Fair Access and Threshold of Care Proposal
Argyll and Bute Council · 17 September 2025
Back to Argyll and Bute HSCP Integration Joint Board (IJB) — 17 September 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 Integration Joint Board Date of Meeting: 17 September 2025 Title of Report: Fair Access and Threshold of Care Proposal Presented by: James Gow, Head of Finance and Charlotte Craig, Interim Head of Strategic Planning, Performance and Technology The Board is asked to: ▪ Consider the report and the recommendation to the Integration Joint Board. ▪ Approve the policy proposal based on the threshold being reviewed annually noting a requirement for the IJB to support an option ▪ Note the risk in year if an option is not supported ▪ Note the potential for increased risk to care delivery/unpaid carers for those with highest need that requires to be monitored ▪ Note the supplementary actions generated by the consultation 1. EXECUTIVE SUMMARY Between 24 July and 31 August, Argyll and Bute Health and Social Care Partnership conducted a public consultation on proposed changes to the delivery of Care at Home services. The consultation aimed to gather views from communities, staff, providers, and carers in response to increasing demand, workforce challenges, and financial constraints in rural care delivery. The consultation sought feedback on a proposed policy introducing a threshold for Care at Home hours, intended to support fair access and sustainable service delivery—not as a cap, but as a trigger to assess the sustainability and cost effectiveness of care delivery. Responses were received through both in-person sessions and an online survey. In-person feedback was generally more balanced, while online responses expressed stronger agreement or disagreement, particularly around the risk of residential or out of area care and flexibility of care provision. The consultation elicited a response of the wide nature of care delivered in communities which we have valued. We have listened and taken on board this contribution. The consultation provided valuable insights that will inform the final policy proposal. While there is recognition of the need for change, stakeholders emphasised the importance of flexibility, fairness, and maintaining local, person-centred care.
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2 2. RECOMMENDATIONS The Board is asked to make a decision based on the information provided. Officers have provided options in respect of the financial modelling of hours and the current need in September 2025. Based on the increased need, outline impact and availability of residential care for both respite and longer term care we would recommend the 28 hour option. However we would seek for the threshold to be reviewed annually considering the wider care environment to ensure that we continue to deliver person centred care within available resources and manage ongoing need and risk. 3. DETAIL OF REPORT We undertook a consultation from 24 July until the 31 August (31 July to 31 August in public) utilising both in person and the online engagement hub. All consultation assets are available online including in person dates, surveys and supporting documentation. https://nhsh.uk.engagementhq.com/argyll-and-bute-hscp-threshold-of-care- policy-consultation Why we consulted Several Local Authorities across Scotland are addressing how they deliver social care either operationally or through policy as we see need rise. As a key resource in ensuring our whole system of rural services are available we wanted to speak with communities, staff, providers, carers and their representatives. Rurally we have some specific challenges: • Increasing demand for services as people live longer and with more complex needs • Workforce shortages and in some areas we have full employment • Cost of social care delivery • Not spending beyond available budget We consulted as a change in how we deliver care would be a change of policy, providing some additional parameters as to how staff would work and how they would get assessed care over the threshold approved. We wanted to gather the views of all the people who may be affected by this to inform our final assessment and policy proposal. In taking action to support how we deliver services within resource we are also making other changes in how we manage our services. This includes increased efficiency and oversight of activity, the care at home redesign, developing a longer term workforce plan and care home strategic planning.
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3 What the consultation told us A detailed report is provided at appendix 1. We engaged with a range of stakeholders and had a range of responses both in person and online. In person responses were well articulated by the facilitator and are in the appendices of the main report. They were more moderate in response possibly given the opportunity to discuss the proposal. One event was an outlier in terms of high-expressed emotion in opposition to the proposal. Online responses tended to be more skewed in respect of whether they agreed or disagreed with the proposal. Online response focussed on the residential element which may be reflective of the lack of discussion. In respect of what we have set out to do we had a reasonable response from our community and stakeholders to provide an informed recommendation. The consultation highlighted themes that we have considered and some actionable points that are outwith the scope of the consultation but will be useful in working with our communities on an ongoing basis. Our findings The in person response elicited the following key themes from communities: Characteristics of Good Care at Home • Flexible and responsive care, not task driven. • Delivered by well-trained, well-paid staff who build relationships and communicate effectively. • Continuity of care is valued. • Reablement as a starting point to maximise independence. • Better information and access to Self-Directed Support options. Holistic and Community-Based Approaches • Care should include local and community solutions. • Holistic assessments that consider informal and community support. • Multi-disciplinary planning involving GPs and access to shared health records. Person-Centred and Preventative Care • Emphasis on early intervention, recovery support, and prevention of long-term dependency. • Care should be person-centred, with technology supporting—not replacing—the workforce. • Support for carers, both practical and informational. Impacts of Introducing a Care at Home Threshold Positive Impacts • Clear policy may reduce postcode lottery and improve fairness. • More people may gain access to care.
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4 • Opportunity for review when threshold is met. • Opens dialogue about high-level care needs and alternatives. • Recognition that residential care can be appropriate in some cases. Neutral Considerations • Day services may become more critical and could be expanded. • Need to compare costs and benefits of different care models. Negative Impacts • Wellbeing risks: deterioration in physical/mental health, loss of independence, anxiety. • Unpaid carers: increased burden, burnout, financial insecurity, impact on younger carers. • Island and rural communities: displacement, reduced visits, cultural disconnection, infrastructure gaps. • Financial and service pressures: unclear funding responsibilities, travel costs, strain on review systems. • Workforce impacts: job losses, increased pressure, risk of professionals leaving sector. Impacts of Not Introducing the Threshold • Increased service demand and pressure on inpatient beds. • Greater reliance on unpaid carers without formal review. • Risk of workforce attrition due to high workload and lack of support. • Task-led care may lack emotional and social support. • No driver for integrated teams and alternative service models. • Underutilisation of Technology Enabled Care and day services. • communication and access for families Further Considerations • Need for better infrastructure, innovation, and compassionate care models. • Consistent quality across providers. • Travel and funding challenges if care is relocated. • Clarity needed on contingency plans for those exceeding 25-hour threshold. • Desire for fair access regardless of geography or financial status. • Address digital literacy barriers. • Ensure local alternatives are in place before implementing thresholds.
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5 Online response The online response offered an opportunity for written narrative. Participants often took the opportunity to share their experience, some formal submissions from providers and staff. Themes were similar however there was more emphasis on the risk of out of area or off island residential care and the impact this could have on individuals and families. The impact on unpaid carers and those receiving care without family connections was articulated noting the increased emotional strain. The disproportionate impact on older adults was questioned and those living longer with complex care needs and potential for reduced quality of life. Workforce was a key factor in both responses, people wanted to see a well- treated, reliable, well trained and well paid workforce that could offer continuity of care to their loved ones and professionals wanted to ensure they maintained trusting relationships with families and people requiring care. A number of respondents expressed disappointment around the reliance on high-cost agency staff in some sectors or locations. Some respondents interpreted the threshold as a hard cap, rather than a trigger for review of planned care. This led to concerns about inflexibility and inability to meet personal outcomes. Some people expressed doubt as to whether it would increase the value of the allocation of the resource available i.e. fair access to service or generate any financial benefit. However there was recognition that people with moderate needs should have access to care alongside those with the greatest assessed need. Finally as with the in person response the requirement for innovation and integrated care models was highlighted including the use of digital technology. We have addressed our professional response both within the main body of the report and in our professional advisory. We have welcomed the rigour of professional challenge within the organisation which is wholly appropriate in ensuring we fully explore the parameter and principles of care delivery in our challenging financial environment, as well as testing policy against a complex legal landscape. Transparency in our challenge supports our culture in ensuring that all staff have a role in influencing policy. Financial Modelling and Options The initial suggested threshold was 25 hours per week. This number of hours was chosen because: • In most (but not all) cases the cost of a care package above this level will be more expensive than alternative provision in a residential facility, modelled against the national care home rate. • It ensures that significant resources are still available to support individuals in their own home and means that there a consistent and fair approach which is not dependent upon how much an hour of care costs in each area.
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6 • Decisions and options regarding care are not impacted by individual financial circumstances or by the cost of an hour of care in the person’s community, this would disadvantage people in Islands, remote communities and towns where we are using agency staff. The first key component is the cost of a care home place. At the national rate this is £46,000. A prudent estimate of the average net cost, after the client contribution, is £36,000 per annum. The second component is the cost of care at home, again a prudent average for the purposes of modelling is £30 per hour, based on an analysis of our ‘cost per hour’ data across commissioned and in-house services. The table below provides indicative financial modelling based upon adjusting the threshold. The figures reported below have been updated to reflect current data and now include Self-Directed Support Clients (not included in the original modelling at the exploratory phase of this policy change). As stated, these figures are based on average costs for the purposes of financial modelling, the actual saving will depend upon the individual circumstances of each person’s care assessment. Number of Hours per week Care @ Home - Threshold Number above threshold @ September 2025 Modelled potential saving £000 25 110 1,870 26 108 1,862 28 77 1,631 30 68 1,548 32 38 1,151 Summary response on the Threshold of Care Proposal The proposal has elicited a wealth of communication and challenge across our stakeholders and communities. This report seeks as far as possible to reflect back the issues, concerns and ideas that stakeholders took the time to raise through this process. The proposed threshold was 25 hours based on the equivalency of a residential care (not nursing) placement. Care assessed at over 25 hours would trigger a review of the assessment with all care over this threshold requiring to be approved by an Adult Head of Service/Chief Social Work Officer. This review would require to include residential care as an option if we were unable to provide you with the care you needed at home sustainably and within our allocated resource. Other options for person-centred and cost effective care should be explored within this review, including a combination of statutory and community supports (as per existing policy around eligibility for social care). Further to our consultation we have provided the IJB with the financial modelling of hours between 25 and 32 hours.
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7 Based on our consultation feedback our recommendation is 28 hours which would remain financially manageable and correspond with maintaining people at home given available respite and residential care capacity. In response to the consultation feedback we will incorporate the following action in our planning: 1. Clarify and Communicate the Proposal Communicate and clearly explain that the threshold is a review point, not a hard cap. 2. Strengthen Community-Based and Flexible Care Models We are investing in reablement services and early intervention to reduce long-term dependency through our whole system process review in 2025-26. This process will begin and require some time to embed. • We have a planned review of day services • We will internally audit care plans to ensure they include non-social care elements (e.g. community groups, informal supports). 3. Address Equity and Island-Specific Needs • Develop localised solutions for island and rural communities through the care at home review. • Review Care Home provision ands local facilities to reduce displacement where possible. • Ensure fair access regardless of geography or financial status. 4. Support and Sustain the Workforce • Pay and conditions for care staff, including agency workers. These are often set rates however we will try through our commissioning review to ensure that we achieve as much consistency as possible across providers. We commit to minimising agency usage as far as possible, only utilising in cases of critical service pressure or regulated staffing levels. • We will support investment in training, career pathways, and retention strategies through workforce planning. • Promote continuity of care by reducing reliance on short-term agency staffing. • Update arrangements for social work governance to ensure consistency of practice and support for professional decision-making within a clear policy context. 5. Support for Unpaid Carers • Improve signposting to services and carers’ rights including financial advice. • Include carers in care planning discussions and strategic decisions.
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8 6. Improve Infrastructure and Digital Access • Address digital literacy barriers to accessing care and support. • Invest in technology-enabled care that supports human care. • Ensure transport and connectivity are considered in care planning, especially for remote areas through better scheduling. 7. Strengthen Integrated and Preventative Care • Expand Hospital at Home and Virtual Ward models. • Improve multi-disciplinary coordination, including GP involvement. • Ensure regular reviews and holistic assessments are built into care pathways. 8. Monitor and Evaluate Impact • Establish a feedback loop to monitor the impact of any threshold policy. • Track outcomes for individuals, carers, and staff. • Use data to adjust policy and ensure it meets evolving needs. 4. RELEVANT DATA AND INDICATORS The final report was informed by internal financial and care review data, online and in person consultation as well as key stakeholder meetings with professionals and providers. As noted we have updated the initial reporting data which informed the proposal provided to the IJB in April and subsequently the public meeting of the IJB in May 2025. This data point is the personal care data return for Scottish Government and will be the baseline for further reporting. 5. CONTRIBUTION TO STRATEGIC PRIORITIES The current relevant strategic priorities are to: • support people to live fulfilling lives in their own homes for as long as possible • support unpaid carers to reduce the impact of their caring role on their own health and wellbeing • reduce the number of avoidable emergency admissions and minimise the time that people are delayed in hospital • Efficiently and effectively manage all resources to deliver best value Our ability to deliver against these strategic priorities in a changing financial environment is substantial. In instituting a robust policy environment that supports our decision making to ensure that resource can be accessed fairly and prioritised according to need is a significant challenge.
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9 Options are provided to the Integration Joint Board, however even within this policy environment there will be risk which will require close monitoring and it is recommended this is remitted to the social work governance group and subsequently the clinical and care governance committee. 6. GOVERNANCE IMPLICATIONS 6.2 Financial Impact The implementation of the policy change will result in a reduction in spend. This arises because care at home over the threshold will typically cost more than a care home placement. The saving cannot be estimated exactly as it there are variables associated with each individual case: Care at home costs per hour vary from £27.66 to £36, they can be significantly higher than this in some cases. The net cost of a residential care placement depends upon individual financial assessments and the level of client contributions. The HSCP is not assuming that implementation of this policy change can deliver cash releasing savings of the magnitude outlined within the financial modelling table in the short term but savings would be made if the policy change is approved alongside fairer resource allocation within the budget allocated. Decisions in respect of the threshold of care must be taken with reference to the HSCP financial risk and budget outlook. 6.3 Staff Governance Facilitated sessions have been undertaken with senior operational staff in assessing roles in both social work and occupational therapy and with care providers. We are aware that across Scotland Local Authorities are making both policy and operational changes to the delivery of social care. This can be exceptionally challenging for the principles and practice of our professionals and our care at homes teams where change in an already challenging environment may feel difficult. Argyll & Bute HSCP opted to consult based on assessing potential impact to the delivery of care within our rural and island environment and in the context of other operational changes. Implementation of any change will require support and clear direction for staff supported by professional guidance. 6.4 Clinical and Care Governance Care at Home is resource bound; however it is also key in supporting the flow of people through the whole system of integrated care. We would anticipate that during a period of change with both policy and operational changes that we require additional oversight and process to support staff, service, manage risk to people who require the service and those caring for them. At this point we anticipate a small number of people who will be impacted by the change in the first instance and this will be supported through review but note that our aging population need will increase and that more people
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10 are living with multiple morbidities and demand is likely to continue to increase and exceed resource. The HSCP maintains its commitment to a person centred approach in line with principles and professional practice. If a threshold is agreed by the Integration Joint Board additional scrutiny on all care over the threshold will be considered by Heads of Adult Service and the Chief Social Work Officer. 7. PROFESSIONAL ADVISORY The HSCP opted to undertake a policy approach to ensure that we can provide both professional staff and the public clear parameters on the ability to provide social care within the resource available. Senior social work staff worked to provide potential exemptions from a threshold of care noting the requirement for safe manual handling, public protection, end of life and where individuals are subject to specific legislation. The Chief Social Work Officer has responded to staff after undertaking due diligence in the precedent of the approach noting that professional judgements cannot be divorced from what can reasonably provided within the resources available. The CSWO has noted the requirement for policy to support professionals noting potential further work in developing a wider scope of eligibility criteria to support consistent assessment. The CSWO also noted that it is essential that professionals do not assess in a silo and that assessments should be scrutinised through a standard process. Advisory is that in exceptional cases beyond an identified threshold then the decision requires to be escalated to a Heads of Adult Services and the Chief Social Work Officer for decision. 8. EQUALITY & DIVERSITY IMPLICATIONS Our data and the consultation responses confirm to us that older adults and unpaid carers will be impacted as they are the primary recipients of social care which are not supported living services for adults. However this is also where we have identified that resource is not accessed amongst this care group equally within the resource available and this does require to be addressed for all older adults. We document this within our integrated impact assessment including our requirement to manage and monitor the risks identified by any change and have outlined for reference the breadth of care delivery at home. Care delivery by care group (summary Week to 31 Aug 2025) People receiving care Hours of care allocated Mental Health Supported Living 44 1104 Physical Disability Supported Living 99 1917 Learning Disability Supported Living 188 7995.95 Older Adults Homecare 910 10742.55 Total 1241 21759.5 9. GENERAL DATA PROTECTION PRINCIPLES COMPLIANCE
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11 In reviewing data the appropriate processes have been followed strictly to ensure compliance with regulation. 10. RISK ASSESSMENT Within the current approach there are no parameters as to how resource is allocated with social care assessed based on identified need that supports an individual to remain within their own home in alignment with current strategic commitment. At present as far as possible resource is prioritised where required to those in most need. There are multiple tangible risks that we are aware of • The impact of unmet need • The lack of affordable workforce • The impact of a lack of short term care which generates a requirement for longer term care, • The lack of available care for high need care packages • The impact on unpaid carers where care needs are not addressed timeously and the requirement for review to ensure developing care needs are addressed as they change • The risk of equity to service for island and remote mainland and care at home models in mainland where there is no workforce or commissioned care. However we would note that these are existing monitored risks. 11. PUBLIC & USER INVOLVEMENT & ENGAGEMENT A consultation was conducted from 24 July to 31 August, with staff consultation ahead of a public consultation from 31 July to 31 August. Staff are the primary point of contact as care managers and were briefed ahead of a public consultation to enable them to support enquiry in a supportive environment. In person sessions were held across Argyll and Bute and an online consultation as reflected in the report. There was a supporting online questionnaire. Sessions were held with senior assessing professionals in Occupational Therapy and Social Work, with Service Managers, Carers representatives and Care Providers. The consultation took both a targeted and broad approach to ensure that there would be a broad spectrum of response. The accompanying report provides and in-depth review of responses. 12. CONCLUSIONS The report provides a broad community and professional response to inform the IJB in respect of a decision. Officers have identified a manageable threshold minimising wider risk within the current managed environment and recommend this should be reviewed on an annual basis. 13. DIRECTIONS
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12 Directions required to Council, NHS Board or both. Directions to: tick No Directions required x Argyll & Bute Council NHS Highland Health Board Argyll & Bute Council and NHS Highland Health Board 14. PREVIOUS REVIEW OF THE REPORT Meeting Title of report Date Output (if relevant) SLT Summary output report 4/09/2025 Reviewed Finance and Policy Committee Fair Access and Threshold of Care Proposal 16/09/2025 tbc REPORT AUTHOR AND CONTACT Author Name Charlotte Craig, James Gow Email charlotte.craig@argyll-bute.gov.uk, james.gow@argyll-bute.gov.uk