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4. ORIGINAL VISION & POLICY INTENTION
The Vision - The Royal Commission
20. The Royal Commission on Long-Term Care had a remit to examine options for a sustainable system of funding of long-term care for older people, both in their own homes and in residential settings, with particular regard to how costs should be apportioned between public funds and individuals.
21. The Commission concluded that doing nothing with respect to the system in place at that time was not an option. The system was too complex and provided no clarity as to what people could expect; and that it too often caused people to move into residential care when that might not be the best outcome for them. It noted that although help was available to the poorest, the system led to the impoverishment of people with moderate assets before they got any help and there was a degree of fear about the system which was concerning in a modern welfare state; that it was riddled with inefficiencies and that the time had come for modernisation.
22. In recommending a way of paying for long-term care, which brought improvements in the short-term and which was also affordable and sustainable, the Commission adopted 3 key principles:
- Responsibility for provision should be shared between the state and individuals - the aim being to find a division affordable for both and one which people could understand and accept as fair and logical;
- Any new system of state support should be fair and equitable; and
- Any new system of state support should be transparent in respect of the resources underpinning it, the entitlement of individuals under it and what it leaves to personal responsibility.
23. In its proposals it recommended that nursing care should be provided free in all settings - thereby removing the anomaly and inequity that existed at the time whereby nursing care was provided free in hospital, residential home, or in the community but charged for in nursing homes. That recommendation was accepted and was subsequently implemented by all 4 UK Administrations.
The Policy - Scottish Executive's Response to the Royal Commission
"We are honouring our pledge to the people of Scotland to provide better, fairer care for our older people, now and in the future." "As an Executive, we have made clear consistently our determination to ensure that the people of Scotland are provided with dignity, security and support in their old age. We have consistently backed that commitment with action, investment and, where necessary, legislation."Minister for Health & Community Care, 26 September 2001
24. The Scottish Executive accepted most of the Royal Commission's recommendations and agreed with the underpinning principles of fairness and equity upon which they were based. Its October 2000 response announced plans to give practical effect to the recommendations and a 3 year investment package, which in addition to the provision of free nursing care (regardless of where a person received that care), included: A huge expansion of care for people in their own homes; targeted investment to tackle delayed discharge and to prevent unnecessary admissions to hospital or care homes; investment in aids and adaptations; measures to enable more people to retain their homes upon entering a care home; joint management of budgets and services; and greater equity of charging.
25. The Royal Commission identified 3 broad components of charging for care in a care home: nursing care, personal care (see definitions below) and accommodation and related costs, often referred to as "hotel charges". It said that nursing care should be provided without charge; personal care should be available after assessment, according to need and paid for from general taxation; and the other components should be subject to a co-payment according to means.
"Nursing care" was thought to be an internationally recognised concept and as such the Royal Commission did not offer a detailed definition of its meaning. It referred to "nursing care" as "care which involves the knowledge or skills of a qualified nurse". The Regulation of Care (Scotland) Act 2001 set out a list of services defined as "care services" which includes "nursing" provided at home and in care homes.
The Royal Commission defined "personal Care" to mean care needs which give rise to the major additional costs of frailty or disability associated with old age. Specifically it defined Personal Care as covering all direct care related to:
- Personal toilet (washing, bathing, skin care, personal presentation, dressing and undressing);
- Eating and drinking (as opposed to obtaining and preparing food and drink);
- Managing urinary and bowel functions (including maintaining continence and managing incontinence);
- Managing problems associated with immobility;
- Management of prescribed treatment (e.g. administration and monitoring medication), and
- Behaviour management and ensuring personal safety (for example, for those with cognitive impairment - minimising stress and risk).
The definition was later endorsed by the Care Development Group and broadly adopted by the Scottish Executive. The detailed definition it was to adopt was set out in the Regulation of Care (Scotland) Act 2001 and subsequently used in the Community Care and Health (Scotland) Act 2002. Schedule 1 of the 2002 Act set out a detailed list of personal care tasks to be "ordinarily charged for".
A Step Further - Free Personal Care
26. The Scottish Executive did not initially accept the Commission's recommendation to provide free personal care as assessed on the basis of needs, preferring instead to adhere to a policy of targeting effort and resources to deliver the maximum possible benefit for the maximum number of people and particularly those in greatest need. However, as it developed its implementation plans to introduce free nursing care, pressure grew to implement the Royal Commission's recommendations in full; even though doing so would not make long-term care entirely "free" as people would still have to pay for their accommodation and related costs and would not address specifically the problem of people eventually having to sell their own homes to pay for care if their assets exceeded the upper capital limit.
27. The shorthand reference to "free care" for older people which began to be used commonly at this point was misleading and has continued to cause great confusion. The main practical affect of making personal care free of charge, would be to reduce the cost of care for the 7,000 or so Scots in residential care who were "self-funding" and in so doing, remove the anomaly between health care, which was free and personal care which was means-tested.
28. In taking forward its plans to give practical effect to the recommendations of the Royal Commission on the provision of free nursing care the Scottish Executive announced that it would look to the nursing profession to ensure that arrangements for the required assessments for that care were based on individual need and invited the Chief Nursing Officer ( CNO) to lead the work. The CNO's report 2 of January 2001 recommended a person-centred, needs based approach, which was different to that developed for assessment and implementation of free nursing care in England. Significantly, it blurred the distinction between "nursing care" and "personal care", recognising that individuals had different levels of dependency often resulting in a complex mix of care needs.
29. The political pressure for Ministers to take a distinctive Scottish approach under the devolution settlement and implement the Royal Commission's recommendations in full, grew in the period October 2000 (when the move to remove nursing care charges was announced) to January 2001 and on 25 January 2001 Ministers announced the move to extend plans to include the provision of free personal care for Scotland's older people.
Care Development Group
30. The implementation of free personal care for Scotland's older people and the associated costs and implications, including the interaction with free nursing care, were taken forward by the Care Development Group, which was Chaired by the Deputy Minister for Health and Community Care. It was asked to "bring forward proposals to ensure that older people in Scotland had access to high quality and responsive long-term care in the appropriate setting and on a fair and equitable basis". The Care Development Group was asked to have regard in its work to 3 key principles:
- Priority to be given to those in greatest need;
- Greater equity in standards and levels of care and charging across Scotland; and
- A person-centred approach to the design and delivery of care, based on need.
31. The Care Development Group had begun its work against a broad background of change in the way in which health and social care services were delivered in Scotland. In the past 15 years care has increasingly moved from an institutional base to one of personalisation. 3 The Government's policy has been to continue this shift in the balance of care, providing care and treatments nearer to people's homes, wherever possible.
32. That shift had begun to take effect in the early 1990's; there was a move towards a single shared assessment process to streamline the way in which individuals' needs for care were assessed; and the direct payments scheme had been expanded to allow payments to be made to anyone over 65, to allow them to determine how they wished to spend payments providing for their care. A major and pressing issue at the time was that of delayed discharge from hospitals, with older people who no longer needed NHS care occupying hospital beds and being denied the individual care more appropriate to their needs.
33. The Care Development Group's conclusions 4 were published in September 2001 and the Scottish Executive accepted its recommendations in full. The Group endorsed the Royal Commission's distinction between the 3 elements of care - nursing care, personal care and living costs and its recommendation that the costs of care should be a shared responsibility between the state and individuals, with self-funders continuing to meet their own living costs in residential care. The Group's report stated that free personal care was right in principle because it removed the discrimination against older people who had chronic or degenerative illness and needed personal care in line with medical and nursing care in the NHS, where the principle of free care based on need was almost universally applied and accepted.
34. The Executive announced in September 2001 that as of April 2002, FPNC would be provided for all Scotland's older people. In doing so, it said it was honouring its pledge to provide fairer care for older people and accepted the definitions and principles which underpinned the Royal Commission's and Care Development Group's reports. The implementation date of 1 April 2002 was later deferred to 1 July 2002 due to the complexities of setting in place the necessary administrative arrangements and due to the need to address the further complication which had arisen in relation to the Department for Work and Pension's stance on Attendance Allowance for those in residential care (examined in Chapter 9 below).
35. FPNC was implemented as part of a much wider package of measures and investment aimed at improving care services for older people and designed to promote independence and choice and which as a whole, have been instrumental in the improvements in long-term care which we see today. The policy has seen us much more successfully meeting the needs of those individuals with more complex care needs, enabling many more of them to remain in their own homes, living as independently as possible, for as long as possible.
36. In the first 3 years of the policy alone there was a 62% increase in the provision of FPC at home. That is a significant achievement but the consequential and rising costs are significant and that is examined in detail later in this report. We also heard evidence from front-line social workers and others to the effect that the policy has also helped to de-stigmatise social care and that it has helped to drive the development of wider reforms, such as shifting the balance of care, which are improving outcomes for those using community care services.
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