The Scottish Government

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MAIN FINDINGS

• Three quarters of respondents felt comfortable about living next door to a frail older person and more than half about living next door to a person with a learning disability. Less than half, however, felt comfortable about living next door to a person with mental illness or with dementia.
• Respondents were strongly in favour of individuals with support needs living in the community rather than in care homes or hospitals. This view was most common for a person with a learning disability and least common (but still the majority) for a person with dementia.
• Most people interviewed thought that a person with a mental illness or a learning disability should not serve on a jury.
• Support needs, it was felt, should in the main be met by paid workers. The exception was for the person with a learning disability needing to be accompanied to a club where the potential contribution of family members and volunteers was cited.
• A substantial majority considered the funding of support to be the responsibility of the government. Respondents with personal experience of care were even more likely than others to take this view.
• There was strong support for individuals remaining within their own homes when this was their wish, even when this was a more expensive option.
• Only a fifth of respondents thought that those able to pay should be able to access better quality provision, suggesting strong support for equity.
• Respondents expressed a willingness to pay higher taxes to generate funds for increased expenditure on health, support for older people and pensions.
• The top priorities for additional government spending on older people were home helps, special housing provision, and district nurses.

Introduction

A module of 40 questions on community care was included as part of the 2001 Scottish Social Attitudes Survey. The questions focused on:

• where individuals with a range of disabilities should live and the ways in which support should be provided;
• how comfortable respondents would be living next to individuals with a range of disabilities and needs;
• how support should be funded;
• the preferred balance of care for older people between care at home and care home;
• priorities for government expenditure.

The survey 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.

Since this survey was commissioned, the Scottish Executive has launched a National Programme for Improving the Health and Well-Being of the Scottish Population. A high profile anti-stigma campaign forms part of the Programme. The findings of this survey complement those of the Scottish Public Attitudes Survey linked to the National Programme.

Research methods

The module was completed with a representative sample of 1605 respondents in face-to-face interviews. An additional self-completion questionnaire was returned by 1383 (86%) of this sample. The sample is a national probability sample of adults aged 18 and over in private households.

The interview made use of four vignettes presenting individuals with a range of community care needs: an older person with dementia; a person with a learning disability; a person with a severe or enduring mental health problem; and a physically frail older person. For 50% of the sample the vignettes were presented as relating to females and for 50% to males. Of the 1605 respondents, 10% had themselves needed regular care or support within the last ten years, while just over 40% had someone close to them who needed regular care or support.

Social inclusion

There were significant differences in how comfortable people said they would feel living next to the different individuals in the vignettes. Three quarters said they would feel fairly or very comfortable living next to an older person who sometimes falls, and more than half (61%) felt this about living next to the person with a learning disability. Less than half however said they would be comfortable next door to the person with a mental illness (45%) or the person with dementia (42%).

Levels of comfort were similar across income and class groups and between rural and urban areas. Moreover personal experience of care did not appear to affect individuals' degree of comfort. Respondents did not react differently according to whether the vignette referred to a man or a woman, save that female respondents were significantly less comfortable when the person with a mental illness was depicted as male.

Asked where they thought it was best for the four individuals portrayed to live, respondents overwhelmingly selected the community-based options (in their own home with support, with family, or in supported housing) ranging from 88% for the person with learning disabilities to 58% for the person with dementia. There was some evidence of age differentials in the preferred options. For example, younger people were more likely than older people to favour individuals with learning disabilities having their own home.

Three quarters (73%) of respondents thought the person with a learning disability should not serve on a jury. The equivalent response for the person with a mental illness was 82%. Younger people and those who had attained a degree were less likely than others to object to jury service in these cases.

Who should care?

The most popular choices as to who should meet needs for each of the vignettes were as follows:

home help for person 'aged 87, often forgets things - needs checked on several times daily and help with bathing'

home help for person 'aged 90 and has falls - needs help with shopping and cooking'

family for person 'aged 44, can't read or write - needs someone to take to a club once a week'

nurse for person 'aged 50 with a mental illness - needs check has taken medication twice a day'.

Older respondents were significantly more likely than younger ones to select a nurse as the best person to care for the forgetful older person.

Arranging care

Social work departments were most frequently cited as the first port of call for access to community care services. Overall, 46% cited social work departments followed by 27% citing GPs. For each of the vignettes, one in five respondents did not give an answer. For the large majority, therefore, community care was seen as a statutorily organised service, accessed through the public routes of social work and general practice.

Who should pay for care?

For each of the four vignettes, respondents were asked to select one of three options for paying for support. In all cases the majority (between two-thirds and three-quarters) considered that 'the government should pay, no matter how much money he/she has'. This response was slightly more common in relation to the person with a mental illness. The option that 'who pays should depend on how much money the person has' was the response of the majority of the other respondents. Only small numbers, no more than 3%, selected the remaining option, 'the person should pay, no matter how much money he/she has'.

Those in lower income groups were more likely to consider that responsibility lay with the government. This view was favoured by a higher proportion of SNP and Labour supporters than by Conservative supporters, although the majority of Conservative supporters also preferred the state funding option.

People with personal experience of care were 3-5% more likely than those without such experience to favour state responsibility for funding. The most marked influence, however, was the respondent being the recipient of care within the last ten years, or perceiving that they might need it in the future. Seventy-four percent of those who had received care, compared with 62% of others, favoured state funding for care in the case of the individual with a learning disability.

The overall level of support for state funding echoes the responses found to a range of surveys in recent years which have explored attitudes in this area. Most recently, in a telephone survey for the Care Development Group, of 2354 individuals aged 50 plus or with experience of providing unpaid care, three quarters expressed the view that the state should pay for personal care and 5% the individual, while one fifth considered that it depended on circumstances.

The balance of care

Attitudes were sought on shifting the balance of care from care home to home-based settings - a key feature of community care policy. In particular the extent to which respondents would endorse home-based options if they were more expensive was explored. Responding to a specific example, three quarters of respondents supported such expenditure: 'the person should be cared for in their own house because that is what they want'. The remaining responses were split equally between those who thought 'they should be cared for in a residential or nursing home because that costs the government less' and those who were unable to choose. The community-based option was most strongly supported by those aged 35 and over and by those familiar with care provision, either as an unpaid carer or as a past or potential recipient.

The extent to which respondents considered that individuals who were able to afford it should be able to access higher quality care was explored in the self-completion questionnaire. Equity of access was strongly supported, three quarters of respondents considering that 'all elderly people who need it should get the same quality of help'. Only a fifth considered that 'elderly people who can afford it should be able to pay for better quality help'.

Expenditure preferences

Respondents were asked their views on the extent to which they would support increased expenditure on particular welfare budgets, and their priorities across these budgets. It was made clear in the survey question that increased expenditure was likely to incur increased taxation. Nonetheless, support for increased expenditure was high.

The strongest support for additional expenditure was in the area of health, endorsed by more than nine out of ten respondents. Eight out of ten favoured increased expenditure on supporting older people at home, while greater expenditure on older people in care and on pensions was endorsed by over three quarters of respondents. Support for additional expenditure on police and prisons was lower with six out of ten respondents in favour. Endorsement for spending 'much more' rises as income levels decline and is higher amongst the older age groups and those who have been in receipt of care.

Survey respondents were also asked to select from a list of seven, their key priority areas for additional government spending on older people. The priorities selected were home helps, special housing provision, and district nurses.

Policy and practice implications

The results of this survey suggest a number of barriers to the attainment of social inclusion for individuals with community support needs. While this representative sample of respondents is happy to endorse the principle of individuals being supported within the community, it appears more reluctant to fully endorse the rights of individuals to full participation as members of that community.

Both more information and a change in attitudes are required. Some areas of uncertainty may arise from lack of awareness of community care needs and the varied ways in which they can be met, together with the potential of individuals with such needs to contribute. Information and education on how risk is managed and how social inclusion can be enhanced must continue.

Routes for accessing support must be as transparent as possible. The agencies currently perceived as the key access points, social work and GPs, must collaborate effectively with other sources of information and referrals, for example Direct Payments Scotland and other routes within health. This will be particularly important as the ways in which community support are delivered become more diverse. The development of Direct Payments, for example, may alter considerably patterns of choice and control.

Strong support is offered by the findings of the survey for free personal and nursing care. Respondents also expressed a willingness to be subject to higher rates of taxation in order to fund enhanced levels of government expenditure in key welfare areas.

Recent policy initiatives designed to accelerate the shift in the balance of care for older people are also given a vote of confidence by the results of the survey. Indeed support for individuals remaining in their own homes, even when the more costly option, suggests increased expenditure on community-based options, irrespective of relative cost, would be welcome.