WRITTEN EVIDENCE
FROM UNISON (PEX 08)
1. REDUCTION
OF PUBLIC
EXPENDITURE OF
SOCIAL CARE
SERVICES
Our research in support of UNISONs response
to the inquiry on understanding the impact of reducing social
care spending shows that Councils are facing an impossible task
of delivering personalised care and support to meet growing demand
with no extra funding whilst also trying to generate efficiency
savings.
Please also see following in support of our
inquiry response:
Appendix A
Who cares Who pays? Personalisation in social
care—by Professor Hilary Land of Bristol University
and Professor Sue Himmelweit of the Open University UNISON (March
2010) http://www.unison.org.uk/acrobat/19020.pdf
Appendix B
UNISON Response to House of Commons Health Committee
New Inquiry Terms of Reference—Social Care (October 2009)
Appendix C
"Shaping the Future of Care Together"
UNISON response to Department of Health (England) Green paper
(November 2009)
Appendix D
Cash or Care? 10 essential questions for
councils on personalisation UNISON (June 09) http://www.unison.org.uk/localgov/pages_view.asp?did=9716
Appendix E
DVD Privatising home care—stories from
Norfolk (March 2010) http://www.unison.org.uk/localgov/pages_view.asp?did=11850
or http://vimeo.com/15225852
2. Levels of commitment of national and
local government to meet long term trends of demand and cost and
social care services scope to manage demand, cost and efficiency
within constrained budgets.
2.1 The pressures on the social care system
are set to increase in coming years as the demographic time-bomb
combines with growing public dissatisfaction with social care
provision in terms of its cost, quality, accessibility, and co-ordination
with other services.
2.2 UNISON believes that Government drives
to contain the costs of social care are likely to accelerate as
a result of the recession—with more responsibility likely
to fall on individuals and their families. The issue of public
spending on social care is a key political issue which needs to
be properly debated. The discussion should focus on affordable
good care and high quality service.
2.3 UNISON is witnessing councils up and
down the country preparing for cuts to adult social care even
before next month's spending review is finalised (CSR 2010). Councils
have prepared for significant budget reductions in social care
provision in a variety of ways:
— by reducing staff by not replacing posts
which are lost through vacancy, voluntary redundancies and compulsory
redundancies;
— removing caps on prices so that elderly
people will face significant increases in the costs they are required
to pay for home care services that help them live independently;
— closing down services such as day care
centres; and
— privatising residential care and other
services.
2.4 Examples on payment cap removals are
Oxfordshire, Lewisham, Warwickshire, Hertfordshire, and Hampshire
who are consulting on removing a payments cap. Channel four news
has documented recent examples around the country http://blogs.channel4.com/factcheck/who-cares/3962
(27th September 2010)
Social care is one of the biggest budgets town
halls manage and raising the ceiling on charges is one of the
easiest ways for councils to make the numbers add up.
— In Oxfordshire they're braced for cuts
as severe as 40% from the Social and Community Services budget.
The council is now charging older people the maximum rate for
care in their own homes, which is £15 an hour, and has doubled,
to £10 a day, the cost of day services in council centres.
— Lewisham is consulting on plans to remove
the cap, or raise the weekly ceiling to £395, up from £290
currently.
— Warwickshire is considering increasing
its hourly charge for adult social care from £9.66 to £12.34
in December and £16.45 in April next year.
— Lincolnshire is looking at almost doubling
the maximum charge from £126 to £250.
— Rochdale council is planning a cut of
more than 50% (£25 million) in the next two and a half years
with savings of £2.98 million from its "intermediate
care" budget. That's help for people leaving hospital. It's
also slashing £2.8 million from community home care.
2.5 UNISON believes that the immediate impact
of cuts in adult social care budgets will prove short sighted
and counter-productive in any efficiency saving and planning of
quality care services. Denying people access to care support and
services may cost the NHS more If people are denied help at home
then they could end up in hospital, therefore costing the NHS
more. People may enter care homes rather than remaining in their
own homes through not accessing support until experiencing crisis
needs, which results in higher costs to local authorities.
2.6 The most disadvantaged and vulnerable
of society will be at risk of losing the care support they need
which will undermine the recent shift and emphasis of preventative
care.
2.7 UNISON believes that underfunding of
adult social care combined with the current roll out of personalised
care will affect the quality of services for care recipients and
the development of a skilled well paid social care workforce.
As a result of under-funding personalisation is becoming synonymous
with less choice, increased privatisation and growth of an unregulated
care service.
2.8 We have previously set out key areas
of concern in relation to the impact of personalisation of services.
UNISON Response to House of Commons Health Committee New Inquiry
Terms of Reference—Social Care (October 2009):
(i) The provision of consumer choice in opting
for either a personal budget, direct payment or individual budget
has in some areas decreased the choice of services rather than
increased or diversified the care market. Some local authorities
have been unable to deliver requested services they have traditionally
provided.
There has been an increase in local authorities
claiming that the introduction of direct payments is forcing them
to close down day care centres. The evidence from our branches
we are receiving are that Councils are unwilling to provide services
at a reduced capacity and blaming direct payments as a result.
These services need to be maintained as local
authorities still retain a duty of care for those they support
and are therefore responsible for making alternative arrangements
when services are interrupted or break down, or needs suddenly
change.
UNISON believes that certain local authority
services need to be ring fenced to protect and guarantee local
well run services as a sustainable choice for people wanting a
Personal Budget and not a Direct Payment. Direct Payment holders
should be free to purchase local authority services if they wish.
(ii) Our research shows that some local authorities
are not offering people the choice of arranging and providing
a service (personal budget) but only offering them a direct payment
and asking people to arrange their own care services or activities.
"Personal budgets are great for
younger people and older ones who have need of detailed services
and have the ability and desire to organise them…helping
them do this can be very satisfying but cannot always be done
rapidly. The principle that all service users have to have individual
budgets for a minimal service is inappropriate. Most frail elderly
people just want a service arranging."— Social worker
and UNISON member
UNISON believes that care recipients need assurance
and a guarantee on their right to choose which type of budget
they want and which type of service they want. This will further
help to nationally standardise local access and provision of equal
quality services and end the post code lottery in the proposed
National Social Care Service.
(iii) UNISON would like to see a guarantee that
direct payments and individual budgets will be uprated each year
to reflect rising costs so they maintain their real value. Currently
some local authorities do not have any agreed indexing of rates,
leaving it to individuals to seek to negotiate uplifts.
(iv) UNISON believes that service users also
need to be guaranteed the time they need to work with qualified
and accountable adult social workers in assessing needs and deciding
how to meet them. UNISON branches are reporting that some local
authorities are using the personalisation agenda to remove, reduce
and not replace social workers in care teams. Instead less qualified
staff are taking on the role of social workers.
"Social workers…are key to
supporting self-assessments, understanding people's aspirations
and ensuring they have access to personalised support Self-assessment
was widely viewed as a misleading term, and in practice it was
found that self-assessment entailed intensive support from care
managers…it was more demanding of staff time and skills than
traditional professional assessment."— CSCI, The
state of social care in England 2007-08
(v) Many people want to be able to direct their
care more but do not want to be an employer. Yet it seems many
councils are only directing people to poor quality agencies as
an alternative where they have to pay a core fee out of their
budget for the provider to manage their budget.
UNISON believes more guidance and support for
Local Authorities is needed to assist those who don't wish to
take up the responsibility of being a micro employer. The emerging
evidence suggests that Local Authorities have not been provided
with guidance in developing models to manage personal budgets.
The emergence of Individual Service Funds (ISFs)
in some authorities has assisted those who would like to have
budgets managed on their behalf by agency providers. However the
core management and support costs charged by providers for this
service are currently 10-15% of an individual's budget which means
that they don't get the same amount of money to buy services as
an individual employer may through direct payments (particularly
if they have multiple ISFs with different providers).In other
words they are financially penalised for not wanting to take over
the responsibility of direct management and employment responsibilities
of their personal budget. The claims of efficiency savings on
funding social care needs using this type of service delivery
model must be questioned.
UNISON believes that there is a need to pilot
and review a service delivery model of personal budgets. The pilot
of a brokerage and budget management role should be accompanied
by the piloting of a direct Local Authority employed personal
assistance (PA) service which allows greater quality, reliability
and economies of scale in terms of cover for absence and also
possibility of one PA working with more than one service user
at a time where their interest/activities co-incide. This currently
being considered by the Scottish Government.
Like mortgage brokers and financial advisors
we believe that there is a need for the regulation of the roles
of "support brokers" and budget managers with clear
national guidelines with risk assessment and training requirements.
(vi) There need to be standard national guidelines
to ensure that people using direct payments to employ care workers
are fully equipped to meet all their legal responsibilities as
employers and employees are clear of their employment rights and
responsibilities.
UNISON branches, employment tribunals and Citizens
Advice Bureaux are all reporting casework involving workers employed
under direct payments. In some cases the individual employer has
no liability insurance, in many cases individuals were not aware
of the full range of employment responsibilities, and often there
is no agreement as to who will pay tribunal awards. Other evidence
shows that service users often feel ill-equipped to deal with
aspects of the employment relationship.
"There were a significant number
of employees who did not enjoy their minimum employment rights
and there were a significant number of employers who were at risk
of having awards given against them at Employment Tribunal."
Scottish Personal Assistants Employers Network
and UNISON, Creating and supporting an informed employer and employee
relationship within the self directed support sector, 2009
UNISON would like to work with employers as service
users, the government and local authorities to establish a Code
of Practice on the employment of Personal Assistants and a
framework for pay and conditions. This would include direct payment
tariffs and model contracts which would enable a decent employment
package for PAs with access to training and development, using
local authority pay and conditions as the benchmark.
All the evidence suggests that without this there
will be increasing casualisation.
(vii) UNISON believes that more guidance is needed
to assist local authorities in their obligations to safeguard
vulnerable people and ensure that providers and micro employers
have been involved in establishing how risk management works and
where lines of accountability lie. There is currently uncertainty
around risk elements of personalisation.
"Managing risk—putting more
choice and control in the hands of people with support needs increases
flexibility but has reduced the control the council has over services.
This requires a closer working relationship with providers involving
more trust than has always been the case in the past."
Managing risk is also more complicated where
providers have been selected in a locality basis delivery framework.
Here the providers use further subcontracting to ensure that they
meet their requirement to cover all levels of support needs.
(Contracting for personalised outcomes. Learning
from emerging practice DH August 2009)
Staff are also concerned about the potential
for targeted abuse of people who are receiving cash for care and
employing their own PAs without requirements for PAs to be undergo
CRB checks and go through the vetting and barring disclosure.
"Not enough thought had been given to protecting
people using self-directed support. CRB checks on potential employees
were not offered automatically to each vulnerable person, but
only if they specifically asked. There had been no strategic consideration
of the council's duty of care versus the less formal arrangements
that self-directed support brings."— CSCI, The state
of social care in England
2.9 In conclusion with regard to personalisation
operating within proposed new adult social care budget constraints
unison believes:
— Councils should be clearly offering the
genuine choice to service users by a) continuing to directly provide
services for personal budget holders to choose from and create
a care package with or b) provide cash for care (direct payments).
— Personal budgets holders should have
the choice of local authority support and budget brokerage services
and be serviced by an in-house employed personal assistant if
requested.
— Councils should have the genuine choice
to retain and develop a comprehensive in house service which delivers
genuinely personalised care including the employment and training
of Personal Assistants (PAs).
— Cash for care should be subject to the
same regulation regimes, vetting and barring schemes, financial
scrutiny, employment law, health and safety, and training requirements
as other forms of home care.
— Certain local authority services need
to be ring fenced to protect and guarantee local well run services
as a sustainable choice for people just wanting a Personal Budget
and not a Direct Payment.
— A Code of Practice on the employment
of Personal Assistants, and a framework for pay and conditions
needs to be developed involving unions, service users and local
and central government.
— National guidelines on risk and vulnerability
are needed to end the current uncertainty of where boundaries
of risk assessment and responsibility lie.
3. CAN CASH
FOR CARE
SCHEMES AND
PRIVATISATION RESTRAIN
PUBLIC EXPENDITURE?
3.1 UK governments have been attracted by
anecdotal evidence that with cash for care arrangements, people
spend more frugally and imaginatively. The Audit Commission found
that where savings were generated, this was through paying lower
rates to individuals, than the hourly cost of services, on the
grounds that they buy from a different market ie friends and families.
There was also a big variation in spending on support services,
although there was no consideration of the training and support
needs of personal assistants (PAs).
3.2 There is growing evidence to suggest
that privatisation has not generally improved the quality of the
homecare service. Indeed, there is growing evidence to the contrary
which suggests that highly fragmented, outsourced care is unpopular
with many users and that the independent home care sector is struggling
to recruit and retain staff. UNISON is receiving increased examples
from its branches of poorly managed care services run by large
UK care agencies.
(Please see the video link attached and UNISON
and our earlier submission highlighting poor terms and conditions
and the need to provide training and career structures for the
care work force )
4. SUSTAINING
THE CARE
WORKFORCE IN
THE PLANS
FOR THE
INTERFACE BETWEEN
THE NHS AND
SOCIAL CARE
4.1 The potential consequences of a joined
up services need to be considered particularly as care is currently
means tested. We are also concerned with the blurring of the boundaries
between means tested social care and free at the point of need
health care.
4.2 We are also concerned that further integration
within the context of the introduction of (pilot) personal budgets
and direct payments in health will likely lead to the blurring
of the boundaries between health and social care funding. We have
raised our concerns about the introduction of personal budgets
into healthcare in a number of forums. We believe that personal
budgets do not have a place in a national health system that provides
healthcare free at the point of need. We believe they are likely
to lead to increasing problems concerning the distinction between
funding of health services and social care services—to the
detriment of free healthcare.
4.3 UNISON believes that in order to achieve
better integration there needs to be much further engagement with
the workforce. There will be differences between employment practices,
terms and conditions, skills and training, career paths and expectations
which will need to be resolved to ensure that workforce planning
and development takes place locally to provide the best service
for service users.
4.4 The skills involved in care work must
be fully recognised and valued. With the boundaries between their
respective tasks blurring, health and social care workers should
have opportunities to work and train more closely together.
5. FUNDING
5.1 Higher taxes will be needed to pay for
a social care system that reaches all. It is worrying that personalisation
can be used as a way to push that inconvenient truth on to care
recipients themselves, since it will be easier to fail to increase
personal budgets in line with wages and prices than to cut services.
5.2 To succeed in providing good quality
social care to all who need it, care provision will have to change
from being the poor relation of the NHS and care will have to
be more highly valued.
September 2010
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