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

CHAPTER FIVE: PREFERENCES AND PRIORITIES

In this final section of analysis, preferences between home and care home and priorities for expenditure are explored. Although the majority of these questions were asked in respect of older people, in policy and fiscal terms they are equally important in relation to younger community care groups. In part the challenge is to extend to older people some of the principles of person-centred and independent living which are starting to be manifest in practice for younger people.

THE BALANCE OF CARE

There is extensive research evidence demonstrating that the preference of the majority of older people who require support is to remain within their own home. There is evidence also (for example Curtice et al, 2002) suggesting that individuals in care home settings could with appropriate domiciliary support achieve this preference.

An area of particular relevance to the debate on resource allocation is the extent to which people believe that individuals should be able to remain in their own home and receive support even if this would cost the government more than supporting the individual in a care home. As recent work has demonstrated (Curtice et al, 2002), policy and practice on thresholds to the cost of domiciliary care packages for older people can vary, both within and across different local authorities. Moreover local authority respondents to a policy survey for the same study suggested that the higher cost domiciliary-based care packages are likely to be allocated to younger rather than older people.

Respondents to this survey were asked to:

'Imagine an older person who needs regular help and wants to stay in their own house. The help would be paid for by the government and would cost more than caring for them in a residential or nursing home. Which of these options comes closest to your view?'

Three quarters (76%) thought that 'the person should be cared for in their own house because that is what they want', 12% that 'they should be cared for in a residential or nursing home because that costs government less' and 12% were unable to choose. The responses varied as follows:

• there was little variation by income
• responses by social class ranged from 70% of the petty bourgeoisie to 78% of the working class
• variation by party identification ranged from 81% Labour to 66 % Conservative, but this was primarily explained by the high proportion of Conservative voters (21%) who were unable to make a choice
• support in the community regardless of cost was most strongly endorsed by those aged 35 plus: 80% of those aged 35-54 and 79% of those aged over 55, compared to 67% of those aged under 35
• familiarity with care provision (as informal carer, past or future recipient or close associate) again gave a higher likelihood of opting for home-based care.

The Public Attitudes Survey undertaken for the Care Development Group also sought details of public preferences in respect of the balance of care. Respondents were asked to indicate whether they agreed strongly, agreed slightly, neither agreed nor disagreed, disagreed slightly or disagreed strongly with the statement that 'as long as suitable care can be made available, it is better for frail, older people to stay in their own homes than to move into residential or nursing home'. Overall 86% of respondents were in agreement, 72% agreeing strongly and 14% slightly. Responses remained constant across different groups. At the same time, however, only 38% of respondents went so far as to agree with the suggestion that 'some residential or nursing homes should be closed to pay for free services for frail, older people in their own homes'. Interestingly there was less resistance to this idea amongst older people. The suggestion that 'any frail, older person who can't look after themselves should be offered a free place in a residential or nursing home' received strong agreement from 83% of respondents and slight agreement from a further 10%. It is probably unrealistic, however, to seek a logical consistency across these responses which would demonstrate a trade-off in resourcing between domiciliary support and care homes. It is not unlikely that, in the absence of forced choice, respondents would seek to maximise the resourcing of both sectors.

The focus groups with individuals in the community (Jones, Ridley and Robson, 2001) did however provide further confirmation of the preference for home-based options.

"There was a clear consensus amongst the groups that they themselves and older people, in general, would wish to stay within their own homes as long as possible. They perceived this as being a means to maintaining independence, dignity and continued community contact." (Jones, Ridley and Robson, 2001:77)

Participants in the focus groups that took place in care homes were not asked to discuss their preferred option. Nonetheless:

"few participants talked about the decision they had made to enter residential care in a positive and proactive way. It tended to be as a result of a crisis, or the 'solution' to a 'problem' - as can be seen in phrases used, such as 'give up', 'that settled it', 'pure desperation'. (Dewar, O'May and Walker, 2001:120)

There are, however, detailed responses on this issue from in-depth interviews conducted with care home residents in an earlier study funded by the Scottish Executive (Curtice et al, 2002). Of 63 recent entrants to a residential or nursing home, for only 21% (13) had it been a positive choice.

QUALITY OF CARE

Of major concern, of course, to both current and future service users is the quality of provision. Moreover, with the establishment of the Scottish Commission for the Regulation of Care and the launch of the range of National Care Standards, regulation of quality is set to assume a high profile. A question was asked which sought to explore whether individuals able to afford it should be able to access higher quality care (this has an implicit, not totally founded, assumption of an equation between costs and quality). This question was included in the self completion element of the survey, hopefully thereby avoiding any distortion by individuals wishing to give an 'acceptable' response. The responses to this question are very interesting. Almost three quarters (74%) argued for equity of provision across individuals - ' all elderly people who need it should get the same quality of help'. 'Elderly people who can afford it should be able to pay for better quality help' was selected by only 21% of respondents, while 5% were unable to choose. There was no difference between the highest and lowest income groups, and little variation by age, political party and care experience. Support for all receiving the same quality of service ranged by social class from 64% of petty bourgeoisie to 77% of working class and routine non-manual. This variation however primarily reflects the high proportion of petty bourgeoisie unable to choose (14%).

EXPENDITURE PREFERENCES

A critical component of welfare expenditure is not solely where responsibility lies, but the levels of expenditure that individuals are willing to endorse. This is of particular salience at a time when the possibility of increased expenditure to fund public services, in particular health, is being mooted. Indeed it is interesting to note that a BBC phone-in poll conducted in early 2002 to elicit priorities for the NHS placed the implementation of free personal care (in England) as the clear top priority

(http://news.bbc.co.uk/hi/english/static/in-depth/uk/2002/yournhs/vote-results.stm).

In this survey, asked whether they would like the government to spend more to support older people at home, 81% of respondents answered in the affirmative, 30% looking for the government to 'spend much more' and 51% to 'spend more'. It should be noted that the question included the injunction 'Bear in mind that if you want more spending, this would probably mean that you would have to pay more taxes. If you want less spending, this would probably mean paying less taxes'. Grouped by social class, the highest proportion looking to spend 'much more' (37%) were classified as 'working class', the lowest (24%) as 'salariat'.

A similar pattern was evident in relation to expenditure both on older people in care and on pensions. Seventy seven per cent of respondents were looking for higher expenditure on older people in care, 27% 'much more' and 50% 'more'. Support for 'much more' expenditure ranged from 32% amongst the working class to 23% amongst the salariat. Greater expenditure on pensions was supported by 76% of respondents overall, 26% seeking 'much more' and 50% 'more'. In this instance those wishing 'much more' expenditure were particularly the working class (31%), compared to 22-28 % for the other groups.

Responses were sought in respect of two additional areas, 'health' and 'police and prisons'. Health generated the strongest support for additional expenditure (92%) and police and prisons the least (60%). (Further information on public attitudes to the healthcare of older people can be found in Braunholtz and Stalker, 2002.)

Table 5.1 Priorities for government expenditure

Again, the variations in demand for increased expenditure can be explored in relation to a range of factors. Tables 5.2-5.7 focus on the proportion of respondents looking to the government to spend 'much more'.

Income

In the main, the demand to spend 'much more' rises as income levels decline. On health, for example, the range is from 44% of those in the high income quartile to 58% of those in the low income quartile. The greatest disparities (in terms of the percentage difference between the highest and lowest income groups) are for spending on the elderly at home (26%) and the elderly in care (20%); the lowest (10%) for police and prisons.

Table 5.2 Spend 'much more' by income quartile

Party identification

The percentage variation in those calling for 'much more' expenditure was between 9 and 12% across the five issues. Party identification with Conservative or Liberal Democrat tended to be associated with the more modest calls for additional expenditure, while Labour or SNP identification was associated with the highest calls on each issue.

Table 5.3 Spend 'much more' by party identification

Age

For all issues, the response to spend 'much more' increases with age. Disparities between the oldest and youngest age groups can be quite large, for example 23% for 'elderly at home' and 21% for 'pensions'. In terms of the models of funding for provision for older people, Jarvis (1999) has looked in some detail at how attitudes vary by the age of the respondent, based in particular on the data sets of the British Social Attitudes surveys. She suggests that 'self-interest seems to be an important motivating factor when it comes to naming priorities', (p220) with health, for example, given higher priority by older age groups, education by younger. For the areas highlighted in this survey, for each area more older people were in favour of higher levels of expenditure; it could be argued, however, that all the cited areas, including 'law and order', are those salient to older people.

Table 5.4 Spend 'much more' by age

Experience of care-giving or receipt

Familiarity with care provision, most particularly as a direct recipient in the past ten years, was associated with enhanced demand for greater expenditure. This was most marked in respect of 'pensions', 'elderly at home' and 'elderly in care'. The impact on 'health' and 'police and prisons' was much smaller. The response in terms of the likelihood of needing care within the next five years is interesting and perhaps less obviously explicable: for all issues, the probability of someone close needing care led to lower demands for 'much more' expenditure.

Table 5.5 Spend 'much more' by unpaid care provider

Table 5.6 Spend 'much more' by receipt of care in past ten years

Table 5.7 Spend 'much more' by likely need for care in next five years

A variant on this approach was adopted as part of the telephone survey for the Care Development Group (Machin and McShane, 2001). For each of six areas - old age pensions, winter fuel payments, nursing and residential homes, reductions on travel fares, leisure and recreation facilities for older people, and services to allow people to continue living in their own homes - respondents were asked to indicate whether they thought it should be a high, medium or low priority for any extra government spending.

Services to allow people to remain in their own homes were of the highest priority, rated a high priority for additional expenditure by 85% of respondents and outflanking old age pensions (83%). This indicates yet further endorsement, particularly from older people themselves, for the vigorous pursuit of policies to transform the balance of care. There were some interesting variations in these responses according to age. The under 50 group, those themselves involved in unpaid caring, were less likely (at 79%) than respondents aged over 50 to give high priority to services to enable people to live in their own homes; conversely, additional spending on nursing and residential homes was most strongly supported by those aged 60-69 whilst the lowest level of support was in the 75+ age group. Women accorded both options higher levels of priority than men, but there were no differences of note between those receiving, giving or likely to need care and others.

Respondents to the Scottish Social Attitudes survey were also asked to select priorities for additional government expenditure on older people - 'here are some areas of government spending to do with elderly people who need regular help to look after themselves. Which, if any, would be your highest priority for more spending than now?'. Table 5.8 illustrates that the key priorities were home helps, special housing provision and district nurses.

Table 5.8 Priorities for additional government spending for older people

N = 1605

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