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HOW DOES THE COMMUNITY CARE? PUBLIC ATTITUDES TO COMMUNITY CARE IN SCOTLAND

CHAPTER FOUR: WHO SHOULD PAY FOR CARE

The survey reported here predates the introduction of free personal and nursing care for older people in Scotland and was conducted during a period when this policy was the focus of high profile debate. Comparison between the findings of other public attitudes surveys and the Scottish Social Attitudes Survey is discussed in this chapter.

The question of responsibility for meeting the costs of providing care or support taps two fundamental issues. Firstly it seeks a decision as to whether an individual respondent supports a model of individual or state responsibility for the provision of support. Secondly it impinges on the debate as to the validity of distinctions between health and social care and the extent to which there should be equity of response to different conditions.

The question posed in respect of each of the vignettes was:

'Suppose that someone outside the family has to provide care for John/Susan etc. Which of these statements comes closest to what you believe about who should pay for this? Bear in mind that under no circumstances would John have to sell the house that he lives in.'

The options from which the respondent could choose were:

• the government should pay, no matter how much money he/she has
• the person should pay, no matter how much money he/she has
• who pays should depend on how much money the person has.

For all four vignettes the majority of respondents considered that the government should pay (Table 4.1), just under two thirds for the two vignettes involving older people and that of the individual with a learning disability and 72% for the 50 year old with a mental illness. The alternative response was to suggest that responsibility should depend on income (26% to 35%), with only small numbers (maximum less than 4%) considering that the responsibility should wholly be that of the individual. The particularly high responsibility placed on the government for the individual with mental illness may suggest that it is the area most clearly perceived as a health responsibility, or, alternatively, where the risk if support is not provided may be perceived as high. It is interesting to note that in all cases where the vignette was presented in respect of a female, support for state responsibility was between 1.2% (Susan) and 2.6% (Sarah) higher.

Table 4.1 Who should pay for care?

Comparison with other surveys

Questions about attitudes to paying for care have been posed in a range of surveys in recent years. Much of the work has been associated with the debate focussed on payment for long-term care for older people, both before and subsequent to With Respect to Old Age, the Report of the Royal Commission on Long Term Care (1999a) established to address this core issue. Of particular value in the Scottish Social Attitudes survey is the opportunity for comparison with the responses to the two vignettes involving younger people. A comparison of findings is summarised in Table 4.2 below.

National Survey on Care for Elderly People

As part of the ESRC Research Programme on Economic Beliefs and Behaviour, Parker and Clarke (1997a; 1997b; 1998) investigated both attitudes and behaviour in respect of paying for care in the context of financial planning. To assist their investigation they conducted a two-stage survey in collaboration with Social and Community Planning Research. This comprised structured interviews across England and Wales with a representative sample of 957 individuals aged 25-70 in the autumn of 1995, followed by more detailed exploration with 102 of these individuals the following summer (Erens and Turner, 1997; Royal Commission on Long Term Care, 1999b). Attitudes to the responsibility for payment for care were explored in some detail, distinguishing, for example, personal care from domestic care and the extent to which the ability to pay of those requiring support influenced the response. The impact of potential tax rises was explored, as were attitudes towards the purchase of insurance policies for long-term care costs. Responses to specific situations were also sought, highlighting both where individuals thought older people in particular circumstances should live and where the responsibility for payment should lie. The more detailed follow-up sought to compare actual behaviour with the previously expressed attitudes.

Overall 'there was a broad consensus that the state should retain responsibility, either for all older people or for those that could not afford to pay for themselves' (Parker and Clarke, 1997b:122). Specifically, 24% believed the 'state should pay, whatever elderly people's income', 48% believed the 'state should pay for basic services, people who can afford it pay for better', 24% believed the 'state should pay only for those who can't afford, everyone else pay for self', and 2% believed 'everyone should make their own arrangements' (1% other, 1% dk). Support for state involvement rose as the level of help required increased. Responses did not vary by gender or age group, although in more detailed scrutiny of particular areas of support needs, the youngest age group (25-39) most consistently supported state responsibility, while the responses for older groups varied according to the nature of support activity.

Comparison across different surveys which have employed somewhat different wording can be problematic. It is important to note that this National Survey offered both the option of state responsibility and of state responsibility plus 'top up'. Later in the survey individuals were asked to respond to various attitude statements; to the statement 'the state should be responsible for providing care for elderly people', 89% indicated that they agreed 'strongly' or 'somewhat'. At the same time, however, 51% 'strongly' or 'somewhat' agreed with the statement that 'people should be expected to pay some of the costs of their own care in old age instead of relying on the state'.

King's Fund

Six years later, the King's Fund commissioned from NOP an interview survey of 1000 people across England in February 2001 (Deeming, 2001), six months after the Government response to the Royal Commission on Long Term Care had accepted (for England) the recommendation of free nursing care but not that for free personal care. The Health and Social Care Bill (for England) was at that date going through the Westminster Parliament. In addition to seeking views on preferred models of funding, those polled were specifically asked to respond to the argument that targeting of resources on those with lower incomes was preferable to spreading resources more thinly.

The following options for financing health and social care services were presented :

• health and social care services should be provided free of charge to people who need them
• people should always pay for health and social care themselves
• the Government should only pay for health and social care for those who can't afford it; everyone else should pay for all of their health and social care themselves
• the Government should pay for basic services for everyone; people who want more than the basic level should be expected to pay from their own incomes for services that are either better in quality or greater amounts of service (sic).

Some form of state responsibility was preferred by virtually all respondents (99%). The majority (61%) opted for comprehensive state funding, with a further 26% supporting the 'top-up' model. A system of means-testing was selected by 12%. Support for comprehensive state funding was significantly higher in the north of England (68%) compared to the south (57%) and, perhaps contrary to some perceptions, amongst younger people.

'It is widely believed that the expectations of this group differ from those of older generations, who are more likely to be wedded to the principles of the welfare state, but our research found no evidence to support this. If anything, younger people seem to expect more from the state.' (Deeming, 2001:21)

Variations between different care settings and by different levels of income were also explored, with stronger support for universal free personal care amongst higher income groups. This could suggest a principled objection to charges, irrespective of ability to pay, or it may reflect a view that higher earners think they are already paying through taxation.

The specific exploration of equity was phrased in the following way.

' The Government believes that people in a nursing home who can afford to pay from their own incomes for help with washing, eating or going to the toilet should pay for these services so that the Government can target more resources at the less well off. Do you agree with this?'

The survey offered little support for the targeting argument. Support for state-financed personal care in nursing homes was at 60%; it remained at this level even when the rationale for targeting was presented. In respect of domiciliary settings, presenting the argument for charging reduced the support for universal free personal care from 58% to 53%, but still left a minority (47%) endorsing the Government's chosen route. Further detail in this survey explored the levels of financial contribution that individuals were prepared to make. Again, however, in both nursing homes and domiciliary settings the majority were arguing that individuals should not be required to contribute. Strong support for fiscal redistribution through the route of health and social care provision was not forthcoming.

Deeming (2001) highlights the more definitive support for unqualified state responsibility in this survey compared to the National Survey on Care for Elderly People (Parker and Clarke, 1998) detailed above, an increase from 24% to 61%. By contrast, the 'top up' option was selected by 48% of respondents in 1995 but only 26% in 2001. It should be noted, however, that whilst Parker and Clarke referred specifically to the financing of care in old age, the wording of the King's Fund survey avoided specific reference to older people, referring more generically to health and social care.

Care Development Group Research

Most recently, and specific to Scotland, work on public attitudes was conducted as part of the public engagement programme of the Care Development Group which was established to examine the detail of implementing free personal care (Machin and McShane, 2001; Care Development Group, 2001). Three specific studies were commissioned, a telephone survey, conducted by System Three and Mori, and two targeted focus group studies.

In the telephone survey, a total of 2354 interviews were conducted with a sample of individuals already contacted through the Scottish Household Survey - but with a sample stratified to select only those aged 50 plus or those with recent experience of providing unpaid care for someone. In this instance the question most relevant to the current study focused on who should pay for personal care; further questions explored definitions of personal care and the elements that respondents considered should be provided free of charge, the attitudes of respondents to the option of cash payments and how they might be used, and, for those involved in the provision of unpaid care, the potential impact of payment for that provision or, alternatively, the impact of enhanced provision of support services free of charge on their own care provision.

In summary, 75% believed that the state should pay for personal care, 5% the individual, and 20% considered that it depended on the circumstances. Those in the under 50 carers group were more likely than those in the over 50 more general group to believe that the state should pay for personal care.

It is perhaps important to note that in the Care Development Group survey there was further routing once the initial response had been received. Those responding that the 'state should pay' were then asked 'should the state pay for this type of help for ALL frail, older people, whatever their income, investments and savings, or should it only pay for those who can't afford to pay for themselves'. Likewise, those whose response to the initial question was that 'people should pay themselves' were asked as a follow-up 'do you think the state should pay for this type of help for frail, older people who can't afford to pay for themselves', while those whose response was that it 'depends' were asked for clarification - 'why do you say that / what does it depend on'.

Responses are then distributed with 34% saying the 'state should pay for everyone', 42% the 'state should only pay for those who can't afford it', 4% 'it depends' and 1% the 'state should not pay for anyone', plus the original 20% who responded that 'it depends'.

The attitudes of those interviewed in the telephone survey were supplemented by a range of focus groups designed to access the perspectives of key individuals who might not otherwise have been represented (Jones, Ridley and Robson, 2001; Dewar, O'May and Walker, 2001). Six focus groups were conducted with individuals in a range of care settings (residential and nursing homes and day care and day hospital) and six with a range of older and younger people and unpaid carers. The two groups with younger people (35-50) were drawn, as with the telephone survey, from earlier respondents to the 2000 Scottish Household Survey.

Discussion in the community-based focus groups confirmed the support for universal rather than selective provision, particularly of the services that might be considered as 'personal care'.

"There was both an expectation of provision by public services of the care necessary to maintain decent minimum quality of life when this is threatened by frailty, and a belief that public services are the 'right' and best way to provide such care." (Jones, Ridley and Robson, 2001:69)

Many of the familiar arguments were rehearsed: the perceived injustice of having to realise assets, particularly the house, for which people had worked and saved all their lives; the associated disruption to finances reserved for family members; the expectation of support where necessary from 'cradle to grave'; the preference for taxation based funding. Such views were common to both younger and older discussants. There was less consensus, however, on the specific activities to be embraced within any definition of 'personal care'.

The responses from the focus groups in care homes and day care were less definitive in respect of universality of provision, perhaps for those in care homes because they were already tied in to existing funding arrangements; the priority was to ensure that the range of an individual's needs were adequately met.

Table 4.2 Comparison across surveys of 'who should pay for care for older people⁵

Note: the results from the Scottish Social Attitudes Survey refer to two separate scenarios involving older people - see Table 4.1.

RESPONSE VARIATION

The extent to which the responses to the present survey varied according to the different situations of the respondents can be detailed.

Income

Those in lower income groups were more likely to consider that responsibility lay with government - 72% in the case of the frail 90 year old and 75% for the individual with a mental illness. The higher levels of support for state responsibility found amongst higher income groups in the King's Fund survey were not replicated.

Table 4.3 Government should pay by income quartile

Social class

In respect of the 90 year old, the reliance on the state ranged from 75% amongst the 'working class' to 58% amongst the salaried professional. Interestingly a higher percentage of respondents across all social classes felt that the government should pay for care of the frail 90 year old as compared with the forgetful 87 year old. Again consistently higher levels of support for state responsibility were evident for Stuart / Pat with the mental illness across the social class groupings.

Table 4.4 Government should pay by social class

Party identification

State responsibility was cited most frequently by those aligning themselves with the SNP (74% for the individual with a mental illness and 70% for the 90 year old), and Labour supporters (73% and 68%). Even amongst Conservative supporters the majority group cited state responsibility (50% for the two older individuals and 59% for the individual with a mental illness). The policy of free personal care was, of course, the focus of the challenge to the Labour / Liberal Democrat alliance within the Scottish Parliament on 25 January 2001. Officially the policy now commands cross-party support.

Table 4.5 Government should pay by political party

Age

With age an interesting pattern of opinion emerges. For all but the individual with a learning disability, there is strongest support for the state being responsible for paying for care amongst the youngest (under 35) and the oldest (55+), although the variation is small. In respect of Alice / David, however, the difference with age is more marked, rising from 58% citing a preference for state responsibility amongst those aged under 35 to 69% of those aged 55 and over.

Table 4.6 Government should pay by age

Although not a directly comparable sample, in the telephone survey for the Care Development Group, those aged under 50 were more likely to support state payment - but these were all carers. In the over 50 group, the view that the state should pay decreased from 78% amongst those aged 50-59 to 67% of those aged 75 and over.

Gender

Consistently across the four vignettes a higher percentage of male respondents favour the government option for payment. These gender differences do not, however, reach the level of statistical significance.

Table 4.7 Government should pay by gender

Personal experience of care-giving or receipt

Having provided unpaid care increased the preference for state responsibility by approximately 5 per cent for the two vignettes involving older people and 3 per cent for those involving younger people. Likewise, either the respondent or someone close to them having received care over the last ten years or likely to need care within the next five years generally increased the level of responsibility laid on the state. This was most marked, however, when the respondent themselves had been the recipient of the care or perceived that they might need it in future (for example for Alice / David with a learning disability state responsibility was supported by 74% of those who had received care compared with 62% of those where the care had been for someone else).

Table 4.8 Government should pay by experience of care-giving

Table 4.9 Government should pay by experience of care receipt in last 10 years

Table 4.10 Government should pay by likely need for care in next 5 years

In the telephone survey for the Care Development Group, respondents who provided care or identified a likely future need for care were more likely to support state responsibility for funding. Again, however, the variations were not great: 79% of those providing care compared to 74% of those not providing care, and 77% of those predicting future care for themselves or someone close within the next five years, compared to 72% not predicting this need. It should be noted that in the telephone survey the reference was specifically to a need for 'personal care'.

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