The honest choice - Elderly Client Adviser

Feature

posted 1 Nov 1998 in Volume 4 Issue 1

The honest choice

In 1991/92 we were members of what was known as "The Shortfall Monitoring Group" this comprised of interested bodies including Age Concern, Care home proprietors and social services monitoring the effect and consequences of the level of income support being inadequate to fund the fees of residential accommodation. On the one hand it aimed to provide support for individuals and their families, who were under pressure to top up fees, facing the threat of eviction, downgrading of accommodation or use of personal allowances and remaining capital to fund fees. On the other hand it monitored the closure of care homes forced out of business by accommodating elderly people at below market rates.

To the rescue was to come the transfer of funding for residential accommodation from central Government to local authorities. In announcing the funding levels

"The Government is fully committed to ensuring diversity and choice in community care provision"

"For this reason, we have decided to issue a binding direction on local authorities which will enshrine the right of individuals to choose the location and character of their residential or nursing home"

"Choice is common senses and an individual right. The elderly and handicapped must not be denied their right to choose how they wish to be cared for at perhaps the most vulnerable stage of their lives."

(Quotes from Virginia Bottomley's speech on transfer of funding to Local Authorities 2nd October 1992).

What wonderful concepts but in reality we know that the constraints on local authority funding does not allow the choice that should otherwise be an individuals' right. Care managers uncomfortably aware of the right of choice find it difficult to exercise best practice in the purchase of nursing home and residential care within their monetary constraints. A recently published report by The Joseph Rowntree Foundation "Disparities between market rates and state funding of residential care" clearly illustrates this problem.

Choice is therefore restricted to means and care managers have to segregate their clients into two categories:

Those that cannot afford to pay and must rely on Local Authority funding and;

those that can afford to pay privately.

But it does not end there. Best practice in purchasing residential accommodation should include considerations for both categories.

The role of Care Managers has changed over recent years. From being enablers in the provision of care services they have also been expected to be accountants holding the purse strings when purchasing care. Although possibly not comfortable with this, they must be transparent in informing families about the limitations caused by their budgetary constraints.

Is there a waiting list for accommodation, if so, why;

what is the maximum amount the Local Authority will pay for an individuals care;

what care facilities are available in the immediate locality that can be purchased within that band;

be open about the right of choice and the accessibility of private and voluntary sector care homes;

allow the user and their carers to be involved in the choice of accommodation;

if the preferred accommodation is in another county, liaise with local care managers in seeking suitable accommodation.

be informative about methods and sources of top-up for more expensive accommodation;

consider the needs and welfare of spouses or carers left at home.

When the need for nursing home or residential care arises whether expected or not, families and carers, unfamiliar with the care system, need support and help in making many difficult decisions. Those that have been assessed as being able to pay for their own care must not be forgotten here.

We are all too familiar with the top-up problems facing older people and their families who entered care prior to April 1993 when, running out of money, five years later their "preserved rights" to income support is still inadequate to meet the cost of their chosen care. The problem was not solved on the transfer of funding to Local Authorities. Many older people who entered care homes post April 1993 are now running out of money and finding themselves in the similar position of wishing to remain in accommodation, which is more expensive than the Local Authority is prepared to pay for. The CRAG does not permit them to use their remaining £16,000 to top up fees. Families find themselves in the precarious situation of having taken responsibility for care home contracts for full fees and unable to fulfil the commitment. The result is distress and disharmony between social services, the care provider and the family. At the centre of all this is the vulnerable older person ending their days in a situation that can hardly be described as dignified.

This need not be the case

Best practice when considering care plans for self-funding care home residents should include:

Reference to the Community Care (Residential Accommodation) Act 1998 which came into force on 11th August 1998 to include a Sec 47 assessment of need;

ensuring the individual or someone close is capable of choosing suitable accommodation;

being involved with and informative in assisting families in choosing appropriate accommodation, this could be achieved by referring them to support agencies like The Relatives Association or The Elderly Accommodation Counsel;

provide advice and guidance on care home contracts and negotiating the right fee;

make them aware of benefit issues for example the loss of attendance allowance if choosing local authority owned or managed accommodation or, the ability to claim additional income support if the Local Authority is not involved in the funding whilst their property is being sold;

considering their ability to meet the cost of their chosen care, not just in the immediate future but over the long term. Bearing in mind that care costs may increase with dependency.

make them aware of the consequences of running out of money. Whether the Local Authority would be prepared to take up the contract. In particular the future possibility of requiring third party contributions and the disallowance of care home residents being able to top-up themselves if their capital falls to below £16,0000. Families should be advised to discuss the consequences of no longer being able to afford a full fee with their chosen care provider. In these circumstances. Many would be prepared to accept a lower fee rather than have an empty bed ;

monitor care plans for suitability even though the may be independently funded;

Paying for care is one of the most daunting issues for older people and their families. Often they are not financially aware but expected to handle large sums of money. Care managers cannot give financial advice even to suggest one leaving money on deposit to pay for care is illegal as well as quite possibly bad advice.

From our experience over the years we know that many of the shortfall problems today would not if these people had received appropriate advice from an adviser who understood their special circumstances at the outset. Some care managers recognise this need by referring their clients to our advisers. Why? Because all the above points apart from the Sec. 47 assessment and choosing appropriate accommodation fall within our remit. More importantly, they recognise that there are very efficient plans for providing care home residents with a guaranteed increasing income to meet care costs for life. Independent advice at the point of entering care should include:

1. A review of entitlements to means tested and non-means tested DSS benefits.

2. Advice on Local Authority charging procedures and Health Authority responsibilities.

3. Guidance on choosing suitable accommodation.

4. Consideration of what legal matters should be attended to, for example setting up enduring powers of attorney.

5. Advice on care home contracts, fee negotiations and arranging fee increase limitation agreements.

6. Taking an actuarial view of life expectancy and the ability to meet care costs over the long term. Ensuring capital is correctly invested enabling the full cost of care to be met for life.

7. Monitoring care fee payment plans for suitability as care needs change.

Would we have a Royal Commission to look at the funding of care costs if the children of our older population were not outraged at them using up all their assets to pay for care? I doubt it. The careful planning and structuring of a care home residents' affairs will benefit all involved:

Care home residents' benefit by receiving their chosen care without feeling a burden on the local authority or the family.

The family as a whole benefit because any financial and legal worries are taken care of. They have peace of mind that their relative can afford their care and will not run out of money.
(Although it may not always be a priority, unlike many older people today the longer many of our clients enjoy their stay in care homes the more money they will be able to leave their children).

The care provider is happy in the knowledge that he will continue to receive a full fee for the duration of the resident's stay.

Social services benefit because their limited funding will never be called on and can be utilised to provide placements for the most needy of cases.

The choice is there but it must be structured within the constraints of available resources.

Philip Spiers, NHFA advice is free and available to all regardless of means. Further information can be obtained from Philip Spiers, NHFA, Old Bank House, 95 London Road, Headington, and Oxford. Telephone 01865 750665 - NHFA Care Advice Line Freephone 0800 998833