The Scottish Government

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CHAPTER ONE INTRODUCTION

Free Personal and Nursing Care

1.1 In January 2001 the Scottish Executive announced its intention to introduce free personal and nursing care ( FPNC) for people aged 65 and over. It established the Care Development Group ( CDG) to advise on the introduction of FPNC within the context of the wider agenda around services for older people and the recommendations of the Royal Commission on Long Term Care. ³

1.2 The CDG's final report, 'Fair Care for All' ⁴ provided the 'blueprint' for the introduction of FPNC based on over 40 recommendations, covering issues such as the definition of personal care, resourcing and payment arrangements.

1.3 The aim of FPNC, as outlined in the CDG report, is to remove discrimination against older people with chronic or degenerative illnesses who need personal care by bringing their care into line with the medical and nursing care in the NHS, where the principle of free care based on need is almost universally applied and accepted.

1.4 The CDG's report was accepted by the Scottish Executive, and its key recommendations were incorporated within the Community Care and Health (Scotland) Act 2002.

1.5 Although FPNC is usually referred to as a single policy it is important to distinguish between the two elements. In relation to FPNC, the Act, which came into force on 1 ^st July 2002, made provision for:

1.6 The definition of personal care for the purposes of the 2002 Act was laid out in the Regulation of Care (Scotland) Act 2001 which states in Section 2(28);

In this Act, unless the context otherwise requires:

"personal care" means care which relates to the day to day physical tasks and needs of the person cared for (as for example, but without prejudice to that generality, to eating and washing) and to mental processes related to those tasks and needs (as for example, but without prejudice to that generality, to remembering to eat and wash)."

1.7 The personal care tasks that are not to be ' ordinarily charged for' are detailed in Schedule 1 of the Community Care and Health (Scotland) Act 2002 (see Appendix 7) and in summary include:

1.8 Detailed guidance on the Act was issued by the Scottish Executive in stages in 2002. Consolidated Guidance on Free Personal and Nursing Care was issued in July 2003. ⁵

The Evaluation of the Operation and Impact of Free Personal Care

1.9 This evaluation is the second of a two stage strategy adopted by the Scottish Executive to evaluate the implementation, operation and impact of Free Personal Care ( FPC) in Scotland.

1.10 The first stage of the strategy (referred to as 'the Baseline Study') was carried out by the University of Stirling. It involved collating and reviewing evidence relating to FPC and setting the implementation of FPC within the broader policy context ⁶.

1.11 The Scottish Executive commissioned Hexagon Research and Consulting and associates in February 2006 to undertake the second stage of the evaluation.

1.12 This evaluation of FPC was commissioned to provide information on its operation and impact and to set out how the policy could be further developed to deliver cost efficient and high quality Free Personal Care for older people in Scotland.

1.13 The research examined the four key stages of the operation of FPC:

• the application process
• the assessment process
• the provision of FPC and care services
• reviewing and monitoring FPC.

1.14 An additional objective was to evaluate the impact that the FPC policy has had on:

• informal care
• the balance of care
• care providers, the broader care sector and the range and availability of care services
• the quality of care received.

1.15 The funding and cost of FPC was not within the remit of this evaluation as the Scottish Executive has established a working group to analyse the cost of FPC and the wider costs of care for older people at a national level.

1.16 This report broadly follows the four stages of operation of FPC ( Chapters 2 - 5) and then considers the impact of FPC on key issues ( Chapter 6) and the potential barriers to the continued sustainability of FPC ( Chapter 7). Chapter 8 brings together the report's conclusions and recommendations.

Methodology

1.17 This evaluation was informed by evidence from a range of sources. More detailed information on the methodology is provided in the Appendices to this report.

Review of existing research

1.18 As well as the Baseline Study, other recent research into the operation of FPC provided background information and evidence including:

• Commissioning Community Care Services for Older People⁷
• Older People and Community Care in Scotland: A Review of Recent Research⁸
• Financial Models of Care in Scotland and the UK. ⁹

1.19 In addition, the Scottish Parliament's Health Committee carried out an inquiry into Community Care issues including the implementation of FPC. Its deliberations and findings ¹⁰ have also been considered in this evaluation.

National stakeholder interviews ( Appendix 1)

1.20 Sixteen representatives of organisations with a national and strategic overview of the implementation of FPC were interviewed at an early stage of the evaluation. Their comments and views informed the research framework adopted for the primary research.

Survey of Local Authorities ( Appendix 2)

1.21 A three part survey was issued to all 32 Scottish local authorities:

• A request for background information related to policies and procedures for implementing FPC
• A questionnaire seeking information and views on key policy and practice issues
• A brief survey requesting up-to-date statistical information on FPC .

1.22 The survey achieved a 100% response rate, although some of the information requested, in particular some statistical data, was not provided by all local authorities.

1.23 In addition, a survey asking local authorities for details of the number of people waiting for FPC payments, personal care services or Direct Payments following assessment was carried out in December 2006.

Public Attitudes Surveys ( Appendix 3)

1.24 Two public attitudes surveys were carried out in July 2006. These included a telephone survey of 1,000 members of the general public across Scotland ¹¹ and a postal survey of 4,000 people who were either aged 65 or over or acted as unpaid carers. One thousand three hundred and twenty seven people responded to the postal survey (a 33% response rate). ¹² Both surveys asked a core set of questions on public awareness and attitudes to FPC. In addition the postal survey asked questions specifically relating to older people's and carers' experience of FPC.

Case Studies ( Appendix 4)

1.25 In-depth case studies of the implementation, operation and impact of FPC from the perspective of local authorities, service users and their carers were undertaken in six local authority areas:

1.26 The case study areas were chosen to reflect a broad spectrum of local authorities reflecting differences in geography, policy and practice.

1.27 In each area a range of local authority officers with strategic, operational or frontline involvement in implementing and providing FPC services were interviewed, along with home care service users, care home residents and unpaid carers and relatives.

1.28 A survey of independent sector home care providers and care homes in the six areas was also undertaken.

Stakeholder Workshop ( Appendix 5)

1.29 Towards the end of the primary research stage of the project an early findings paper outlining the main findings to date and highlighting some of the key challenges arising from the research was produced as the basis for discussion at a Stakeholder workshop. The workshop was attended by 40 representatives from 20 local authorities, and a range of national organisations including the Scottish Executive, COSLA, the Care Commission and voluntary organisations such as Alzheimer Scotland and Capability Scotland.

The Operation of Free Personal and Nursing Care

1.30 Free Personal and Nursing Care ( FPNC) is the means by which local authorities, supported by the Scottish Executive, pay for the cost of personal and nursing care for people aged 65 and over. They may be living at home (where the local authority is responsible for providing personal care services) or in a care home (where the local authority is responsible for making payments for personal and/or nursing care).

1.31 Eligibility for, and access to, FPNC is subject to an assessment of need and risk. This is governed, not by the Community Care and Health (Scotland) Act 2002, but by previous legislation (principally, the Social Work (Scotland) Act 1968 and the National Health Service and Community Care Act 1990) and related guidance on Assessment and Care Management ( SWSG 11/91 and SWSG 10/98) and Single Shared Assessment ( CCD 8/2001).

1.32 The process by which someone accesses FPNC is illustrated in the flowchart below which highlights the key stages from referral through to review. The processes identified in the flowchart will be discussed in greater detail in the proceeding chapters.

Flowchart 1: The Operation of FPC - Routes into Care Services

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