Actividades y aprendizaje personal

The three LAs that agreed to take part in this study were all situated in outer London and had a population ranging from about 150,000 inhabitants to approximately 300,000, according to the 2011 Census (Office of National Statistics 2014a). Still according to Census data, the population of the three participating LAs was relatively older in comparison to greater London as a whole: LA#3 had about 16% of people aged 65 and older, while LA#1 had about 12% and LA#3 13% compared to 10.7% for London as a whole (Office of National Statistics 2014a). As for the ethnic composition of the population, LA#1 was mostly ‘White British’ with a sizeable ‘White Other’ population and very few inhabitants of other ethnical background.

LA#2 was by far the most ethnically diverse with people with Asian background as the largest ethnic group (mostly from India, Pakistan, Bangladesh and other Asian countries besides China), while ‘White British’ accounted for a third of the population and ‘Black African’ and

‘Other Whites’ were also sizeable minorities. Finally, the older population in LA#3 was overwhelmingly ‘White British’ (close to 80% of its population) with ‘Black Africans’ as its second largest ethnic community (less than 10% of the population). According to several indicators displayed in the report Focus on London 2010, Income and Spending at Home (Walker 2010), such as equivalised median household income, percentage of households with equivalised household income below 15,000 GBP and housing prices (all data for 2009), LA#1 could be considered as a higher income LA, while LA#2 and LA#3 were close to the London average.

The interviews carried out with LA and support agency staff members (see section 5.1.3) provided detailed information on the profile and operating processes of adult social care services for older people in each of the LAs (Table 6.1). The eight LA staff members who participated in interviews included a senior commissioning official in LA#2, a senior responsible for adult social services in LA#1 and LA#3; and five social care workers directly involved in the assessment and support procedures of older users of DPs (two in LA#1 and LA#3 and one in LA#2). Furthermore, a staff member who supervised provision of information on DPs from the independent support agency commissioned to provide information and support in LA#3 was also interviewed.

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Table 6.1 – Summary of information on DPs in the LAs participating in the study

LA#1 LA#2 LA#3

Source: Interviews conducted with LA and support agency staff.

Notes: (1) Refers to home care agencies contracted to provide LA-managed care.

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Regarding provision of information on DPs to users, in LA#1 and LA#2 this is usually provided by LA social workers at the time of the assessment of needs. LA#3 has put in place a brokerage system which provides users with information about PBs after the needs assessment and establishment of a care plan. The brokerage team is also responsible for monitoring the use of PBs. In LA#1, users that show interest in hiring a PA are referred to a user-led organisation that has been contracted by the LA as the support agency. This support agency plays a vital role in setting up DPs. It is the support agency that is responsible for setting up the care plan together with the user after receiving information from the LA on the needs assessed and amount allocated to the user. Besides providing support with payroll, the support agency can also act as a brokerage agency (i.e. assembling support from several organisations, including volunteers) and it also manages a directory of PAs from where users in LA#1 can hire their paid carers. Alternatively, the support agency can assist users that wish to recruit their own PA or contact and purchase care from home care agencies. As housing prices were relatively high in LA#1, staff members were concerned that not many users had a chance to hire PAs locally, which meant that PAs had to travel from afar. Similarly, LA#2 and LA#3 have also contracted support agencies (in the case of LA#2 the support agency is also a user-led organisation) to provide information and support in hiring PAs or to liaise with payroll management agencies. These support agencies do not, however, manage DPs on behalf of the user, nor do they set up the care plan. There was not yet a directory of PAs available in either LA#2 or LA#3 at the time of the interviews²⁹.

PBs have been in place in LA#1 since 2009, date when PBs were extended nationwide.

Regarding the choice set (Klein & Millar 1995) of users at the time of the interviews, LA#1 had also established framework contracts with four agencies contracted to provide LA-managed care. This means that these agencies are not guaranteed any volume of work and have to attract users, including those receiving DPs. To this end, older DP users in LA#1 can purchase care from these four agencies³⁰ at the same rates as users with LA-managed care, which is unlike the other two LAs. There is also a directory of other home care agencies operating in the borough, although quality is only monitored for those agencies currently under contract

29 In response to perceived difficulties in hiring PAs, both LA#2 and LA#3 were in the process of setting up these directories at the time of the interviews.

30 LA#1 actively promoted the rotation of agencies under contract, i.e. incumbent contracted agencies were purposely replaced after three years. At the time of the interviews, the incumbent user-led support agency had also not seen its contract renewed and although it would continue to operate in the borough, another support agency had been contracted by LA#1 to assist DP users.

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with LA#1. LA#3 has also established framework contracts to deliver LA-managed care and DP users can purchase care from these agencies. However unlike LA#1, users pay the same (higher) rates as privately funded users when purchasing care from these agencies. DP users may, however, freely top-up their payments to get more hours of care. There were, at the time of the interview, fifteen agencies under contract with LA#3, and only information on these was available in a directory of home care agencies. DP users in this LA could also choose to have their DPs deposited into a LA-held bank account with an attached pre-paid card. They could then use this card to make their payments for care. As for LA#2, it had not yet implemented PBs at the time of the interviews³¹. DPs are thus the only option available for users in LA#2 that do not want to take LA-managed care. Upon assessment, prospective DP users in LA#2 have their hours of care converted into a cash payment at a lower hourly rate compared to LA-managed care. DP users can choose to have their DPs managed by one of four home care agencies under a scheme denominated Independent Service Fund (ISF). The ISF is aimed at diminishing the burden of managing DPs directly (e.g. payroll management), while allowing users greater flexibility in defining their care plan with the agency managing their DP. Under the ISF, DPs are paid directly by LA#2 to the home care agencies, which also allows for greater control over their use. In both LA#2 and LA#3, LA staff interviewed recognised that older DP users faced less constraints in changing home care agencies than users on LA-managed care. The former could freely change agency at any time, while the latter often faced a lengthy waiting time to change agency or needed to have a reasonable motive for the change to take effect.

The monitoring of how DPs are used is carried out by the brokerage team in LA#3 after the first three months and on a yearly basis after that. In practice, LA#3 staff showed more concerns about how users spend the PBs that had been taken as DPs. Monitoring of DP use is arguably stricter than for the other two LAs. DP users in LA#3 cannot accumulate unspent DPs, (e.g. to account for contingencies), unless specifically authorised by the LA - otherwise, the unspent DPs have to be returned. The above described LA-held bank account and pre-paid card was aimed at facilitating and speeding up the process of opening a dedicated bank account required for DP users, but, as openly admitted by LA#3 staff, it was also meant to allow for tighter control over the use of DPs. Not only did it prevent cash from being used to pay for items other than care transactions, but the LA could instantly check on amounts spent or left unspent as it also has live access to the bank account. LA#2 also has similar

31 According to LA staff interviewed, LA#2 planned to introduce PBs by April 2013.

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limitations in place regarding the accumulation of DPs. The exception is the ISF, which allows users the possibility to accumulate up to 3 months of unspent payments for contingency.

Among the participating LAs, LA#1 was the one whose staff members were arguably more positive about the option to take PBs as a DP. Partially as a consequence, LA#1 follows a purposely “hands-off” approach to monitoring the use of DPs. There is a yearly audit on how the money is spent, but otherwise there are no directives favouring either agencies or professional PAs as the deployment option of DPs.

At the time of the interviews, all three LAs had set their eligibility criteria to substantial and critical needs level after having initially provided publicly-funded care also to users with needs assessed as moderate. Four years before the interviews took place, LA#2 had further tightened eligibility by dividing the substantial level in two echelons, lower and upper, and providing publicly-funded support to the latter only. Staff of all participating LAs recognised that as eligibility thresholds tightened, users receiving publicly-funded care were becoming frailer. Concomitantly, as budgets diminished, personal care is prioritised in publicly-funded care and other needs such as socializing are now much less often considered for funding.

Concerns regarding how users spend public money also underlined some of the interviews from staff. Reflecting national regulations that normally prevent the employment of close co-residing relatives, the use of DPs to employ relatives as PAs is approached with caution and decided on an individual basis in all three participating LAs.