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This research was commissioned by the Scottish Executive to evaluate the operation and impact of Free Personal Care ( FPC) in Scotland. The evaluation was carried out between February 2006 and January 2007 and was informed by a wide range of qualitative and quantitative evidence.

Main Findings

• FPC has achieved its primary aim to remove discrimination against older people who have chronic or degenerative illnesses and need personal care by bringing their care into line with the principle of free medical and nursing care in the NHS.
• Public awareness and understanding of FPC is low. There is strong public support for the principle of FPC. A majority of people believe that frail older people should be "offered FPC to help them continue living in their own home, as long as they choose, whatever the cost to the public purse."
• The process by which an individual moves from first contact with the local authority (referral) through to delivery of services (or payment) works well in the vast majority of cases. However there is large variation across Scotland in key aspects of the operation of FPC.
• FPC has helped to support unpaid carers in their caring role. The majority of service users are positive about their experience of receiving FPC and the dedication of care staff. Concerns focused around the length of time allocated to specific tasks, the timing of services and lack of flexibility in the way services are delivered.
• Very little, if any systematic research has been carried out by local authorities to assess unmet need/ demand for FPC. There may be some unmet need for FPC amongst older people who are cared for by unpaid carers.
• The vast majority of people have received FPC services/ payments without undue delay or complication. However, the evaluation found people waiting for assessments and FPC services/ payments following assessment in a number of local authorities.
• Waiting is mainly due to staff vacancies, a shortage of care home places, user choice, or issues related to service capacity. Only four local authorities directly attributed waiting to insufficient funding.
• There have been different interpretations by local authorities of what is meant by 'assisting with the preparation of food' leading to different policies on charging for food preparation.

Introduction

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. Although FPNC is usually referred to as a single policy it is important to distinguish between its two elements:

• For people at home: where the local authority provides care services to people who have been assessed as requiring them, it does not charge for those particular services detailed in the Community Care and Health Act 2002.
• For people in care homes who pay their own costs: the local authority provides payments of £145 and where appropriate £65 per week to care homes on behalf of the resident for the cost of the personal and nursing care they receive in the care home.

Personal care tasks not to be charged for include help with bathing and washing, help with managing incontinence, assistance with eating and preparing food, help with getting up from/ going to bed and help with simple treatments.

The Evaluation

The evaluation sought to assess the operation of FPC across Scotland and included specific objectives focussing on those areas where improvement may be required in order to enhance the delivery of FPC to elderly people.

Methodology

This evaluation was informed by a wide range of evidence collected between February 2006 and January 2007:

• A detailed review of existing research
• Interviews with representatives of national organisations with an interest in FPC
• A survey of all 32 Scottish local authorities requesting information on policies, procedures and statistics
• A telephone survey of 1,000 members of the public across Scotland and a postal survey of 4,000 unpaid carers or people aged 65 or over
• Six case studies ¹ involving interviews with over 130 service users and carers, 120 managers and frontline staff and a postal survey of independent sector care homes and home care providers
• A Stakeholder Workshop attended by 40 representatives from over 20 organisations.

The four stages of FPC

APPLICATION

Public awareness, understanding and support for FPC

Two thirds of people have 'not heard of' or 'know nothing about FPC', whilst just over 30% have 'heard of FPC' and claim to 'know a little or a fair amount about it.'

People generally have a low understanding of the operation of the policy and of what services are covered by FPC.

There is strong support for personal care being provided free without means testing. A majority of people (over 60%) support the concept of frail older people being 'offered FPC to help them continue living in their own home, as long as they choose, whatever the cost to the public purse.'

The application process and referrals

Apart from care home residents who are meeting their own care costs (self funders) people do not apply for FPC. Elderly people living in the community or being discharged from hospital are referred, or refer themselves, for a care assessment that may result in the provision of personal care services or placement in a care home with FPC/ FNC payments.

The NHS (primary and acute care) is a major source of referrals for care assessments. There is no evidence to suggest that the source of referral has any bearing on outcome.

Groups not applying for FPC

Very little, if any, systematic research has been carried out by local authorities to assess unmet need/ demand for care services either among the general older population or within specific vulnerable groups such as black and minority ethnic groups. The generally held view among local authorities is that: "by and large the community care system is picking up people who are eligible for support." However, a significant proportion of unpaid carers provide personal care for older people who do not receive FPC, suggesting that there may be unmet need for FPC amongst older people who are cared for by unpaid carers.

ASSESSMENT

The assessment process

Local authorities screen referrals to prioritise assessments and ascribe target times to their completion according to factors such as risk and complexity. Target times vary considerably across Scotland.

Local authorities use a range of different assessment tools but there is no evidence to suggest that the assessment tool used has any impact on whether/ how FPC is provided.

From the perspective of service users and carers, their relationship with the professional carrying out the assessment is more important in determining their satisfaction with the process than the assessment tool used.

Delays in assessments

A number of definitional and data collection issues need to be resolved before a robust measure can be provided of the number of elderly people waiting for assessments, or of the time taken to complete them.

However, around half of Scotland's local authorities reported having people waiting for assessments to be completed, mainly due to a lack of staff to meet the demand for assessments. No local authority reported that assessments are being delayed because of funding pressures on their budget for providing FPC.

Local authorities use a number of approaches to reduce the number of people waiting for assessments and to manage waiting lists, including: screening and prioritising referrals, reviewing and monitoring waiting lists, reviewing services and restructuring social work teams.

Improving the assessment process

The assessment process generally works well. However there are legitimate concerns about delays in completing assessments in some areas. Full implementation of Single Shared Assessment ( SSA), the principal means by which care assessments are undertaken, should improve the speed and effectiveness with which assessments are carried out.

PROVISION

Prioritising service provision

More than half of Scotland's local authorities have a threshold for determining whether an assessed need will be met by the provision of care services. Although in most local authorities people with personal care needs will be in priority categories, some local authorities may restrict access to FPC services for people if their personal care needs can be (and are being) met by carers or other service providers.

Delays in delivering FPC

Differences in eligibility criteria between local authorities mean that it is difficult to collect comparable data on the number of people waiting for local authority provided FPC services. A snapshot survey of local authorities carried out in December 2006 found the following totals of people waiting six weeks or more for FPC/ FNC payments or the delivery of FPC services following an assessment of need:

• 38 self funders in care homes (in six councils) waiting for FPC/ FNC payments to be provided
• 192 self funders (in 20 councils) requiring FPC/ FNC in a care home waiting for a care home place and payments to begin
• 31 people ready for discharge from hospital (in 10 councils) waiting for FPC services to be put in place at home
• 391 people (in nine councils) waiting for any FPC services to be delivered at home
• 13 people (in four councils) waiting for Direct Payments for FPC services.

Lack of vacancies in care homes is the main reason reported by local authorities for people waiting for a care home placement following an assessment.

Lack of capacity to provide personal care services at home, either in the location or at the specific time of day requested, was reported as the biggest factor contributing to people having to wait for all or part of their care package to be delivered. People waiting for local authority FPC services were having their personal care needs met by informal carers and other service providers. The majority of people waiting for services were already receiving some personal care services from the local authority.

Four local authorities directly attributed delays in service provision/ payments at the time the latest survey was carried out to a lack of available funding.

Limiting or 'capping' care packages

Nine local authorities operate a 'cap' or limit on home care packages and a further five local authorities operate a formal process to review the cost of home care packages that reach a threshold level. Caps on home care packages are usually set at around the gross cost of a care home place. Local authorities apply caps flexibly by reviewing each case on its merits and trying to accommodate the needs and wishes of the client and family.

Although operating caps on home care packages goes against the view that frail older people should be supported to live in their own homes for as long as possible, it is in line with guidance that local authorities have to take account of "the availability of resources and services for meeting needs" when drawing up care packages.

Involving carers and offering choice

Few formal Carers' Assessments are being carried out. A significant number of carers interviewed for the evaluation were concerned that their views and needs were not always taken into account and reflected in care plans.

Local authorities are not required to offer choice to service users and carers and offer limited choice to users and carers about the type and level of service and who will deliver it. However, the level of choice that can be offered is often constrained by lack of service capacity particularly in more rural areas and at peak demand periods.

Contractual arrangements

The majority of self funders in care homes are on Route 2 contracts (whereby the resident contracts directly with the care home and the local authority pays the FPC/ FNC payment to the care home). Local authorities prefer Route 2 contracts since it reduces their liability and is simpler for them to administer. Care homes also prefer Route 2 contracts since it gives them greater flexibility in setting charges. Care homes are reluctant to accept Route 3 contracts (whereby the local authority contracts with the care home on behalf of the resident).

The research suggests that self funders and their relatives may not be given sufficient information to allow them to make informed choices about contractual routes.

REVIEW

Monitoring and reviewing individuals' needs

In line with guidance on care assessments, all local authorities have policies in place for monitoring and reviewing individuals' needs and target times for undertaking scheduled reviews. However, there is no national monitoring of whether reviews are carried out as scheduled within target times. Local authorities that have people waiting for assessments are also likely to have problems completing reviews of cases and 'non-urgent' reviews are sometimes delayed.

The evaluation found mixed views from users and carers about whether their needs are being reviewed regularly enough and whether the monitoring and review process is effective in identifying and meeting additional needs.

Monitoring and evaluating FPC

Whilst local authorities do produce substantial amounts of statistics for the Scottish Executive on aspects of home care, these statistics provide only a partial picture of the operation of FPC. A large number of local authorities still lack community care information systems that can readily produce robust statistical information on key aspects of the implementation of FPC such as numbers of people waiting for services, unmet need, and the level and type of support provided by unpaid carers.

Although the development of Local Improvement Targets has driven significant progress towards an outcomes focus in Community Care, there continues to be wide disparity of performance across Joint Future Partnerships.

The impact of FPC

Informal care

Just over half of the carers who responded to the evaluation's postal survey said that FPC has not affected the type or level of care they provide. A quarter said that they provide the same level of care but have changed the type of care they provide. Almost a fifth of carers said that FPC has allowed them to reduce the amount of care they provide.

Qualitative evidence from interviews with users and carers suggests that FPC has generally helped unpaid carers in their caring role by freeing them from tasks such as bathing. This has enabled them to continue caring in other ways.

Balance of care

There has been a substantial increase (74%) in the number of older people receiving FPC since it was first introduced and a shift in the balance of publicly provided care from non-personal care to personal care.

The provision of personal care is very important in helping older people stay in their homes longer. However, FPC is only one element of a holistic approach to care along with informal care, domestic care, the provision of equipment and adaptations and housing support required to assist people to stay in their homes longer and shift the balance of care from residential to home care.

Care providers

There are major differences in care home capacity across Scotland. Lack of care home vacancies in some areas has led to people waiting for care home places and FPC/ FNC payments.

Some local authorities have introduced a third band of payment for local authority funded care home residents to recognise the additional costs of providing augmented care that falls short of nursing care but is greater than basic personal care.

There has been a substantial increase in the size of the independent home care sector across Scotland since 2002, but local authority provision still dominates the market. Some local authorities continue to rely almost wholly on in-house provision of home care.

Mixed markets of home care provision, where local authorities rely on independent sector providers for a significant proportion of home care services, have generally developed in an unplanned manner without options appraisal or competitive tendering. Sourcing care providers, especially for complex packages of care involving services being provided at evenings and weekends or in remote locations, can be a resource intensive process.

There are particular problems in recruiting home care workers or sourcing independent home care providers to provide services in rural areas and islands.

Quality of care

The majority of service users interviewed for the evaluation were generally very positive about their experience of receiving FPC.

Users' and carers' concerns about the way home care services are provided centred around the length of time allocated to providing specific tasks, the time at which services are provided, and lack of flexibility and continuity in delivering care packages.

Potential barriers to the sustainability of FPC

Guidance

Different interpretations of the guidance on 'assisting with the preparation of food' have led to local authorities adopting different policies on charging for food preparation. The Scottish Executive has provided guidance but most local authorities still believe there is ambiguity about which services should be provided free of charge.

Assistance with medication is another area of the guidance that some local authorities have suggested should be clarified.

There is a strong view amongst local authorities that the guidance on FPNC lacks clarity on the key issue of whether/ how local authorities are able to take resources issues into account in determining access to care services and FPC.

Staffing/ Workforce issues

Staffing and workforce issues are a major constraint on how FPC is being delivered. Shortages of staff have contributed to delays in assessments and in the delivery of home care services, and inefficient working practices and staffing structures have restricted home care services' ability to meet demands for services.

Relationship with the NHS

The relationship between local authorities and their NHS partners is a crucial determinant of how FPC operates now and in the future. Three issues need to be considered: the interface between personal and nursing care, the need to implement SSA, and funding, principally 'resource transfer'.

Conclusion

The vast majority of FPC recipients have received their FPC payments or personal care services without undue delay or complication. However, the evaluation did identify some problems in relation to key aspects of the operation of FPC and found that there is large variation across Scotland in relation to both the implementation and operation of FPC.

A fundamental issue that needs to be resolved by policy makers is whether FPC is a national policy that aims to deliver the same range and quality of services across Scotland; or whether local authorities should continue to be given discretion in how they deliver FPC, taking into account their financial resources.

If it is the former, this will require the establishment of national criteria for prioritising access to services, national target times for assessments to be completed and services to be delivered; and national guidance on whether the cost of home care packages can be capped.

If it is the latter then there will have to be an acceptance that access to care services and FPC may differ across Scotland depending on local policies and practices and the level of resources available in individual local authorities.

As with any other policy that involves public expenditure, the future sustainability of FPC depends on ensuring it is adequately funded.

A list of recommendations arising from the research is contained within Chapter 8 of the full report.

1 Angus, Argyll and Bute, Dumfries and Galloway, Edinburgh, Stirling and West Dunbartonshire.

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