Memorandum by Age Concern England
RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES
(HSS 34)
2. AGENCY RESPONSIBILITIES
2.1 Anomalies in responsibilities
2.1.1 In order to access the care which
is required at the point when it is needed, older people, their
relatives, friends and carers, must have a knowledge about, and
an understanding of, the current highly complex system of accessing
services, equipment, treatment and care. Over many years, there
has been a great number of changes in the system, and this has
led to the creation of anomalies in agency responsiblities which
Age Concern believes must be addressed.
2.1.2 For example, nursing care is available
"free at the point of use" from the NHS for older people
living at home, in sheltered housing, in residential homes and
in hospitals; but the NHS has no responsibilities to provide general
nursing services for the majority of older people living in nursing
homes. Similarly, it is the responsibility of the NHS to fund
continence supplies for older people living in all settings, except
for those who pay towards their care in nursing homes.
2.1.3 Age Concern believes that:
— all elements of nursing care should
be provided free at the point of use irrespective of the type
of accommodation in which the older person lives. (A copy
of a joint publication from Age Concern and the Royal College
of Nursing which sets out a formula for calculating the nursing
element of care for those in nursing homes, is included in this
submission, at Annexe A).[1]
— continence supplies should be
provided by the NHS to those who live in nursing homes.
2.2 Local boundaries
2.2.1 Many of the boundaries between different
agencies' responsibilities are contained in separate, locally
set eligibility criteria for community care, continuing health
care and housing services. However, many of the older people,
their relatives and friends who contact Age Concern are unaware
either that criteria exist, or which criteria operate for what
services, or that criteria for different services may vary inequitably
both between agencies and across the country. Those who discover
there are different criteria around the country often do so as
a result of moving from one area to another. They may discover
that what was a need which one authority met through services,
may no longer be considered a need elsewhere and so help with
services may be denied.
2.2.2 Age Concern believes that:
— that there is an urgent need for
Government to set national eligibility criteria so that needs
which are deemed to exist in one part of the country must be similarly
recognised in another area.
2.3 Need for information
2.3.1 A key factor in older people's abilities
to successfully access services is through the provision of accurate,
clear and timely information. However, access to such information
remains a central concern. The Audit Commission reports that as
many as three-quarters of users and carers have not received any
information about services before these were provided or arranged
by social services departments. (Reviewing social services:
annual report 1997, Audit Commission, 1997). This figure offers
no estimate of the numbers of potential users who may have failed
in their attempts to access services through a lack of information.
Moreover, reports to Age Concern suggest that older people are
not receiving a written copy, or other permanent record, of their
care assessment, service decision and care plan. Such information
may be vital for individuals to understand the purposes for which
each service is provided.
2.3.2 Age Concern continues to receive many
enquiries from older people, their relatives and carers, who have
not been given any information about how hospital discharge procedures
will work, despite the long-standing requirements in Government
guidance. The Health Service Ombudsman continues to investigate
similar complaints.
2.3.3 Age Concern believes that:
— the Government must ensure that
each local and health authority provides people with clear information
about its responsibilities and any individual decisions that are
made about their care;
— hospital discharge guidance must
be issued as a Direction by the Secretary of State for Health
in order to underline its mandatory nature. (A point we made
in our evidence to the previous Health Select Committee in its
Inquiry into NHS responsibilities for meeting continuing health
care needs in 1995-96.)
2.4 Assessments for continuing health
care services
2.4.1 The reality for many older people
is that it is enormously difficult to access a health care assessment
from the NHS for continuing health care services if the individual
is in any setting other than in hospital although, even in hospital,
older people's experience of assessments for services remain mixed.
In respect of those already paying towards care in residential
or nursing homes, anecdotal evidence to Age Concern suggests that,
in many cases, the NHS simply refuses to accept that any responsibility
may exist for continuing health care services, or for the necessary
transport in order to attend health clinics or as hospital outpatients.
2.4.2 Even those who are admitted to hospital
from a home are often discharged back to that home without a new
multi-disciplinary assessment having been carried out, although
there is nothing in Government guidance which would suggest that
this is either appropriate or that no responsibilities for an
assessment exist in these situations. This may mean that individuals
are not assessed for rehabilitative services, nor for any specialist
services or equipment, which the NHS has responsibility to provide
irrespective of the type of accommodation in which the person
lives.
2.4.3 Further, it does not seem that many
older patients' needs are assessed whilst in hospital to confirm
that the home in which they are currently resident continues to
be appropriate. The only exceptions reported to Age Concern are
when staff at the home have suggested that they will not re-accept
the resident after hospital care has finished.
2.4.4 Older people's care needs may change
over time. Needs which initially met a social services department's
criteria for means-tested nursing home care, may now meet the
health authority's criteria for NHS continuing inpatient care.
In some areas, health authorities are routinely reassessing, on
a six monthly basis, all those for whom they have accepted funding
responsibility for NHS continuing inpatient care. However, we
are concerned that such reassessment by the NHS may be more concerned
with ceasing to fund, rather than monitoring the ongoing health
care needs of those patients.
2.4.5 There is no evidence that health authorities
are similarly reassessing those whose needs for care have not
previously met their criteria. Without routine reassessments by
the NHS, an individual would need to know not only that criteria
existed and how to obtain the details; but would further need
to understand that if their health became worse they might be
eligible for an NHS funded nursing home place. Finally, they would
need to know who to contact within the NHS in order to request
a health care assessment.
2.4.6 It could also be suggested that local
authority social services departments should, when routinely reassessing
residents for whom they provide financial support in private and
voluntary sector residential and nursing homes or residents in
their own "Part III" residential homes, contact the
NHS and request a health care assessment. However, social services
departments may not have responsibilities to assess or reassess
all older people who pay towards care in residential and nursing
homes: for example, the estimated 24 per cent (91,000) of those
in independent sector homes who pay for this care in full themselves,
(Care of elderly people: market survey 1997, tenth edition,
Laing and Buisson, 1997) and the estimated 28 per cent (108,000)
of older residents who were already living in private or voluntary
sector homes prior to 1 April 1993, and continue to claim their
"preserved rights" to higher levels of Income Support
from the Department of Social Security (Income support statistics:
quarterly enquiry August 1996, DSS, 1997).
2.4.7 Moreover, whilst evidence suggests
that as many as 37 per cent of referrals to social services departments
come from NHS sources, Age Concern England is not aware of any
evidence to suggest that social services staff are routinely referring
individuals to the NHS for health care assessments. (Community
care trends 1997 report, Local Government Management Board,
1997).
2.4.8 Age Concern believes that:
— the Government must give urgent
consideration to the ways in which access to assessments for NHS
continuing health care services are made available for those in
non-hospital settings.
2.5 Disputes over responsibilities for
services
2.5.1 The experience of many older people
is that, where any referrals between health and social services
authorities do take place, these are generally connected with
disputes over funding between health and local authorities in
circumstances where neither is willing to accept responsibility
for meeting the individual's needs. Individuals caught in the
middle of such disputes may therefore not receive the necessary
services, equipment or care.
2.5.2 An example of such disputes concerns
bathing services. For many years, Age Concern has raised concerns
over the withdrawal by the NHS from the provision of bathing services
by community nursing services. Instead, bathing services are either
not provided at all, or are provided or arranged by social services
departments: as with nursing care, this raises the issue of individuals
paying towards a service which was previously provided without
charge. Behind such changes are assumptions that some bathing
services are provided by the NHS because they are deemed to be
of a clinical nature; but that others are provided for non-clinical
reasons and thus have become a responsibility for social services
departments.
2.5.3 Age Concern believes that:
— there is a need to identify an
appropriate mechanism which can be enforced by Government to resolve
disputes over responsibilities for services between health and
local authorities;
— all bathing services should be
undertaken within the general supervision of the district nursing
services, which should have a clear role in monitoring the health
care needs of older people.
2.6 Agreements over criteria between
agencies
2.6.1 Despite repeated Government guidance
that health and local authorities must agree their respective
eligibility criteria for community care and continuing health
care services, evidence suggests that this is still not being
uniformly met. In research jointly commissioned by Age Concern
England and the Continuing Care Conference (Research Briefing:
eligibility criteria for social services for older people in England,
PSSRU, University of Manchester, 1997), only 63 per cent of
responding local authorities described the continuing health care
criteria as agreed. According to requirements in guidance, this
response should have been100 per cent. The same research reports
that only 55 per cent of responding local authorities linked their
community care eligibility criteria with the respective health
authority criteria for continuing health care.
2.6.2 In addition, there are concerns as
to whether community care and continuing health care criteria
are applied consistently within areas. Anecdotal evidence to Age
Concern suggests that decisions about services for older people
can vary depending on which member of staff compares assessed
needs with criteria. We believe there is a need to ensure that
application of criteria is consistent. The confusion which follows
often results in individuals being able to receive a free health
care service in one area but in another area the same service
is provided by social services for which there is a charge.
2.6.3 Age Concern believes that:
— the Government should ensure that
health and social services authorities agree their eligibility
criteria ensuring there are no gaps and monitor how consistently
these are applied.
2.7 Changes in the responsibility of
one agency
2.7.1 Even where agencies have previously
agreed criteria, problems can arise when one agency unilaterally
changes part of its criteria. Where such changes result in the
withdrawal or reduction of services, there may be a major impact
not only on individual older people, but also on other agencies.
2.7.2 For example, legal judgement has confirmed
that local authorities may not hold responsibilities to arrange
care in homes for those who will be self-funding, and who can
either make private arrangements themselves, or where there is
another person who can act on their behalf (R v Sefton Metropolitan
Borough Council, ex parte Help the Aged and others 1997).
2.7.3 This has an immediate effect on the
responsibilities held by the NHS and social services departments
to older patients who have been assessed as meeting their local
authority's criteria for care in a residential or nursing home,
but who will pay for this care in full. In these circumstances,
the hospital may wish to discharge the patient, but has no responsibility
to help the patient find an appropriate home. The health authority
bears no responsibility to find a home, since the patient does
not meet its criteria for continuing inpatient care, although
it may subsequently hold responsibility for the provision of other
NHS continuing health care services for residents in the home.
If a patient, who will fully fund themselves in a home, can make
private arrangements or, where another person could do so on their
behalf, then the social services department is unlikely to hold
any responsibility in law to make those arrangements.
2.7.4 However, the patient will still require
help, assistance, information, advice and support in order to
leave hospital—for example, information and advice about
suitable homes; support in order both to come to terms with the
fact that he or she will not be returning home, and in order to
visit and talk to residents and staff in homes; and advice about
the nature and detail of the contractual relationship into which
they will enter with the home. In practice, roughly half of those
entering residential or nursing homes make private arrangements.
(Care of elderly people: market survey 1997, tenth edition,
Laing and Buisson, 1997).
2.7.5 Age Concern believes that:
— health and local authorities should
have a duty to ensure that patients receive information and are
supported, where necessary, when they fund their own places in
homes.
2.8 Waiting lists and delays
2.8.1 The response by some social services
departments, in the face of budgetary constraints and pressures,
has been to develop waiting lists for both residential and non-residential
services. The way in which such waiting lists are used reveals
one of the key differences between how responsibilities towards
individuals are fulfilled by the NHS, social services departments
and housing authorities.
2.8.2 For example, the NHS appears to be
positively encouraged to operate waiting lists for hospital treatment,
and housing authorities allowed in law to delay the provision
of funding by as much as 12 months following receipt of a completed
application for adaptations such as a stair lift under the Disabled
Facilities Grant system. However, there is no general acceptance
that social services departments should use waiting lists for
services. In short, the NHS is considered to have a general duty
towards the health needs of its population, rather than an absolute
duty towards an individual. Housing services have duties towards
individuals, but these may be lawfully delayed. For social services
departments, however, the view seems to be that once the need
for a service has been identified, there is a duty on the authority
to make those provisions immediately.
2.8.3 These inconsistencies in the type
of responsibility towards older people, and the ways in which
these must be met, have an enormous impact on individuals whose
need for services is immediate. For example, a hospital may be
seeking to discharge an older NHS patient back to their home but
cannot do so safely without the provision of a stairlift by the
relevant housing authority under the Disabled Facilities Grant
system, yet may do so on the promise that the service will be
made available.
2.8.4 The hospital's agenda and timetable
for immediate discharge appears to have no relationship with that
of the housing authority, which may legitimately take 12 months
or more to provide this adaptation. Nor does the housing authority
have any apparent responsibility towards either the hospital or
the NHS in general to facilitate patient discharge in order to
meet the Patient's Charter waiting times for hospital treatment.
2.8.5 In such situations, greatest emphasis
is generally placed on the need for hospital beds to be vacated.
However, the hospital's responsibility will only be to ensure
a safe discharge. This is entirely different from responsibilities
which may be held by other agencies, including social services
and housing authorities as well as health authorities, to ensure
that discharge is both appropriate and will enable an older
person to develop and maintain independence.
2.8.6 Age Concern believes that:
— the Government should review waiting
time rules in order to ensure that services are available when
they are needed; rather than patients waiting in hospitals when
they would like to go home, or being sent home without immediate
access to services.
2.9 Gaps in responsibilities
2.9.1 Where criteria are not jointly agreed,
gaps in responsibilities for services inevitably arise. Such gaps
in criteria, or withdrawals or reductions in services by one agency,
leave individual older people with no statutory agency holding
a responsibility towards them.
2.9.2 Eligibility criteria for services
can be changed at any time. Where one agency implements reductions
or withdrawals, but does so in isolation from other agencies,
the impact is invariably felt by individual older people who find
that they cannot get the services they need. The lack of co-terminosity
between health, local and housing authorities further exacerbates
the differences between local criteria, and the impact of any
changes.
2.9.3 For example, on average, older people
represent over 70 per cent of an NHS chiropodist's caseload: yet
new research by Age Concern, due to be published early in 1998,
shows 40 per cent of NHS chiropody managers report that services
have been cut. If such cuts are made to this vital service, health
authorities should ensure that an adequate nail-cutting service
is available for people unable to perform the task safely for
themselves.
2.9.4 Reports from older people to Age Concern
about the availability of continence supplies from the NHS for
those living at home or in residential homes suggests that, rather
than issuing supplies based on the individual's clinical needs,
the numbers of continence pads are restricted to an absolute number
each month which may be insufficient to meet the needs of individuals.
In these cases, where withdrawal by one statutory agency is not
matched by another taking over responsibilities, individuals may
face a stark choice between paying privately for chiropody or
additional continence supplies, or going without.
2.9.5 Age Concern believes that:
— the Government should specify
core services which must be met by the NHS wherever people live;
— where a health authority finds
that it cannot meet a health care need which the NHS has traditionally
met, it should ensure that other statutory agencies, voluntary
or private providers are available to meet that need rather than
ignoring the problem.
2.10 Withdrawal of care
2.10.1 It is increasingly clear that services
for many older people are being unilaterally withdrawn by some
social services departments as authorities increasingly target
services on those with higher level of needs. For example, it
is becoming more and more common for domestic cleaning services
to be provided only for those who the local authority deem also
need help with personal washing and dressing.
2.10.2 The view that community care services
should be targeted on those in greatest need, one of the six key
principles in the 1989 White Paper, Caring for People, has been
reiterated in the Audit Commission's recent criticisms of local
authorities who are failing to do so. (Reviewing social services,
Audit Commission, 1997). Since 1993, following the implementation
of the community care reforms, such targeting has generally meant
an increase in the numbers of households provided with five hours
or more home care services at the expense of households receiving
what is termed "low level care"—that is, home
care two hours or less per week (Community care statistics
1996, Departments of Health, 1997). However, overall 40 per
cent of all home care visits are still for less than two hours
per week (The coming of age, Audit Commission, 1997).
2.10.3 In addition, an increasing number
of social services departments appear to be prioritising—and
thus providing or arranging services for—only those who
are at serious risk, or a danger to themselves or others: these
individual older people are frequently very highly dependent and
require a correspondingly high level of care. Such prioritisation
may be in line with legal judgements: for example, that local
authorities should not, by the withdrawal, reduction or refusal
to provide or arrange non-residential services for older people
with disabilities, leave an individual "at severe physical
risk" (R v Gloucestershire County Council ex parte
Mahfood 1996).
2.10.4 It may also be consistent with the
Government's view of the role of social care from social services
departments. Rather than social services departments being the
first port of call for older people needing services, they appear
to be considered the last resort. In his speech to the annual
Association of Directors of Social Services conference in October
1997, the Secretary of State for Health stated that "So long
as there are frail old people, vulnerable children, people with
physical or learning disabilities, mentally ill people and other
vulnerable groups there will be a need for social care provided
by professionals to augment what families provide, itself augmented
by help from both professionals and volunteers organised by voluntary
bodies" (Department of Health press release 97/315,
31 October 1997).
2.10.5 In some local authorities, the tightening
of criteria and introduction of waiting lists for community care
services means that many older people are effectively excluded
from services. In such situations, individual older people may
find that they cannot access sufficient or suitable care from
other sources.
2.10.6 Age Concern believes that:
— there is an urgent need for national
eligibility criteria. We believe this is the only way that problems
created by a lack of co-terminosity, and arbitrary changes to
criteria will be best tackled to ensure that individual older
people have some certainties about the services and assistance
which the state must provide;
— the Government should issue detailed
guidance, which is readily available, and which clearly sets out
the statutory responsibilities of health and local authorities;
and in so doing, makes clear what are health and what are social
care services;
— national criteria and detailed
guidance must establish the "bottom line" of responsibilities
held by statutory agencies towards individuals. We are hugely
concerned for those older people where service withdrawal, prioritisation
and reduction leaves them with no statutory protection. We are
convinced that it is a proper role for Government to identify
"bottom line" responsibilities towards individuals held
by health and local authorities, and in doing so, to recognise
where gaps in responsibilities arise, and take the necessary steps
to alleviate this;
— if essential services, such as
nail cutting, bathing or "low level" home care, are
no longer deemed to be the responsibility of the NHS or social
services, the Government must ensure that vulnerable older people
are able to access these services in the community.
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