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OUT OF SIGHT: THE FORGOTTEN ELDERLY
By Paul Burstow MP
Liberal Democrat Shadow Minister for Older People
OUT OF SIGHT: THE FORGOTTEN ELDERLY
Key Pressures on Social Services Departments Survey
From December 2000 through to March 2001 a survey of Social Services departments was undertaken by Paul Burstow MP, Liberal Democrat Shadow Health Minister to ascertain what key pressures they were facing in terms of residential and nursing provision, staffing & community care budgets and the degree of implementation of pooled budgets.
Following anecdotal evidence of key pressures, 150 councils in England were sent a questionnaire, 60 responded a 40 % response rate for completed questionnaires. 6 responded that they did not have the resources to complete the form.
The three key pressures identified by those responding to the survey in order of severity were:
· An overspent community care budget
· A shortage of assessment and homecare staff.
· A shortage of EMI (elderly mentally infirm) provision
Beds Shortage
760 care homes closed in 1999-2000 with the loss of 15,000 beds. A further 760 care homes closed in 2000-2001 with the loss of 16,200 beds.
(Laing & Buisson Care of The Elderly Market Surveys 2000 and 2001)
A survey by the Association of Directors of Social Services of 18 local authorities in the south east in July 2000 found that the average loss of nursing home beds was 9.5 %, twice the national average.
Our survey of Councils across England shows:
That this reduction in capacity has not abated, in 58.33 % of social service departments who responded to the survey 62 nursing homes have closed in the last 6 months, with a loss of 1,441 beds. Similarly 61.67 % of councils responding reported 123 residential home closures with 1,565 beds lost.
The main reasons for closure of homes are that:
Care home incomes are not increasing in line with costs. 53% of places in independent sector homes are paid for by local authorities. Local authority fee levels have increased by under 2% on average compared to a 5 % increase to those private payers directly funding themselves.
The government's plans to introduce national minimum standards for care homes, without a corresponding increase in fee income is causing some providers to close homes.
There is significant pressure on care home wages, particularly in London and the south east due to both high levels of employment in the economy generally and stronger competition from the NHS to attract a dwindling pool of qualified nursing staff.
Rising property prices, particularly in the South are also making it attractive for owners to sell up, compared with the shrinking profit margins on running a care home.
Mortality rates in residential and nursing homes are falling and therefore residents are living longer causing increased pressure on budgets; thus the inexorable rise in the demand for more placements in nursing homes is in part explained by the increased longevity of some residents.
The Forgotten Elderly
EMI (Elderly mentally infirm) homes may either currently be Residential or Nursing. Specialist residential EMI is not a distinct legal registration category. Specialist nursing EMI nursing homes can be registered as a distinct legal category from other nursing homes (they are required to have a qualified mental health nurse on duty at all times)
The types of mental health problems common in older people in EMI homes primarily include dementia and functional mental illnesses (i.e. Not usually associated with physical degeneration of brain cells) such as clinical depression.
Where an individual requires care or supervision continually or at brief irregular intervals each day then a EMI residential or nursing home may be the only suitable provision.
Our survey of Councils in England shows:
Of those Social Service Departments who responded:
72% are unable to meet current demands for Nursing EMI beds
68% are unable to meet current demands for Residential EMI beds
58% report shortfalls in provision of specialised dementia care and
62% report shortfalls in provision for those older people with Challenging behaviour.
The numbers of beds required by local authorities needed to meet shortfalls in provision varied from 2-5 beds to one local authority reporting the need for 1000 residential EMI beds and 350 nursing EMI beds.
It was widely reported in November 2000 that there were no nursing EMI places currently available in Hampshire, and a specific nursing home shortfall in Southampton with no NHS long stay Continuing Care beds. Plans have been made to open up a hospital ward with local authority carers to staff the ward as a response to the nursing home shortfall.
Resources
Our survey of Councils in England shows:
That 62% of councils, who responded to the survey, reported an overspent Community Care budget as a key pressure impacting on service delivery. In conjunction with the pressures on children's budgets highlighted by the ADSS Budget Pressures Survey below, substantial overspends in Social Service Departments budgets are likely to be reported when final figures for 2000/2001 are published.
ADSS Budget Pressures Survey-September 2000 (71 out of 150 in England responded) Key findings were:
Average projected mid-year budget over-commitment is 2.1% (22 authorities at 3% over budget an average of £2 million with tough remedial action needed by 12 authorities)
Major over commitment is attributable to children's services (52%) with older people (28%) and learning disability services (20%). The over commitment in children's services is due to escalating costs and rising numbers of care orders (up 8%)
Position with same time last year: 72% said worse, 68% anticipated worse for next year.
Unitary authorities followed by London boroughs are on average projecting the greatest over-commitment per head of the population.
Staff
The Chief Inspector of Social Services Denise Platt, has admitted that local authorities are having “utmost difficulty” recruiting social care staff and has accepted that many posts offer worse pay than do less demanding jobs in supermarkets (9th Annual Report of the Chief Executive of Social Services- Modern Social Services)
Social and Health Care Workforce - Group workforce survey - 1999. Key findings were :
Numbers of Dip SW's qualifying fell by 27% from 592 to 432 between 97/8 and 99/2000 and expenditure by 28% from 6.6 million to 4.8 million. Newly qualified as % of total field social worker workforce fell from 2.4% in 1991 to 0.5% in 1999.
“The 1999 statistics, added to by later surveys, show two-thirds of all social services departments reporting recruitment and retention problems by mid -2000, with difficulties focused on social work and residential care, especially in London and the South East.”
Full-time vacancy rates for occupational therapists at 12% (13% for England) and highest in London boroughs.
In community homes FTE vacancy rate at 10% (8% for elderly and EMI)
Applications to study social work (diploma level) have more than halved since 1995. (Times Higher 21/4/200)
The National sickness absence report undertaken by the Employers Organisation and the Association of local government found that in 99/2000 the median sickness absences rates for a range of Social Services department occupations were higher than for local government as a whole. Compared to an overall local authority average of 4% for non- manual occupations, field social workers recorded an absence rate of 5.2%. Compared to an overall local authority average of 5.7% for manual occupations those working in community homes were absent for 8.1% of the time, and those working in homes for the elderly 7% of the time.
The Recruitment and Retention Survey 2000 by the Social Care Task Force of Social Services highlighted that vacancy rates averaged 16% for social workers, 11.3% for home care workers and 9.4-11.5% for care staff and that vacancy rates were generally highest in London and the South East.
Retention was also an increasing problem with turnover rates significantly higher than previously recorded for Social workers (15.3%) and home care workers (16%). Turnover for care staff had remained at a relatively constant rate in the range of 10.5% to 12.3%.
The combination of reductions in the number of trained social workers, relatively poor pay of care staff, higher than average vacancy rates, higher than average sickness absence rates and high turnover rates is a severe pressure on social service departments, with London and the South East being affected overall the hardest. This message is clearly underlined by our survey, with a shortage of assessment and home care staff being reported as a key pressure upon social services departments.
Strategic planning
In terms of pooled budgets, intermediate care and key Audit Commission recommendations on residential accommodation for older people with mental health problems there is evidence of a lack of readily available strategic information and patchy implementation.
Our survey of Councils across England shows:
That 1/4 of Social Services Departments responding are reporting no use of pooled budgets for the provision of intermediate care, and that many were unable to indicate firm plans for Financial year 2001/02.
The joint commissioning / financing of intermediate care beds is at early stages in many authorities - with the majority reporting low numbers of joint intermediate care beds. There is some but patchy evidence of joint forward planning of intermediate care.
The Forgotten Elderly
The Audit Commission report Forget me Not (January 2000) noted a significant disparity in funding of total services for older people with mental health problems of a magnitude of 8 to 1 between different areas.
It was stated that the in the National Service Framework for Older people to be published in 2000, mental health would be identified as a priority area and that its aim would be to improve quality and decrease inequities in services across the country. To assist in finding gaps in services cross cutting audits of all relevant partners and agencies were announced to take place in 2000/1.
The National Service Framework has identified mental health of older people as a priority area, however specific targets for decreasing inequities in services across the country have not been set.
The Audit Commission's major recommendations included that Social services should encourage providers in their area to develop some specialist residential care for older people with dementia, and should be prepared to fund places at a higher rate to reflect the specialist skills needed and that there should be sufficient places available to enable people to leave hospital when they are ready. It was also proposed that Health and social services should share information and plan together for long-term care, to enable people to be cared for in the most appropriate setting. Pooled budgets that enable a more flexible use of health and social care resources can help to achieve this.
Paul Burstow's survey of Councils in England shows that almost eighteen months after the publication of Forget Me Not its laudable aims and objectives are still just that, aims and objectives. There is a large and increasing shortfall in provision of residential and nursing accommodation for older people with mental health problems, with homes closing, patchy evidence of the use joint planning and pooled budgets all consequently intensifying pressures upon social services departments.
Conclusion
The pressure on Social Services departments to deliver a full range of services to older people is a daily struggle. The services range from help at home, targeted rehabilitation and where appropriate residential and nursing home provision for the frail and mentally infirm. The findings of this research reveal how intense the pressures are and how quickly they could turn to crisis and tragedy.
The following immediate action should be undertaken:
The recently published National Service Framework for Older People should be strengthened through Department of Health guidance. It should include a target to reduce the wide disparity of expenditure on specialist mental health services for older people to ensure that resources are targeted so that needs are met.
· The findings of the cross cutting audits undertaken following the Forget Me Not (Jan 2000) report should be acted upon immediately on an area by area basis.
Quality social and nursing care needs to be promoted. It is estimated that up to 75% of those in long term care have some degree of dementia. Skilled social and nursing care is required to meet the complex physical and mental health needs of those with dementia. Knowledge about dementia needs to be widely disseminated throughout the caring professions. Nursing and care staff ratios are an important indicator and precondition for quality of care. It is regrettable that the National Minimum Standards announced in Care Homes for Older People (March 2001) did not specify staffing ratios. The DoH should issue guidance for consultation on staffing ratios, which adequately reflect the needs of residents with dementia.
· Ring fenced budgets and guidance from the DOH should be introduced to enable the planned extension of both non-residential, residential and nursing EMI provision in areas where there is an identified shortfall. Ring fenced cash could for example ensure that councils are able to enter into private public partnerships which allow an adequate return on capital to allow on expansion of provision in the medium term.
A thorough review of the methodology and resources employed in the strategic planning of Personal Social Services. This should encompass central government, local authorities and all health bodies outlined in the Health & Social Care Bill. Strategic management information is not available at an aggregated level with which the DOH can make reasonable informed decisions on a timely basis e.g. vacancies for Social Services departments are not collected on a regular basis centrally.