Upper Cost Parameters of Community Based Packages of Care
Devon Adult and Community Services Guidance
Revised October, 2006

Amendments agreed by;

• OP&PD Locality Directors
• DPT Director - Health and Social Care
• Assistant Director - Learning Disability
• Strategic Planning and Commissioning Manager

Lead Officer- Paul Grimsey, Policy Manager Adult and Community Services

Contents

• Key Guidance Note
• Scope and Context
• Practice Guidance
• Assessments and Care Planning
• Position for NHS services
• Principles
• Issues to Consider

KEY GUIDANCE NOTE
The maximum weekly cost gross cost to Devon County Council for the community based care packages should in all but exceptional circumstances be no more than the gross weekly cost to Devon County Council of the Care Home placement that is required to meet the users assessed needs and inline with appropriate banding for Residential care where applicable.

Two exceptions to this general principle, where there are services primarily for carers or where double handed care is required, are described further on in this Guidance.

SCOPE AND CONTEXT
This Guidance applies to all adult social care service users including those receiving Direct Payments. It should be applied where a high cost community care package is being considered for an individual which may exceed the gross cost of a Care Home and where the individual has been assessed as having eligible needs that require social care funded services.

This Guidance must be read alongside;

• The FACS Policy Guidance
• The Policy on Financial Delegated Authority, and for Adults Services Staff
• The Matching Needs and Services Guidance

The National FACS Guidance states that:

' Councils are reminded that they should consider potential outcomes for individuals and the cost effectiveness of providing care to them, on the merits of each individual case. In doing so they should tailor services to each individual’s circumstances, and should only use upper-cost parameters of care packages as a guidance………. The aim should be to secure the most cost effective package of services that meets the user's care needs, taking account of the user’s and carer’s preferences. When supporting the user in a home of their own would make a better life, this is to be preferred to admission to Residential or Nursing Care. However, Local Authorities also have a responsibility to meet needs within available resources and this will sometimes involve difficult decisions where it will be necessary to strike a balance between meeting the needs identified within available resources and meeting the care preferences of the individual. ’

PRACTICE GUIDANCE
With the exceptions described below of double handed care and services primarily for carers the maximum weekly gross cost to Devon County Council for the community based care packages should, in all but exceptional circumstances, be no more than the gross cost of a care home placement per week to Devon County Council, excluding Funded Nursing Care contribution or other NHS contributions.

The upper cost parameter for Domiciliary Care for people who are 65 yrs. or older should be the gross cost of the type of Care Home provision that they would otherwise require, based on the banded rates for Care Home placements.

The upper cost parameter for Domiciliary Care paid for by the Social Services for people who are under 65 years old should be the gross cost of the type of Care Home placement that they would otherwise require.

In cases where an individual’s Care Home costs would be particularly high due to very high and complex levels of need, it is important to remember that this Guidance should be considered in the context of the National FACS Guidance quoted on the first page of this paper i.e.

“Councils are reminded that they should consider potential outcomes for individuals and the cost effectiveness of providing care to them, on the merits of each individual case………”

Double Handed Care
For the purpose of applying this Guidance only double handed community based care should be costed as single handed care when comparing the cost of community based package of  care with the cost of the Residential placement that would otherwise be necessary.

Services for Carers
Services provided primarily for carers should be separately identified for the purposes of this Guidance and the cost of these carers services should not be included in the calculation of the total package of community based care when considering the upper cost parameter.

Services primarily for carers will normally be seen as the following;

a.  Short term breaks or day care that is identified as partly or wholly to relieve a carer in a joint or separate carer's assessment.

b.  Other Services identified as necessary as a result of a carers assessment

Care Managers must therefore establish:

• The gross cost of the Care Home placement suitable to meet the eligible need of the individual.  
• The gross cost of community based services required to meet eligible needs (excluding Funded Nursing Care contribution or other NHS contributions)
• Then compare the gross cost of the Care Home package against the gross cost of the Community based package
• The gross cost of services is provided as guidance only. Decision making must be based on a combination of needs rather than on tight boundaries about the average costs per user group.
• Where Community based care packages are above the upper cost parameter this cannot be used to deny community based support in the first instance. Practitioners will need to discuss all such cases with their manager.
• Any care packages above the upper cost parameter will require Budget holder approval.
• The process of Budget holder approval should not add delays to the care package being agreed and arranged.
• The practitioner must record any differences of view and the service user/representative must always be informed of their right to make a complaint using the Social Services Complaints Procedure if they remain unhappy with the decision.
• Social Services reserves the right to review all care packages and provide a cheaper alternative if this will meet the needs of the service user.
• If a service user to whom this Guidance has been applied wants to remain in the community but does not want to top up the care package to the level of that recommended as a result of the assessment, a risk assessment should be carried out to ensure that we do not fund or part fund a care package that puts the service user or care staff at unacceptable risk.  

ASSESSMENTS AND CARE PLANNING
Assessments are key to decision making about whether an individual has eligible needs or not. There must be an up to date (within twelve months) (re) assessment of a person’s needs sufficient to define the objectives of care, outcomes being sought and levels and types of support required to meet the needs and manage the risks. For further guidance refer to the FACS and the Matching Needs and Services.

The National FACS Guidance (DoH 2003) states that:

'Cost ceilings may be used as a guide, but they should not be applied rigidly. Councils should always base their decisions on the assessment of a particular individual’s needs and if spending above the ceiling can make a difference to an individual, then the Council should consider doing so.

THE POSITION FOR NHS SERVICES
All NHS health care is free at the point of delivery; there is no concept of “top-up” feeds  for individual contributions to fund elements of NHS care. The NHS must ensure that Individual need is assessed and eligibility criteria for Continuing NHS health care area applied to determine which elements of an individual’s needs should be met by the NHS.

In providing care packages to meet the assessed health need of an individual each PCT has to be mindful of its overall responsibilities to provide care for the whole population within its available resources. Therefore the appropriate care packages for each individual must be decided upon on a case by case basis.

The NHS does not have to provide care in the community if it is more expensive than providing care in a residential setting. However there should be clear evidence that a full range of options for care have been explored in partnership with the individual and their carer. This should include clear evidence that patient choices and shared risk management approaches have been considered as a means of meeting individuals’ preferences within available resources.

This Guidance should also be read alongside The South West Peninsula Strategic Health Authority Joint Policy on Reimbursement Sept. 2003, Appendix 1. Delayed Transfer of Care and Reimbursement May 2004. This policy is particularly relevant when making decisions about interim arrangements, either when choosing a Care Home or awaiting a Care Home of choice when a person no longer needs hospital care. Section 2. on Maintaining Independence highlights the importance of avoiding older people being discharged from hospital into long term Residential or Nursing Care.

For all service users, where the Guidance on upper cost parameters of Community Based Care may be relevant, it must be ensured that screening for eligibility for Continuing NHS Health Care, and Continuing NHS and Social Care has taken place and a copy of the assessment for possible eligibility is available on the Social Services’ Service User Records.

PRINCIPLES
The principles underpinning this policy are:

• Decisions must not discriminate against individuals on the grounds of age, gender, ethnic group, religion, disability, culture, disability and /or personal relationships. This means that it may be necessary to pay more (or less) in order to meet an individual’s eligible needs in a way that does not discriminate against them.
• Decisions must promote independence, autonomy, and self determination
• A service users ability to pay, or not, for their care should not be taken into account once a decision has been made that the person both requires and wishes social care funded services. That means we compare gross and NOT net costs of the Care Package.
• Where service users are entitled to apply for support from the Independent Living Fund (ILF), they will be encouraged to do so.
• The Fairer Charging Policy must be applied to care funded by Social Services, except:
  • Where service users are subject to Section 117 of the Mental Health Act 1983.
  • Where in the case of the application to the Independent Living Fund ( ILF) the effect would be to extend the services required to be provided by the Authority.
• Subject to the above, it is a matter for the Authority how to supply services to meet the assessed needs of an individual, and it is the right of the service user to refuse services.
• Appropriate services to meet eligible needs should be provided in the most cost effective way. These may be either traditional or non traditional if the latter meet the needs more effectively and/or cost effectively.
• Individuals and/or their families may fund additional community care costs by separate contract with the same or other providers.
• Direct Payments MUST be offered for all eligible needs (except for the few people who are ineligible (see Direct Payments Policy and Guidance).

ISSUES TO CONSIDER
In deciding how to proceed, Practitioners and Managers will need to consider each individual situation. Some factors that will need to be taken into account include:

• Is there an up to date Assessment and Care Plan specifying needs and outcomes?
• Is the person eligible for fully or partly funded NHS continuing care?
• Has ILF been fully explored for adults under 60 years of age?
• Has the assessment been examined with the service user to see if any of the eligible needs can be met in less expensive ways or with assistance from other agencies. For example, by use of ordinary community facilities or by the provision of equipment and/or adaptations.
• If Direct Payments are not the preferred method of providing services what is the reason for this?

Back to top