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Chapter One Introduction
1.1 Free personal and nursing care were introduced in Scotland in July 2002, after the Community Care and Health (Scotland) Act (2002) received Royal Assent. The background to its introduction lay in the recommendation of the Royal Commission on Long-Term Care (1999) that:
"The costs of long-term care should be split between living costs, housing costs and personal care. Personal care should be available after assessment, according to need and paid for from general taxation: the rest should be subject to a co-payment according to means." Royal Commission on Long-Term Care (1999)
1.2 The rationale for providing free personal care lay in the argument that the need for personal care, though not of itself a medical treatment, was associated with a variety of medical conditions, some of which were chronic. In 2002, older people whose assets exceeded £18,500 were expected to pay in full for the costs of personal care in care homes. Those with assets between £11,500 and £18,500 were expected to make a tapered contribution towards their costs. If continued over even a moderate period of time, these costs could be extremely onerous, rapidly depleting the older person's assets. The UK has never had an efficient market to insure against care home charges. Frail older people were therefore often caused considerable anxiety by the prospect of having to pay for personal care. It was felt that those requiring personal care were often treated differently from those with acute medical problems, where the costs of treatment and recuperation were fully covered through the NHS. This was one of the major arguments put forward in support of the provision of free personal care.
1.3 The Scottish Executive was established in 1999. In 2000, the ruling Labour/Lib-Dem coalition decided to introduce free personal and nursing care. The Care Development Group ( CDG) was set up in February 2001. It was asked by the Executive "to bring forward proposals for the implementation of free personal care for all, along with an analysis of the costs and implications of so doing." The Care Development Group reported in 2001. The Executive moved quickly on its recommendations. The Community Care and Health (Scotland) Act 2002 received Royal Assent in July 2002. This Act prevented local authorities charging for personal and nursing care. It was followed by the Community Care (Personal Care and Nursing Care) (Scotland) Regulations 2002, which provide that those in receipt of social care who meet the specifications of Section 1 of the 2002 Act, receive the appropriate care free of charge if they live at home and for those living in care homes a £145 weekly contribution for personal care costs. The contribution for those requiring nursing care in care homes is £65. The annual payment for a client requiring both personal and nursing care in a care home is thus £10,920. Those requiring personal care at home have that care provided free by the local authority, irrespective of cost. The average cost of providing care at home is £3,000 per annum (Scottish Executive 2004a). It should however be noted that people receiving personal care at home typically have less intensive care needs than people receiving personal care in care homes. Delivering intensive packages of personal care at home can significantly exceed the cost of delivering personal care in care homes. Due to the different intensity of need between those receiving home care and those in care homes a straight comparison of the costs should not be made.
1.4 The Scottish Executive does not transfer these payments directly to clients. Instead, local authorities are given additional funds by the Executive to purchase or provide personal care for people at home and to make payments to care providers for the personal and nursing care provided to people in care homes. In some cases, the local authority is itself the care provider. This is particularly true for care at home. Total payments by the Executive to compensate local authorities for the costs of purchasing personal and nursing care in the first two years of the policy were £250m.
1.5 The definition of personal care for the purposes of the 2002 Act was laid out in the Regulation of Care (Scotland) Act (2001) which states in Section 2(28):
"In this Act, unless the context otherwise requires-
"personal care" means care which relates to the day to day physical tasks and needs of the person cared for (as for example, but without prejudice to that generality, to eating and washing) and to mental processes related to those tasks and needs (as for example, but without prejudice to that generality, to remembering to eat and wash)."
1.6 Based on the definition provided in the Regulation of Care (Scotland) Act 2001, the Scottish Executive provided guidance to local authorities on the implementation of the policy (Scottish Executive Health Department 2002b). This guidance, which was used in the implementation process, offered "further explanation of the components of personal care" to be "read in conjunction with the relevant legislative provisions". The guidance suggested that personal care should be understood as encompassing:
- help with washing, bathing and showering;
- help with managing continence including using continence equipment such as catheters and stomas;
- assistance with eating, managing special diet and preparing specialist meals such as pureed food;
- help to move around indoors; and
- help with simple treatments such as applying creams, lotions and dressings.
1.7 To qualify for assistance, clients had to be individually assessed. However, when the policy was introduced, it was assumed that all care home residents required personal care without the need for assessment. This meant that 7,100 individuals immediately received personal care in July 2002 and, of these, 4,600 received nursing care. By mid 2004, the number receiving personal care in care homes had risen to 8,100 and those also receiving nursing care had risen to 5,300. Over this period the care home population remained around 32,000. Those receiving care at home had to be assessed before receiving free personal care. In July 2002, 23,300 older people had received an assessment and were deemed to require personal care. As assessments proceeded, this number increased steadily, reaching 39,100 in June 2005. This implies that in 2005, 5.7 per cent of the Scottish population aged 65 and over were receiving free personal care.
1.8 The aim of this study is to consider the baseline against which the development of the policy of free personal and nursing care in Scotland can be evaluated. This study therefore comprises the first part of the evaluation process. It will be followed by a more extensive evaluation of the policy itself. This larger evaluation will also be managed and funded by the Scottish Executive.
1.9 The first objective of this research is to develop a framework in which to evaluate the policy, to map out the availability of baseline data, to collate available information, to identify gaps or weakness in the baseline data and to suggest how these might be overcome. We begin this work by more closely examining the evolution of the policy described above. Clearly, an important part in the development of the policy was played by the CDG. The CDG Report (2001) sets out the case for introducing free personal care, its definition, its likely effects and estimates of its current and future costs. Hence we devote several chapters of this report to issues identified by the CDG. These cover issues such as demography and health expectancy, the balance of care, and unmet need.
1.10 Its second objective is to establish the context for free personal and nursing care. This involves examining other policies that impinge on free personal and nursing care, reviewing relevant research and statistics since the implementation of the policy to the present. This work is mainly captured in our policy review. However, other chapters include reference to relevant policy developments and evaluations. We have also included descriptions of key statistics relevant to free personal and nursing care that have been published since 2002.
1.11 In addressing these objectives, we have conducted an extensive research review, which not only considers research directly concerning free personal care, but also examines related areas of work to inform further the evaluation of free personal care.
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