Memorandum submitted by Social Policy
Ageing Information Network (DD 22)
1. INTRODUCTION
1.1 The SPAIN group is a consortium of over
30 voluntary organisations of and for older people, which meets
on a regular basis to work together on issues to do with social
care and older people.
1.2 The SPAIN groups welcomes the Committee's
inquiry into delayed discharges. The consequences of the lack
of social care for older people are stark. Social care for older
people, like the NHS, has suffered from long term under-funding.
Like the NHS, it shows signs of major strain, with rationing on
many fronts. But while substantial new investment is promised
for the NHS, there has been no comparable review of social care
funding. The SPAIN group has documented the impact of delayed
discharge and the difficulties that older people and their carers
experience in trying to access care.[12]
1.3 Just over a million older people receive
formal social care, nearly half in their own homes, the rest in
care homes. The great majority are in their 80s and older, all
are frail, many are disabled and a high proportion suffer from
dementia or other mental health conditions. They experience huge
difficulties in trying to access the care system. In addition,
older people make up two-thirds of all hospital patients.
1.4 The government has taken major steps
to modernise the health and care system. Older people and organisations
that represent their interests warmly welcome the Government's
commitment to improve services through the NHS Plan, the National
Service Framework for Older People, the setting of minimum standards,
improved joint working and the modernisation of social services.
We also welcome the commitment to substantial new investment in
the NHS. However, for older people and their carers, health and
social care are part of the same system. The underfunding of social
care leads to back-ups and bottlenecks in the NHS which jeopardise
the realisation of the Government's objectives for the health
service.
2. SOCIAL
CARE FOR
OLDER PEOPLE
IS SEVERELY
RATIONED
2.1 There are waiting lists for older people
even in the highest need categories—people may have to wait
for weeks or months without help for residential or nursing home
care or for support in their own homes. There is limited support
for those older people assessed as being in moderate categories
of need, as those in the highest categories have first call on
resources, resulting in unmet care needs and reduced quality of
life and a need for more expensive care later on.
2.2 With ever tighter eligibility criteria
for access to social care, those being looked after by Social
Services are frailer and more dependent each year. The intensity
of services has therefore increased, with fewer people receiving
more hours of home care, as reflected in Department of Health
statistics and the attached chart (App 2). Local authorities,
perhaps understandably, give priority to older people living alone.
However, too little help is available for carers, including older
carers living with their sick husband/wife, who may themselves
be of a similar age and in a poor state of health; research demonstrates
that older co-resident carers receive little help from health
or social services.[13]
2.3 Although provision for respite care
is rising nationally, there is not enough to give carers a break
and those needing care a change in routine, whether in their own
home or in another location. Many carers have been caring for
years without a break. Day care lacks focus and clear purpose.
It may not be available to those who could benefit and doesn't
deliver what people want.
2.4 Ethnic minority community organisations—the
only gateway to health care and support for many ethnic elders—are
poorly and insecurely funded and have to restrict access, resulting
in isolation for many elders. There is little or no scope for
innovation and development of preventative services or for investment
in community-based services to support the continued independence
of older people, severely impacting on Standard 8 of the NSF.
The merging of prevention and partnership grants has exacerbated
this situation.
3. UNDERFUNDED
SOCIAL CARE
RESULTS IN
LOW COST
CEILINGS ON
INDIVIDUAL CARE
PACKAGES FOR
OLDER PEOPLE
AND RESTRICTED
CHOICE
3.1 Social services authorities customarily
place lower cash limits on social care packages for older people
than those for younger people, irrespective of the level of need
and contrary to Standard 1 on the NSF for Older People. For example
units costs of residential and nursing care in 2000-01 were £342
for older people, £512 for those with physical disabilities,
£423 for adults with mental health problems, and £669
for adults with learning disabilities.[14]
If local authorities are to equalise levels and quality of care
between older people and younger adults, a major new injection
of resources is going to be needed to bring older people's services
up to those routinely expected by other groups.
3.2 Home care hours are tightly rationed
for those who do meet the eligibility criteria; short task-orientated
visits are commonplace, and there is little or no scope to promote
quality of life. Tasks undertaken by home care workers are strictly
limited and tightly defined, resulting in little or no choice
for the user and lack of person-centred care. Home care is rarely
able to adapt or be responsive to changing needs or personal circumstances.
It tends to be fixed in the mould of the original assessment,
and unable to adapt without ponderous reassessment procedures.
3.3 Older people are denied the choice of
staying in their own home when the cost ceiling for home care
is reached. Local authorities have a financial incentive to require
people to move into residential or nursing homes when their needs
are high, since they can insist that someone's home is sold to
pay for care once someone is no longer living there. Moreoever,
the quality of life and quality of care in residential and nursing
homes is restricted due to lack of staff time, skills and resources.
4. LOCAL
AUTHORITIES ARE
REQUIRED TO
MEANS-TEST
THOSE WHO
ARE ELIGIBLE
FOR RESIDENTIAL
OR NURSING
HOME CARE
AND TO
IMPOSE A
CHARGE, AND
MOST LOCAL
AUTHORITIES DO
THE SAME
FOR HOME
CARE.
4.1 Charging for personal care impacts most
on the oldest and frailest pensioners—it is discriminatory
in its effect, increases pensioner poverty, promotes social exclusion
and adds to the likelihood of needing long term care. Charging
regimes are discretionary with regard to home care, day care and
respite care, resulting in widely variable charges in different
areas, inequity and a postcode lottery.[15]
4.2 The public does not recognise the distinction
between personal and nursing care, resulting in widespread confusion
and a sense of injustice amongst older people and their families
when they are required to pay for care. The additional assessment
process for people in nursing homes using the Registered Nursing
Assessment Tool requires yet another process which distracts from
person centred care and creates confusion and delay.
4.3 There is little help and support available
for self-payers in most areas at a point where they are having
to make critical life-changing decisions. Some local authorities
refuse assessments to those with savings over the capital limit,
leaving them to find their own way through the care system (the
Fair Access to Care Initiative should deal with this when it comes
into force).
4.4 The single assessment process is complicated
by the need to undertake a financial assessment as well, and financial
assessments are difficult to carry out when people are very ill,
very frail or in a hospital bed—the very times when they
are most likely to need care.
5. INTERMEDIATE
CARE
5.1 £900 million funding was allocated
in the NHS Plan for Intermediate care, and the development of
active recovery and rehabilitation services and rapid response
teams to prevent admission to hospital. An additional £300
million over two years has recently been announced. The adequacy
of this level of funding in relation to the level of need is unknown.
There are, however, concerns about the distribution of the money
between health and social services; evidence from the Social Services
Inspectorate indicates that there has been "a diversion of
intermediate care resources into acute services."[16]
5.2 The new money is geared to tackle only
the most visible tip of the iceberg—older people occupying
a hospital bed who need alternative care. Others are waiting out
of sight in their own homes and many of those who are helped to
leave hospital will need long term support.
5.3 Social care is an essential element
in intermediate care, not an added extra. A substantial proportion
of intermediate care resources will need to be transferred to
social services if older people are to receive the balance of
care they need. Both the adequacy and the distribution of intermediate
care resources will need to be closely monitored.
5.4 Intermediate care is only intended to
meet the short-term needs of older people discharged more quickly
from hospital or avoiding admission. The guidance indicates that
six weeks is the maximum period envisaged during which such care
will be provided and the norm is expected to be as little as one
to two weeks. Many of those who are helped to return home or to
stay at home will need much longer term support from social care
services in order to live independently, in many cases life-long.
It is far from clear where these extra funds are going to come
from.
5.5 Despite Government guidance that all
Intermediate care should be free to the user, some local authorities
appear to be charging for personal care aspects. Intermediate
care cannot be effective without adequate social care to back
it up once the intermediate care period is over. Without long
term support, Intermediate care will result only in a short delay
before intensive services are again called upon. There is therefore
a clear need for substantial additional resources for longer-term
social are to prevent a "revolving door" cycle of hospital
admission or emergency care.
6. THE IMPACT
ON OLDER
PEOPLE AND
THEIR CARERS
The following case studies illustrate powerfully
the plight of those seeking help with their daily lives and of
their families, and the impact delayed discharge has on older
people and their carers. These very recent case studies are drawn
from the Helplines of several members of the SPAIN group of voluntary
organisations including Counsel and Care, Help the Aged, the Association
of Charity Officers and the Alzheimer's Society.
— Mrs K has been in hospital for 25
weeks, awaiting discharge to her home. She has been assessed as
needing two care workers four times a day but due to understaffing
she has been placed on a waiting list. The Social Services department
will not consider other options, such as paying private carers
or offering direct payments. She is extremely depressed in hospital.
August 2001.
— Mrs B's mother-in-law was assessed
as needing residential care while in hospital in November 2000.
The financial assessment has yet to be carried out. She has remained
in hospital the whole time. The caller has been told that funding
can only be arranged when a currently funded resident "no
longer requires help" or extra resources are allocated by
the government July 2001.
— Mr M's mother is 93 and has been
in hospital since February. She has been assessed as needing residential
care, has no property to sell and has savings of below £11,500.
Mr M has been told by the Social Services Department that there
is a six month wait for residential care funding and it has suggested
the "benefits loop-hole" as an interim way to pay the
fees. July 2001.
— Mrs Z is in hospital and has been
assessed as needing a further night call once she returns home.
The Social Services department has said that there are insufficient
resources to provide this extra call and advised her of her right
to use the formal complaints procedure. September 2001.
— Mr T's mother has been in hospital
for six months awaiting Social Services funding for a care home.
The Social Services Department has informed the caller that funds
are not available for this at present. He has made a formal complaint,
contacted the MP and press and sent letters from a solicitor but
to no avail. June 2001.
— Mrs R has dementia and needs a hoist.
Her husband was told by Social Services that it would have taken
a minimum of nine months to get a hoist. This would have resulted
in his wife remaining in hospital for that length of time. Mr
R approached us for help with purchasing the hoist. June 2001.
— Mr C was in hospital and assessed
as needing a nursing home. The consultant said that only a few
homes were capable of providing the level of care needed. The
family were told the Social Services limit, £346, which was
substantially lower than the cost of suitable homes. The family
were looking at a top up of over £100 per week in order to
get Mr C into a suitable home. All other homes had turned him
down. The family complained. The Complaints Officer told them
that they couldn't use the complaints procedure to complain about
funding levels. The family have now made a stage two complaint.
— Mrs P is in hospital awaiting an
assessment. The Social Services Department has advised her daughter
that if her mother returns home, it can no longer afford to provide
her with her previous domiciliary care package or any additional
care she now needs. They have also said that they "will not
be able to afford to pay any residential care fees", although
Mrs P has less than £11,500 in savings. July 2001
— Mr A is in hospital following a stroke.
The Social Services Department has assessed him as needing grab
rails to help him with bathing when he returns home, but has said
they no longer provide such items. June 2001
— Mrs H had been in hospital for over
six months and had been assessed as needing a nursing home. The
family identified a suitable, local home but the council said
that it was above their funding level.
7. SUMMARY AND
RECOMMENDATIONS
7.1 Social care is not a luxury or an added
extra. People seek help from the Social Services only when they
can no longer manage their daily lives or when they are at serious
risk of harm. Social care involves helping people to get in and
out of bed, get dressed, keep clean, eat a reasonably balanced
diet, have their nails cut, use the toilet, have clean laundry
and live in a decent environment. Increasingly it involves additional
help which would once have been seen as nursing care: changing
catheters and dressings, preventing or treating pressure sores,
managing medication and so on. Ideally social care also involves
enhancing the quality of life of older people, enabling them to
keep in touch with friends and family, to get out from time to
time, to pursue interests and remain part of society—but
with social care in such short supply, these aspects are very
often neglected. The SPAIN group has made the following recommendations:
— The Government should undertake a
comprehensive review of social care funding for older people in
parallel with, and in support of, its new investment in the NHS.
— There is an urgent need for a "whole
systems" review of funding levels for social care for older
people.
— The Royal Commission on Long Term
Care [17]
recommended the establishment of a National Care Commission, which
would "monitor longitudinal trends, including demography
and spending, ensure transparency and accountability in the system,
represent the interests of consumers, and set national benchmarks,
now and in the future" (recommendation 2). We suggest that
such a commission would be of great value to the Government, to
those charged with managing services and to the public, and is
long overdue.
January 2002
12 Social Policy Ageing Information Network, 2001,
The underfunding of social care and its consequences for older
people, London. Available from the Policy Unit at Help the
Aged on 020 7239 1881. Back
13
Milne et al, 2001, Caring in Later Life: reviewing
the role of older carers. Help the Aged/University of Kent. Back
14
Department of Health/Office for National Statistics 2001,
Social Services Performance Assessment framework 2000-01 October
p 14. Back
15
Audit Commission, 2000, Charging with care, London. Back
16
ibid. Back
17
Royal Commission on Long Term Care, 1999, with Respect to
Old Age, The Stationery Office, London. Back
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