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Chapter Four Balance of Care

4.1 The balance of care reflects the relative importance of different care settings for frail older people. The balance of care had undergone considerable change prior to the introduction of free personal and nursing care. The main changes that had taken place were:

• A significant reduction in long-stay geriatric care;
• Substantial increases in sheltered housing, medium dependency housing and care at home;
• A decline in local authority and voluntary care home places.

In this chapter we review these changes and consider how they integrate with the policy of free personal and nursing care. We also consider trends in informal caring, which provide an important contribution towards caring for frail older people at home. We include reference to published studies identified through our literature review throughout.

Changes in geriatric care

4.2 In the last two decades, there has been a substantial shift from NHS provided care to local authority provision of care for older people. This has accelerated in recent years. Local authority spending on all forms of care for older people increased by over 50 per cent in nominal terms between 2000/01 and 2003/04 while NHS spending on geriatric care increased by only 15 per cent between 2000 and 2004. Within local authorities there has also been a significant switch in emphasis with spending on care homes increasing by 38 per cent while spending on care at home increased by 66 per cent. Thus the balance of care appears to be moving quite sharply away from NHS provided care and towards care at home.

4.3 Transfers from geriatric long-stay to care homes were promoted as part of the Joint Futures Agenda. The NHS compensated local authorities for accepting clients who would previously have occupied long-stay beds. There was a 56.5 per cent increase in 'resource transfer' from the NHS to local authorities to provide nursing home places between 1999/00 and 2003/04. In 2003/04 the value of this resource transfer was £67m. The value of the 2003/04 resource transfer would buy around 1,100 patient years of geriatric care in NHS hospitals and around 3,000 patient years of care in care homes, due to their lower average costs. These continuing care payments account for about 8 per cent of the total revenue of Scottish care homes.

4.4 Overall spending on geriatric care (including resource transfer) increased by 14.7 per cent between 1999/00 and 2003/04. The growth in spending on geriatric care has been much slower than the overall increase in NHS spending in Scotland. Between 1999/00 and 2003/04 funding for geriatric care grew at only 37 per cent of the rate of increase of the overall NHS budget.

4.5 The reductions in long stay geriatric care are at least partly related to the development of improved systems for supporting older people discharged from hospital, such as Rapid Response teams, which provide intensive home care, including personal care, for short periods following discharge. According to Petch (2003), the Scottish approach, which involves 'integrated care' or a 'whole system' approach has proved more effective in supporting these discharges than the English approach of 'intermediate care'. In England, this has been a particularly contentious area of service provision, as it necessitates harmonious and effective working between health and social care service providers, as well as attempting more effective involvement of older people themselves in developing their care packages (Andrews, Manthorpe and Watson 2004).

Care homes

4.6 There has been a slight decline in the number of residents accommodated in the care home sector in Scotland between 2000 and 2005. Table 4.1 shows that, while the number of care homes fell by 7.5 per cent, the number of places available declined by only 1. 9 per cent and the number of residents fell by 2.2 per cent. There were closures of local authority, voluntary and private care homes over the period. But provision of new, larger care homes mainly in the private sector has kept the sector at broadly the same size in terms of the number of places it is able to provide.

Table 4.1 Care homes, places and residents by sector/places, per 1,000 population, 2000-2005

Notes to Table
Source: SCHC1 March 2005 (Scottish Care Homes 2005. xls)

4.7 This contrasts with England, where, for example, the number of nursing homes and private hospitals declined by 9.2 per cent between 1998 and 2001 (Care Home Statistics, Department of Health). This may reflect greater cost pressures in England. These are in part due to the more rapid rise in house prices in England, which increases the value of alternative uses of the land occupied by nursing homes.

4.8 Penrice et al.'s (2001) study of low dependency residents in eight care homes in Scotland concluded that assessment procedures were effectively promoting care homes, even for people who did not really need that form of care. Some of the low dependency care home residents (6% of the 26% with low dependency) needed only personal care. They raise questions about why this personal care could not have been provided in people's own homes, and their work suggests that attention to the appropriateness of the balance of care in terms of which older people are entering care homes may be merited. Data on dependency levels of older people in care homes are not readily available however, although SSA- IoRN offers a theoretical possibility that such data may be available in the future (Penrice et al 2001 used the SCRUGs measure). The study pre-dates FPC, and it is not clear whether current practices continue to promote care homes, despite the policy encouragement to the contrary.

Sheltered housing

4.9 Sheltered housing forms a small, but important component of the balance of care. Data on the availability of different types of sheltered accommodation are shown in Table 4.2 and Figure 4.1 illustrates significant changes in the composition of sheltered accommodation. Between 1995 and 2004 there was a steady increase in very sheltered housing of five hundred per cent, albeit from a low base, while the amount of standard sheltered accommodation declined slowly from 36,100 units in 1998 to 32,800 units in 2004. The amount of moderate dependency housing, which averaged around 17,000 units between 1994 and 2002 increased sharply in 2003 to 34,000, as a result of reclassification of 14,000 previously unclassified dwellings due to stock transfer in Glasgow. The number subsequently dropped in 2004 because 13,000 of these were reclassified again as general needs accommodation. The overall trend in the numbers of moderate-dependency sheltered housing units is therefore one of slow decline.

Table 4.2 Housing provision for older people by public authorities and housing associations as at 31 March

Notes to Table
Source: Housing Statistics 2004, Housing inc sheltered 2004. xls

Figure 4.1 Sheltered housing in Scotland 1995-2004

Notes to Figure
Source: Scottish Executive Housing Bulletin Mar 2005

4.10 These trends were already in place before the introduction of free personal and nursing care and do not seem to have been influenced by their introduction. It is more likely that the size of the sheltered housing stock is affected by issues such as the size of local authority capital budgets. Note that there is no 'right to buy' for either sheltered housing or other forms of group housing schemes for persons with special needs. This is confirmed by the guidance that accompanies the Housing (Scotland) Act 2001.

4.11 Sheltered housing is sometimes seen as a potential solution to people's wishes to stay in their own homes. However, commentators have identified general issues with shortage of supply (McLaren and Hakim 2003), and a need to improve service quality (Reeves and Thompson 2002) and the nature of delivery (Clarke 2004). However others such as Oldman (2000) have argued that an 'enhanced' form of sheltered housing - with better support services - might in the long term even replace residential care. Thus personal care received at home would become even more significant than currently is the case.

Care at home

4.12 The number of clients receiving home care had been in steady decline since 1995 (Figure 4.2). This occurred even though the contribution of the private and voluntary sectors increased in size during the latter half of the 1990s and the first part of this century. Nevertheless, the home care market continues to be dominated by local authorities. However, the decline in numbers of clients does not give the full picture. The average number of hours devoted to each client has been rising significantly (Table 4.3) from 5.1 hours per week in 1998 to 7.8 hours per week in 2004. As a result the total number of home care hours provided to clients rose by 13 per cent between 1998 and 2002, even though the number of clients fell by 19 per cent. Some of the changes in home care provision in Scotland are mirrored in England (Table 4.4). There was a 16 per cent reduction in client households between 1999 and 2004, but a 26 per cent increase in hours of care provided. Both in Scotland and England, home care provision is focussing on clients that require intensive home care. In England the concentration is greater, with an average provision of 9.5 hours per week compared with 7.8 hours in Scotland in 2004.

Figure 4.2 Home care clients 1980-2002 by sector

Notes to Figure
Source: Community Care Statistics 2003

4.13 But these data reveal another significant difference that has emerged in recent years between homecare provision in England and Scotland. The growth in homecare hours between 1999 and 2004 is the result of a massive expansion in privately provided home care in England. Hours provided by local authorities fell by 22 per cent, while those in the private sector increased by 73 per cent. In 2004, 69 percent of home care hours in England were provided by the private sector. When free personal care was introduced in Scotland in 2002, 14% of clients received a service purchased from the private/voluntary sector. Already a growing sector, the number of clients receiving a service purchased from the private/voluntary sector has continued to grow reaching 23% of clients in 2005. In Scotland private/voluntary providers generally supply more intensive packages of care with the result that the number of hours provided solely by local authorities has fallen from 74% of all home care hours in 2002 to 60% in 2005 (Table 4.5 and Scottish Executive 2005e). This is probably the major difference in the balance of care between Scotland and England that has emerged in recent years. English home care is dominated by private providers, while in Scotland it is local authorities that monopolise provision.

Table 4.3 Homecare numbers and hours provided

Notes to Table
Source: Community Care Statistics (Scotland) 2003

Table 4.4 Care at home, England 1999-2004

Notes to Table
Source: Community Care Statistics (England) 2004

4.14 Free personal care has had an important effect on homecare provision and thus on the balance of care. Data on the number of home care clients receiving free personal care, the number of hours provided and the average hours received per client are shown in Table 4.6. The number of clients increased sharply initially, perhaps due to lack of awareness of the policy and to assessment lags, but since 2004 growth has been more moderate, with the total number of clients reaching 39,000 in June 2005. The number of hours supplied increased between July 2002 and June 2005 from 161,000 to 268,000.

4.15 The CDG did not estimate the number of clients likely to be receiving personal care at home. Instead it based its costing on the numbers that received personal care and contributed to the cost of that care. This is an extremely important distinction which reflected the essence of the CDG approach to the costs of free personal care. We revisit this point in Chapter 6. Based on data from the UK Home Care Association, it estimated that there were 3000 individuals buying personal care privately and that it would cost £10m to recompense them for the costs of that care. Similarly, the CDG estimated that it would cost £10m to repay those who paid charges to local authorities for receiving personal care at home. This implies a total cost of providing free personal care at home to those already receiving personal care and paying for that care of £20m.

Table 4.5 Care clients and hours provided by provider of service, 1998-2005

Notes to Table
Source: Scottish Home Care Statistics 2005

4.16 On average, there were 268,000 hours per week of personal care being provided free by local authorities in Scotland in 2005 (Table 4.6). Comparison with estimates of total hours of care provided in Table 4.3 suggests that this is around 47 per cent of the total hours of care supplied. Between 2001 and 2004 total home care hours supplied by local authorities increased by 37 per cent. But within this overall increase, personal care hours increased by 59 per cent while the hours devoted to other domestic tasks increased much more slowly - by 22 per cent.

Table 4.6 Free personal care 2002-2005

Notes to Table
Source: Scottish Executive

4.17 This switch in the focus of home care provision is reflected in Audit Scotland's data on local authority care. Table 4.7 gives a number of statistics intended to measure local authority performance in care delivery between 2000/01 and 2003/04. It is also evident from these data that there has been a substantial increase in care provision by local authorities. The number of community care assessments increased by 14.8 per cent over the period, the number of reviews of those with dementia by 31 per cent, and the number of people receiving a community care service by 20.1 per cent. The estimate of the total number of clients in 2001/02 of 60,000 is consistent with the Community Care Statistics estimate of client numbers.

4.18 The information on hours of care in Table 4.7 suggests a significant switch away from care packages involving small numbers of formal care hours to much more intensive care packages that often involve working at unsocial hours. Thus, for example, the number of care packages involving less than 10 hours of care per week has fallen, while the number involving more than 10 hours of care increased by 31 per cent between 2000/01 and 2003/04. Over the same period, there were comparable increases in the amount of overnight and weekend provision of care. This suggests a considerable substitution in local authority activity away from provision of domestic care towards personal care, which is more likely to account for long care packages involving unsocial hours. Note that Table 4.7 also contains some specific information on personal care. Data on the number of clients is broadly consistent with the information in Table 4.6.

Table 4.7 Social care in local authorities 2000/01 to 2003/04, Performance Indicators

4.19 Generally, literature suggests that older people in the UK and Scotland prefer to stay at home as long as possible (Godfrey, Townsend and Denby 2004, Curtice et al. 2001), though it is important that there is still choice within the system (Curtice et al. 2001). A focus on care at home would seem to support this. We return to these matters in Chapter 7.

Informal care

4.20 Consideration of the balance of care should also include discussion of informal caring, which is a vital component of care provision for frail older people, particularly those living at home. Substitution between informal and formal care was also a particular concern of the CDG, which made financial provision for substitution from informal to formal care.

4.21 The supply of informal care is a key factor affecting whether people with care needs are able to remain in their own homes (MacDonald 2004). Informal carers are important suppliers of personal and other care, and their availability and willingness to perform these tasks are essential to the system as it now stands. In particular, personal care performed by informal carers produces no direct call on the public purse. Whilst some policy approaches have promoted a "carer-blind" approach to support and care for older people in favour of a focus on the older person themselves (Pickard 2001), available research emphasises the importance of these informal carers, including their role in supplying personal care.

4.22 Table 4.8 compares numbers of informal carers (thousands) in Scotland, England and Wales over the period 1996 to 2003 using the Family Resources Survey. There is inevitably some year-to-year variation in estimates of the numbers of carers, particularly in Scotland and Wales since the number of carers in the annual sample is relatively small. The table shows that there has been an upward trend in the numbers of informal carers in England, Scotland and Wales over this period. In 2003, there were 384,000 adult carers in Scotland, 10 per cent of the adult population. The proportion in England is very similar to that in Scotland, while in Wales there are a higher proportion of carers, perhaps because of the high rates of disability among the Welsh population. The gender breakdown of carers is fairly stable, with slightly more female carers in Scotland (64 per cent) than in England (61 per cent). The SHS contains information about informal caring patterns, and a topic report is due to be published by the Scottish Executive in June 2006.

Table 4.8 Informal carers total and by gender 1996-2003 (thousands)

Notes to Table
Source: Family Resources Survey

4.23 Bell, Heitmueller and Bowes (2006) compare trends in informal caring in Scotland, where FPC was introduced, with those in England and Wales, where it was not. They show that there was no change in these trends in Scotland relative to England and Wales following the introduction of FPC. This is an important result because it suggests that the CDG may not have needed to make provision for substitution away from informal care to formal care once formal care was provided free.

4.24 As with formal care provision, the amount of assistance given by informal carers depends not only on their number, but also on the average number of hours that they provide. Most surveys, including the Family Resources Survey, group the hours of care provided into bands (0-2 hours, 3-4 hours etc). This makes the calculation of total hours provided problematic. We have assumed that hours provided are given by the mid point of the relevant band and that no-one provides more than 110 hours of care per week.

4.25 Table 4.9 shows the number of carers in Scotland by the hours of care they provide. Most carers provided less than ten hours of care per week. However, a significant proportion of informal carers claim to give more than 100 hours per week. Taking their claimed hours at face value, and imposing an upper limit of 110 hours of care, total weekly hours provision of informal care in Scotland in 2003 was 8.6m hours per week (see the Hours(1) row in Table 4.9).

Table 4.9 Informal carers by hours of informal care (thousands) and total hours (thousands)

Notes to Table
Source: Family Resources Survey

4.26 With this level of provision of informal hours, local authorities simply could not afford to pay for the additional hours of formal care required if there was a substantial reduction in informal caring. In practice, local authorities would have to limit formal provision, most likely by limiting the hours any individual client could receive and reducing the contact time for those receiving smaller weekly packages of formal care. Suppose that authorities provided half of the contact hours that informal carers provide and imposed a maximum weekly provision of 28 hours of care per week. Then the 'local authority equivalent' number of hours in 2003 would be 3.5m hours (see the Hours(2) row in Table 4.9). Valuing this at the average hourly pay (£6.10) for care assistants, the salary costs of providing these hours would have been £1.1bn in 2003. This figure includes all care provided at home, including free personal care but does not include administrative expenses, travel, etc. The cost of providing a service is more than simply the wage that someone receives. The full cost of providing these hours of care would significantly exceed the £1.1bn salary costs.

4.27 Comparison of the hours provided by the formal and informal sectors in Table 4.3 and Table 4.9 clearly demonstrates that informal care hours very significantly exceed formal provision of care hours. And while it is very unlikely, based on recent evidence, that there will be any substantial changes in informal caring behaviour, the conservative estimate of £1.1bn for the costs of replacing formal care with informal care emphasises the importance of the contribution that informal carers make, both to the well-being of their friends and relatives and also by allowing publicly provided resources to be deployed on other issues. This research reinforces the recent report on unpaid care in Scotland (Office for Public Management 2005) which argues that:

"One overriding and consistent message emerged: unpaid carers are the largest group of care providers and as such, the largest component of the Scottish care 'workforce', making an enormous contribution to society, however this is valued." (Office for Public Management 2005, p2)

4.28 The wider research record on the supply of informal care has also considered changes in supply or potential supply. Pickard (2002) found that co-resident intergenerational care had declined between 1985 and 1995, though noted that co-residence was only one possible pattern of intergenerational care. Other work has stressed the significance of co-resident spousal care and the involvement of both men and women (Hirst 2001) in this activity. Glaser and Grundy (2002) found class differentials in spousal care among people aged 55-59, with working class people more likely to be involved in this because of poorer health. Their data came from 1988-89, but raise questions important for exploring the supply of and demand for care across different socio-economic groups. Our finding that informal care has not declined is supported by other evidence including Grundy and Shelton (2001), who found no clear evidence of decline in intergenerational contacts. Similarly, Hirst's (2002) analysis of a UK-wide sample from the BHPS showed increasing involvement of UK adults in informal care, especially (Hirst 2001) in terms of the intensity of care. All this material, as well as the Scottish evidence and the current emphasis and direction of policy, suggests continuing involvement of informal carers in the delivery of personal care.

4.29 Support for informal carers is highlighted in literature as essential to permit policies which promote care at home. Despite evidence of continuing commitment, there may be increasing pressure on informal carers if the supply of alternative accommodation, such as care home places, reduces. However, supplying support for carers is a complex matter and evidence of its effectiveness is sparse (Ashworth and Baker 2000). For example, respite care may permit informal carers a break in their care work, but may also promote worries of suggesting they cannot cope, or delivering inferior support to their relatives (Ashworth and Baker 2000).

4.30 As previously noted, for BME communities, formal service providers may assume that family care or voluntary sector care are readily available. There is a wealth of research demonstrating that this is not necessarily the case, both in Scotland and more widely (e. g. Ahmad et al. 2004, Chiu and Yu 2001, Bowes, Sim and Srivastava 2001). For example, Ahmad et al. (2004) point out that for some groups in which the availability of family care has been assumed, notably South Asian communities, changes in family patterns may not justify this assumption. They find that for South Asian families, responsibility for care of older people is likely to fall on one person, and not to be shared among the extended family. Similarly, Chiu and Yu (2001) identify potential shortfalls in family care in Chinese communities, and Harper and Levin's (2005) review supports both. They, and others, argue that a central element of policy promoting care at home has to be support for informal carers.

4.31 One neglected area of research is the end of informal caring at home, and the transition to residential care. It is known that one of the most common factors influencing admission to residential care is lack of informal care, or informal carers who cannot provide the necessary support any longer. Davies and Nolan (2003) argue that consultation with informal carers should be an element of the transition process. It is possible that during this process, personal care may transfer from the informal carer to care staff, becoming a formal service and a new experience for the client. Research of this kind raises questions about the division of labour in personal care, of which very little is known, as well as the changing "careers" of individual carers (Hirst 2002) and the need for support services to be aware of these. Informal carers may become involved in personal care at a stage in their caring "career", and may need particular support at this time or with the tasks involved.

Innovations

4.32 A number of innovations are in progress in the organisation and delivery of care and support for older people that are likely to affect the balance of care and therefore where, how and by whom personal care is being provided. These include developments in housing and communities, new approaches to staffing configurations especially linked with the use of technology, and continuing developments in the promotion of 'joined-up' working.

4.33 The precise impact of changing housing patterns for older people in Scotland remains to be explored. While older people in Scotland are currently less likely to own, or wish to own, their own homes at present, for future generations, this will change, and this has been identified as a particularly significant shift in the resources available to individual older people (Bell and Bowes 2006). It is likely that housing wealth will become increasingly significant in permitting people choice in older age, including choices to stay at home (cf Hancock et al. 2002, who found that home ownership decreased people's likelihood of entering residential care) and the possible use of housing wealth to fund long term care (Bell and Bowes 2006).

4.34 In recent years, increasing attention has been given to alternative approaches to supporting people at home in the form of various models of 'housing with care'. Dalley (2001) for example predicts increasing demand for private sheltered housing for older people, linking this with changes in preferred living arrangements for older people. Her comments are in tune with our findings on changes in the supply of sheltered housing in Scotland.

4.35 Research on the "continuing care retirement community" at Hartrigg Oaks in York (Croucher, Pleace and Bevan 2003) found very positive responses among the (self selected) residents to the opportunities provided by this community for people to live there for many years, only moving into the on-site care home if their care needs became very significant. The insurance-based funding of this community, as well as the private sheltered housing considered above, clearly require a level of affluence among clients.

4.36 A Scottish example of a housing based model of care and support provision is to be found in West Lothian in new developments which replace former care homes with tenanted, self-contained flats and bungalows, built around a central 'community hub' in which care and support staff are located. Recently evaluated by the University of Stirling, (Bowes and McColgan 2003), this model of care emphasizes capacity-building, and aims to move away from models of care which can promote dependency. Alternatively, Madigan and Milner (2004) explore the potential of the concept of a "lifetime home" to promote housing design suitable for people to stay in all their lives, without having to move away if care needs increase.

4.37 Research literature indicates that new developments in care provision have the potential to shift the range of services provided, especially where there is pressure on existing resources. A key example is the as-yet unrealized potential of "telecare" (Barlow Bayer and Curry 2005), often linked with housing developments. Several local authorities in Scotland, including West Lothian have tested the use of technology to supplement face to face care and support (Bowes and McColgan 2003, Fisk 2003). Elsewhere, innovations include the use of technology such as in "telenursing" (Arnaert and Delesie 2001), increasing focus on "hospital at home" services (Bentur 2001), informal carer support using technology (Magnusson, Hanson and Brito 2002). The Audit Commission (2004) has argued that "assistive technologies" can not only support people's independence more effectively, but also promote modernisation of services.

4.38 As the balance of care shifts towards care at home, there is some evidence in Scotland (Bell and Bowes 2006) of significant increases in the delivery of high intensity care packages at home. Challis and Hughes (2002) explore "care at the margin", that is care and support for people with high support needs in the community who might otherwise enter residential care. They identify and discuss a number of issues including the importance of skilled assessment and the likelihood of changes in staff roles to support new populations at home. In West Lothian for example, the population of people receiving high intensity care packages outside care home or hospital is linked with changing roles for staff - staff working in the community or in housing with care are now working with clients frailer than those formerly encountered. These changes are important because they suggest increasing needs for personal care at home - this increase is supported by available statistics.

4.39 Novel approaches to staffing care for older people are beginning to emerge in Scotland. These include 'Evercare', an American model whereby one nurse concentrates on maintaining an older person at risk of going into hospital at home. Evercare has been piloted at 9 UK sites, and is being actively considered in Scotland (Agnew 2004).

4.40 Whilst there is often optimism about the potential of these new approaches to deliver effective care, others have argued that they require careful innovation in models of care and its delivery to be fully effective (Barlow and Venables 2004, Barlow, Bayer and Curry 2005). Personal care has to be considered in the context of changes such as these.

4.41 Despite the Joint Futures initiatives and attempts to promote more 'joined up' working between health, social care and housing services, it is clear from the research record that significant challenges remain, both within Scotland and across the UK. The delivery of personal care services affects all these, and involves public, private and voluntary sector providers. There is also evidence that the divisions of labour between providers in different sectors are not necessarily effective. We have already noted that formal care services do not necessarily work effectively with informal carers. Lewis (2001) documents long standing barriers between health and social care services in particular. One barrier which differs between England and Scotland is identified by Abbot and Lewis (2002) and concerns free health care and means tested social care, in that personal care, part of social care, is now free in Scotland. The breakdown of this particular barrier might be expected to facilitate integration of services, but there is no clear evidence to support this contention.

4.42 There are many researchers who identify persistent barriers and boundaries to service integration, multidisciplinary working and so on, echoing points we made earlier in Chapter Two. Atwal and Caldwell (2002) identify the limited impact of integrated working in discharge planning in a London hospital. Difficulties of integrating services, and, significantly, for understanding the impact of integration on outcomes for clients, are identified in Brown, Tucker and Domokos' (2003) study of two integrated health and social care teams in rural England. They found that the teams were not in fact well integrated, despite attempts to the contrary, and that it was not possible to identify benefits for clients. Karicha et al. (2004) argue that there is very little robust evidence that formally promoted service integration actually benefits users, and argue that this needs to be more carefully researched. Whilst case study evidence exists in Scotland ( e.g. Black 2002, Cameron and O'Neill 2003, Kydd 2004, Miller 2005, Robertson 2001), and elsewhere ( e.g. Beavis 2002, Hamilton Primrose and Muir 2000, Reed and Stanley 2003) and researchers have presented integration as a "good thing" (Rummery and Glendinning 2000) there are no fully systematic studies. One study of partnership working in England (Rummery 2004a) is in progress. Interim findings suggest that benefits for users remain to be identified.

4.43 Exploring relationships between sectors also reveals difficulties. Coid, Crombie and Murray's (2000) work found inconsistencies between Scottish Health Boards in their work for older people's services with voluntary sector providers on a scale which implied deficiencies in this form of cooperation. Bell and Bowes (2006) demonstrated a consistently ambivalent relationship between local authorities and private care home providers in Scotland. Dewar Tocher and Watson (2003) importantly explore ways of promoting partnerships between formal service providers and informal carers in the context of hospital wards, including the context of case conferences, in which care plans on discharge are discussed. Since the effective provision of personal care may involve a range of formal providers as well as informal carers, better relationships between sectors need further development.

Conclusion

4.44 Community care policy in Scotland has for some time favoured a change in the balance of care towards provision of more care to people in their own homes. The CDG was keen to reinforce this policy:

"To meet increased demand from unmet need and the expected shift from informal to formal care, we strongly recommend that a significant proportion of the available resources should be used for improving the quality and quantity of community services available and that this should be built up over a 3 year period." ( CDG, 2001, p64)

4.45 It allocated £50m in the first three years of the policy to expand the capacity to provide home care. Thus one of the key outcomes of any review of the free personal care policy would be an examination of the success of the policy in shifting the balance of care towards home care.

4.46 The balance of care has an important bearing on the costs of care. The most efficient use of public funding would be to find the lowest cost balance of care that is consistent with providing the quantity and quality of service that older people require. This point is emphasised in Bell and Bowes (2006).

4.47 This chapter has identified a number of gaps in knowledge about the balance of care. The reasons why the care home sector in Scotland appears to be more robust than that in England are not well understood. There is an argument for more detailed exploration of the care home market in Scotland.

4.48 Innovative forms of care, such as extra-care may become increasingly important in the future. It is important that these are quickly incorporated within the framework of community care statistics.

4.49 It is important to form a better understanding of the implications of reducing the provision of low-level care packages, while at the same time substantially increasing the number of hours of care devoted to intensive packages of care at home.

4.50 There has also been increased overnight and weekend provision of care. The implications of these changes for informal carers as well as for those being cared for are not yet well understood.

4.51 Informal carers supply considerably more hours of care than does the formal care sector. There is a need to understand the finding that there has been no drop in informal care following the introduction of free personal and nursing care. It may be the case that informal carers are substituting different forms of caring for personal care. It may also be the case that the switch in the balance of care towards care at home has provided more opportunities for care at home. At present, there is no evidence on how their behaviour has been modified.

4.52 The evidence on the private home care market is extremely sparse. The data have not improved since the CDG report, even though estimates of charges in private homecare were an integral part of the estimates of the costs of the policy.

4.53 The importance of home care commissioned by local authorities, but provided by private providers, has grown massively in England in recent years. Growth in Scotland has been slower with local authorities themselves still providing more than half of the care. (See Table 4.5) There is a need to better understand what factors explain these differential growth rates

4.54 The market for privately purchased/privately supplied personal care is much less well understood. Research conducted by the UK Home Care Association for the Care Development Group suggested that around £10m of personal care was purchased privately in Scotland in 2001. No more recent figures are available on this market, though one might have expected some decline when free public provision of personal care was introduced. Of course, since local authority budgets are not ring-fenced it is not possible to know the extent to which monies were allocated to replacing such private expenditure.

4.55 Similarly, little is known about the private market for domestic care. In contrast to the market for personal care, the market for domestic care may have expanded as local authorities have focussed on more intensive care packages, often involving personal care.

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