Source: http://www.gov.scot/Publications/2009/12/18144507/1
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Evaluation of the Adults with Incapacity (Scotland) Act 2000 Part 4 - Research Finding
Health and Community Care Research Findings No.93/
The Adults with Incapacity (Scotland) Act 2000 ( AWI) protects the welfare of adults in Scotland who are unable to take decisions for themselves. Part 4 of AWI enables managers of authorised establishments such as care homes and hospitals to manage the finances of residents who are incapable of managing them themselves. This study examined users' experience of Part 4 and explored its effectiveness, uptake and benefits for residents.
There was very low level of uptake of AWI Part 4 across all sectors of health and social care. This was much lower than was anticipated when the legislation was drafted.
The majority of people living in care homes and hospitals who were not capable of managing their own finances had their funds managed through a DWP Appointeeship. People appointed by the DWP to look after a person's funds can only use income from benefits to pay for expenses such as personal items. They cannot deal with capital or other income belonging to the person.
The underlying principles of the AWI were welcomed by the majority of those managing the finances of adults with incapacity. It was felt that AWI Part 4 had clarified the position with regard to handling the finances of people who have incapacity. Those health board respondents and care home managers who used it felt that it also provided them the opportunity to take action to improve residents' quality of life.
Some misgivings were expressed about the responsibilities AWI Part 4 placed on individual officers and managers. Many of those working for the supervisory bodies were unsure about their suitability for this role. They felt that they were working outside of their area of expertise and were being granted too much autonomy, were not sufficiently regulated and were uncomfortable in their roles.
Managing monies accrued from benefits was the area where most concern was raised in the health and social care sectors. Different organisations have interpreted the legislation differently. This has caused problems for transfer of patients across sectors and localities and there was some evidence that this delayed discharge of patients from hospital. In addition, some hospitals were managing patients' funds for long periods post discharge.
This research suggests three major problems in the implementation of AWI Part 4:
the legislation is complex,
applying to manage a resident's finances was considered burdensome,
there was confusion around how accrual of benefits should be handled.
It is recommended that the application procedure be re-examined and simplified and that new and/or additional guidance be provided to the management of accrued benefits and what money can be spent on.
The Adults with Incapacity (Scotland) Act 2000 ( AWI) protects the welfare of adults who are unable to take decisions for themselves. Part 4 of AWI enables managers of authorised establishments to manage the finances of residents who are incapable of managing them themselves.
Three supervisory bodies are responsible for authorising and supervising establishments to manage residents' finances: NHS Boards, the State Hospital Board and the Care Commission ( CC). NHS Scotland hospitals and the State Hospital require a Note of Authority from their NHS Board before they can manage under AWI Part 4. Establishments required to register with the CC, are authorised by virtue of their registration.
A certificate of authority must be applied for from the supervisory body to allow a manager to manage an individual's funds.
Assess the effectiveness of AWI Part 4 including: the uptake; benefits to residents; and key stakeholders' experiences of using Part 4.
Make recommendations on any action needed.
The project used both quantitative and qualitative research methods, involving questionnaires, face-to-face and telephone interviews. There were three main stages to the research:
A survey of supervisory bodies,
Case studies involving care homes in 4 health board areas: Tayside, Dumfries and Galloway, Glasgow and Highland,
Interviews with groups representing the interests/views
of those whose finances might be managed under AWI Part 4.
Questionnaires were sent to each of the supervisory bodies including the 14 health boards, the State Hospital and the CC. The questionnaire collected data on the number of people currently having their finances managed under AWI Part 4 and the associated policies and procedures.
Follow up interviews were conducted with 13 Health Board representatives.
The second stage case studies, involved interviewing 11 care home managers from care homes serving a range of clients and spanning the private and charitable sectors.
The third stage involved interviewing 9 representatives of organisations of and for disabled people and older people including representatives from, Capability, Enable, Alzheimer Scotland, the Highland User's Group, the Mental Welfare Commission and the Office of the Public Guardian.
All interviewees were asked about their experiences and views of AWI Part 4.
Uptake of AWI Part 4
Use of AWI Part 4 was much lower than anticipated when the legislation was drafted. The CC reported that there were 30 establishments in Scotland with residents whose finances were managed under AWI Part 4. These figures must be treated with caution as the CC recording practices at the time of research made the provision of this data difficult.
The number of patients with their finances managed under Part 4 ranged from over 50 patients in two boards to zero in others. Overall, a total of 165 patients had their finances managed under this scheme in 2008-2009. This figure must be treated with caution as the data is incomplete.
The low uptake and the difference between health boards may be partially explained by:
Changing provision of care throughout the 1990s means that hospitals are no longer providing long-term care for large numbers of individuals.
Differences in the social and physical environment in which the various health boards operate may result in individuals having differing access to wider family and community ties, enabling them to use mechanisms such as power of attorney, rather than AWI Part 4, to manage finances.
A number of health boards considered monies accrued from DWP benefits as falling within the remit of DWP Appointeeship so used this mechanism to manage patients' funds, others viewed the accrual of such funds as requiring the use of AWI Part 4.
This last point highlights a key issue uncovered in this research; the accrual of benefits and the different interpretations of how these monies should be treated. This has caused confusion, especially where these two differing views intersect for example, in the transfer of patients from hospital to care home. Evidence from some respondents in this study suggested that this delayed discharge of some patients from hospital. Also some hospitals were being compelled to manage patients' funds for long periods post discharge.
Views on AWI Part 4
Where used AWI has clarified the position for many health boards and care home managers regarding the handling of finances of patients'/residents' with incapacity. AWI Part 4 allowed people to act for individuals and improve their quality of life.
However, all respondents felt that the policies and procedures around AWI Part 4 were too complex, ambiguous and too demanding, both in terms of time and resources. Respondents reported that they found it difficult to interpret and to enact. The length of time it took to process an application to manage a patient's funds under Part 4 meant that it was of little value to short stay patients. Concern was also expressed by care home managers about their ability to claim for the time spent managing patients' finances from patients' funds. The research uncovered some evidence to suggest that low uptake and use of AWI Part 4 was related to the complexity of the legislation.
It was considered that AWI Part 4 was 'written for another time and place', and was based on a social care system that no longer operates. Much of the terminology was not considered to fit with the current health and social care sector. It was felt that the 'one size fits all' arrangement of the AWI part 4 did not allow for enough flexibility in managing residents' finances.
Some health boards expressed concern about their suitability to act as both a supervisory body and to oversee the practices of their own employees with regard to AWI Part 4. There were also some concerns about the CC acting as a supervisory body for example, there was a suggestion that this role would be better suited to the Office of the Public Guardian. Some care managers felt the CC's expertise lay in regulating care not finances.
The majority of health boards had developed policies, procedures and monitoring mechanisms in relation to AWI Part 4. Patient Fund Systems were utilised to manage patients' funds and a range of auditing tools were used to ensure the appropriate use of funds. Decisions around the spending of monies involved the multi-disciplinary review team which included the patient, family, social worker, consultant, staff nurse and key care workers as well as the patient fund officer.
Those care homes which were part of a larger organisation also had clear policies and procedures in place to manage AWI Part 4. Smaller care homes were less likely to have such policies in place.
The level of responsibility expected of care home managers by AWI Part 4 was of great concern to managers. Some felt that they did not have the expertise to manage the finances of clients.
Banking was one of the major issues raised by both health boards and care homes in managing residents' finances. Banks were deemed to have varying levels of awareness of the legislation and as a result difficulties could be experienced in establishing and managing bank accounts for residents.
There was also concern about what spending was acceptable or justifiable. Many managers felt that they did not have sufficient guidance on what they could spend their client's money on.
The Effectiveness of AWI Part 4
The fact that Part 4 was being used so rarely has made it difficult to evaluate and assess its effectiveness and the extent to which it has benefited adults in care and improved their quality of life. The low uptake means it is difficult to make recommendations about whether or not the legislation needs to be reformed.
Notwithstanding these concerns evidence from this research would suggest that AWI Part 4 has had some impact in some health boards on the processes for dealing with residents' finances, but as far as could be assessed, there was minimal impact in the care home setting.
There is also some evidence to suggest that, where used, AWI Part 4 has the potential to improve the quality of life of those whose funds are managed under it. By using powers under AWI Part 4 to purchase a range of goods and services some health staff and care home managers were able to enhance residents/patients' life experience.
In light of the findings set out in this report, this concluding section outlines a series of recommendations from the study.
Provision of additional advice on the management of accrued benefits should be considered. The DWP and Scottish Government should consider the need for clearer advice on how monies accrued from DWP benefits should be handled.
The application procedure should be re-examined. The current application procedure is, far too complex and time consuming. The introduction of a fast track procedure should also be explored so that, in an emergency, action can be taken.
A light touch element should be introduced to managing finances. Currently many managers are put off AWI Part 4 because of its bureaucracy and 'one size fits all approach'. Every penny spent under AWI Part 4 has to be accounted for. Some form of risk assessment needs to be included. A sliding scale of accountability should be considered relating to the level of spending.
New guidance should be provided on what money can be spent on. This guidance should make it clear that managers of care homes can claim back some costs associated with implementing the legislation and with managing a client's finances. Information about other services that AWI Part 4 monies can be used for, such as befriending schemes, should also be made clear.
The suitability of health boards and the Care Commission to act as supervisory bodies should be examined. An external body such as the Office of the Public Guardian may be better suited to this role.
Supervisory Bodies should be reminded of their roles in terms of record keeping. The health boards and the Care Commission have a clear duty to keep and maintain up-to-date records of the certificates of authority they have issued. A simple annual return to be completed and submitted to the Scottish Government Health Directorate would ensure that such data were routinely collected and recorded and would enable more effective monitoring.
More publicity and better information on AWI Part 4 should be provided. There is clearly a need for better publicity in this area, both in the care sector and beyond. Banks should be a main target of any publicity campaign.