« Previous | Contents | Next »
Listen
10. SUSTAINABILITY - RE-ALIGNMENT OF COSTS & PLANNING FOR THE FUTURE
"While we believe that the cost of this policy makes it affordable in the short-term, (i.e for the next 5 years)… in the longer-term the impact of demographic change and the rapid growth in the number of older people, which will begin to bite in about 5 years time means a more holistic review of public funding arrangements is called for. "
10. SUSTAINABILITY - RE-ALIGNMENT OF COSTS & PLANNING FOR THE FUTURE
The Review Group recommends that the Scottish Government with COSLA should in the medium-term:
- Review and re-model the costs of long-term care, ensuring these are reflected accurately in future local government finance settlements and capacity planning by local authorities and their health partners.
The Review Group recommends that the UK and Scottish Governments recognise the reality that the demographics and cost profiles present for the future of social care funding and start now to plan for that: Specifically, they should:
- In the medium-term (and certainly within the next 5 years) - in the light of growing demand for long-term care and sharply increasing cost pressures - the Scottish Government should fully engage in discussions with the UK Government on the question of whether the £500 million per annum in public funding for long-term care of older people in Scotland might be better targeted/prioritised to ensure that all those assessed as in need of care services, including personal care, can have those needs met; and
- In the longer-term, Government at all levels should take a comparable sufficiently long-term view of planning for the future shape of our society. It should seek to establish a vision for dealing with the challenge of demographic change, not just for long-term care but also for pensions, employment, housing and other key aspects of public policy.
Introduction
122. The long-term sustainability of the Free Personal and Nursing Care ( FPNC) policy in Scotland was the fourth and most critical strand of our remit. It was the strand which led us to consider a number of practice aspects which on the surface may appear to be beyond our "funding" remit but on further examination, they are clearly relevant if we are to embed and mainstream the policy within the context of broader social care for older people and secure it for the future.
123. Serious concerns over practice issues were raised in much of the evidence we heard. Concerns over issues such as the variation in service provision we see across the country; the use of waiting lists and different eligibility criteria dependent on where in Scotland you live; and inconsistencies in the interpretation of guidance on issues like charging for food preparation are clearly strongly felt. They are affecting the credibility of the policy and are addressed elsewhere in our recommendations and are detailed in Chapters 6 to 8 above. In securing the policy for the long term it will be important to address these practical issues which call into question the fairness and equity of the policy and have often over-shadowed the benefits it has brought about in its early years.
124. However, our examination of the effects of demographic growth and of the broader picture of funding of long-term care has highlighted for us the critical importance of looking forward and setting in train soon the more challenging and radical long-term planning that will be required. It is this forward-looking aspect for the medium to longer-term that we examine in this chapter and which is examined in depth in the economic analysis set out in Chapters 11 to 13 of our report.
Care Development Group's Work
125. The original decision to implement the FPNC policy was taken by the then Scottish Executive and by the Scottish Parliament on the basis that the policy was sustainable into the future. In reaching that decision, the Care Development Group ( CDG), which considered the implications of the policy, emphasised the need to consider FPNC within the much wider overall context of health and long-term social care expenditure.
126. Seven years after the CDG examined the issue in early 2001, we have similarly looked at the future sustainability of the FPNC policy in light of the total costs of long-term care, across health, social care and the benefits system. Experience, even over the years since the policy was introduced, emphasises the uncertainties in predicting future care demands and costs. Over this period there have been significant changes in the demographic projections, in particular for the very elderly population, aged 90+, but also positive developments with technologies such as Telecare, which have the potential to help people live more independently in their own homes for longer, resulting in lower care costs.
Long-term costs and affordability
127. We have also addressed the question of adequacy of the funding in support of the policy and the financial impact it has had on Scottish local authorities but by far the most critical issue and the area which we have spent longest deliberating is the question of long-term costs and future affordability. The person-centred needs based approach adopted by the Scottish Government in the design and delivery of long-term care makes it essential to look beyond the single funding stream of FPNC. Community care services cannot be provided in that narrow way. Care and support needs to be provided in a holistic way and to a degree already is; but in our recommendations we are seeking to take that approach a step further. We outline this in paragraphs 128 & 129 below; but there are a number of other issues or policies, which run beyond our specific remit but which will be important in terms of sustainability and the future of long-term care. Key amongst these are:
Partnership Working/Joint Budgets
127.1 Improving outcomes through joint working remains an important government goal. The Community Care and Health (Scotland) Act 2002 promoted integration in other ways by enabling the delegation of functions, the transfer of resources and the pooling of budgets between local authorities and NHS Boards. We have seen a good deal of progress in that direction in the past few years and the new Scottish Government has said it is committed to improving outcomes through partnership working across organisational boundaries, encouraging health and social care agencies to work together to provide joined-up, community focussed services. The Review Group believes that a greater aspiration towards more joint working and joint budgets will be important for the future. Joint working leads to better outcomes and consequently, outcomes rather than structures and systems drive the agenda. It will be important too in supporting the outcomes based funding model for local government finance, which came into effect on 1 April 2008.
Shifting the balance of care
127.2 Shifting the balance of care to people's own homes and to the community has been a key part of community care policy for some time now and Better Health, Better Care 12 promotes a similar shift in the NHS. More joint services, more intermediate interventions, more self managed care, including greater support for carers and taking the opportunities which technological advances, such as Telecare present will all be important to the long-term goal of supporting people at home for as long as possible, optimising their quality of life and giving them choices.
127.3 We heard strong evidence on the effective use of Telecare, which covers a range of devices and services available to people in their home to help them live with greater independence and safety and on its benefits in alleviating pressure on systems and ensuring that resources are more effectively targeted and deployed where they are most needed. Equipment and adaptations also play a vital role in supporting community care policy and enabling people to live independently and can provide cost effective alternatives to other care at home services. The Review Group noted that these would be important support options in terms of the re-alignment of resources to meet the demand for long-term care in the future.
Self-directed support
127.4 The new Scottish Government has said it is committed to modernising services to achieve better results. Part of the policy agenda it is pursuing is about empowering individuals and that includes a commitment to increase the take-up of Self-directed support (formerly known as Direct Payments) for those eligible, including older people and those in receipt of free personal care. It provides individual budgets for people to buy their own support packages to meet their assessed personal, social and health care needs. Practice currently varies across local authorities in the extent to which health resources have been integrated into self-directed support packages and work has recently taken place to examine barriers to up-take and practical solutions. That led to the issue of new national guidance last summer and 2 working groups are now looking at different aspects of how to improve local access to Self-directed support for eligible people.
Housing
127.5 The importance of appropriate housing services and joint working with housing partners in support of care at home was recognised by the Review Group. The Royal Commission had recognised in its work that existing established models of provision, care homes and sheltered housing, which combine accommodation and care were unduly limiting and was keen to encourage the development of "innovative housing schemes", involving forms of assisted living.
127.6 New more flexible, person-centred models combining care and accommodation were being, and continue to be developed with a range of aims, such as promoting independence, reducing social isolation, providing an independent home, improving health status and well-being, all within a framework of cost-effectiveness. The Review Group noted there had been some modest growth in this type of provision in recent years, with the new models developed to provide housing with care for older people known as "Extra Care Housing" or "Very Sheltered Housing". It noted the important and growing contribution these were adding to the range of options for caring for frail and vulnerable older people in forms which are attractive to them. While they do not generally cater for a population with a dependency profile identical to care homes there is a significant overlap and the review group considers that increased levels of provision would make an important contribution to the maintenance of independence and dignity of many older people.
Demand for Care
127.7 The Review Group heard evidence on the importance of capacity planning and noted the wide variation in practice across local authorities. The Chief Social Work Inspector highlighted this in her evidence to the Group, noting that the most progressive of local authorities and their health partners had range and capacity plans in place and overall there was an increasing sophistication in approach but that there were still a number of areas where the focus in commissioning was still on driving prices down with no eye to the changing needs of the client group.
127.8 The Review Group considers that effective planning and commissioning arrangements are crucial to delivering effective services and ensuring that people are provided with the right service at the right time and in the right place. And that these will be all the more important in the light of the future cost projections for long-term care we have outlined in Chapter 13. It noted the work of the Scottish Government's Joint Improvement Team in developing tools to assist partners in these processes.
Supply of Care
127.9 Workforce and staffing issues for the care sector were raised in evidence offered to the Group and mainly centred on training and recruitment and retention of staff and the implications of the ageing demography on the working population and the ability of the sector to compete for staff to provide personal care, both in care homes and in the community. Some local authorities said that their difficulties with workforce issues impacted on the provision of FPC services within a particular timeframe and that delivery problems were not always about financial resources. The need to tackle such issues, which may be constraining the delivery of FPC already in line with the growing demand for care and are likely to have a much greater impact in the future, was highlighted in the Hexagon Evaluation and other recent research. The Review Group noted its concern about this and the impact workforce issues may have on the quality of care available to some of the most vulnerable people in society and recommends that the Scottish Government and local authorities do not lose sight of this issue as an important element in the broader development of community care policy.
The need to review and re-model within the next 5 years
128. While we believe that the cost of this policy makes it affordable in the short-term, (i.e for the next 5 years) - and addressing the immediate funding and variability of provision problems will make it viable - in the longer-term the impact of demographic change and the rapid growth in the number of older people, and indeed of the "oldest old", which will begin to bite in about 5 years time means a more holistic review of public funding arrangements is called for. The demographic situation is clearly illustrated in Figure 2(Percentage Change in Population Projections for those Aged 65+, 1998 to 2006) in Chapter 13 below.
129. There are other uncertainties associated with projecting future costs and these are also examined in detail in Chapter 13. Whilst work with the UK Government on a more holistic review of public funding needs to commence within that 5 year period, we will also need to review and re-model to take account of the other uncertainties described and in the light of the impact of the shorter-term actions to address the funding and practice problems which we are recommending to Ministers to stabilise the policy.
Broader reviewing of public funding
130. Within the next 5 years there needs to be a closer and much more radical examination of the total costs of care provision and some difficult and probably politically unpalatable decisions on prioritisation will likely be called for, in Scotland and across the UK as a whole. Free Personal Care is a relatively small component of a complex system of care and of the total costs of care and even if the policy were abandoned tomorrow the future costs of long-term care are still likely to increase significantly.
131. In Scotland, the bulk of provision of long-term care for older people is provided by local authorities but there are other funding streams of significance, including around half a billion pound a year paid directly by the Department for Work and Pensions. Rising costs and the pressure of the demographics on social care budgets make a strong case for careful re-examination of all the funding streams supporting social care in Scotland and for possible realignment to ensure that support is effectively targeted towards those with greatest need. Chapter 12 looks at these costs, which in 2005-06 amounted to £2.296 billion; which is equivalent to 8.6 % of 2005-06 Scottish Total Managed Expenditure (i.e. the Aggregate Budget of the Scottish Government) with around £1 billion of that coming from Scottish local authorities.
132. Chapter 13 looks specifically at modelling the costs of long-term care for Scotland and although there is inevitably the element of doubt and uncertainty about making care cost projections the estimate shows those costs rising to £3.3 billion by 2016 and to £4.1 billion by 2021. That surely cannot be afforded without the more holistic re-examination and re-alignment of costs we refer to above.
A more radical vision for the future
133. In the longer-term, the consequences of the demographics will reach far beyond this policy and require much greater transformation of long-term planning and policy making. They will have a huge potential impact on many areas of public policy and expenditure, such as health care, pensions, housing, transport, social security and benefits. Many of the issues will be reserved to the UK Government and will call for careful futures planning by government at all levels. But in addressing the shorter-term issues the Scottish Government needs to keep in sight the need to plan for the future shape of our society and establish a new vision for dealing with the many challenges that presents.
« Previous | Contents | Next »