Set system, involving independent sector and local authority homes, and domiciliary care services

• Consistent pricing policy for all community health and social care services in recognition of the aim to achieve equity in funding, standards and quality of service for public and independent sector providers and a fair price for care

• Equity in eligibility and access to services with better information made available for service users and carers and planning in conjunction with independent sector providers for emerging and changing market requirements

• The development of “smart” commissioning and contracting arrangements - national standards for the regulation of care providers should be complemented by innovative national standards for commissioners and purchasers in service specifications and contracts particularly with independent sector providers

• Robust regulation of care services with discretionary flexibilities to maintain capacity and local provision together with review and revision of national minimum care standards to ensure that they remain realistic and attainable, within the resources available, as well as taking account of changing needs and expectations

• Workforce training strategies that recognise the independent sector workforce contribution to publicly funded services and linked to funding through the creation of Individual Learning Care Accounts in conjunction with the Social Care Workforce Development Programme funding

• Consolidated and co-ordinated community care funding and purchasing arrangements – the budget flexibilities policy still depends too much on the willingness of local authorities to work in cooperation with the NHS to enable the aim for integrated, seamless service provision to be a reality

• All-Wales funding formula for community care services that will promote the National Assembly policy of having a robust and financially viable independent care sector

• Commitment to a mixed economy of community health and social care provision - the principal aim of which should be to ensure that services are provided locally to meet assessed needs rather than political and professional prejudices about who provides taking priority over a strong and viable range of local service provision

• Coordinated arrangements at local, regional and national level for all organisations and agencies – the new Commissioning guidance emphasises the need work through organisations and systems that involve all stakeholders. The Welsh Assembly Government should take a strategic role in promoting partnership in care by making resources available to support the independent sector representative organisation and its activities as it does for the local government representative body – the WLGA.
   

1. Equality in assessment

Statutory guidance should be issued to local health boards and local authorities on the implementation of a unified single assessment process across Wales. It is inefficient, unreasonable and unjustifiable that so many different assessment methods and systems should be used. The rights of service users and carers to impartial and structured assessments of care needs require the adoption of a single, unified assessment system that is consistent in its application across Wales. Anything less will be seen as putting service users and carers after political and professional considerations.

2. Consistent pricing policy for all community health and social care services

Equality and consistency in assessment of individual care needs together with an All-Wales funding formula would enable the implementation of a consistent pricing policy. It would promote consistency in approach whilst allowing for the actual fees to reflect local variations in conditions. It would avoid the huge inconsistencies evident in the present arrangements whereby the fees for some NHS funded placements are far more realistic than local authority funded placements - with the differences sometimes due to extraneous factors other than care needs. The potential for savings on administration, negotiations, challenges to local decisions together with the potential for improvements by delivering services quicker and in ways that better meet assessed needs, make this a high priority.

3. Equity of eligibility and access to services

Common, consistent criteria should be used to determine service user and carer eligibility for service provision and access to the services to meet assessed care needs. This will require better information on service availability and better strategic planning across local authority and local health board boundaries. Higher priority needs to be given to the management of information using the technology available to improve access to information by service commissioners and purchasers as well as service users and carers.

4. The development of “smart” commissioning and contracting arrangements

Innovative “smart” commissioning and contracting arrangements should be developed consistently across Wales. This would ensure greater efficiency and added value in contracting arrangements with the independent sector. The current duplication of effort in commissioning and contracting by local authorities and local health boards should be reduced by the adoption of a standard national contract in Wales for community health and social care services. This would save considerable time and effort by public service employees and lawyers and avoid the present inconsistencies and inefficiencies when each local authority and each local health board has a separate contract for purchasing services - that are all regulated to the same national minimum standards by the National Assembly!

5. Regulation of care services and review and revision of national minimum standards

The new regulatory regime introduced by the Care Standards Act 2000 is being developed by the Care Standards Inspectorate for Wales in consultation with, and taking account of feed back from, care providers. It is widely accepted that national minimum standards are necessary to achieve consistency in the quality of services. However, it has become apparent very quickly that, it is necessary to balance robust regulation with reasoned flexibilities – if service users and carers are not to be disadvantaged by the loss of provision simply on the grounds that ‘one size fits all’. Structured, reasoned and recorded flexibility, taking account of the particular circumstances of individual service provision, the locality and the alternatives or lack of them, is necessary by regulators in exercising professional judgement and understanding the impact of national minimum standards on existing care homes. This approach should be monitored so that a balance is maintained between compliance with national standards and the needs of local communities. Protection for vulnerable adults and the powers of regulators in the publication of reports must be balanced with the rights of providers to challenge regulatory aspirations that may have unintended business consequences affecting the costs of care and creating further instability in the care sector.

The existing national minimum standards represent what was considered acceptable when they were determined. The review and revision of national minimum care standards continues to be necessary to ensure that they remain realistic and attainable, within the resources available, as well as taking account of changing needs and expectations. The impact of compliance should be reviewed in advance of post-dated deadlines to avoid further undermining of confidence in the stability of care services in all sectors as those dates approach. It may become necessary to review and amend some of the implementation dates or the standards, if compliance proves unlikely or impossible without a serious threat to the continuity of existing services that are acceptable to service users and that meet their assessed care needs.

6. Workforce training strategies linked to funding

The current bureaucracy and differing interpretations of eligibility for funding for training of care sector staffs should be reduced and simplified. A system of Individual Care Learning Accounts is proposed for all care sector staff. This would enable education and training funds to be directed to employees in all sectors. This would promote the training and qualifications necessary to achieve a competent, trained and qualified workforce in social care. It would give practical effect to the recommendations of the Workforce Task and Finish Group and do much to demonstrate the value placed on social care practitioners and managers.

7. Consolidated and co-ordinated community care funding and purchasing

The funding routes and sources for community health and social care services have increased in both number and complexity over the past five years. This has increased administration systems and costs for funding agencies and care providers, using time and costs that could be better used in direct service provision. Care Forum Wales calls for consolidation and coordination in the funding and purchasing arrangements for community health and social care services. Repeated exhortations to the many agencies and organisational structures to work together in the interests of service users has led to increased gaps in service funding arrangements rather than led to the seamless service provision intended. The continuing difficulties between NHS and local authority priorities and funding is evidenced by delays in securing care services in the community for patients in hospital beds. It is time to take action and to make better, more efficient, organisational arrangements for the funding and purchasing of community health and social care services. The rationale for the formation of social services departments in 1971was that there should be one door on which can knock for all social services. This principle needs to be applied now to funding and purchasing to reduce inefficiencies and use all resources to better effect. It requires grater control over policy implementation that may only be achieved by hypothecated funding.

8. Consistent funding formula for community care services

Care Forum Wales calls for a formula to be agreed nationally for Wales to determine the factors to be included and the method used to determine the fees for all health and social care services – whether purchased from independent sector providers or for local authority directly provided services. An enormous amount of time and energy continues to be spent by all stakeholders in wrestling with the present inequalities of funding and costs for purchased services. This could be better devoted to improving the quality and standards of service by agreeing a national formula for calculating fees that will apply to all purchasers and all providers. Fees for exceptional or individually specified services outside of, or in excess of, the formula provisions would then be subject to individual negotiation. A number of studies have been completed and published on the costs of care and Care Forum Wales calls on the Welsh Assembly Government to consider adopting an independently developed and transparent formula for calculating care costs across Wales e.g. the Joseph Rowntree model

9. Commitment to a mixed economy of community health and social care provision

The Welsh Assembly Government should commit itself to promoting actively a regulated, mixed economy of care that can deliver the services required to meet individually assessed care needs. The range of services and locations means that no one provider can ever hope or expect to meet all requirements. Strong partnerships committed to focussing in the needs local communities and individual service users and carers are necessary. The current situation whereby some authorities and agencies can subvert National Assembly policy by default - failing to work with independent sector providers in a meaningful way - is simply not good enough. Service users should no longer be made pawns in political struggles between the National Assembly and local authorities. The National Assembly should take all necessary steps to ensure that its policies and strategies are implemented consistently in the interests of all those who need and depend on community health and social care services. The recent statutory guidance - Promoting Partnership in Care – Commissioning across Health and Social Care Services gives a succinct exposition of the key factors needing action by all agencies and is warmly welcomed by Care Forum Wales.

10. Coordinated arrangements at local, regional and national level for all organisations and agencies

The Welsh Assembly Government should take a strategic lead in promoting partnership in care by making resources available to support one representative organisation to work on behalf of the independent sector and its activities, as it does for the local government representative body – the WLGA. By using the existing structure of Care Forum Wales, independent sector care providers would be encouraged to play a more active part in consultations, information sharing, planning and service development if they could see the National Assembly’s commitment to developing a more formalised structure to work with the whole sector. Such a step would demonstrate the Assembly’s commitment to involving all stakeholders and improve the efficiency and effectiveness of communications with and involvement of the large and diverse range of providers of social care services.

Summary

Care Forum Wales calls on the Welsh Assembly Government to focus its attention and action during the next term of office on Consolidating Community Care Services in Wales. Its priority should be strategic action to ensure that its policies, strategies and guidance are implemented in practice so that Welsh health and social care provision is truly worthy of what service users and carers expect in the 21st Century.