Memorandum by the Department of Health
(continued)
PUBLIC EXPENDITURE QUESTIONNAIRE 2001
REMUNERATION AND
PERFORMANCE IN
FOSTER CARE
Researchers:
Derek Kirton, Kate Ogilvie and Jeni Beecham,
University of Kent at Canterbury
44. The principal aim of the project is
to explore in-depth the relationship between remuneration and
other resources available to foster carers and the performance
of fostering services. The context is set by the very wide variations
in levels and systems of payment for foster carers, and differences
of philosophy, ie whether foster care should be seen as an essentially
voluntary activity or a job. Equally important is the perceived
crisis in foster care, of recruitment and retention, placement
breakdowns, and failure to meet children's needs, in education
or preparation for leaving care.
45. The research seeks to explore different
patterns of resource allocation (with particular reference to
remuneration) from the perspective of carers, workers and managers
and their relationship to key performance indicators for fostering
services.
46. The research is taking place over two
stages:
Stage 1: analysis of remuneration and performance
data on foster care from all local authorities in England to identify
links at the "macro" level.
Stage 2: detailed investigation to take
place in 20 agencies (to include 3-4 independent fostering agencies),
comprising:
— data on agency performance indicators
— semi-structured interviews with service
managers
— focus group discussions with family
placement workers and foster carers
— questionnaire for foster carers (sample
c. 2000).
Start date: September 1999
End date: August 2002
CHILDCARE COSTS:
VARIATIONS AND
UNIT COSTS
Researchers:
Jeni Beecham and Andrew Bebbington, University
of Kent at Canterbury
47. Understanding child care costs has become
increasingly important. Local issues include pressure to contain
costs and the introduction of quasi-market delivery systems.
At the national level there are concerns about the rising costs
of child care, local authorities' different levels of spending
and the costs associated with supporting children who are not
formally looked after. More appropriate information could provide
a better evidence base for both policy and practice decisions.
The new Children in Need Data Collection has the potential
to aid our understanding of child care costs as it contains integrated
information on the characteristics and needs of all children who
are seen by the social services department, the service responses
and their associated costs.
48. The study builds on previous research
at the PSSRU on variations in unit costs and work with the social
services departments who participated in the Children in Need
pilot. We are using data generated by the Children in Need
Collection to contribute to improving the efficiency in the
delivery of services by providing a better understanding of variations
in child care costs. The study involves preliminary analyses of
the first data set in the summer 2000 and then a fuller analysis
in 2001, supported by data drawn in from other sources and information
from interviews in a sub-sample of local authorities. (Phase
I June/July 2000; Phase II June 2001—May 2002).
Start date: June 2000
End date: May 2002
Table 1
SUMMARY OF OSCA PROJECTS
A PEN PICTURE
OF THE
PROJECTS
49. A brief description of the projects
follows. This is intended to be purely descriptive of objectives
and approach, rather than analytical of the findings or conclusions.
OLDER PEOPLE
WITH DEMENTIA
AND THEIR
CARERS
50. This project focuses on a primary care
based intervention with informal carers of people with dementia.
In particular, the project considers whether low-level early intervention
is successful in preventing crisis, or whether it serves to increase
the recognition of problems and needs and leads to an earlier
breakdown of care at home. The project has compared a group of
carers receiving an intervention package from a specially trained
worker, with a control group receiving the usual pattern of care
available.
THE MANAGEMENT
AND EFFECTIVENESS
OF HOME
CARE ASSISTANTS
51. The study focuses on different homes
care services in the independent and public sectors, and explores
criteria against which performance can be measured, and variation
explained. Research was conducted in four northern authorities
and employed both quantitative and qualitative methodologies.
The study describes the problems which are found in the organisation
and delivery of home care and considers different staff and organisational
influences on service performance.
ROUTINE USE
OF A
STANDARDISED ASSESSMENT
FOR MEASURING
OUTCOMES
52. The primary objective of this project
is to evaluate the ability of a new assessment instrument (the
Minimum Date Set Home Care—MDS-HC) to capture the outcomes
of social care from routine assessment information. The assessment
instrument has been used in a randomised controlled trial, compared
with current community care assessment instruments. The study
is concerned with the extent to which an assessment instrument
in routine use can detect measurable change in key domains of
survival; accommodation; activities of daily living; cognitive
and social functioning; mood and carer burden.
DEVELOPING A
MEASURE OF
OUTCOMES OF
SOCIAL CARE
FOR ELDERLY
PEOPLE
53. The project is developing a broad measure
across a few key social care domains (food and nutrition; personal
care; social participation; safety, and control over daily living).
In each domain, the instrument is used to assess level of unmet
need, informal/formal support, and level of need in absence of
intervention. Later stages of the project involved establishing
the relative importance of different domains to older people,
and allocating appropriate weightings.
INTEGRATING SOCIAL
AND HEALTH
CARE
54. This study focuses on whether the promotion
of closer working relationships between front line practitioners
in social services, primary care and community health services
offers better outcomes for service users and their carers. The
research compares two different models of collaboration between
social services and primary care, and compares their costs and
outcomes.
SUBJECTIVE AND
OBJECTIVE QUALITY
OF LIFE
ASSESSMENT
55. Focusing on residential services (staffed
houses) for people with learning disabilities, this study addresses
the measurement of quality of life using both objective and subjective
measures, and to explore the relationships between these measures.
The study also investigates variation between different types
of service provider. Three key quality of life domains are assessed:
choice and control; constructive activity; and social and community
affiliation.
EVALUATION OF
GOAL ATTAINMENT
IN COMMUNITY
LEARNING DISABILITY
SERVICES
56. This project involved the implementation
of a Goal Attainment Scaling (GAS) system. GAS involves the setting
of goals with individual service users and/or their main carers;
the development of a five point scale against which outcomes can
be measured, and using this scale to provide a score for goal
attainment. These scores can be aggregated and used to monitor
and evaluate service performance in achieving outcomes with users
of the service. The objective is to incorporate GAS within routine
community care paperwork and systems.
CARERS' AND
USERS' EXPECTATIONS
OF SERVICES
(CUES)
57. The purpose of this project is to develop
instruments which will measure outcomes from the perspective of
service users and carers, with a focus on self-assessment. The
instruments explore a number of different domains of life and
services. It is intended that the instruments should enable service
users and carers to inform health and care workers of their social
function and outcomes from their perspective. The approach should
contribute to and be a component of care management and care plans.
TEN YEARS
ON: OUTCOMES
AND COSTS
OF CARE
58. This study is looking at the outcomes
and costs of care in the community for people with learning disabilities
and mental health difficulties 10 years into a process of de-institutionalisation
and the development of community care. The project allows a longitudinal
evaluation using original instrumentation for comparisons over
time, but also developing new measure to ensure comparisons with
wider research evidence. The project has developed some innovative
approaches to communication in user interviews.
COST-BENEFIT
EVALUATION OF
AN OPEN
ACCESS DETOXIFICATION
SERVICE
59. Detoxification services have tended
to be evaluated solely in clinical terms. This project looks
at wider costs and benefits and offers an audit tool for use in
service planning and measuring the indirect cost-benefits. The
original intention of the study was to compare the service with
a non-treatment seeking control group. This was not practical,
and the study in fact compares two different types of detox services.
CARING RELATIONSHIPS
OVER TIME
60. Using detailed analysis of three nationally
representative data sets, the research relates outcomes for carers
to the timing and duration of care giving episodes within the
life course. Longitudinal analysis of data sets allows a better
and more detailed understanding of the dynamics of providing care,
and an exploration of the impact of past care episodes on current
circumstances. The impact on carers' health, employment and pension
arrangements, are all examined.
CARERS' NEEDS
AND THE
CARERS' ACT
61. This study investigates the impact of
the Carers (Recognition and Services) Act, 1995 in terms of changes
in local policy and practice, and from the perspective of a sample
of carers who have received an assessment under the Act. The
effect on carers has been evaluated in terms of increased service
provision; tailoring of services to needs; and improved quality
of life.
DEVELOPING EVIDENCE
BASED SOCIAL
CARE POLICY
AND PRACTICE
62. This project differs from the other
twelve in its approach and methodology. Rather than involving
new research, this project provides a systematic review which
identifies and synthesises research evidence on effectiveness
and outcomes in two main areas. These are: rehabilitation for
people with severe and enduring mental illness, and preventive
services for older people. A further report offers reflections
on the feasibility of undertaking systematic reviews in social
care.
63. Alongside the 13 OSCA projects, a related
programme of work on outcomes was commissioned from the Social
Policy Research Unit at the University of York. Throughout the
co-ordination of the OSCA programme this parallel work was also
included.
THE RELATED
SPRU OUTCOMES PROGRAMME
64. The SPRU programme has focused on developing
and testing practical ways in which purchasers and providers can
obtain feedback on outcomes, and using outcome information in
routine activity. Interviews and focus group work with users and
carers, with front line staff and service managers, have been
used to identify different types of outcome related to continuing
quality of life; time limited change; and the quality of the service
process.
INTRODUCTION
PSSRU RESEARCH PROPOSALS
2001-2005
The PSSRU
65. From its establishment in 1974 at the
University of Kent at Canterbury, the PSSRU has undertaken a considerable
volume of analysis and research aimed at the improvement of equity
and efficiency in social care (and increasingly also in health
care). The move to three branches—continuing at Kent, together
with new developments at the University of Manchester and the
London School of Economics and Political Science—has allowed
the Unit to build new institutional links and develop new empirical
bases while continuing its research and analysis programmes.
66. The logic of the transition to a three-branch
Unit, which was strongly encouraged by the Department of Health,
reflects a broadening of research scope and, in particular, the
desire to build research alliances with other disciplines and
groups. Closer links have been built with medical, health service
and policy research, and empirical studies have been conducted
over a wide geographical area. The Unit is also well positioned
to undertake multi-centre research studies. The proposed programme
builds on the strengths and expertise of current unit members
and we would also see investment in training and development as
an integral part of the process of delivering the work, in accordance
with the Investors in People accreditation achieved by the Kent
and Manchester branches.
Fields of study
67. The PSSRU forward programme of research
is primarily concerned with studies of equity and efficiency in
the organisation, financing and delivery of social and health
care; with a particular focus on the definition and measurement
of costs, outcomes and needs-related characteristics of users,
the links between them, and how they can be improved.
Forward programme
68. This document sets out the forward programme
proposals for PSSRU for the period beginning January 2001. These
are outline proposals, and are likely to be subject to development
and change in the light of Department of Health priorities and
PSSRU capabilities. This is a working document and will form a
platform for more detailed proposals.
69. As a preface to these forward programme
proposals, we briefly describe here the activities at each of
these three Unit branches.
University of Kent at Canterbury
70. Organisationally, the Kent branch is
linked to the School of Social Policy, Sociology and Social Research,
which has consistently achieved a high rating in the HECFE Research
Assessment Exercises. Staff in the Kent branch undertake collaborative
research locally, nationally and internationally. The research
programme at Kent links programmes to inform and create fresh
ideas for the new policy agenda. There is an emphasis on quantitative
research, building on a unique range of data sources.
71. The proposed new programmes address
policy issues relevant to social and community health care for
both adults and children, including: performance assessment, inter-relationships
between costs, quality, standards and outcomes; effectiveness
in a variety of care settings, including intermediate care; and
planning on the basis of need. Proposed research programmes to
be undertaken at Kent (in some cases, jointly with other branches)
include:
— Community Care Reform: UK and International;
— Economics of Child Social Care;
— Evaluating Community Care of Elderly
People;
— Needs-Based Planning; and
— Roles, Quality and Costs of Care
Homes.
London School of Economics and Political Science
72. The LSE branch of the Unit was established
in January 1996 and is now part of LSE Health and Social Care
in the Department of Social Policy. The Department was awarded
the highest rating for social policy in the UK in the 1996 RAE
assessment. Close working links have also been forged with the
Centre for Civil Society and the Centre for the Analysis of Social
Exclusion (both at LSE), the Centre for the Economics of Mental
Health (Institute of Psychiatry) and the Nuffield Institute for
Health (University of Leeds).
73. The future research programme at LSE
would be pursued within this developing context, building on accumulated
experience in a number of policy areas. Among these areas are:
relationships between costs, needs and outcomes; measurement and
promotion of performance; commissioning, competition and partnerships
in social care "markets"; motivations and behaviour
in the "mixed economy" of care; long-term care financing;
economic and policy analysis in mental health care; and the voluntary
or non-profit sector. Proposed research programmes at LSE (in
some cases, jointly with other branches) include:
— Community Care Reform: UK and International;
— Competition and Performance (Mixed
Economy of Care);
— Evaluating Community Care of Elderly
People;
— Long-Term Care Finance; and
— Mental Health Economics and Policy.
University of Manchester
74. The Manchester branch of PSSRU, founded
in 1996, is integrated into the Faculty of Medicine, Dentistry,
Nursing and Pharmacy. The unit has received strong backing financially
and organisationally from the University of Manchester in the
development of its infrastructure. The unit has particularly close
links in the University with the Departments of Old Age Psychiatry,
Geriatric Medicine and Nursing, as well as Social Policy and Social
Work, and is developing links with other relevant groups, such
as the Health Services Management Unit and the University of Manchester's
newly formed Institute of Health Sciences. The latter aims to
bring together major groups at the University engaged in health
sciences research. As a consequence of these links the unit is
very well placed to tackle issues relating to the health/social
care interface.
75. The future programme at Manchester is
specifically designed to reflect and respond to the new policy
agenda in relation to the key themes of integration and partnerships,
more consistent and effective services, and improvement of service
delivery, performance and efficiency. It is designed to build
upon and develop from the substantial investment in the area of
co-ordinated care, service integration, assessment and care management,
and performance measurement undertaken by the research team. There
are two interlinked programmes of activity:
— Assessment, Performance Measurement
and User Satisfaction in Older People's Services; and
— Coordinated Care, Care Management,
Service Integration and Partnerships.
COMMISSIONING AND
PERFORMANCE (MIXED
ECONOMY OF
CARE)
Background and research problem
76. Two of the major themes running through
social care policy are performance assessment and the commissioning
of quality provision. Modernising Social Services sets
national objectives, including the goal "to plan, commission,
purchase and monitor an adequate supply of appropriate, cost-effective
and safe social services for those eligible for local authority
support" (p.111). Other policy proposals are pertinent. The
Performance Assessment Framework (PAF), as described in A New
Approach to Social Services Performance, and the "best
value" initiative, as launched by the White Paper Modern
Local Government: In Touch With The People, set challenging
agenda for social care services.
77. Well-tempered commissioning is clearly
going to be fundamental to the achievement of these goals, and
will make a central contribution to the improvement of performance.
As defined in Modernising Social Services, commissioning
comprises needs analysis, strategic planning, contract setting/market
management and contract monitoring. Our work to date suggests
that commissioning does have a significant impact on the shaping
of local social care markets, cost containment, and the promotion
of quality care, but that the relationships are complex. Local
authorities have been prepared to develop commissioning. What
is now evident is a willingness to introduce new commissioning
arrangements which have the potential to achieve more rapidly
and successfully the broad national and local policy objectives
set for social care.
78. At the same time, social care delivery
is more dependent than it has been for perhaps 50 years on private
and voluntary sector providers. Those providers have themselves
been developing, as they learn to adapt to new patterns of association
with, and dependence on local authority purchasers. They are also
having to adapt to new generic labour market regulations, while
operating under conditions of unsettling uncertainty about what
is expected from them under the new regulatory regimes. The managed
and intensively regulated markets of the early 2000s will be very
different from the relatively "hands-off" environment
of the 1990s. The provider side of the social care market will
likely transform dramatically. Many of the small businesses which
have traditionally dominated the field could be forced out by
economic pressures and demanding quality standards, while contractual
and regulatory burdens erode much of the autonomy and control
over their own affairs which attracted them to this field in the
first place. "Corporate" providers, in both the private
and voluntary sectors, look set to consolidate powerful positions.
Policy questions to be addressed
79. The aim of the Commissioning and Performance
Programme (C&PP), formerly known as the Mixed Economy of Care
Programme, is to evaluate how different commissioning approaches,
and different commissioned services, can enhance the performance
of social care services in delivering quality care and improving
user quality of life. We propose to explore the details of commissioning,
and its relationship to performance, in the context of a better
understanding of the motivations and behaviour of providers.
The new programme would comprise five specific
components:
— first, to paint a comprehensive picture
of social care commissioning arrangements employed by English
local authorities, especially in relation to services for older
people, and the links with health care commissioning. Descriptions
of commissioning to date have been limited to small samples of
authorities; we aim instead to collect data nationally.
— to analyse the relationships between
commissioning arrangements and performance, as measured by the
performance indicators of the PAF, and other measures to be developed.
This evaluation would be conducted at the level of the local authority,
thus complementing our previous work at the "transaction"
level.
— third, to cost different commissioning
arrangements and assess the benefits for different stakeholders
of improvements as measured by the performance indicators. This
third component would thus build on the first two, and would amount
to the specification of cost-outcome relationships for different
commissioning strategies.
— to explore in detail how the motivations
and behaviour of public purchasers and regulators is experienced
and interpreted by providers. This must be a priority in understanding
providers' (reciprocal) behaviour, and hence in understanding
"performance".
— finally, to understand the motivations
of providers. These motivations are intimately bound up with the
character and quality of providers' relationships with purchasers
and regulators. The rapidly changing policy and practice contexts,
and particularly changing commissioning approaches and the changing
structure of the provider side, mean that evidence on motivation
and behaviour from the 1990s may no longer provide a sound guide
to understanding the unfolding present, nor to anticipating future
performance and events.
80. One focus for much of this work, at
least in the short term, is to examine the economics of care home
closures.
Research approach
81. As with our previous work, we will meld
a range of approaches and data sources, continuing to build on
other PSSRU data collections (for example, those being gathered
in the Care Homes programme led by Ann Netten, and which are already
being used in the Commissioning and Performance programme). We
would also collect new data from commissioners and providers.
A new departure would be to conduct a national data collection
from all English authorities (in collaboration with appropriate
national bodies).
82. Again, as in our current and previous
work, we would build multidisciplinary conceptual structures and
empirical collections, drawing on economics, social psychology,
public administration, social policy and other bases. We would
build upon the combination of quantitative and qualitative data-gathering
strategies in our current programme. "Performance" would
be defined not only in terms of the elements of the current PAF,
but also so as to embrace such contributions to ultimate performance
as the building of trust and social capital. A wide range of factors
would need to be examined in understanding variations in performance
so as to reflect the unprecedented degree to which private and
voluntary providers and public authorities are now interdependent.
83. It is hoped that the PSSRU programme
can continue to be pursued in collaboration with researchers at
the Nuffield Institute for Health, University of Leeds.
Programme management and branch
84. This research programme is managed by
Professor Martin Knapp and conducted at the LSE branch of the
PSSRU.
COSTS AND
OUTCOMES
Background
85. During the previous quinquennial period,
the Unit Costs programme drew together information about unit
costs of a wide variety of services in a format that is transparent
and easily adapted to particular circumstances. This has fed into
many other programmes of research both within and outside the
unit, nationally and internationally. The demand for the work
is therefore both direct, for those who need information about
unit costs for specific purposes, and indirect, through the results
of research which has drawn on the work.
86. For the most part the programme has
drawn on costing undertaken as part of other, unrelated studies.
However, two pieces of specific costs research have been commissioned
during recent years. First, a study developing a Ready Reckoner
for health service staff costs has contributed to our understanding
about the costs of initial training of health service professionals,
and about incorporating these in unit costs in a way that reflects
the expected working life of these professionals. Second, research
has been undertaken into the costs of regulation under the current
arrangements. Related work within the Unit has examined trends
and variations in unit costs across services, and their implications
for efficiency.
87. For the most part PSSRU studies have
drawn on previously developed scales of general welfare or particular
aspects of people's lives when investigating outcomes. In a new
development, as part of the OSCA initiative, a project underway
is developing an innovative measure of social care outcome for
older people (SCOOP). This measure is designed to reflect the
core objectives of social care and the preferences of older people
in a way that measures such as EQ5D do for health services and
the general population.
The policy questions
88. The current policy drives for Best Value
and raising standards have as a key component the national Performance
Assessment Framework (PAF) with associated Performance Indicators
(PI). Ideally the PAF, together with the arrangements designed
to encourage partnerships with health services, would provide
incentives for authorities to improve efficiency, encourage independence
and improve the quality of care provided. In order to do this
PIs should include indicators of cost and outcome that together
could provide clear messages about relative efficiency. In practice
the initial PIs have had to be based pragmatically on data collections
designed for other purposes. As a result, the initial PIs are
very much proxy indicators. For example, the majority of indicators
of "Effectiveness of service delivery and outcome" are
focused on process, rather than the ultimate objective: outcome.
In addition to measurement concerns there is a temptation to assume
that variations in unit costs are explained more easily than they
actually are. Over-simplistic interpretation could mean that in
the drive to improve efficiency, policies adopted to reduce PIs
may result in unmeasured drops in quality, while genuine efficiency
gains are missed.
89. The drive to improve the efficiency
and effectiveness of health and social care partnerships in practice
raises important issues about the composition of the workforce.
Any initiatives that have implications for the long-term composition
of the workforce need to be evaluated in a way that reflects the
costs of training and educating the relevant professionals. The
work undertaken to date takes us some way towards achieving this
for many health service professionals. However, there is insufficient
information at present about training costs and expected working
lives of social care professionals.
90. The programme aims to contribute to
the derivation, interpretation and development of PIs and more
generally improve the measurement and wider understanding of cost
and outcome measures in research, policy and practice. Some of
this work will be directly undertaken as part of the core programme,
but where there are large scale fieldwork implications the programme
will provide a base from which to seek competitive funding.
Costs research
91. The aims of the costs element of the
programme would be to investigate:
— reasons for variation between areas
in the proposed cost-based performance indicators and their constituent
elements;
— the relationship between cost and
performance;
— the relevance, availability and use
made of cost data within local authorities as a means of monitoring
efficiency, and barriers to that use;
— other indicators (or existing indicators)
that might contribute to interpretation of cost PIs.
92. The programme would also:
— continue to provide estimated unit
cost information for a wide variety of services;
— provide a source of information and
advice on costing issues;
— seek funding to investigate issues
such as costs of training the social care workforce and changing
costs of regulation.
93. The work would ensure close links with
the planned Economics of Child Social Care and Commissioning and
Performance programmes. Links would be maintained with other bodies
with interests in the area, such as the Audit Commission and other
research organisations.
94. The annual publication Unit Costs
of Health and Social Care would continue, disseminating information
about unit costs from a variety of sources, identifying gaps and
informing unit cost estimation. A key element in this would be
to identify sources of information on the costs of intermediate
care in a variety of settings.
95. Data that have already been gathered
by the Unit (for example from the residential care surveys and
MEOC) would continue to provide evidence about what we can say
about expected variations in unit costs and prices.
96. Where information is limited, specific
data collection(s) would be undertaken to investigate trends and
variations in unit costs and performance indicators. It is anticipated
that this would include a survey of provider organisations for
home care. In these data collection(s) the aim would be to investigate
causes of variation in costs and prices. These would include factors
both beyond the control of the authority and those within control
that are associated with both quality and efficiency, and factors
affecting income as well as expenditure.
97. It is anticipated that data collections
would include views of purchasers and providers within local and
health authorities and, if possible, those receiving the services,
in order to establish the degree to which the information that
can be collected directly from provider organisations matches
client perceptions.
Outcomes research
98. Specific developments depend largely
on the outcome of the SCOOP project (see above), which is due
to be completed early in the new core programme period.
99. The programme would aim to:
— Test out the use of the measure of
outcome for social care of adults in conjunction with other fieldwork
undertaken as part of the Coordinated Care programme;
— To seek out opportunities to contribute
to performance measurement through the use of outcome measurement.
For example, incorporating indicators from the SCOOP project in
client satisfaction surveys undertaken by local authorities.
— To seek funding to develop the
approach further. Potential areas to be considered are:
— A large scale survey to develop the
utility weightings for older people;
— Domains of outcome and their relevant
importance to different ethnic groups;
— Linking the measure to other utility
based measures of health related quality of life.
— Developing a linked utility-based
measure of outcome for carers.
100. This is clearly a very broad programme,
so priorities will need to be discussed with the Department.
Programme management and branch
101. This research programme will be managed
by Dr Ann Netten and conducted at the Kent branch of the PSSRU.
5.12 Fees and Charges
5.12a Could the Department update Tables
5.12 providing separate figures on residential care for each
client group? Could the Department quantify the degree of variation
in domiciliary charges between authorities? Could the Department
provide a commentary?
5.12b Could the Department provide an
analysis, to include chart, tables and commentary, of (i) the
recent national trend in the percentage of gross expenditure on
residential accommodation for older people recouped through fees
and charges and (ii) the recent national trend in the percentage
of gross expenditure on home care/home help for all client groups
recouped through fees and charges?
5.12c Could the Department provide an
analysis, to include chart, tables and commentary, of (i) the
local authority variations in the latest year in the percentage
of gross expenditure on residential accommodation for older people
recouped through fees and charges and (ii) the local authority
variations in the latest year in the percentage of gross expenditure
on home care/home help for all client groups recouped through
fees and charges?
1. Table 5.12.1 updates last year's information
and provides separate figures on residential care for each client
group. Figures 5.12.1 and 5.12.2 illustrate the recent national
trends in the percentage of gross expenditure on residential accommodation
for older people recouped through sales, fees and charges and
the percentage of gross expenditure on home care/home help for
all client groups recouped through sales, fees and charges.
2. The table shows that the percentage of
gross expenditure recouped in sales, fees and charges for residential
care for the elderly rose from 35 per cent in 1997-98 to 38 per
cent in 1999-2000 (mainly as a result of increased use of the
independent sector where councils are able to recoup a higher
proportion of their recorded expenditure from charges) ; in absolute
terms the amount recouped rose from £958 million in 1997-98
to £1,243 million in 1999-2000. The amount recouped for home
care and home help service also rose from £129 million in
1997-98 (representing 10 per cent of gross expenditure) to £187
million (13 per cent of gross expenditure) in 1999-2000.
VARIATIONS IN
CHARGES FOR
DOMICILIARY SERVICES
3. Figures 5.12.3 and 5.12.4 illustrate
the percentage of gross expenditure recovered in charges by each
local authority for home help/home care and meals on wheels services,
the two main items of service provided in a domiciliary setting.
Table 5.12.2 sets out in tabular form the percentage of gross
expenditure on home care/ home help recouped through sales, fees
and charges.
4. At the Local Authority level, there is
a wide variation in the amounts raised in sales, fees and charges
made from domiciliary provision. Local Authorities are free to
decide upon the level of charges to raise on domiciliary services
in the light of what it is reasonable to expect the client to
pay. A wide range of charging policies are in operation ranging
from flat rate charges to income-related charges. The Government
believes that the scale of variation in the discretionary charging
system, including the differences in how ability to pay is assessed,
are unacceptable. We have considered how best to improve the system
in the light of both the Royal Commission's report on the funding
of long term care, and the Audit Commission's study of local authority
charging practices (published as "Charging with Care"
in May 2000). We took new powers through the Care Standards Act,
2000 to issue statutory guidance to councils in respect of these
discretionary charging functions. On 3 January 2001, we issued
for consultation draft guidance, "Fairer Charging Policies
for Home Care and other non-residential Social Services".
We intend to issue guidance in light of the consultation shortly.
Our aim is to establish greater consistency and fairness in charging.
5. There are a number of instances where
Local Authorities have reported that they raised no sales, fees
and charges income for home care/home help services provided;
at the other extreme, some authorities reported recouping in excess
of 30 per cent. Such wide variability of individual authority
figures points to issues of data quality and there is a risk that
misreporting of data by local authorities has had an effect. The
current Performance Management Framework for Best Value in Personal
Social Services will help to reinforce the message to Local Authorities
that it is important they report their PSS financial data accurately
on the central returns.
6. For England as a whole, 13 per cent of
the direct cost of the home care/home help service was recouped
in sales, fees and charges to clients. Within authorities, the
actual figures reported varied from zero in the case of five authorities
to 30 per cent or more in three authorities. The middle 50 per
cent of authorities had recoupment rates between 9 per cent and
17 per cent compared to rates between 8 per cent and 16 per cent
for the previous year.
7. For meals on wheels services the overall
England recoupment rate was 44 per cent: LA figures range from
zero in 22 authorities to over 100 per cent in two authorities
(8 authorities reported no expenditure). The middle 50 per cent
of authorities had recoupment rates between 29 per cent and 64
per cent compared to rates between 35 per cent and 64 per cent
for the previous year.
VARIATIONS IN
CHARGES FOR
RESIDENTIAL SERVICES
8. Figure 5.12.5 illustrates the percentage
of gross expenditure on residential accommodation for older people
recouped through sales, fees and charges. Table 5.12.3 tabulates
these figures.
9. The charges levied to individual residents
in care homes are determined nationally. The overall recoupment
rate for residential provision for the elderly in England was
38 per cent. LA figures varied between 2 per cent in one authority
and 59 per cent in another authority. This may again just reflect
misreporting by local authorities. The middle 50 per cent of authorities
had recoupment rates between 33 per cent and 44 per cent compared
to rates between 31 per cent and 43 per cent for the previous
year.
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