CHAPTER EIGHT: CONCLUSIONS AND IMPLICATIONS FOR POLICY AND PRACTICE
IMPLICATIONS FOR POLICY AND PRACTICE
8. 33 It is not appropriate for this report to make detailed recommendations: instead, this final section will draw out broad implications for policy and practice arising from the findings. The Scottish Executive will need to give careful consideration to the question of how far it should be prescriptive in any future guidance. Authorities rightly value their ability to develop local solutions to local problems, but there is evidence to suggest that clarification is needed in a number of areas. Part of the problem can be traced back to ambiguities in the original guidance and perhaps within the concept of care management itself.
The need for differentiation
8. 34 One of the main conclusions of the research is the need for clearer differentiation at a number of levels:
• between simple and complex cases
• between the level of assessment appropriate to different cases
• between the frequency and form of monitoring and review appropriate to different cases
• between the activities of qualified and unqualified staff.
8.35 Various references have already been made to Edwards’ (1996) model of care management. The findings of this research suggest that Edwards’ thesis is very useful in differentiating between administrative, co-ordinating and intensive approaches to helping people. What is less useful is the fact that she called all three of these distinct activities “types of care management”. One way to address current inconsistencies in policy and practice, the potentially misleading use of terminology, and the lack of clarity surrounding some aspects of care management would be to issue guidance distinguishing between three approaches to helping people with community care needs. These are:
• Information and advice-giving and the provision of very simple services, such as bus passes
• Care co-ordination, aimed at people with relatively straightforward and /or stable needs, involving the provision of simple services
• Care management, (or ‘intensive care management’) offered only to people with complex or frequently or rapidly changing needs, requiring complex packages of care and active, on-going support.
8.36 The first of these, which would involve no care manager contact, would be carried out (as of course it already is in many authorities) by duty or reception staff, some of whom may be administrative workers. Care co-ordination could be carried out by unqualified staff with adequate support and supervision from qualified colleagues. Once a package was in place and the situation well settled, these cases could be placed on a review system. However, users would need to be given a name and number to contact if they wanted to, and service providers would have an enhanced role in monitoring.
8.37 Care management would be carried out only by qualified staff. Edwards (1996) suggested the following criteria for triggering what she called intensive care management:
“Where the needs and /or circumstances of the user are complex, high risk and/or volatile, or
Where the care plan a) is volatile, or
b) requires high-status co-ordination
Where a transfer of responsibility would jeopardise the user’s acceptance of ongoing assistance or rehabilitation”. (Edwards, 1996, p123).
Joint working
8.38 The research has shown that where single shared tools were being used, professionals were positive about the benefits. However, many authorities are still in the early stages of developing or piloting such tools. The targets currently set by the Scottish Executive for having these in place across Scotland – October 2001 for older people and those with dementia, and March 2002 for other groups - are unlikely to be met by more than a handful of authorities. Rather than authorities rushing to adopt or implement tools without proper preparation, it would be sensible to postpone these dates. Clarification of what is meant by a single shared assessment tool - a tool that can be completed by staff from different agencies, for example by either local authority or health, and accepted by others – might also be helpful.
8.39 A number of different organisational arrangements regarding team structure and location of staff were identified in the research. The benefits of attaching care managers to GP surgeries were weighed against the advantages of placing them in multidisciplinary teams. The latter however cannot be easily linked to GPs. It is likely that there needs to be different organisational arrangements for different groups.
8.40 The Scottish Executive may wish to consider ways of encouraging medical professionals to complete and return specialist assessments more promptly than is currently happening in some areas.
8.41 The research shows a need for social work authorities to work more closely with their housing colleagues. Finding ways to involve them more routinely and yet more formally within the assessment process would be beneficial.
Budgetary arrangements
8.42 Authorities may need more encouragement to devolve budgets to care managers. Although various objections to doing so were raised, and a few authorities had experienced difficulties in the past, the provision of good financial information to care managers and sound accounting systems can address these issues. The evidence overall
8.43 The findings indicate an urgent need to consider allocating more resources to care management. These should be used to develop more round-the-clock care to keep individuals with complex or frequently or rapidly changing needs at home.
Workloads
8.44 A number of authorities reported that care managers were carrying heavy workloads. Having about 15 intensive cases was seen as about right. Again, this is a point the Scottish Executive may wish to reconsider in respect of the Joint Future Group Report.
Recording information
8.45 With regard to local authorities’ data collection activities, it is worth considering the usefulness of recording care managed cases separately from other community care cases. Similarly, it might be helpful if community care user groups were classified consistently across the country.
Training needs
8.46 Finally, a long and diverse list of unmet training needs was identified among care managers. Most often mentioned were law, finance, specific user group issues and care manager role and tasks. The research suggested that training in screening and care planning would also be helpful. Different levels of training are needed to suit differing levels of experience.
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