| The study |
| Cases were recruited to the study from four of the former regions in Scotland. Two operated a 'task' model of care management, care management carried out by individuals alongside other aspects of their work (Regions C and D); two had recruited individuals specifically to operate as care managers, the 'role' model (Regions A and B). Two hundred and forty seven cases were tracked in the four regions for a nine month period; 65 practitioners were involved. |
| Assessment |
| Much of the initial energy in the implementation of the new community care arrangements focused on the assessment process, key in turn to the optimal achievement of care planning. |
| User group was influential in terms of referral source, response time, length of assessment, others contacted by the worker, and the costs of the process. Assessment tended to take longer, and involved greater contact with other professionals, for individuals with learning disabilities. The cost of the assessment process was also highest for this group of service users. |
| In respect of a specifically 'needs-led' assessment, practitioners were still on a learning curve, as were other professionals with whom they worked. There was evidence of referrals still being made to obtain services rather than for a comprehensive identification of needs. Moreover the authority of the care management assessment may be undermined by the practice among service providers of undertaking duplicate assessments. |
| Overall, two-thirds of the costs of assessment were accounted for by the care manager costs, the remaining third stemming from the contacts other service professionals had with the care manager and special assessments carried out at the same time as the comprehensive needs assessment. |
| Two-thirds of all care manager costs at assessment were accounted for by contacts with users and carers. Patterns of contact varied, however, both within and across user groups. Amongst service users, with people with mental health problems were contacted most frequently in the course of assessment. Amongst carers, contacts were highest in relation to people with learning disabilities. |
| The centrality of users and carers to the assessment process was reflected in their generally high level of satisfaction with the practitioners as people willing to spend time and to listen. Nonetheless, this could also be coupled with frustration at the worker's perceived inability or slowness to respond in practical terms to the concerns expressed. |
| Care planning and implementation |
| Beyond the assessment stage there was considerable variation in the extent to which the core tenets of care management had been developed. The role of practitioners ranged from the management of a 'rolling programme' of care to that of gatekeeper for specific services. |
| For the group of older people in the sample, high risk and the inability of carers to continue caring were closely associated both with practitioner recommendation for residential placement and with subsequent admission. Service response was strongly influenced by factors outwith the practitioner's control: the role of the informal carer, user preferences and the actions of other agencies. Very few examples of intensive domiciliary care arrangements emerged; those that did were in the regions where practitioners had the greatest autonomy. |
| A lack of suitable accommodation was an important constraint on meeting the needs of people with learning disabilities and mental health problems. There was a low take-up of day time services and occupation by people with mental health problems, often explained by service provision not meeting users' own perceived needs. Providing regular support to carers, both practical and emotional was more evident for people with learning disabilities than others. |
| Purchasing and providing |
| The four regions studied had adopted contrasting approaches to both purchasing and providing, including a range of budgeting mechanisms. The 'demand led' approach adopted in Region A gave care managers greater authority to negotiate individual service contracts than in other regions. They also had, in some circumstances, a direct input to planning for, rather than merely recording, unmet need. A more tentative approach to freeing some of the budget for 'spot purchasing' was evident in other regions. In terms of provision, Regions B and D had concentrated on the development of a more flexible range of in-house services supplemented by the voluntary sector. Only in Region A was significant use being made of private sector services. |
| Unmet need due to lack of facilities and funding for basic services was still apparent, with three-quarters of the 53 case studies identifying at least one unmet need. |
| 0 Eligibility criteria operated by service providers also created a significant barrier to meeting needs in many cases. |
| Notions of justice or fairness as well as of value for money and actual cost influenced the attitudes of users and carers towards paying for services. Collective family finances could constrain what was available for the individual service user. |
| The social work departments were all prescriptive about using in-house services first, but with varying levels of enforcement. In Regions B, C and D there was no evidence of use of the private sector for subsidised domiciliary care, other than in relation to one service user in Region C. Use of voluntary sector services was particularly evident in providing support services for people with learning disabilities or mental health problems. |
| On average, accommodation and associated care accounted for 80% of the total cost of care, but a range of services were used independently of accommodation arrangements. There was no statistical association between the costs of assessment and subsequent service package costs. |
| Costs were significantly greater for females than for males, and for people who died during the nine months following assessment. Costs were also higher where housing, household management and challenging behaviour needs were to be tackled, or where users were judged to be at immediate risk. Few cost differences were attributable to style or activities of care management. |
| Monitoring and review |
| Once a care package was in place, there was much ambiguity as to case status. A case being 'open' did not necessarily imply ongoing intensive input; being 'closed' did not presuppose the cessation of responsibility on the part of the worker. Likewise, what was meant by monitoring and review was subject to different interpretations. While in part different practices may reflect the needs and circumstances of individual users, a lack of direction in terms of procedures and systems, workload contingencies and perceptions of role was also influential. |
| In role model regions, an awareness of a long-term commitment as integral to care management may be compromised by other workload demands. Identifying others as monitors and an arms-length approach by the worker may, however, undermine the independence and efficacy of the monitoring function. In task model regions, a longer-term involvement would be adopted only where workers saw a role for themselves as social workers or occupational therapists. |
| Users' and carers' attitudes towards the frequency with which they saw the worker reflected their felt need for contact and the availability, or otherwise of an alternative source of support. Infrequent contact may, 1' however, render workers peripheral to the users' and carers' experience. Few users or carers were aware of the means for dealing with complaints or seeking redress; only a small number were aware of reviews or meetings to monitor progress. |
| Before and after implementation:Supporting older people |
| The existence of an earlier study of older people, together with a more detailed sub-study, allowed comparison of the outcomes for this group before and after the implementation of care management. |
| The characteristics and circumstances of older people receiving care management suggested they were a highly vulnerable subgroup compared with the older people referred in the earlier study. |
| Factors associated with entry to residential or nursing home care were high support needs of carers and a high degree of assessed risk to the user. In the earlier study a wider spread of personal needs was also associated with a move away from home. |
| There was no evidence to support the hypothesis that people with higher levels of need or a wide range of needs were supported in greater numbers after the implementation of community care than before. However, those elderly people whose circumstances made them especially vulnerable, but who remained at home were provided with significantly more services than in the past. These individuals appeared to be the main beneficiaries of the reforms. |
| In practitioners' approach to assessment, there was only minor evidence of a shift towards greater emphasis on user choice, wider information-gathering, or the use of more imaginatively needs-led responses. The impression was one of continuing change, rather than a radical break with past practice. |
| The study was carried out by the Social Work Research Centre, Stirling University. Funding was provided by The Scottish Office Social Work Services Group and Chief Scientist's Office. |
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| Alison Petch, Juliet Cheetham, Roger Fuller, Charlotte MacDonald and Fiona Myers with Angela Haliam and Martin Knapp |
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