Care Act: How to afford and manage the changes

Guidance on the Care Act 2014 was issued by the Department of Health in October 2014. We now know that the final part
of the implementation of the Act, including the much-anticipated funding reforms (and the £72,000 cap), has been delayed until at least
2020 and perhaps beyond.

The Care Act put into law a number of new concepts, not only in relation to the person but
also to their carers.

1. Wellbeing principle

The Act brings into focus the importance of considering the wellbeing of the whole person, with local authorities having to consider not just the cost of providing care but also issues such as giving the person control over their day-to-day life and their physical and mental wellbeing.

2. Shift from providing services to
meeting needs

Following on from the wellbeing principle, local authorities now have a duty to meet eligible needs rather than just provide services, which is a major cultural shift. Regardless of who provides the actual service, the duty to meet those needs
rests with the authority.

3. Support for carers

In June 2013, the Office for National Statistics (ONS) produced a report on the amount of informal care entitled 'Valuing informal adult care in the UK'.
The report estimated the value of this care in 2010 at £61.7bn, or 4.2 per cent of GDP. This had almost tripled in 15 years. A Carers UK report issued in November 2015, 'Valuing carers 2015 - the rising value of carers' support', estimates the value of caring at £132bn, which is almost like paying for another NHS.

The Act attempts to recognise the crucial role that carers play and the burden caring can place on them and their families. It recognises for the first time a carer's right to have their needs assessed, independently of the needs of those that they
care for.

4. Assessment of needs and the national eligibility criteria

The Act pulls together the guidance for assessing residential and domiciliary care (previously covered by the 'Charging for residential accommodation' and 'Fairer charging policy' guidance respectively). Prior to the Act, each
local authority would interpret both sets of guidance in its own way, which made it difficult
for families to plan for social care needs as the person moved from domiciliary to residential
care. It was also a postcode lottery, with different authorities interpreting the rules in different ways.

The new framework attempts to address this
by determining what is meant by 'eligible needs'. The assessment of needs must identify how a person's needs affect their ability to achieve their outcomes and how that affects their wellbeing.
The criteria for deciding if needs are eligible has also been laid down:

• Are the needs related to a mental or physical impairment or illness?

• As a result, can a person achieve their outcomes, for example, without assistance, pain, or distress, or without it taking longer than expected? Outcomes are now defined and include maintaining hygiene and nutrition, being safe
  in their own home, and being able to work or upskill; and

• As a result, does this have a significant impact on their wellbeing?

For needs to be eligible, all three conditions have to be met. The guidance does not, however, define 'significant', and this could be open to interpretation by local authorities.

5. Duty to provide information and advice

Part of the difficulty for vulnerable people needing care and support is getting the right advice at the right time. This is particularly important during times of crisis or during the transition from care in the home to residential care.

Previously, in addition to dealing with the stress of supporting their loved ones, families would be faced with a myriad of different (and sometimes contradictory) rules and information. Very often they would need to go to a number of different sources to try to gather as much information as they could.

The Act gives local authorities a statutory
duty to provide information and advice, and,
if implemented, this could support the person
and their family and point them in the right direction.

For those who are assessed as being responsible for funding their own care, a further layer of complexity is added. The Act attempts to address this issue by allowing for local authorities to direct those who are self-funding to relevant advice, including financial advice. It's too early
to say how this will work, but it could involve advisers who are trained in this specialised
area of financial advice.

6. Personal budgets

Personal budgets were put into law for the first time by the Act and are one of the main tools to support the 'wellbeing principle' by allowing the person to have some control over how their care is delivered. It also allows them to plan their care and their own finances more effectively.

The personal budget covers:

• The total budget to meet assessed needs;

• The amount the local authority will pay; and

• The amount the person must contribute.

In summary

In the six months since the implementation of the guidance began, some common themes are emerging.

First, the lack of integration between health and social care is being identified as a major obstacle in delivering person-centred care, which is highlighted in the King's Fund report on place-based systems of care published in November 2015. The question is whether holistic social
care can be delivered without integration with healthcare, particularly for the elderly, where
the line between them can be blurred. The lack
of quality social care can also lead to more hospital admissions and 'bed blocking'.

Second, there are questions surrounding the assessment of needs. This process is where it all begins and is critical to the wellbeing principle. The guidance does not specify how an authority should act, only what rules it needs to follow.
This has meant that people are still facing an element of the postcode lottery as each authority decides on how the guidance should be implemented. Some authorities use junior staff to conduct initial assessments, potentially impacting on the quality of the assessment and therefore the outcomes for the person.

In terms of eligible needs, the guidance does not give a definition of a 'significant' impact on wellbeing, which raises concerns that cash-strapped authorities could 'interpret' the guidance based on what is affordable rather than what a person needs. If this is the case, the burden on carers could continue to increase, leading to more crises and the need for more urgent and potentially more expensive interventions. Where there are no family members or friends providing care, there is again the possibility of more crises and perhaps a greater burden for the NHS.

Third, given the cuts to local authority budgets, it must be asked whether high-quality person-centred care can truly be delivered to those who cannot afford to pay for it themselves. The Better Care Fund was established with a budget of £3.8bn for 2015/16 to support health and care locally. However, £1.9bn was taken from the NHS - is this a case of robbing Peter to pay Paul?

At the root of many of the issues at a local authority level is funding. The recent Autumn Statement announced that local authorities would be able to increase council tax by 2 per cent to support the provision of social care. Norman Lamb MP, the previous minister for care and support, commented that the 'black hole' in social care spending would be over £6bn by 2020, while the 2 per cent tax increase announced could raise around £2bn. The real question has to be whether the local authorities can really deliver quality person-centred care with a funding gap
of that size. SJ

Lynn Buckley is a consultant at Frenkel Topping, a UK-wide specialist asset manager for vulnerable individuals