Care & Support Services - Achieving Best Practice

Eligibility

Eligibility

Local authority social care services are responsible for assessing the needs of individuals with learning disabilities who live in their area.

The eligibility criteria for qualifying for care services differ in each authority. This section highlights the four eligibility levels, as recommended by the Department of Health. Each level stipulates whether an individual receives care. These levels are:

1. Critical
2. Substantial
3. Moderate
4. Low

Local authority social care services are responsible for assessing the community care needs of people who live in their area. In general, local authorities may provide care to individuals with needs arising from physical, mental health, sensory, learning disability or age related problems. Services are provided under numerous Acts of Parliament ranging from the National Assistance Act 1948 through to Health and Social Care Act 2000.

What are 'Eligbility Criteria'?

Eligibility Criteria is the professional term used to describe the circumstances which ensure individuals who have either a disability, impairment or other problems are eligible to receive support or assistance. The Department of Health, in its document, LAC (2002) 13 - 'Fair Access to Care Services - (Guidance on eligibility criteria for adult social care) 2002', details comprehensive guidance to assist local authorities in drawing up a framework for their criteria. The guidance is designed to assist local authorities in developing such a framework, which should lead to a more consistent approach to judging eligibility and fairer access to care services across the country.

The fundamental purpose of the document is for local authorities to make only one eligibility decision for those seeking support, namely whether they are eligible for assistance or not.

Any decision over an individual's eligibility will usually take place after assessment of an individual's 'presenting needs' and clear establishment of their 'eligible needs'.

To clarify further - 'presenting needs' are those circumstances with which an individual initially presents, whilst 'eligible needs' are those circumstances which, following an assessment, are seen as fitting within the eligibility criteria to secure a service.

When assessing for 'eligible needs', local authorities will take into consideration the following framework to evaluate how serious the risk is to an individual's independence and other potential consequences. There are four levels on which the Department of Health made the following recommendations for guidance.

Critical, in other words, when:
- life is, or will be, threatened; and/or
- significant health problems have developed or will develop; and/or
- there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or
- serious abuse or neglect has occurred or will occur; and/or
- there is, or will be, an inability to carry out vital personal care or domestic routines; and/or
- vital involvement in work, education or learning cannot or will not be sustained; and/or
- vital social support systems and relationships cannot or will not be sustained; and/or
- vital family and other social roles and responsibilities cannot or will not be undertaken

Substantial, in other words, when:
- there is, or will be, only partial choice and control over the immediate environment; and/or
- abuse or neglect has occurred or will occur; and/or
- there is, or will be, an inability to carry out the majority of personal care or domestic routines; and/or
- involvement in many aspects of work, education or learning cannot, or will not, be sustained; and/or
- the majority of social support systems and relationships cannot, or will not, be sustained; and/or     - the majority of family and other social roles and responsibilities cannot, or will not, be undertaken

Moderate, in other words, when:
- there is, or will be, an inability to carry out several personal care or domestic routines; and/or
- involvement in several aspects of work, education or learning cannot, or will not, be sustained; and/or
- several social support systems and relationships cannot, or will not, be sustained; and/or
- several family and other social roles and responsibilities cannot, or will not, be undertaken

Low, in other words, when:
- there is, or will be, an inability to carry out one or two personal care or domestic routines; and/or
- involvement in one or two aspects of work, education or learning cannot, or will not, be sustained; and/or
- one or two social support systems and relationships cannot, or will not, be sustained; and/or
- one or two family and other social roles and responsibilities cannot, or will not, be undertaken.

In responding to an individual's account of their presenting needs, the assessment should explore relative intensity, such as the presence and level of physical pain or distress, or disruption associated with the presented need. There should be consideration of how a need impacts both on a day to day basis and in the long term, and whether it combines with other factors to exacerbate an overall situation.

Assessment can include information from other local agencies that may be in contact with the individual.

Care Plan

If an individual is eligible for help, then the local authority should develop a Care Plan. This should be written down and a copy given to the individual. Guidance suggests that the following components should be included in the Care Plan: 
- A note of the eligible needs and associated risks
- The preferred outcomes of service provision
- Contingency plans to manage emergency changes
- Details of services to be provided and any charges the individual is assessed to pay, or whether direct payments have been agreed
- Contributions which carers and others are willing and able to make
- A review date

Review

It is a requirement of good practice that there should be regular reviews of individual Care Plans. An initial review should take place within three months of a service being provided. Thereafter, reviews should be undertaken at least annually or more frequently if the circumstances of the case warrant it.
In a review, the following should be assessed: 
- Establish how far the services provided have achieved the outcomes, set out in the Care Plan
- Re-assess the needs and circumstances of individual service users
- Help determine the individual's continued eligibility for support
- Confirm or amend the current Care Plan, or lead to closure
- Comment on the effectiveness of direct payments, where appropriate

Reviews will be led by a professional who is competent in assessment, who knows the Eligibility Criteria and can include, in addition to the subject of the Care Plan, other service providers, agencies and the representatives or advocate of the person. Following the review, a new or revised Care Plan will be formulated or stopped if it is no longer needed or inappropriate to the eligibility needs of the individual.

Resources

Local authorities are required to provide or commission services to meet eligible need, but this is subject to their resources. Most authorities prioritise the needs assessed in the eligibility framework of criteria (see previously) and provide a service to those considered as 'Critical' or 'Substantial'. Eligible needs considered as 'Moderate' may get addressed, whilst in reality those considered 'Low' are unlikely to trigger any service.