Draft Self-directed Support Statutory Guidance on care and support

Section 8: The Role of the NHS and the NHS Professional

This section considers the role of the NHS professional. It clarifies what is possible under the respective legal frameworks and it provides some case study examples of combined packages of support for individuals. It encourages the respective professionals and organisations to work together, to conduct assessments based on personal outcomes and to pool budgets at the level of the individual.

83. Social care and healthcare, particularly community healthcare, are closely related. It is not uncommon for a supported person to receive on-going healthcare - care that is funded by the NHS - and to receive social care and support at the same time. Moreover, a supported person's needs and outcomes - indeed their life as a whole - will not always respect traditional boundaries between healthcare services and social care services. The relevant professionals and organisations should consider their respective roles, contributions, expertise and resources.

What is meant by NHS or "health" support?

84. This section of the guidance uses the shorthand term "healthcare" or "NHS support". This is referring not to acute healthcare (hospital based healthcare, treatments or operations) but to community based healthcare - the range of NHS-funded support provided by district nurses and allied health professionals such as occupational therapists. Support funded or arranged by the NHS may be provided to a person alongside social care provision or it may be provided in place of social care provision. It is important that the relevant health and social care professionals are alive to this reality and take steps to collaborate and work together in the interests of the supported person/patient.

What is meant by a joint approach?

85. A joint approach is not simply about the pooling or transfer of budgets. At its core it is about a joint "person-centred" approach to assessment and support planning. It is about recognising all available opportunities to pool expertise, share common approaches and combine resources at every stage in supported person's pathway. This requires ingenuity, a "solution focused" or "problem-solving" approach and a determination on the part of the health and social care professionals (and senior managers) to take full advantage of the broad powers afforded them in legislation.

Case study 1:

Lisa's story: a package of support jointly funded and supported by health and social care

Lisa is 21, she was involved in a road traffic accident 4 years ago resulting in an acquired brain injury, significant physical disability and communication impairment.

In the 3 years following Lisa's discharge from her local rehabilitation unit, Lisa was totally reliant on her parents, including getting out of the house in her manual wheelchair the physical demands of which limited the scope for family members taking Lisa out. An electric wheelchair had been provided for Lisa but it wasn't being used.

Lisa's occupational therapist told Lisa & her family about the opportunity to take more choice and control - to direct their support - and helped them complete the required paperwork.

Lisa was awarded a joint self-directed support package funded by both health and social care, Lisa and her family, with the support of their occupational therapist, identified her need to gain confidence in using her electric wheelchair independently, and part of her direct payment was used to employ a personal assistant from a local care agency to support Lisa using her wheelchair to access her local community.

By using her wheelchair independently Lisa significantly increased her confidence in using it, particularly in crowded places, and developed her social skills; this has resulted in Lisa starting a college course and to begin to participate in activities in her local community i.e. archery.

The impact on Lisa's family has also been very positive, caring for Lisa is now less physically demanding, and they report that life is easier and that they have respite from their caring role when she is out with her personal assistant. They feel that this experience will enable Lisa to work towards more independent living, through improved communication and more active decision making on her part.

Lisa reports that she feels 'superb' in her ability to go out independently

Examples of shared healthcare and social care needs

86. The respective legal duties in relation to the assessment of social care needs and the provision of healthcare support were framed in a very broad way. There is no definitive list of social care and healthcare interventions. This provides quite a high degree of discretion to the professionals and organisations involved. The following are illustrative examples of joint or shared health and social care interventions - interventions that may be provided using jointly funded packages of support:

• interventions to assist with a supported person's general health such as skincare, the management of pressure sores, the administration of percussive physiotherapy;
• on-going management of aspiration and suctioning;
• specialist cancer, MS, brain or spinal injury care, and;
• epilepsy or diabetes care.

What is "allowed"?

87. What can be done under social care and healthcare legislation? The relevant professionals can do the following:

• They can contribute their professional healthcare expertise to a single assessment and support plan.
• They can arrange for the transfer of funding from the NHS to the local authority in order to pay for aspects of social care provision. The funding can then be directed by the supported person under the 2013 Act. The jointly funded package can be arranged by the relevant professionals on the supported person's behalf, it can be directed by an individual in the form of an individual service fund or it can be released direct to the individual in the form of a direct payment.

Joint assessment and delegated assessment

88. Where the social care assessment function is delegated to the NHS all of the legal powers and duties associated with that assessment will transfer to the NHS professional. The NHS professional must comply with this duty to assess and to meet the person's assessed needs under Section 12A of the 1958 Act or Section 22 of the 1995 Act. In addition they must provide choices over the person's support as defined by the 2013 Act. They must offer the various choices to the supported person and they must "give effect" to the supported person's choice. In addition, the healthcare professional should discharge the relevant duties in line with this guidance.

Joint Funding

89. Under the framework provided by the Community Care (Joint Working etc.) (Scotland) Regulations 2002 (SSI 2002 No. 533) ('the 2002 Regulations') the local authority and the health board can transfer funding between themselves and they can combine their funding at the level of the individual. This flexibility, which applies to "high level" strategic budgets and funding at the "micro level" of the individual, will be retained and enhanced by the forthcoming legislation on the integration of health and social care.

Budgets are pooled: what happens next?

90. Once a decision has been taken to pool budgets the combined funding pot can be released in a variety of ways. Some example scenarios are provided below:

• "Health funding" (funding to address health needs) is added to funding from the local authority. It is then released to the individual as a direct payment. The payment is used to employ a personal assistant with the requisite health training and skills. The assistant is provided with the necessary training. Alternatively, a portion of health funding is used to increase the number of hours funded so that a second personal assistant is provided with the necessary training and can attend to health needs at specific times of the day.
• Health funding is added to a virtual budget in the form of an individual service fund. The budget is then released to a provider by the local authority. The budget is used to purchase support from an agency with staff who are able to assist with healthcare tasks that may otherwise have been provided separately by the NHS. The relevant health professionals must be assured that the agency staff are sufficiently trained and competent to meet the health needs of the supported person.
• The relevant health and social care professionals work together to arrange a package of services on behalf of the individual. The services may be provided by the local authority, a third sector or private sector provider or the NHS.

Case study 2:

Steven's story: a package of support jointly funded and supported by health and social care

Steven is a tetraplegic. Paralysed following a serious accident in 1978, Steven was cared for at home by his mother until 1996. Using the Independent Living Fund and a direct payment he moved into his own adapted accommodation when his mother was 73 years old. This package was successful for several years allowing Steven to continue to work and live independently supported by his team of personal assistants.

During this time Steven was also supported by the District Nursing Service daily who attended to various aspects of his care including bowel management and administration of certain medications.

Unfortunately Steven's physical health began to deteriorate and repeated chest infections led to hospitalisations and the subsequent need for overnight respiratory support. Steven was very keen to ensure that he could return home and continue to enjoy his independence, at the age of 60 he felt that a nursing home placement was not for him.

The Care Manager and District Nurse put together a case for joint funding. The District Nurse provided training to all members of the care team on all healthcare interventions and the respiratory team provide training on ventilation which was required overnight. There was significant debate between social work and health service managers on the share of the funding which required evidence from the care manager and the district nurse. Once agreed, Steven was able to come home from hospital to be supported by his trained care team.

Steven says 'Living independently with joint funding has made a huge difference to my life. The advantages have been: being in charge of my life and making my own decisions; organising my household and shopping myself, choosing my menus; inviting my own friends and family to visit, organising social events and going out with my family and friends, privacy in my home; able to continue to work as a quantity surveyor, until 2011 when I had to retire because of ill health; choosing and employing my own staff, which allowed continuity in my care.'

Monitoring and review

91. The professionals involved in jointly funded packages of support should put in place the appropriate joint arrangements for the on-going monitoring and review of the supported person's needs. It is important that the NHS professional continues to bring their professional expertise to bear. They will want to be reassured that the supported person's health needs are being met in an effective way and by someone who is competent and trained to deliver those interventions. At the organisational level the local authority should liaise with the Health Board to develop effective arrangements around the corporate policies for the assessment and monitoring of all self-directed support packages where there is a health care component.

Draft Statutory Guidance on Care and Support

Consultation Questions

Section 8 : The role of the NHS professional