The Scottish Government

« Previous | Contents | Next »

Listen

Chapter Two Policy Review

2.1 This chapter identifies key policy developments in the areas of social care and health, housing, benefits and pensions, and citizenship and rights that have affected or may affect the continued implementation or operation of the policy of Free Personal Care.

The policy context of free personal care

2.2 The Free Personal Care policy was neither conceived nor implemented in a vacuum; it was shaped by, and since its adoption has shaped, other policies in a variety of expected and unexpected ways. Interactions have been principally, but not exclusively, related to policies on community care, and span social care and health, housing, benefits and pensions, and citizenship and rights settings. The timeline set out in Table 2.1 maps the development of a number of policies discussed further below:

Table 2.1 Timeline for policies interacting with or with the potential to interact with free personal care

Social care and health

Care at home

2.3 The UK government for a number of years has pursued the general policy aim of moving social care from an institutional setting towards care in the community generally and in particular towards care services delivered in people's own homes. In 1998 the Scottish Office published 'Modernising Community Care: An Action Plan', a report that laid out a strategy for the development of care services in Scotland. The three key elements in this strategy were; shifting the balance of care so that more people are cared for at home; emphasising improved working in localities; and developing more flexible services. The first of these elements had earlier been one of the objectives expressed in 'Caring for People - Community Care in the next Decade and Beyond' (Department of Health et al. 1989) and was also central to the 'Aiming for Excellence: Modernising social work services in Scotland' white paper (Scottish Office 1999). Following devolution in 1999 the new Scottish Parliament and the Scottish Executive took over the policy lead for community care.

2.4 Policies that promote care in the community reflect the general preferences of older people to stay and to receive care in their own homes and within their own communities for as long as possible (Godfrey, Townsend and Denby 2004, Curtice et al. 2001). Such policies promote choice, dignity and independence. They help older people to avoid the distress and disorientation sometimes associated with moving into residential care and, in many cases, may be more cost effective than institutional care (Royal Commission on Long Term Care 1999, Research volume 2 Chapter 8). The free personal care policy can be regarded as supporting the care at home objective by providing a number of older people with greater choice over if, and when, they move from their own homes into residential care.

2.5 The potential benefits of care in the community policies have been well rehearsed over an extended period. Perhaps because of this the recent literature tends to highlight problems in realising that potential. The literature review identified a number of issues. Some commentators voiced concerns about the ability of policies promoting care in the community to deliver the personal independence and social inclusion that they promise. Others questioned the adequacy of local authority support services provision to meet the needs of black and ethnic minority older people. The failure of current care at home policies to specifically address the complex and unpredictable needs of growing numbers of older people with conditions related to "brain failure" ( CCC 2004) was seen as an important issue.

2.6 Morris (2004) describes care in the community as a "disempowering framework" in terms of its ability to enable disabled people, including older people disabled due to age or infirmity, to live "independent" lives, identifying "fundamental problems with the legislative framework" that act as barriers to independent living. These include; the lack of specific individual legal entitlements to receive support services including advocacy or to live at home; the complexity of enforcing current entitlements; and the lack of support available for many activities that are part of able bodied people's 'normal' lives, such as work or leisure-related activities.

2.7 If policy goals of independent and socially included living within the community are to be achieved, then support services where required need to be sensitive to and able to accommodate cultural differences. Manthorpe (2004) reported on a survey of UK local government bodies undertaken on behalf of Better Government for Older People in 2003 that explored the bodies' strategies, plans and priorities in relation to older BME people in their communities. Included in the 128 responses were 13 from Scottish local authorities. Two had complete strategies for BME older people, six were in the process of developing strategies and five had no plans to develop a specific strategy.

2.8 Some authors have expressed concerns that the emphasis on continuing care in the community may come at the expense of established forms of care. For example, CCC (2004) draw attention to the complex and unpredictable needs of increasing numbers of older people with high levels of dependency due to "brain failure" most frequently occasioned by dementia. They make a case for caution in the expansion of new forms of domiciliary care and recognition of the long-term care policy implications of needing to provide adequate person-centred care for growing numbers of older people with brain failure-related needs.

2.9 In a similar vein Harwood (2004) in an editorial commenting on continued need for care home provision, identifies choice-based and pragmatic limitations to the application of care at home for older people. He agrees that "In theory, it should be possible to manage anyone at home with sufficient will and resources" but suggests that in some situations there will not be sufficient of one or the other. He points out that the desire to remain in their own homes is not universal, and some older people may have preferences for receiving care in an institutional setting. Equally, Harwood asserts, there are not always sufficient resources to maintain an older person in their own home; it may be difficult to access support services such as night-time support and the costs of care at home packages with more than four hours of support a day may be greater than those of care home placement.

The Joint Future agenda

2.1 Following slow progress in delivering the 'Modernising Community Care' agenda, the Scottish Executive established the 'Joint Future Group' in November 1999 with the primary objective of finding "ways to improve joint working in order to deliver modern and effective person-centred services". The Group's Report 'Community Care: A Joint Future' (Scottish Executive 2000c), delivered in November 2000, made 19 key recommendations ranging from changes to assessment procedures, to joint service arrangements, to guidance on home care charging policies. These were accepted by Ministers in January 2001 and the Joint Future Unit ( JFU) was subsequently set up to "develop and implement the key recommendations of the Joint Future Group's Report".

2.2 The JFU website describes Joint Future as "the lead policy on joint working between local authorities and the NHS in community care" with the primary aim of providing "faster access to better and more joined up services through improved joint working". Under Joint Future arrangements local partnerships are expected "to take holistic decisions on the management, financing and delivery of community care services for all care groups" ( http://www.scotland.gov.uk/Topics/Health/care/JointFuture/Introduction). Single Shared Assessment ( SSA) and Indicators of Relative Needs ( SSA- IoRN), eCare and Data Standards are all elements of the Joint Future agenda. Circular CCD5/2004 explains the relationship between them, suggesting that SSA is pivotal and other elements "should integrate around it".

Single Shared Assessment ( SSA) and Indicators of Relative Needs ( SSA- IoRN)

2.3 Provisions contained primarily in the Community Care and Health (Scotland) Act 2002 prohibit local authorities from charging for personal and nursing care provided by them to those aged 65 and over who need it. An assessment of needs is a prerequisite for eligibility for free personal and nursing care. The development of Single Shared Assessment ( SSA) began with the proposal in the Final Report of the Joint Future Group that there should be a "single, shared assessment" (Scottish Executive 2000c, Para 4.7). The Report of the Chief Nursing Officer for Scotland's Group on Free Nursing Care (2001), published some two months later, echoed the sentiment. It recommended that "All older people with identified needs should have a single shared holistic assessment of their care needs carried out by the person/professional most suitable to do so" and that agencies across Scotland should use a single resource utilisation tool to determine entitlement to payments for nursing care.

2.4 Scottish Executive Circular CCD8/2001 'Guidance on Single Shared Assessment of Community Care Needs' (Scottish Executive 2001a) sets out what is to be understood by single shared assessment together with the key steps necessary to achieve its implementation. The latter included partners in social work, health and housing agreeing to a tool for and systems to sustain SSA as well as agreeing arrangements with the consent of clients to share information. The 'Bottom Line' letter of January 2002 (Scottish Executive Health Department 2002a) initially suggested a timetable for the implementation of SSA but its introduction has been subject to considerable delay. The Joint Futures Unit website states that " SSA is currently being implemented incrementally across Scotland. It is expected that all partners will be using SSA by March 2006" ( http://www.scotland.gov.uk/Topics/Health/care/JointFuture/SSA, accessed 4 November 2005).

2.5 The objectives of SSA are to avoid duplication of needs assessment across different agencies and in doing so to make services available to users more quickly. The equity of availability of free personal care to older people is linked, amongst other factors, to the uniformity of understanding and application of SSA across different local authorities and across different professional groups working within community care that might be called upon to administer it.

2.6 The Single Shared Assessment Indictor of Relative Needs ( SSA- IoRN) has evolved since 1999 from its developmental predecessor, the Resource Use Measure ( RUM). RUM was conceived as a tool to determine entitlement to free care. However, its successor SSA- IoRN is intended to be a standardised measure of relative need whose function is to support professionals and managers in decisions about the use of resources and the planning of services (Scottish Executive Health Department 2004a), scheduled for full implementation across Scotland by 31 March 2006.

2.7 There has been little formal evaluative research on the use of SSAs in Scotland. 'The Review of the early implementation of the Resource Use Measure ( RUM)' (Craigforth Consultants 2004) looked at the pilot implementation of RUM across five Scottish authorities. The Review revealed variations in the applications of the Executive's SSA guidance across authorities, uncertainty as to the purpose of RUM, confusion over the consent required to share RUM information between agencies and a lack of formal use of data generated by RUM. The report of the Review was influential in the subsequent renaming of RUM as SSA- IoRN and served to highlight differences in approach that developed following the Scottish Executive's decision to provide non-prescriptive guidance and therefore allow local authorities a degree of autonomy in the implementation of SSA.

2.8 Future standardisation in the delivery of SSAs may occur as a result of SSA-related developments under the eCare programme. Part of the Joint Future agenda, this programme aims to deliver the Scottish Executive's policy of providing better and more joined up care, advice and assistance to the people of Scotland via the use of computers and communication technology. In the context of SSA current eCare developments, with the client's consent, will enable information to be shared securely between professionals in care and health-related public and voluntary agencies.

2.9 Two UK studies, Stewart et al. (2005) and Challis et al. (2004), have evaluated the outcomes of involving different professional groups in care needs assessment processes. Stewart et al. (2005) reported on research to compare costs and outcome of occupational therapy-led assessment with social worker-led assessment of older people, in terms of their independence and quality of life. They found no statistically significant difference in mean costs and concluded that from a policy perspective, the lack of significant difference in clinical and cost-effectiveness indicated that social work or occupational therapy services would be equally successful in making care assessments that enabled older people to remain in their own homes.

2.10 Challis et al. (2004) conducted research to assess the effect of an assessment from a geriatrician or old age psychiatrist in addition to the normal care management assessment on older people at risk of care home entry. They concluded that involving specialist clinicians in the assessment process could lead to a range of benefits, including the identification of previously undiagnosed illnesses (in Challis et al.'s study these included cognitive impairment, depression and osteoarthritis), for "modest marginal cost".

Joint working

2.11 The objectives of creating joined up services and promoting greater joint agency working and practice permeate UK and Scottish social care policy. They formed one of three key sets of objectives in 'Modernising Community Care - An Action Plan' (Scottish Office 1998) and one of the key tasks entrusted to the Joint Future Group was the formulation of practical proposals on "ways to improve joint working in order to deliver modern and effective person-centred services". The systematic review of recent literature suggested that a number of issues have been raised related to joint working arrangements, although the majority of commentators have approached their subjects from a UK rather than a specifically Scottish perspective. Bridgen (2003) and Lewis (2001) highlight difficulties in overcoming entrenched barriers to the development of joint planning and service provision. Petch (2003) discusses the decision to adopt integrated care systems in preference to an intermediate care model. Davey et al. (2004) voice concerns that the drive to adopt joint working arrangements had moved ahead of the evidence of any benefits accruing either to patients or to the wider community. Finally, Knott (2003) notes continued confusion over responsibilities for the provision of services such as foot care in the community.

2.12 Both Bridgen (2003) and Lewis (2001) consider the post-war development of policies to encourage joint working arrangements between health and social care services in the UK, with the former considering joint planning arrangements and the latter specifically focusing on the integration of services for older people. Bridgen identifies "lack of organisational homogeneity" and "absence of domain consensus across the health/social services boundary" as the primary barriers to progress on joint planning, together with local agencies' distrust of central government's more general policy intentions in this area. Lewis outlines what she describes as the 'textbook' characterization of the health-social care boundary, in which the difficulties of integration are attributed to financial, administrative and professional divisions between the two services. She proceeds to argue that whilst the three dimensions of the health-social care division "are important" and "have proved extremely problematic" they are insufficient to explain "the nature and scale of the persisting problem in the UK" (2001: 344).

2.13 Lewis (2001: 345) asserts that a "growing number of older people with "intermediate" care needs have been rationed out, ignored, or had their needs inappropriately met on either side of the boundary". She asserts that this has been largely due to the way in which central government sought to define the responsibilities of heath and social care services without explicitly addressing the resource implications of that definition. In 1995 new guidance on the responsibilities of the NHS issued by the Department of Health appeared to accept and reflect the view that had developed over the preceding 40 years that basic nursing care for chronically but not acutely ill patients was regarded no longer as part of a comprehensive national health service.

2.14 The NHS Plan (Department of Health 2000) specifically addressed the position of people in England with intermediate care needs and committed substantial additional funding to catering for the needs of this group. The Plan was followed by the Department of Health Circular HSC 2001/01: LAC (2001)/1 'Intermediate Care', (Department of Health 2001a) which provided a definition of intermediate care, outlined different service models, and stressed the role of intermediate care within a continuum of health services from health promotion to acute hospital care. The 'National Service Framework for Older People' (Department of Health 2001b) subsequently incorporated a Standard for Intermediate Care.

2.15 The Scottish Executive has not followed the policy lead of Westminster. It appears instead to have pursued a policy goal of closer integration of health and social care services. Petch (2003: 11) quotes a senior Scottish Executive official as saying during the course of an address in March 2003 "We don't need the artificial vehicle of something called intermediate care if we can deliver integrated care. The future lies in partnership with patients and people in need of care. It lies in integrated services".

2.16 The Scottish Executive's response to the Royal Commission on Long Term Care (Scottish Executive 2000b), published on 5 October 2000, introduced funding for the establishment in local authorities across Scotland of a range of service provisions for older people. These included; joint, multi-disciplinary rapid response teams; free home care for up to four weeks following hospital discharge; joint management and resourcing of services for older people; joint intensive home support / augmented home care services; more long-term home care packages; more flexible short breaks; further investment in equipment and adaptations; and funding to tackle delayed discharges.

2.17 In addition to the treatment of those requiring 'intermediate care' the Scottish policy approach to resolving issues at the boundary between health and social care and promoting joint working arrangements is substantively different to that employed elsewhere in Great Britain in other respects, for example in respect of delayed discharges from acute hospital beds (Petch 2003). The English approach has been to introduce 'reimbursement', seen as effectively penalising local authorities that fail to make timely community care arrangements. The Scottish approach was to invest £20 million in local NHS/local authority partnerships, ring-fenced for partnership initiatives to tackle delayed discharges and with a substantial proportion of each authority's allocation withheld until the Scottish Executive had approved the partnership's plan for the reduction and prevention of delayed discharges.

2.18 Other joint working practices developed prior to the implementation of FPC included the advent of three-year joint community care plans between health boards and local authorities and the transfer of resources from health boards to local authorities following the transfer of responsibilities for long-stay care provision. Resource transfer enacts the general policy of locating both the responsibility for and resources for provision of care of older people at a more local level. It also acknowledges the shifting boundaries between the roles of the NHS and local authorities. Under resource transfer arrangements NHS Boards were to transfer resources saved by the closure of inappropriate continuing care beds to local authorities to enable them to develop and provide services in the community for older people. Disputes over the timing and amount of resource transfer highlight the difficulties inherent in redefining boundaries and responsibilities.

2.19 Policies such as those adopted by the Scottish Executive in the provision of services to older people that place greater emphasis on joint agency working, planning, management, and budgeting, have not been welcomed unreservedly. Davey et al. (2004) strike a note of caution in suggesting that there is behind the drive to integrate services and adopt joint agency working practices an underlying but, as yet, unproven assumption that fuller integration will result in benefits to both users and their carers. The authors argue that this perspective tends to obscure the pressing issue of resource availability, particularly in relation to practical community services such as district nursing and home help.

The regulation of care

Care Standards

2.20 The Scottish Office White Paper 'Aiming for Excellence: Modernising social work services in Scotland' (Scottish Office 1999) set out an agenda for the future of social work services in Scotland which included proposals to independently regulate care services in order to promote "more consistent quality" of services across Scotland and "help to raise standards". The proposals were subsequently taken forward by the Scottish Parliament and enacted in 'The Regulation of Care (Scotland) Act 2001' (the Act), which introduced legal requirements for the regulation and inspection of care services and for the registration of social workers and other prescribed categories of social service workers in Scotland.

2.21 The Act established the Scottish Commission for the Regulation of Care (known as 'The Care Commission') as the national regulator of care services in Scotland. The Care Commission is charged with a general duty to further "improve the quality of care services provided in Scotland". It also has responsibilities in relation to the provision of information and advice; complaints about care services; and registration and inspection of care services.

2.22 The Care Commission regulates care services against the Act, taking account of the National Care Standards. Twenty one sets of national care standards have been developed, including sets for: Care at Home; Care Homes for Older People; Hospice Care; Housing Support Services; and Short Breaks and Respite Care Services for Adults. Services provided to older people coming within the ambit of 'care services' include support services, care home services, care at home services and housing support services.

2.23 The Act also established the Scottish Social Services Council ( SSSC) which is charged with general duties to; promote "high standards of conduct and practice" among social service workers and in social services education and training. The SSSC is responsible for maintaining registers of social workers and other prescribed categories of social service workers, publishing codes of practice for social work employees and employers, and approving courses for social workers and social service workers.

2.24 There are a number of potential interactions between the operation of the free personal care policy and initiatives directed towards the regulation of care. There are potential cost implications for service providers in complying with registration requirements and in meeting the National Care Standards. At the same time as providing service users with assurances of quality, regulation also places additional administrative burdens on service providers.

2.25 Commenting on the introduction of National Standards for Care Homes for Older People in England, Holden (2002) suggested that meeting the new physical and staffing standards would "impose significant new costs on all providers". This he suggested would be likely to lead to further concentration of the care home sector that might in turn precipitate a shift in the balance of power between purchasers and providers in favour of the latter that would in turn result in higher fees. He saw concentration of the sector as likely to affect current and future consumers through the effects of transfer of home ownership on residents; the reduction in consumer choice where concentration leads to monopolistic service provision; and possible reduction in the quality of care services without business competition to drive quality improvements.

Housing and housing benefits

Supporting People

2.26 Further changes in the community care policy framework were being proposed prior to the implementation of FPC in relation to housing support services. The consultation document 'Supporting People: a new policy and funding framework for support services', published on 10 December 1998 (Department of Social Security 1998), signalled significant changes in the way that housing support would be resourced throughout the UK. The Paper outlined problems with previous provision and proposed new funding arrangements that would combine housing benefit ( HB) and other funding streams including Special Needs Allowance Package ( SNAP) and Resettlement Grant into a single budget to be distributed to local authorities and applied by them at the local level based on individual need. The resulting programme, known as 'Supporting People', came into force across the UK in April 2003 with the Scottish Executive taking responsibility for its implementation in Scotland. Section 1 of Folder 1 of the Scottish Executive's 'Supporting People Final Guidance' (Scottish Executive 2000) describes the initiative as "a policy and funding framework for people in supported accommodation or in receipt of floating housing support" of benefit, amongst others, to those "affected by infirmity or ageing". The purpose of the support is to assist individuals with particular needs to occupy or continue to occupy accommodation other than residential accommodation.

2.27 The Supporting People Final Guidance (Scottish Executive 2002) suggests that the overall aim of providing good quality services will be achieved through a number of mechanisms. These include focusing provision on local need, improving the range and quality of services by developing a wider range of support services more geared to the needs of the people receiving support, and enabling more flexible support where appropriate. Integrating support within wider local strategies across social work, housing and the health service and introducing arrangements for funding and managing service provision that lead to transparent decision-making and cost effective administration are perceived as important, as is monitoring quality and effectiveness through the Best Value regime and the work of the Care Commission.

2.28 The transition from previous arrangements to the new funding framework described by Supporting People has been complex. The ambition of the policy is illustrated by the fifteen consultation papers issued by the Scottish Executive between confirmation of its adoption in 'Better Homes for Scotland's Communities' in 2000 (Scottish Executive 2000a) and its subsequent implementation across Scotland in April 2003. These have covered subjects ranging from decision-making processes and working arrangements to service reviews of sheltered housing for older people to management information.

Direct Payments

2.29 'Direct Payments' are not a benefit, but an alternative means of delivering the community care that local authorities assess people as needing. Once a person eligible for direct payments has been assessed as having care needs, they can choose to become responsible for buying some or all of the services that they require, giving them the opportunity to direct and manage their own care. Service users must use the payments only to meet their assessed needs. Self-directed care is seen as a means of increasing the flexibility, choice and control that users have over the community care that they receive and helping them to live more independently.

2.30 Local authorities are obliged to offer direct payments to eligible service users as an alternative to arranging the services themselves. Until recently eligibility for direct payments in Scotland was restricted to disabled adults and children. In January 2004 Scottish Executive Circular CCD 1/2004 announced the Executive's intention to extend the direct payments system to other service users (Scottish Executive 2004c) and the Community Care (Direct Payments) (Scotland) Regulations 2005 extended eligibility for direct payments from 1 April 2005 to people over the age of 65 who need care and attention arising out of age or infirmity. This means that every person assessed as requiring free personal care is now entitled to elect to use direct payments to provide this element of their assessed care needs in preference to local authority-provided care and support services.

2.31 In giving eligible service users flexibility, control and choice over how their care needs are met, who provides services and when they are provided, direct payments are seen by the Scottish Executive and the UK government as furthering both social justice and modernising welfare policy agendas (Riddell et al. 2005). The impact on free personal care of the extension of the duty to offer direct payments will depend to some extent on its uptake. Data on the numbers of over 65s in Scotland taking direct payments since April 2005 may be insufficient to give an adequate picture of the likely longer term uptake rate of direct payments for this group. However, data available for uptake of direct payments in Scotland by previously eligible groups indicates low rates of uptake (Scottish Executive 2005b).

2.32 Recently published research (Riddell et al. 2005) on the UK-wide uptake of direct payments suggests that as of February 2004 the uptake rate in Scotland represented 0.57 per 1000 people with long term illness or disability ( LTID), just over half the rate of uptake in England (1. 0 per 1000 LTID). Research has shown that in the past the uptake rate of direct payments has been influenced positively by the provision of support and advocacy services. The creation of new, or the tailoring of existing support services to meet the needs of newly eligible older people has possible resource implications for local authorities.

2.33 The Scottish Executive has recognised the need to increase the uptake of direct payments by older people if the system is to deliver its potential benefits in relation to aiding social inclusion, enabling independence and improving quality of life for service users. A short-life working group on Direct Payments for Older People was convened between May 2004 and March 2005 to consider barriers to uptake and how to overcome them, including providing the necessary local support for users (Scottish Executive website, accessed 21 March 2006). As part of its 2004 local government spending review the Scottish Executive allocated local authorities additional funding for direct payments of £1.8 million for 2006-07, and £2.0 million for 2007-08 (Direct Payments Scotland 2005a). A Scottish Executive Health Department letter to local authorities dated 14 December 2004 explained that the additional funding was to "alleviate waiting lists for direct payments and increase uptake", with the expectation that local authorities would appoint "a dedicated worker…whose priorities would be the development of support organisations and training personal assistants and their employers" (Scottish Executive Health Department 2004c). The Executive also provided 12 months' funding to train staff answering calls for the Scottish Helpline for Older People ( SHOP) and other helplines in the provision of basic information on direct payments, including signposting and referrals to local support organisations (Direct Payments Scotland 2005b).

2.34 Previous research and commentary (E.g. Dowson 2002; Glasby 2002) suggests that there may be a variety of issues in successfully promoting the use of direct payments generally and (Clark and Spafford 2002) by older people in particular. Glasby (2002) identified availability and access to appropriate information and support and the attitudes of social work professionals concerned that direct payments amount to "privatisation by the back door" as obstacles to be overcome. Clark and Spafford (2002) noted a number of "barriers" to working in an empowering partnership with older people. They concluded that whilst resource constraints had an important role to play, there was also "a need for a change in culture, values and attitudes if direct payments in particular, and user choice and control more generally, are to become a reality for older service users" (2002: 255).

2.35 There is a recognition of the potential of direct payments to be "positive option for older people, giving them greater choice and control and improving their quality of life and their emotional, physical and social health" (Clark, Gough and Macfarlane 2004). The Joseph Rowntree Foundation Task Force on Housing, Money and Care for Older People sees increasing take up of direct payments from social services as a key driver of change from a service-led to a consumer-led approach to the provision of services for older people, and as an element in a well-being approach to old age that both recognises older people's desire to maintain choice and control and enables them to participate actively in decision-making and planning of services that affect them (Joseph Rowntree Foundation 2004). Whilst research to date has largely identified concerns over the process of direct payments it has also been suggested in research on direct payments for disabled people, one of the earlier eligible groups, that with the "right approach and support, infrastructure barriers can be dismantled or, better still, prevented from arising altogether" (Witcher, Stalker, Roadburg and Jones 2000), and that process problems in the direct payments system "could be fairly simply (if not necessarily cheaply) addressed" (Rummery 2004b).

Attendance Allowance

2.36 Attendance Allowance ( AA) is a non-contributory benefit administered on a UK-wide basis by the Department of Work and Pensions ( DWP) and payable to people aged 65 or over meeting the Great Britain residency conditions who "are so severely disabled physically or mentally that they need help with personal care" ( DWP 2005). There are two rates of AA, with the higher rate applying where both a day time and a night time care condition are met.

2.37 The rules on eligibility for AA have had a substantial bearing on the differential impact of the free personal care policy. The Care Development Group's ( CDG's) recommendations for the implementation of free personal care were based on the assumption that those already in care who were self-funding and in receipt of AA would continue to be eligible to receive it ( CDG 2001). This assumption proved to be incorrect. Recipients may only receive AA for the first 28 days after admission to a hospital or similar institution, or to a care home where "the costs of accommodation" are met partly or wholly by a local authority ( DWP 2006). The Scottish Executive allocates money to local authorities to make payments in respect of free personal care. Payments made by Scottish local authorities in relation to free personal care are deemed by the DWP to be contributions towards "the cost of accommodation" ( DWP 2006). Thus, the pre-existing rules on eligibility for AA and the manner of distribution of and interpretation of the nature of the free personal care payments resulted at implementation in the unintended creation of different classes of policy beneficiary.

2.38 At the time of the policy's implementation there was a presumption of eligibility for free personal care without assessment for those already in care homes on 31 March 2002. Those in care homes who were self-funding and not in receipt of AA benefited in terms of additional income to the full amount of the payment. Those who were self-funding but in receipt of AA were entitled to the payment, but on taking it up became ineligible for continued AA, thus deriving a smaller net benefit from the policy's implementation. A third group of clients, whose care home costs were already being met partly by the local authority at the time of implementation, had no entitlement to AA at that point and so experienced an increased income to the extent that the free personal care payment exceeded the local authority's previous contribution towards their accommodation costs. A final group, for whom care home accommodation costs were being met wholly or substantially by the local authority prior to the policy's implementation and who were obliged to use all income to reimburse the local authority as far as possible, saw no net change to their income. The effect of the interaction between AA and the free personal care policy at the time of implementation was thus contrary to the policy aim (that was implicit in a flat-rate payment) of benefiting all older people with care needs resident in care homes equally.

2.39 Although it has received relatively little attention to date, with increasing emphases on distributive justice in relation to benefits and the elimination of age discrimination additional interactions between AA and the free personal care policy in the future may centre on possibilities for change in AA itself. The Scottish Parliament has no powers to vary benefits, but at some point in the future the UK Government might choose to do so, for example to resolve the differential positions of people over 65 receiving AA and receiving Disability Living Allowance ( DLA) explained below.

2.40 DLA is also a non-contributory benefit administered on a UK-wide basis by the Department of Work and Pensions ( DWP). It "is paid to people who are severely disabled and who, as a result, have either personal care needs or mobility needs or both" ( DWP 2006). It has care and mobility components, with the care conditions to be met to qualify for the middle or higher rate of the care component very similar to those applicable to AA. DLA must be applied before the applicant's 65th birthday, but recipients can continue to receive it after the age of 65 as long as the care conditions are met. The middle and higher rates of the care component of DLA are marginally higher than those for AA, but DLA also has a mobility component with higher and lower rates. The potential exists for people over 65 with similarly debilitating conditions and care needs to be in receipt of benefits that vary in value by the amount of the DLA higher mobility component, currently £42-30. In addition, on entering a care home where a person is assessed as requiring and receives payments in respect of free personal care, eligibility for AA and for the care component of DLA ceases, but not for the mobility component of DLA which is also disregarded in calculating an individual's contribution to the cost of care where met by the local authority.

Pension Credit

2.41 Pension Credit is a two-part 'top-up' benefit introduced from 6th October 2003 and administered by the Department for Work and Pensions ( DWP). It provides people aged 60 or over living in Great Britain a guaranteed minimum income ('Guarantee Credit') and provides an additional savings-related benefit for people who are, or who have partners who are, aged 65 or over ('Savings Credit'). Where care home placements are fully or partly funded by local authorities the Guarantee Credit element of Pension Credit is considered income in assessing older people's contributions towards the cost of care home accommodation, but a proportion of the Savings Credit element is disregarded.

2.42 Help the Aged's (2005) advice document 'Paying for your Care Home' suggests that one effect of the introduction of Pension Credit on the free personal care policy might be increased effort by the local authority directed towards client income maximisation. It suggests that local authorities "will want to make sure that you are claiming Pension Credit if you are entitled to it" because "it will mean that they have to contribute less towards your fees, saving them money". Whilst this appears slightly cynical, a review paper by Kerr, Gordon, MacDonald and Stalker (2005) on effective social work with older people written as part of the 21st Century Review of Social Work suggests that the maximisation of income would be a key element in future effective social work with older people. Pension Credit interacts with the operation of the free personal care policy in that it increases the incomes of those receiving it. People in care homes who receive free personal and nursing care are required to contribute to the costs of their care home accommodation, with the size of their contribution calculated on the basis of their income and assets. Where such people receive pension credit this increased the amount of the contribution that they are able to make. No evidence is currently available on the extent of increases in contributions to Scottish local authorities as a result of the introduction of Pension Credit.

Recent developments with the potential to affect free personal care

Public pension reform

2.43 Changing demographics and the costs of future provision have led to increasing concern over the adequacy and sustainability of pension provision in the UK. The concern has extended to both occupational pensions and state pension provision. In 2002 the Government established the Pensions Commission to review the UK private pension system and long-term savings, to assess its effectiveness and to make recommendations for change. The Commission published its First Report, 'Pensions: Challenges and Choices' (Pensions Commission 2004) on 12 October 2004, in which it outlined the basic choices in relation to pensions. The Pensions Commission's Second Report, 'A New Pensions Settlement for the Twenty-First Century' (Pensions Commission 2005), was published on 30 November 2005. It contains two central policy recommendations. First, the creation of a National Pensions Saving Scheme to encourage private pension provision at an acceptable level of earnings-replacement and to allow everyone a low cost opportunity to save for a pension. Second, reform of the state pension system to provide a non-means tested flat-rate state pension, improve the treatment of those with interrupted paid work records and caring responsibilities, and address the issue of long-term public expenditure and the state pension age.

2.44 The policy directions adopted in relation to pension reform have the potential to make a critical impact on the future operation of the free personal care policy because they will influence the future incomes and assets of those who will become entitled to free personal care and hence have a significant bearing on the future costs of the policy.

A Commission for Equality and Human Rights

2.45 On 30th October 2003 the UK Government announced that after consultation it had reached the conclusion "that a single body represents the best option for realising its vision of a fairer, more inclusive and prosperous Britain. A single equality body provides an effective and flexible framework for supporting our equality legislation as well as underlining the importance of equality as a mainstream concern" (Department for Trade and Industry 2003). The White Paper 'Fairness For All: A New Commission for Equality and Human Rights' (Department for Trade and Industry 2004) set out the government's vision for and the proposed duties and functions of the new Commission for Equality and Human Rights ( CEHR), to be established by October 2007. The white paper proposed that the CEHR would replace and assume the duties of the Commission for Racial Equality, the Disability Rights Commission and the Equal Opportunities Commission as well as consulting stakeholders, promoting human rights good practice and enforcing the law in the new areas of discrimination legislation covering sexual orientation, religion or belief and age.

2.46 The Equality Bill, which would have provided the legislative basis for the CEHR, was published in March 2005 but it failed to become law before the dissolution of Parliament for the general election. The Queen's speech announced the Equality Bill at the beginning of the new Parliament and the Bill was introduced to the House of Lords on 18 May 2005 and received royal assent on 16 February 2006.

2.47 The potential of the CEHR to affect the free personal care policy lies in its powers to address different aspects of age discrimination. Although the CEHR will only have powers to act against ageism that contravenes the new legislation on workplace and training age discrimination, the existence of a body to champion age equality may make it easier to tackle age discrimination in other areas of life. In confronting discrimination on grounds of age the CEHR may help to encourage recognition of ageism as a form of prejudice and influence public attitudes to discrimination in other areas of life both against and in favour of older people.

The Commissioner for Older People (Scotland) Bill

2.48 A 'Commissioner for Older People (Wales) Bill', drafted following the recommendations of the Advisory Group on a Strategy for Older People in Wales, was formally introduced into the House of Lords by the UK Government on 25 ^th May 2005. A similar 'Commissioner for Older People (Scotland) Bill', "to establish a Commissioner for Older People with duties to protect and further their rights and interests" was proposed as a Member's Bill and first lodged with the Scottish Parliament on 7 December 2004 but has not yet been introduced to the Scottish Parliament.

2.49 The consultation paper for the Bill was published in October 2004. In the foreword the Bill's sponsor, MSP Alex Neil, suggested that "The Bill's aim is broadly to create an older people's champion in the shape of a Commissioner to specifically ensure that their rights are being observed and that government legislation, whether current or planned; or the policies of other agencies and organisations take account of their views and interests". If given this remit, a Commissioner would have powers amongst other things to examine and report on aspects of the operation of the free personal care policy.

21st Century Review of Social Work Services

2.50 The 21st Century Social Work Review was established in August 2004 with six broad objectives. The first was to define clearly the role and purpose of social workers and the social work profession. The second was to identify improvements in the organisation and delivery of social work services. The third objective was to develop a strong quality improvement framework and culture, supported by robust inspection. The fourth was to strengthen leadership and management giving clear direction to the service. The fifth was to ensure a competent and confident workforce. The sixth objective was to review and if necessary to modernise legislation.

2.51 The relevance of the Review to the Scottish older people's policy agenda is explored in Kerr, Gordon, MacDonald and Stalker (2005) 21st Century Social Work Review Paper 'Effective social work with older people', published 6 October 2005. Paragraphs 3.10 to 3.15 refer specifically to free personal care, noting that "although a non-means tested universal benefit, free personal care has mainly benefited better off older people in care homes" and that price rises in the care home sector have further eroded the benefit that was anticipated to result from the policy's implementation. The paper notes the central role of social work in the free personal care assessment process and suggests that "Effective social work with older people will ensure that income is maximised through assistance with benefit claims and other financial advice" (2005: 17, para 3.14).

2.52 The 21st Century Social Work Review Group submitted its draft recommendations to the Ad Hoc Ministerial Group for discussion and presented the final report to Ministers for consideration and discussion in October 2005. 'Changing Lives', the report of the 21st Century Social Work Review (Scottish Executive 2006a) and the Scottish Executive's response to 'Changing Lives' (Scottish Executive 2006b) were published simultaneously on 7 February 2006. Amongst the many recommendations of the Review that the Executive gave commitments to implement, involving users and carers more in decisions about their own care and the design and delivery of services and developing a framework to enable front line social workers to operate autonomously, supported by a system that ensures professional accountability and risk management have the potential to directly affect the future operation of free personal care. A comprehensive plan for the implementation of the recommendations of the 21st Century Social Work Review Group is expected to be published in June 2006.

Scottish Parliament Health Committee Care Inquiry

2.53 On 9 December 2005 following public consultation and calls for evidence the Scottish Parliament Health Committee announced the remit of its review of the implementation of the Community Care and Health (Scotland) Act 2002 and the Regulation of Care (Scotland) Act 2001. Launching the inquiry, committee convener Roseanna Cunningham MSP said "Free personal care for the elderly was one of the landmark decisions of the first Parliament. We want to see how it is working in practice, and whether it is delivering what was promised". The inquiry will also examine the registration and inspection activities of the Care Commission.

2.54 The Health Committee issued an open call for written evidence with a deadline of 10 February 2006. The ProForma for the submission of written evidence sought views on; whether the free personal care policy has improved conditions for those who receive it; the ways in which it is operating effectively and those in which its operation is ineffective; what improvements could be made; and whether and why the policy should be extended to other groups. A range of other evidence-gathering activities were also planned as part of the inquiry, including three local authority case studies of the implementation of free personal care. The Committee is scheduled to launch the Care Inquiry Report on 13 June 2006 (Health Committee 2005/06 Work Programme, accessed via the Scottish Parliament website on 21 March 2006).

2.55 The remit of the inquiry covers some of the same issues that will be explored in the Executive's formal evaluation of the free personal care policy, and the publication of the inquiry report will pre-empt that of the formal evaluation. The latter does however have a wider remit and a longer timescale for the gathering and evaluation of evidence. Rather than being seen as an unfortunate duplication of effort, the inquiry may complement the subsequent evaluation as the written and oral evidence submitted to the inquiry will provide a resource on which the formal evaluation can draw.

The Future of Unpaid Care in Scotland

2.56 The Scottish Executive's Care 21 Unit published its final report 'The Future of Unpaid Care in Scotland' in September 2005. The report sets out twenty-two recommendations based on the findings of a research project on the future of unpaid carers in Scotland commissioned by the Care 21 Unit and executed by the Office for Public Management ( OPM) between October 2004 and August 2005. The report argues for "a bold new vision for unpaid carers in Scotland - a vision based on a strong framework of rights, in line with the Universal Declaration of Human Rights". In the envisaged framework "the caring contribution of carers to society will be fully recognised, the economic impact of their contribution accepted, and as such they will be wholly included in a society which will provide adequate support to carers" (Office for Public Management 2005: 1).

2.57 The 'vision' of a rights-based approach to unpaid caring articulated in the report elaborates on the widely held view of those consulted that unpaid carers should "be afforded the opportunity to choose when, how, and if they care". Included in the vision statement are rights to flexible employment practices; adequate financial support and planning; accessible information and technology; practical support; regular breaks from caring; adequate housing; training and health care; good transport links; and accessible leisure and recreational opportunities.

2.58 There are potential resource implications in implementing both the specific recommendations and the broader vision contained in the Care 21 Unit's final report. These need to be considered in the wider context of the delivery of community care and local authority services generally, rather than simply in relation to free personal care. For example, the costs associated with introducing a legal right to respite from caring in terms of providing regular short-term residential accommodation or replacement care services for people with care needs should be considered against potential savings that might result from its introduction. The right to respite from caring may produce savings in the NHS through reducing the numbers of emergency hospital admissions for older people where caring roles have broken down, and may lead to a reduction in demand for formal care services - research suggests that non-supported carers are more likely to use formal care services (Bookwala et al. 2004). Additionally, providing better support for carers may help to delay the need to provide residential places to those they care for (Ashworth and Baker 2000 but see Gilmour 2002). The Scottish Executive's response to 'The Future of Unpaid Care in Scotland' report is expected in Spring 2006.

2.59 To give legal status to rights such as that to have regular breaks from caring would have resource implications that would need to be considered in conjunction with the resource requirements of care-related policies such as free personal care. For example, for most older people with care needs the weekly cost of home-based personal care services provided by local authorities is likely to be less than the weekly cost of residential care. It would seem inappropriate that a right to breaks from caring should incur charges in excess of the cost of an older person remaining in their own home, and so the cost might have to be borne by local authorities. The question also arises as to whether a right to regular breaks from care might also give rise to a corresponding duty to ensure an adequate supply of respite care places, again with possible cost implications. Adjustments to the free personal care policy might become necessary to help balance the interests and expectations of carers and those they care for in apportioning a finite care budget.

Conclusion

2.60 Free personal care provides older people with care needs with additional resources to access care services that enable them to stay in their own homes and reduces the financial burden on older people should they require care home placements. The policy furthers the strategic objective of altering the balance of care towards greater care in the community. The development and implementation of free personal care has coincided with that of policy initiatives spanning social care and health, housing, benefits and pensions, and citizenship and rights. These have in the main been directed towards overarching policy themes of improving the quality and flexibility of services and providing greater independence and choice for service users.

2.61 A critical point to note is that because of the relative novelty of arrangements enacting the policies discussed in this chapter, much of the literature to date suggests theoretically possible or likely interactions rather than providing empirical evidence. As yet, relatively little is known of the exact nature of policy interactions. It is however possible to indicate a number of key policy intersections, those with the greatest potential to affect the range of, equity of availability of, access to or quality of care services, each of which is critical to the effective operation of free personal care.

2.62 The first key policy intersection is with the changing landscape of client assessment, in which joint working and Single Shared Assessment ( SSA) are now established features. SSA avoids duplication of needs assessment across different agencies and it should make services available to users more quickly. However, the equity of availability of free personal care to older people is linked, amongst other factors, to the uniformity of understanding and application of SSA across different local authorities and across different professional groups working within community care that might be called upon to administer it. The evidence to date suggests that differences still exist. The provision of joined-up care services such as SSA and integrated services for those with intermediate needs requires the development of joint working arrangements. Whilst increasing the range of services available such services also place additional burdens on local authority resources, possibly to the detriment of other care and support services. In addition, the lag in development of cross-agency communications infrastructures to support joint working arrangements is compromising the efficient operation of free personal care.

2.63 The second key policy intersection relates to the regulation of care. For free personal care to operate as intended older people in Scotland with care needs have to be able to access the same range and quality of services irrespective of location. The regulation of care should raise standards and promote consistent quality of services across Scotland but, whilst providing service users with assurances of quality, compliance with National Care Standards and registration requirements also places additional administrative burdens on service providers. Regulation may prove to be a catalyst for concentration of ownership in care-related sectors with adverse outcomes in terms of consumer choice and continued service improvement.

2.64 A third key policy intersection concerns the delivery of free personal care. In the past services have been provided by or sourced by local authorities. However, eligibility for direct payments has recently been extended to people over the age of 65 with assessed care needs, and the Scottish Executive is actively trying to stimulate uptake. The extent to which this delivers choice and control for service users is dependent amongst other things on the availability of alternative service providers and the extent of user knowledge about alternatives.

2.65 Key developments on the near horizon with the potential to affect the operation of free personal care include the Scottish Executive's response to 'The Future of Unpaid Care in Scotland' report, expected in Spring 2006, and the Executive's detailed plan for the implementation of the recommendations of the 21st Century Social Work Review Group, anticipated in June 2006. The likely impact on the operation of free personal care of these and other recent developments is unclear, since the detail of most has yet to be fully established.

« Previous | Contents | Next »