Service Users of Home Care - Report - 27 February 2017

Health and Social Security Scrutiny Panel

Service Users of

Home Care

Presented to the States on 27th February 2017

S.R.1/2017

CONTENTS

1. Executive Summary.................................................................................................  4
2. Findings of the Panel...............................................................................................  5
3. Recommendations of the Panel................................................................................ 5
4. Family Nursing and Home Care funding; An Overview....................................... 6 P.82/2012 – Changes within the Health Department..................................................... 6 Redesign of services offered by FNHC........................................................................... 6 Funding for Family Nursing and Home Care in the Future............................................  10
5. Issues for further consideration....................................................................  12
6. Conclusion................................................................................................................. 13
7. Appendix 1............................................................................................................... 14 Membership of the Panel............................................................................................... 14 Terms of Reference........................................................................................................ 15 Evidence Considered..................................................................................................... 15 Briefings......................................................................................................................... 15 Public Hearings.............................................................................................................. 16

8. Appendix 2............................................................................................................... 17 Timeline of correspondence...........................................................................................  17

1. Executive Summary

In September 2016, Family Nursing and Home Care (FNHC) announced that from January 2017 the Health and Social Services Department would no longer be subsidising the home care service it provided. Due to the introduction of the Long-Term Care Scheme, there are now a large number of approved providers of home care in the island, of which FNHC is the only one to receive any kind of Government funding. As a result of receiving the grant, FNHC were able to offer a reduced rate of £11 per hour to its clients, as opposed to the private market rate of between £19 and £22 per hour. Due to the increase in market providers, the Health and Social Services Department was no longer willing to subsidise the home care services of FNHC and aimed to remove this element of funding completely by January 2017. In order to offset the financial hardship this may place on service users of FNHC, the Department intended to assess all clients for the Long-Term Care Scheme and introduce a new flexible care component of Income Support through the Social Security Department.

The Panel has found that there were a number of issues with this process. Due to the complex nature of how the funding from the Health and Social Services Department was allocated by FNHC, it has been difficult for both sides to agree on how much of the block grant is allocated to home care. Negotiations on this matter had been ongoing for a year, with little evidence to show agreement had been reached on how the funding was apportioned. This has proven to be a sticking point which has protracted this situation. The Panel recommend that the Health and Social Services Department confirm how the funding is apportioned as a matter of urgency.

It became increasingly apparent during 2016 that the necessary work required to mitigate any effects on FNHC clients would not be completed. As a result, the Minister for Health and Social Services has extended the funding agreement with FNHC until January 2018 in order to allow for a smoother transition. This was to ensure that clients of FNHC had been assessed for the Long-Term Care Scheme, and also allow for the introduction of the new flexible care component. The Panel is pleased that the Minister has taken this course of action.

The Panel also found that the new flexible care component of Income Support was initially scheduled to be introduced in line with the original cut-off date of the subsidy. As of August 2016, there was no confirmation that the new component would be available, as full law drafting instructions had not been provided to Social Security from the Health and Social Services Department. Without funding for home care in place, it is possible that many clients of FNHC would have been directly affected by the increase in their care costs. The Panel feel that the Health and Social Services Department have attempted to remove this funding without a viable alternative in place.

The Panel has raised issues for the Minister for Health and Social Services and the Minister for Social Security to consider. These include, the potential effects of changing terms and conditions on the level of care available from FNHC and the potential inconsistency of two different assessment tools within the Income Support care components.

2. Findings of the Panel

FINDING 1

The Health and Social Services Department and FNHC appear to have operated for years without full knowledge of the costs attributable to home care. As a result, it has been difficult to disentangle the funding utilised for home care services from the remainder of the commissioned services. The subsidy and how it is broken down has been a sticking point in negotiations.

FINDING 2

Negotiations for the removal of the subsidy between the Health and Social Services Department and FNHC were slow, with long gaps evident in the process. Both Health and Social Services and FNHC bear responsibility for this. Health and Social Services failed to clearly communicate its change in position to FNHC and then attempted to make changes in a short timeframe. On the part of FNHC there was a seeming reluctance to accept and engage with the changes. This failure to agree led to FNHC's announcement in September 2016 with regards to their staff terms and conditions.

FINDING 3

Letters inviting FNHC clients to be assessed for the Long-Term Care Scheme were sent out in September, only 4 months prior to the planned removal of the subsidy. As of August 2016, there were no clear instructions for the new flexible care component. This was not a realistic timeframe in which to complete the work required. It is appropriate therefore to extend the funding until this is resolved.

3. Recommendations of the Panel

The Panel make the following recommendation from this review;

RECOMMENDATION 1

It is unsatisfactory that there is no information as to how the subsidy is allocated to services. The Minister for Health and Social Services should confirm how the block grant for the core commissioned services is broken down by the end of the first quarter in 2017.

4. Family Nursing and Home Care funding: An Overview

P.82/2012 – Changes within the Health Department

In 2012 the States voted to adopt the Health and Social Services Department White Paper P.82/2012 "Health and Social Services: A New Way Forward"[1]. Within this redesign of the health service, more emphasis was put on caring for people in their own homes. This was directly linked to feedback gained from the consultation process that informed the White Paper;

"Most respondents agreed that People should be able to live in their own home for a long as possible, providing they have the right health and social care support from the States of Jersey"[2]

At this stage, FNHC received funding of approximately £6.4 million from Health and Social Services in the form of a block grant. This related to delivery of District Nursing, Home Care Services and Children's Services which included health visiting, school nurses and community paediatrics[3]. FNHC also provided a domiciliary care service to help clients with general household tasks. Since 2014[4], the Health and Social Services Department has commissioned FNHC to provide Rapid Response and Reablement services and Maternal Early Childhood Sustained Home-Visiting (MESCH). This was directly linked to P.82/2012 and additional funding was provided in order to carry out these services under separate service level agreements.

Finance Director, FNHC

"Then there is the White Paper funding that came on board for rapid response reablement and the M.E.C.S.H. (Maternal Early Childhood Sustained Home-Visiting) which is an extension to the health visitor programme, a core commissioned service[5]"

In December 2013[6] the States Assembly approved the introduction of the Long-Term Care Scheme to help support people with long term care needs. This has prompted a change in the market for homecare and there is now a larger number of approved home care providers on the island offering the same home care service as FNHC.

Redesign of Services offered by FNHC

Due to the subsidy received from the Health and Social Services Department, FNHC were able to offer home care services to their clients at a cost of £11[7] per hour as opposed to the market rate of between £19 and £22 offered by private care providers. As home care was being delivered by private agencies in a competitive market, Health and Social Services began to look at removing the subsidy to FNHC. Health and Social Services told the Panel that it began discussing the removal of the funding with FNHC in 2014[8], however FNHC told the Panel that discussions began much later. The Panel has not been able to discern which is correct, although the following letter clarifies the position as of October 2015;

Director Re-design and Delivery, Letter to FNHC 16th October 2015 Intention 4: Homecare

"Throughout 2016 HSSD will review the block funding arrangements for home care as individuals transfer to long term care scheme funding. It is the intention that by the end of Q2 2016 each of the circa 490 FNHC homecare clients will have been assessed by a social worker for Long Term Care Scheme funding and throughout 2016 individuals will be transferred to the appropriate funding source[9]"

The FNHC Committee expressed concern at the removal of the subsidy and requested a longer period of time with which to make the transition;

Chair, FNHC, Letter to HSSD 24th November 2015

"What is absolutely clear is that sudden withdrawal of monies for Homecare support next year would seriously jeopardise the operational capability of the organisation and make it financially unviable. There is a need for a five year transition agreement on funding if you are seriously thinking of withdrawing funding for social care." [10]

Further discussion took place between FNHC and the Health and Social Services Department in the first quarter of 2016 with FNHC seeking clarity over the situation and the potential changes it faced.

Following a meeting between the Health and Social Services Department and FNHC on the 1st April 2016, a letter was sent to FNHC confirming that the home care subsidy would be completely removed from 1st January 2017. The Health and Social Services Department confirmed it would fund home care until then, however, any clients of FNHC who were already in receipt of the Long-Term Care benefit would cease to be subsidised from 1st August 2016.[11]

FNHC were formally notified of a reduction of its funding for 2016 at a meeting on 29th July 2016[12]. This was a c£600,000 reduction in the overall home care service but FNHC negotiated this reduction to £432,000. [13] Based on these calculations, the Health and Social Services Department were estimating that £1.5 million was apportioned to the home care service supplied by FNHC[14], however this was not based on any official breakdown. The table below sets out the funding position in 2016 after the reduction in the subsidy;

Finance Director, FNHC

"In 2016 we have had a reduction of £430,000-odd, so we are down to about £7 million of our net revenue from Health and Social Services for all of our commissioned services. From that we know there is about £5.9 million that is around those original core commissioned services of district nursing, child and family and home care, and then there is other specific elements for rapid response reablement and the MECSH programme" [16]

The Panel note that to date there is no information available as to how the £6 million subsidy is allocated to the core commissioned services. This has made it incredibly difficult to identify the amounts relating to the home care service provided by FNHC.

FINDING 1

The Health and Social Services Department and FNHC appear to have operated for years without full knowledge of the costs attributable to home care. As a result, it has been difficult to disentangle the funding utilised for home care services from the remainder of the commissioned services. The subsidy and how it is broken down has been a sticking point in negotiations.

RECOMMENDATION 1

It is unsatisfactory that there is no information as to how the subsidy is allocated to services. The Minister for Health and Social Services should confirm how the block grant for the core commissioned services is broken down by the end of the first quarter in 2017.

In order to prepare clients of FNHC for the removal of the subsidy, the Health and Social Services Department requested that FNHC send out a letter to its 147 clients of FNHC who received home care, offering them the opportunity to be assessed for the Long Term Care Scheme. FNHC were first informed of this decision in a letter from the Health and Social Services Department in April 2016[17].

Finance Director, FNHC – Email to Scrutiny Office

"HSSD sent us a draft of a letter to us on 5th August 2016, approved by the Health Minister, which was to encourage our clients to take up the offer of a LTC assessment. It was intended for FNHC to sign and send on FNHC headed paper. We weren't comfortable with this as it would mean the client calls for assessment would generally come direct to us, even though a HSSD number was in the body of the letter. HSSD agreed that it would make sense for them to sign the letter on their own headed paper and we agreed to send it out on their behalf along with our monthly billing cycle." [18]

Deputy G.P. Southern :

"Those letters did not go out until September/October."

The Minister for Health and Social Services:

"Yes, exactly. It took far too long. The whole thing has taken far too long, to be honest. Once it became very clear ... to be fair, you were questioning me in the States as to whether I would delay the introduction for a couple of months and we were already at the stage where we probably would do that, but I needed to make sure. [19]"

The letter was sent out in September 2016. This meant that there were only 4 months available for the Health and Social Services Department to assess up to 147 clients for the Long-Term Care Scheme prior to the removal of the subsidy.  

The news of this cut in funding was made public at the same time as a meeting with all FNHC staff on 29th September 2016. This announcement was published in the Jersey Evening Post the following day[20], and gave the impression that this funding cut was a sudden decision on the part of the Health and Social Services Department. There was a reaction from FNHC staff who felt that they had not been informed early enough and further comments from FNHC management stating that the Health and Social Services Department had not listened to its pleas for a lengthier transition[21] although it was first informed in April 2016.

On the 30th September, the Minister for Health and Social Services responded with a statement explaining that discussions had been ongoing with FNHC since 2014;

"Minister for Health and Social Services

HSSD has been engaged in discussions with FNHC about their homecare provision for some time – it was first signalled in 2014 – and it is wrong to give the impression that this was a recent development on HSSD's part." [22]

FINDING 2

Negotiations for the removal of the subsidy between the Health and Social Services Department and FNHC were slow, with long gaps evident in the process. Both Health and Social Services and FNHC bear responsibility for this. Health and Social Services failed to clearly communicate its change in position to FNHC and then attempted to make changes in a short timeframe. On the part of FNHC there was a seeming reluctance to accept and engage with the changes. This failure to agree led to FNHC's announcement in September 2016 with regards to their staff terms and conditions

Funding for Family Nursing and Home Care in the Future

On the 1st November 2016, the Minister for Health and Social Services confirmed in a response to a question from Deputy Southern that funding for home care services provided by FNHC would continue until at least July 2017[23] to allow for home care clients to be assessed for the Long-Term Care benefit and also allow for the introduction of a new flexible care component of Income Support. It had been identified that there was a gap between the highest level of the personal care components of Income Support (£145[24]) and the lowest level of the Long-Term Care Scheme (£350[25]) and this new component was designed to fill that funding gap. The Minister confirmed this in a joint statement issued between Health and Social Services and FNHC on 11th November 2016;

Minister for Health and Social Services;

"This extension of financial support for current FNHC home care clients will allow the introduction of the new income support flexible personal care component, giving more time for a safe and smooth transition for them." [26]

The Minister for Health and Social Services also confirmed the reasons for the extension in a Public Hearing with the Panel on 10th November 2016[27].

Deputy G.P. Southern :

"You have had a year, in effect, where you have not been able to say: "We cannot do that ... and we cannot meet that target"?

The Minister for Health and Social Services:

"Effectively, yes, and there were 2 reasons for that. I was part of the problem because I wanted fully to understand the effect and the numbers of people that it affected, and secondly - and I am not putting any blame on anyone else - it became clear that... okay, put the blame on us. We had not given Social Security the final details and instructions necessary for them to proceed with the regulations. Once we are in a position to do so, Social Security will then lodge the legislation next year. Plus Family Nursing asked for more time for the transition, particularly I think the difficulty they had was more around their staff arrangements.[28]"

In order to transfer clients to an appropriate funding source, a new flexible care component of Income Support is scheduled to be introduced to fill the gap in provision between the highest level of income support personal care and the lowest level of Long-Term Care.

The intention of the Health and Social Services Department was that this new component would be available to clients by the end of 2016[29], to allow for funding to be in place for clients of FNHC once the subsidy was completely removed.

The  Health  and  Social  Services  Department  tasked  Social  Security  to  undertake  the necessary law drafting in order to make the component available, however this was only sent to the Law Draftsmen in August 2016 as confirmed by the Policy Director of Social Security;

Policy Director, Social Security;

"Yes, the Minister issued law drafting instructions in August but we were not able to provide all the law drafting instructions in August because we did not have instructions from Health as to what they wanted to achieve, so we have done as much as we are able to at the minute. We do have draft legislation and there are some small details to be finished off. [30]"

Without the completed instructions, Social Security could not complete the necessary actions in order to introduce the new flexible care component. This meant that the Health and Social Services Department would be unable to provide an existing funding source to clients of FNHC who may not be eligible for the Long-Term Care Scheme or the Income Support personal care components.

This, coupled with the length of time it took to offer assessments to clients of FNHC, was acknowledged by the Minister for Health and Social Services;

Deputy G.P. Southern :

"I could direct the next question at you, but I think I would like to just briefly come back to the Minister to ask when did you realise that you were not going to do all of this by the end of 2016?"

The Minister for Health and Social Services:

"Recently. We were asking the questions, I think, earlier, but we realised that we were not going to get the responses back. It is Family Nursing that is getting the letters out on our behalf, if you like, working together, but it became very clear that we were not going to get the responses back.[31]"

The Minister for Health and Social Services:

"We had not given Social Security the final details and instructions necessary for them to proceed with the regulations. Once we are in a position to do so, Social Security will then lodge the legislation next year[32]"

FINDING 3

Letters inviting FNHC clients to be assessed for the Long-Term Care Scheme were sent out in September, only 4 months prior to the planned removal of the subsidy. As of August 2016, there were no clear instructions for the new flexible care component. This was not a realistic timeframe in which to complete the work required. It is appropriate therefore to extend the funding until this is resolved.

5. Issues for further consideration

The Panel would like to highlight the following issues for consideration by the Minister for Health and Social Services and the Minister for Social Security.

• FNHC is in the process of changing the terms and conditions for some of its staff. The Panel has heard evidence to suggest that FNHC will be remodelling its home care service with attention being paid to staff working hours and benefits received. At present there is no evidence to suggest service users will be affected, but the Panel feels this is a potential risk worth noting at this stage.
• The Panel has found that the new flexible care component of Income Support will be assessed in the same manner as the Long-Term Care Scheme, but funding for the new component will reside in Income Support and not the Long-Term Care Fund. There are two assessment methods for different personal care components in the Income Support system and each assessment method is carried out by officers from different departments. There is no evidence to suggest that the assessment method used by Health and Social Services is comparable to the assessment method used by Social Security, therefore it cannot be known which one accurately reflects the needs of clients on the different levels.

6. Conclusion

At the start of this review the Panel was concerned that the timescale for this transition was unrealistic and unachievable. The proposed timescales, coupled with the absence of the new flexible personal care component should have shown that removal of the subsidy would have been unviable for service users who relied upon the subsidy to FNHC.

It is the view of the Panel that the Health and Social Services Department has tried to implement too much change in a short period of time and this has put pressure on FNHC to make major changes to its business model. It is also unsatisfactory that no information is available with regards to how the block grant is broken down, and this has ultimately protracted the issue. The Minister for Health and Social Services should confirm how the block grant is apportioned as soon as possible.

Had the Minister for Health and Social Services not extended the deadline for removing the funding, then service users of FNHC would have been directly affected, possibly forcing some individuals to lose the number of care hours they were receiving. The new Income Support component was not ready to be introduced by the time the subsidy was meant to be removed, and subsequently, had the Minister not extended the transition period, no funding would have been in place for those individuals who fell outside of the Long-Term Care Scheme or had yet to be assessed for it.

FNHC will need to work together with the Health and Social Services Department over the coming year in order to ensure that all of its clients are in receipt of the funding they require in time for the cut-off date of 2018. At the same time, FNHC will need to consider its options with regards to its home care delivery as the terms and conditions of its staff will be changing. It is clear that FNHC offers excellent delivery of home care, with well trained and highly experienced staff.

The Panel are satisfied that the necessary steps have been taken to prevent potential hardship for service users of FNHC, but assessments will have to be completed and the new flexible personal care component will have to be implemented prior to the removal of the home care funding in January 2018.

7. APPENDIX 1

Panel Membership

Deputy Richard Renouf (Chairman)

Deputy Geoffrey Southern (Vice- Chairman)

Deputy Jackie Hilton

Deputy Terry McDonald

Senator Sarah Ferguson

Terms of Reference

1. To question the Minister for Health and Social Services publicly on the reduced funding to Family Nursing & Home Care in order to assess what other support is available for service users of home care
2. To examine what impact the changes to home care services provided by Family Nursing & Home Care will have on service users.
3. To question the Minister for Social Security on the availability of Income Support and Long-Term Care benefits to support Family Nursing & Home Care clients who are currently accessing the home care service.
4. To assess what strategies are in place to increase service user awareness and understanding of the proposed changes to home care provision.

Evidence Considered

1. P.82/2012, Health and Social Services: A New Way Forward
2. Hansard, 1st November 2016
3. Hansard, 11th December 2013
4. Written Question from Deputy G. Southern to Senator A.K.F Green, Minister for Health and Social Services
5. Joint Statement from Health and FNHC, 11th November 2016.
6. Income Support Personal Care Component Information,

http://www.gov.je/Benefits/IncomeSupport/Pages/Rates.aspx

7. Long Term Care general leaflet March 2016 V04.
8. HSSD response to FNHC Media Release, Statement from the Minister for Health and Social Services 30th September 2016
9. Various Letters and Correspondence between HSSD and FNHC between July 2014 and October 2016 (A summary is attached in Appendix 2)

Briefings

The Panel received private briefings from the Minister for Health and Social Services and from members of the Family Nursing and Home Care management team prior to the launch of the review.

Public Hearings

8.  APPENDIX 2

The Panel was provided with the following correspondence between the Health Department and FNHC;

[1] Hansard; 23rd October 2012, p.140

[2] P.82/2012, Health and Social Services: A New Way Forward, p.27

[3] Public Hearing with FNHC, 23rd November 2016, p.3

[4] http://www.fnhc.org.je/how-we-can-help/rapid-response-crisis-reablement/

[5] Public Hearing with FNHC, 23rd November 2016, p.3

[6] Hansard, 11th December 2013, p.33

[7] Public Hearing FNHC, 23rd November 2016, p.8

[8] Analysis of FNHC Home Care Services and Recommendations for change – Report by Out of Hospital Commissioner to Finance Director and Director Re-design and Delivery – 28th November 2014

[9] Letter from Director Re-design and Delivery to CEO, FNHC, 16th October 2015

[10] Letter from Chair, FNHC to Director Re-design and Delivery, 24th November 2015

[11] Letter from Director Re-design and Delivery to CEO, FNHC 13th April 2016

[12] Email from Finance Director, FNHC to Chairman, Health and Social Security Scrutiny Panel, 3rd October 2016

[13] Public hearing with FNHC, 23rd November 2016, p.3

[14] Email from Finance Director, FNHC to Chairman, Health and Social Security Scrutiny Panel, 3rd October 2016

[15] Written Question from Deputy Southern to the Minister for Health and Social Services, 1st November 2016

[16] Public Hearing with FNHC, 23rd November 2016, p.3

[17] Letter from Director Re-design and Delivery to CEO, FNHC, 13th April 2016

[18] Email from Finance Director, FNHC to Scrutiny Office, 13th October 2016

[19] Public Hearing with the Minister for Health and Social Services, 10th November 2016, p.16

[20] Jersey Evening Post, Friday 30th September 2016, p.1 and p.2

[21] Jersey Evening Post, Friday 30th September 2016, p.2

[22] HSSD response to FNHC media release, Statement from the Minister for Health and Social Services, 30th September 2016

[23] Hansard, 1st November 2016, p.34

[24] http://www.gov.je/Benefits/IncomeSupport/Pages/Rates.aspx

[25] LTC general leaflet March 2016 V04, p.10

[26] Joint Statement from HSSD and FNHC, 11th November 2016

[27] Public Hearing with the Minister for Health and Social Services, November 10th 2016, p.16

[28] Public Hearing with the Minister for Health and Social Services, November 10th 2016, p.16

[29] Letter from Director Re-design and Delivery to CEO, FNHC, 13th April 2016

[30] Quarterly Hearing with the Minister for Social Security, 23rd November 2016, p.19

[31] Public Hearing with the Minister for Health and Social Services, November 10th 2016, p.16

[32] Public Hearing with the Minister for Health and Social Services, November 10th 2016, p.16