On my travels around the country, whenever carers are mentioned, the main question seems to be what has happened to carers’ short breaks?
It’s not really surprising, given that carers’ breaks were provided in most (if not all) authorities for 15 years or so, whether delivered as weekly sitting services, vouchers for flexible breaks or as rudimentary direct payments made directly to carers. Their origins were discussed in more detail in my previous blog.
Although eligibility criteria and provision differed between authorities, within authorities most schemes remained fairly consistent for long periods. This meant that many carers became accustomed to a service which was often routinely agreed, year upon year.
The Care Act replaced the power to provide services to anyone who counted as a carer with the duty to do so if the carer is eligible. It set out National Eligibility Criteria for carers for the first time. The focus now is not on providing a fixed and often quite arbitrary sum of money but on meeting specific outcomes – none of which include the concept of the relief provided by a ‘short break’.
Carers and workers therefore feel that something has been lost. I would argue that it ain’t necessarily so….’short breaks’ may have gone, but the duty to provide, where appropriate, ‘replacement care’ is still alive and well.
If Care Act procedures are followed then there is no reason why those families, whose needs can still best be met by the existing support, should not continue to receive it.
This may not be true, however, where needs may have changed, or where more appropriate provision is available, or where people just do not fall within the new criteria. A change in national eligibility criteria is one occasion where a service may be lawfully withdrawn: but only after the person has been individually assessed under those new criteria. The Act’s guidance [10.27] also says that local authorities have to ensure that they have enough money available to comply with legal duties towards the whole population. They can therefore take funding into account when deciding how eligible needs are met – but not whether they are met.
A second issue is that the Care Act makes it clear that care and support provided to the adult is a service to that adult, not to the carer. Therefore where an adult has eligible needs and the carer’s needs can be met by providing support to the adult then the funding for this should be included in the adult’s personal budget [Guidance 11.38]
The previous legislative framework was less than explicit about that, given that services for carers could be anything at all, rather than defined types of input. The Department of Health was happy for ‘sitting services’ to be recorded in performance indicators as ‘carers’ services’ so that Local Authorities could demonstrate support for carers. The only stipulation was that this type of service could not be turned into a direct payment, if it included intimate care, without the person’s consent (or an emergency as a backstop justification).
When short breaks were introduced, they were funded by a new National Carers Grant allocation and were non-chargeable services, whatever the resources of the recipient. Even when the grant ceased to be ring-fenced and authorities could charge, most continued not to do so.
The Care Act makes it clear that carers must not be charged for any service provided to the adult, even if it is provided with the aim of supporting the carer. [Guidance 11.3]. Only the adult can be charged for a service provided directly to him or her. Although they may choose not to, it appears that most authorities are financially assessing and charging the adult for ‘replacement care’. ie: any care provided to replace that which a carer is unwilling or unable to provide (more on ‘unwilling or unable’ below).
Although it is not they who may be charged, many carers feel that no-one should pay for what they see as a small recompense for, or acknowledgement of, their caring role. They point out that the costs of providing care, if they didn’t provide it, would far outweigh the cost of a ‘short break’ and many workers would agree. But I am afraid that the only response to this is to point out tactfully that, as discussed above, local authorities have to ensure that they have sufficient money to meet their legal duties and this means charging those who can afford to pay, as long as it’s legal. Legally speaking, it is the carer’s choice whether to care and just how much to care, not a duty. Although of course I recognise that many carers, due to a variety of circumstances, don’t feel that they do have any real choice.
This approach is also equitable. Consider the situation of a person requiring care and support who has no carer with that of a person with identical needs who does have a carer. The former may have to pay for all their care, the latter for a small proportion….because of their carer’s choice. Of course some carers will welcome the discussion that they need to have with the person they care for and some will not, but that is inevitable in the variety of caring relationships that arise in the real world.
Just as an aside: although most, if not all, authorities are charging for replacement care, currently the majority of authorities are not planning to charge carers for services provided directly to them meet their own needs, although they have the power to do so.
So where are the ‘short breaks’ then?
Here is a reminder of the assessment and care planning process discussed in my last blog:
Firstly – consider which of the eligibility criteria the carer comes within, as being a domain that they are unable to achieve, or putting themselves at a risk to their health, and in either case, the situation having a consequential significant impact on their wellbeing.
Most carers are unlikely to think of things in these terms – they will be thinking of the most useful response to their needs, not the description of the need itself. They might say that they would like a rest, or they might be more specific; they might say that they would like to spend time with friends, or see their grandchildren, get more exercise, do their housework, go on holiday, tinker with their car, spend time gardening, read a book or just do absolutely nothing at all. It will be for the worker to match what they say against the relevant criterion (which might be the overarching one that they feel that their health will deteriorate without the time ‘off’.)
Second: Clearly identify the barriers the carer faces in meeting these outcomes.
Once the carer has identified something they cannot do, it will then be time to ask them – what is stopping you and what is the impact on you? Not exactly in those words I would hope…this is about what you need to ask carers; I am assuming that people know how you should ask! For guidance on deciding what impact the problem has or will have, on the person, I refer you again to Lorna’s blog on Consequential Significant Impact.
Third: Think carefully about what you need to do to remove those barriers and who you might need to support
There are a number of ways of meeting carers’ eligible needs and these will entirely depend on the nature of the barriers to achieving outcomes, or maintaining health; and the carer’s views (and where relevant, those of the adult).
Who gets the support and whose needs are being met?
To reiterate, support provided to the adult (at home or in a residential setting whilst the carer rests) is a service to that adult, because rather than MEETING the carer’s needs, the provision of the care relieves the carer of the caring input – and/or reduces the impact accordingly. The guidance [at 11.37] says that consideration may have to be given as to whose needs are being met and offers the possibility of joint budgets when support is being provided to meet the needs of the adult and the carer.
Consider this example:
A carer providing a large amount of care and support says that she wants to continue caring but tells you that what upsets her most is becoming isolated from a group of long-term friends. She wants to be able to join them each Wednesday when they go out for lunch, shop, go to a matinée or a film. She feels that this break will help her to carry on providing care. She says that she cannot leave her husband and would like someone to support him, so that she can go out.
The carer is identifying needs against the outcome ‘maintaining significant personal relationships’. She has made it clear that her needs can be met by providing support for her husband for a particular period. Are the needs hers, or her husband’s?
The needs are her husband’s as he is facing a shortfall in his care for this period: a period for which she is effectively ‘unwilling’ and ‘unable’ to provide care, given her concerns.
She hasn’t put it like that; she would probably never put it like that, nor should she have to – but thinking of it that way helps to clarify that the focus should now be on meeting the adult’s unmet needs during this period.
It is perfectly possible that having looked at the adult’s needs and how they want them met that this is an occasion when a ‘sitting service’ may be appropriate – although I would argue that in this case the traditional 3 hour period wouldn’t be sufficient. It could be however, that a community alarm or a day activity for the adult would provide better outcomes. In this example the carer may have no eligible unmet needs of her own if the appropriate support is provided to her husband.
However had she also said that even if his needs were met she could not afford theatre tickets and she would not like her friends to know that her finances are so poor, then it may well be determined that she met the criteria for a personal budget of her own to enable her to maintain the relationship with friends. That could be money, on top of the replacement care, with which to pursue a recreational activity.
The decision about what percentage of the cost of accessing a desired recreational activity to fund lies with the Local Authority – who will consider the issue of consumption vs support to access the theatre, ‘wants’ and preferences versus needs. However a rational way (and best value way) of looking at it would be to consider what the costs of providing care and support would be if the carer ceased to provide care at all, either from exhaustion or discouragement.
There are of course many variations on this scenario and they cannot all be explored here. I am just trying to make the point that there are many ways of meeting need. If a sitting service is the most appropriate way to support the adult while the carer has time to meet their own needs, then it is still a perfectly acceptable response, but that is not always going to be the case.
The issue of consent
An adult with eligible needs and mental capacity may of course refuse a service – although there is nothing in the Act which requires them explicitly to accept one. Refusal discharges the council from its duty to provide that service. A person who lacks capacity could still be provided with services in their own right despite a refusal, under ‘best interests’ guidance. But if a person with capacity does refuse a replacement care service then some other way must be found to support the carer who would have benefited, as consent is a mandatory requirement before the service can be put in via the alternative route of a carer’s service – for instance if the adult is ineligible or refusing assessment.
This brings us on to:
“Carers’ personal budgets where the adult being cared for does not have eligible needs”
This section of the guidance [11.42-11.46] explains that there may be situations where a carer’s needs may be eligible without regard to whether the cared for adult has any eligible needs. It says that a local authority may meet those needs by providing a service directly to the adult and suggests that the carer might be given a direct payment to buy replacement care. It requires some thought to conceive of when this might be an appropriate response:
Eligibility guidance [6.124] says “the carer must also be providing ‘necessary’ care. If the carer is providing care and support for needs which the adult is capable of meeting themselves, the carer may not be providing necessary support. In such cases, local authorities should provide information and advice to the adult and carer about how the adult can use their own strengths or services available in the community to meet their needs.”
If the person is providing care that the person is capable of doing for themselves or related to a deficit that could be managed through mainstream services, the care probably won’t be regarded as ‘necessary’, so the carer won’t be eligible.
But given the definition of eligibility for the adult, ‘necessary’ care could be being given to an adult experiencing difficulty in ONLY one area of the service user regulations; or difficulty in two or more, but without consequential significant impact for the adult as yet, thus rendering them ineligible.
There are also carers providing support for several people, none of whom have eligible needs. However taken together the support they require places significant stress or limitations on the carer. These carers need to be supported but:
– Would this be by providing replacement care for a person assessed as having no needs for such care or would there be a better way of supporting them?
– And would a council be justified in charging them – or is this an instance where “it may not be” [Guidance 11.45] (since all charging is discretionary)?
– Would you ever put in such care without having a care and support plan for the adult, as the guidance suggests would be the case?
Just returning to the issue of consent at this point: if such a course of action were agreed, the adult would need explicitly to consent to having such a service, (which may well be chargeable), provided to them, as a service to support the carer.
I would welcome anyone else’s thoughts on any of these issues and do please share any examples where you have agreed such provision.
But hopefully this blog does explain where all the short breaks have gone…… ………..they’re supporting outcomes, every one.