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INTRODUCTION & SUMMARY OF RECOMMENDATIONS
"Despite some practical difficulties in its formative years, the Free Personal & Nursing Care policy remains popular and has worked well in the largest part, delivering better outcomes for Scotland's older people."
1. INTRODUCTION
A new approach to paying for long-term care in Scotland
The policy to provide personal and nursing care in Scotland, which is free at the point of delivery and which is assessed according to need, was modelled on the Royal Commission Report "With Respect to Old Age" published on 1 March 1999. The relevant Act was passed by the Scottish Parliament in 2002.
The policy was implemented with expedition, and on the whole the process has gone well; one might even say, granted the constrained timetable, surprisingly well.
A number of factors contributed to this. In the first place there was clear resolve in the Scottish Parliament that this should happen and the resources of the relevant areas of government were marshalled very effectively. Equally important was the response of the local authorities and their social work departments and partners who are to be congratulated on the positive and effective and speedy steps which they took to implement the policies at local and personal level.
They were aided in this by the fact that a significant volume of personal care was already being delivered, and that the relevant structures for assessment and care management were already in place in a number of areas.
These factors were complemented by positive responses from both the private and voluntary sector providers, and the culmination of all of this was a good supportive environment for the policy and its implementation. One response which was less than supportive was that of the Department for Work and Pensions ( DWP) which ruled that Attendance Allowance should be withdrawn from Scots receiving free personal care in a residential setting and that the expenditure savings resulting should fall to DWP, rather than be transferred to the Scottish budget to offset the costs of the policy. The sum in question is now estimated to amount to around £30 million a year.
The policy has proved popular with the people of Scotland. (The number of complaints received by the Scottish Public Services Ombudsman is very low - in single figures per week. By contrast the Health Ombudsman in England has received complaints about the alternative policy there, numbered in thousands, and the NHS has already had to allocate payments in compensation for services wrongly charged approaching £200 million.) Nonetheless, there were good reasons for a Review at this stage. Indeed this was anticipated by the Royal Commission Report which made provision in its recommendations for revisiting the implementation of the policy after 5 years.
Concerns about the operation of the policy
On the one hand, it would be surprising if there were nothing to be learned from the first 5 years of operating such a ground-breaking policy, especially one implemented with speed and resolution. On the other hand, a number of matters of concern have been raised, both by those operating the policy and by those who are its real and potential beneficiaries.
These matters include the following:
- there are questions raised about consistency of provision between different local authorities;
- these concern the use of waiting lists, and the use of differing eligibility criteria from one authority to the next;
- there has been continuing debate about specific issues such as food preparation;
- questions have been raised about the practical implications of the legal ruling in the 'Macphail' case; and
- allowances for residential care have not been raised in line with inflation.
Underlying some of these concerns is the fact that the policy was introduced to a system in which there were already (legitimate) variations in provision of care between different authorities. That is to say, there was not a single level playing field already in place from which local authorities could build at the same speed.
Key Considerations and Messages
Our recommendations, summarised below, might best be viewed in 3 distinct sets:
The first are for action in the short term and among other issues, are intended to address the immediate funding and variability of provision problems.
The uncertainty associated with projecting future costs of long-term care and other factors of uncertainty described in our report, means demand and costs must be reviewed and re-modelled regularly. That coupled with the demographic projections and the rapid growth in the numbers of older people - including growth in the numbers of the "oldest old" and all the implications that will have - mean the position should have the benefit of a further review within 5 years. That review and a wider, holistic review of public funding for long-term care form the second distinct set of recommendations.
If our recommendations are accepted, we believe that - with action to address the funding shortfall which has emerged in the past few years and the problems with variability of provision we describe - the policy can be stabilised and maintained at the level originally envisaged for the immediate future, until the demographics really begin to bite, from around 2013 onwards.
Our conclusions have been conditioned by 2 key factors which require considered thought and careful planning in terms of the period beyond the next 5 years: They are factored into our recommendations for the medium and longer term and are explained in detail in the economic analysis which supports our findings. Briefly, they might best be described as follows:
The first is that we have examined the existing funding streams which support the care of the older members of the population. These are significant in number and we are in no doubt that there is a strong case for co-ordinating them. The sums involved are considerable and are split between those which are matters for the Holyrood Parliament - health, social and personal care and housing support - and those which are matters reserved to Westminster, for example, Attendance Allowances and Disability Living Allowance.
We have recommended that a thorough examination of these be undertaken to ensure consistency of assessment criteria across the range of these allocations, and to consider whether the effectiveness of such a range of allocations could be improved by a more co-ordinated approach to financing the care and support of older people. We believe that comparable questions are under consideration in Whitehall, and this might ease the possibility of fruitful cross-border conversations.
The second major factor which has huge potential impact is the change in the demographic predictions made by the General Register Office for Scotland between the date of introduction of the policy, when calculations were based on the most recent data at that time (1998) and the new data issued based on 2006 figures. Our recommendation here is for a very radical examination of the effects of demographic growth on the nature of the society in which we live. Free Personal and Nursing Care is one proportionately small part of the costs of such potential demographic change.
If change of this kind does take place, much else will need to be taken into account. For example, the costs of health care, the adequacy of current pensions policy and practice, the patterns of work/life balance, changing retirement dates, the availability of sufficient people of working age and fitness, the patterns of housing need, changed transport systems, new patterns of lifelong education and learning, and policies for the current deployment of resources to support appropriate patterns of research expenditure, and so on.
Nothing less than a new vision of the changing nature of such a society and of the possible directions which it might take is required. And that we view as the third set of actions within our plan.
We have time to engage in such an examination of future options. The signs of the need for it are there and for example, most recently the Director of the Medical Research Council identified Demographic Change and Ageing as one of the 3 major issues facing our society. The other 2 were Global Warming and Water Supply. This gives some indication of the research as well as social priorities which we must give to these questions.
In such a context, planning for and funding personal and nursing care is only one element of a much wider picture. In Scotland we have created a base on which such far-sighted discussions may build fruitfully. The adequate provision of personal and nursing care is now part of the way we want to live. We must therefore build it into the mainstream of our planning for the future, and cease regarding it as the sole cost and consequence of demographic change. It is rather like climbing a Scottish mountain. Having reached the vista provided by one horizon we realise that a much larger vista lies before us for which we must prepare.
The Scottish Government is well placed to take the initiative in these matters.
Lord Sutherland
April 2008
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