INDEPENDENT FUNDING REVIEW OF FREE PERSONAL & NURSING CARE, Evidence Gathered
Summary of Written and Oral Evidence: Gathered During the Review.
1. In line with its remit, the Independent Review Group agreed at its first meeting to maximise the use of the sizeable body of evidence already available on the operation of the Free Personal & Nursing Care policy in Scotland and in particular the relevant aspects of:
¨ The report of the Parliament's Health Committee's Care Inquiry, published in June 2006 and the Scottish Executive's response;
¨ The Hexagon Evaluation of Free Personal Care, published in February 2007, and the Scottish Executive's response;
¨ The work of the Care Costs Sub-group; and
¨ Other recent research findings, such as the work of the Joseph Rowntree Foundation.
2. It did not feel it was necessary to ask bodies or individuals to recount evidence already offered in previous reviews or studies as it would have regard to that evidence anyway. The Group also sought to avoid duplicating the work of Audit Scotland (which was carrying out a post legislative study into the operation and impact of the policy) and an early meeting with the Auditor General secured agreement on the practical arrangements for the 2 projects and in particular the sharing of the data which Audit Scotland would be collecting from local authorities in respect of their expenditure on the policy since it was introduced. In terms of the impact of the policy on older people, the Review Group also had regard to the outcome of the Scotland-wide listening exercise which Age Concern Scotland conducted in October 2007 for the Audit Scotland Review, which gathered information on older people's experiences of FPNC.
Local Authorities
3. The Review Group did however agree that it needed to approach certain key stakeholders inviting their views on the key issues and evidence that it should consider in establishing as coherent, credible and up-to-date an understanding of the financial circumstances and impact of the policy as possible. With that in mind, at its first meeting, the Group agreed that in order to gain a clear perspective of the impact of the policy from the Local Authorities' view point Lord Sutherland should write to all 32 Local Authority Chief Executives seeking their views, as an immediate priority. He did so on 14 September 2007, explaining the tight timeframe the Review Group was operating in and inviting them to present their position by 8 October 2007. The Group agreed that the invitation should be as open as possible, affording Chief Executive's the opportunity of a more qualitative input focussing on the wider impact the policy has had across social care, local authority, health and housing support finances and on the quality and effectiveness of overall services provided to older people in need and other vulnerable groups. The invitation also specifically invited individual local authorities to set out views on how the Review Group might move forward in considering the challenges the issue presented.
4. In addition to the individual responses subsequently offered by 21 of Scotland's 32 local authorities, emphasising the issues specific to their particular area, 3 local government professional associations set up a working group to provide the Review with a detailed joint submission. The bodies concerned were:
¨ The Society of Local Authority Chief Executives and Senior Managers (SOLACE, Scotland);
¨ The Association of Directors of Social Work (ADSW); and
¨ The Charted Institute of Public Finance and Accountability (CIPFA).
Other Stakeholders
5. The Review Group took the decision to extend the scope of its evidence taking beyond that of the local authority perspective. Lord Sutherland wrote on 8 October 2007 to the 37 bodies that gave evidence in the Parliament's Health Committee's Care Inquiry of 2006; the intention was not to have them re-state their views but rather to afford them the opportunity to add or to up-date the evidence they had previously provided. Nine of those bodies and 2 individuals took up the opportunity to provided additional evidence to the Independent Review.
6. The Review Group also approached the Conveners of the Scottish Parliament's Audit, Finance, and Health & Sport Committees to draw their attention formally to the Group's work; the timetable it was working to; and present the Committees with the opportunity to offer views on how the Group might best move forward; and to make a contribution from their individual remits. Two of the 3 Parliamentary Committees responded and a personal submission was received from Mr Alex Neil MSP, who is a member of the Finance Committee.
7. The Review Group also sought input from the Scottish Public Service Ombudsman (SPSO) and the Chief Social Work Inspector. Lord Sutherland wrote to the SPSO on 2 October 2007 to request an overview of the complaints she received against local authorities and NHS Boards across Scotland in regard to free personal and nursing care funding and provision. The Ombudsman provided a comprehensive response which she presented in oral evidence to the Review Group at its November 2007 meeting.
8. Overall, the Ombudsman's findings on Free Personal and Nursing Care policy were generally very encouraging, with the level of complaints very low in comparison to the level of complaints about provision of long-term care of the elderly by her counterpart in England. Although the impression publicly might seem otherwise with the tendency for media attention to focus on a few high profile complaints cases and rarely to highlight the positive. Complaints received were critical of both local authorities and health boards regarding 'funding and mainly fell into 2 broad categories: the assessment or provision of care for 'self-funders'; or for those in need of 'NHS continuing care'. There was no clear geographical pattern to the complaints received.
9. Lord Sutherland also wrote to the Chief Social Work Inspector (CSWI) on 1 November 2007 seeking her input to the Review. She also painted a more positive picture than might have been expected from the impression given in the media. She noted that FPNC was a complex policy which was implemented in an extremely tight timescale, and overall it represented a significant step in the right direction.
10. The Chief Social Work Inspector's evidence was based on her considerable experience in the development of the policy in the first instance and largely from the Social Work Inspection Agency's (SWIA) national inspection programme. The evidence provided focused on the overview of the consistency and standards within the 18 completed performance inspections which where carried out between May 2005 and December 2007 and the SWIA pilot of a new task group methodology.
Summary of Responses Received
11. A summary of the written and oral evidence received during the Review is set out below under the 4 key strands of the Review Group's remit.
Responses regarding the TOTAL level of resources MADE AVAILABLE
12. The SOLACE, ADSW and CIPFA Working Group's response along with 19 of the 21 local authorities individual responses highlighted a number of key areas regarding the level of resources for FPNC which they felt the Review Group should consider. The joint response stated that local authorities could no longer consider their budget for FPC in isolation, "rather, they needed to consider the delivery of FPC within the context of their overall resources". It also noted that the original policy intention was for FPC to be fully funded by the Scottish Government. The working group noted that the majority of local authorities felt that the Government had not delivered on this and offered evidence to back-up its view that by 2006-07 the policy was under-funded nationally by at least £26 million. The working group submitted details of how it had calculated this figure in a follow-up submission of 11 January 2008. It acknowledged the well rehearsed uncertainties over consistency in the data submitted in the Local Financial Return for Social Work (LFR3). Problems in the consistency in recording of expenditure on personal care at home in particular were acknowledged; where the problem related to recording FPC expenditure separately to other support services received by the elderly at home. The joint response noted that Audit Scotland was looking at the date problems in the field work it was undertaking in its study and it was hoped that definitive expenditure figures might finally be produced as a result of that exercise.
13. The Joint Working Group used comparisons of local authorities' actual expenditure (based on LFR returns) and assessed need to spend - Grant Aided Expenditure assessments (GAE) - to calculate its figure on the potential funding shortfall. Individual local authorities variously reported funding shortfalls which they addressed by recourse to Council Tax or by prioritising spend on FPNC over other services. In terms of addressing the "funding gap" the following proposals were suggested.
13.1 Resource Transfer. First, the joint working group response and 7 of the individual responses from local authorities identified areas where care needs had traditionally been provided by the NHS and had now transferred to community care services. However, they reported that the requisite resources had not always followed. They recommended that if the Scottish Government determined to continue the shift in the balance of care from the acute sector of health to social care, then a corresponding system of resource transfer should be established; and
13.2 Housing Benefit Model. Second, the joint working group and 4 of the individual responses from local authorities suggested that if FPNC was to be a universal entitlement, akin to the entitlement to NHS care and therefore "demand-led", an alternative form of funding needed to be found. The 'housing benefit' model was proposed, whereby local authorities would continue to assess need and provide the service locally but effectively "invoice" the Scottish Government for the costs incurred in doing so. The model would negate the need for any local interventions to manage demand through the use of waiting lists or eligibility criteria that were fuelling inequity and confusion over entitlement.
14. The Scottish Public Service Ombudsman's (SPSO) findings on the overall level of resources highlighted the most common complaints received against councils as being those by 'self-funders' relating to the provision of long-term care and in particular personal care and the funding of those services; and those about NHS continuing care, which were almost exclusively about the eligibility criteria and assessment of eligibility and funding for such care. She noted:
14.1 Self-Funders. Problems with delays in provision to individuals who where assessed as in need of personal care were prominent and were to an extent compounded by the nature of "self-funders" as a client group, and as the beneficiaries of the FPNC policy. As a group they had often had very limited contact with social services in the course of their lives and might previously have made their own arrangements as a matter of personal autonomy. Therefore issues have arisen with the Group making their own arrangements for going into a care home and then seeking assessment retrospectively, with the expectation that local authorities would back date payments from the date of assessment. This issue had been highlighted by the recent Lord Macphail ruling; and
14.2 NHS Continuing Care. The general lack of clarity in respect of the distinction between social care and NHS continuing care was not at all helpful. Individual local authorities reported concerns about NHS continuing care to the Ombudsman as they suggested it had traditionally been funded by the NHS but there was now some blurring of boundaries. The Ombudsman highlighted the guidance as a common theme to complaints about NHS continuing care but the guidance, which was set out in MEL 1996(22) was under review and a revise expected in 2008. She recommended that the guidance was revised as soon as possible and that NHS Boards and local authorities worked in closer partnership in the provision of care services.
15. The Chief Social Work Inspector's evidence to the Review Group on the overall level of resources highlighted 4 main issues with a bearing: provision of funding through the GAE mechanism; the disparity in costs and quality of provision that is evident; commissioning services (particularly capacity planning); and partnership working/joint budgets. She noted:
15.1 Total Funding Allocation. SWIA did not normally comment on the resources for specific services where funding was distributed through GAE, although they had done so in published reports in a few cases where there appeared to be a major diversion of resources between services, or in cases where there was evidence of significant waiting lists or other forms of "rationing" operating.
15.2 Per Capita Funding. The evidence showed wide variations on the disparity in overall cost, per head funding allocation and in the quality of service provision for FPC across local authorities. It also showed that matching the needs to appropriate service provision and competing priorities with social work budgets for other client groups was leading to problems in certain areas and was one of the reasons for the increasing use of "rationing" of services. It was evident though that the best local authority providers were not necessarily the highest spenders.
15.3 Planning of Services. There was also wide variation in practices between local authorities in the commissioning and capacity planning of services. It was clear that better performing local authorities tended to have adopted longer term planning partnership approaches, whereas the local authorities with the poorer performances were more focused on simply driving down costs.
15.4 Partnership Performance. While there had been progress over the past 10 years in terms of partnership working and joint budgets, there should be further aspirations towards joint working/budgets as there were considerable benefits in terms of delivering better, more effective services. The Scottish Government's Joint Improvement Team was continuing to drive change and assist local authorities and their health partners to work together.
16. Evidence from other groups and individuals totalled 14 responses of these 9 commented on the total level of resources available to local authorities. This section explains their responses which varied over 7 specific issues relating to the total level of resources. Of these 7 issues some were expressed by more than one group or individual. Responses are therefore presented ranked below in descending order, i.e those issues where the greatest number of concerns were raised by respondents are listed first:
16.1 Resource Allocation. Five of the other groups and individuals that responded raised concerns regarding either the initial funding allocated to support implementation of the policy or future funding levels to sustain it, or both. They highlighted a lack of financial and risk assessment of the policy at the outset, resulting in a drift towards under funding at a national level and also raised concerns over the adequacy and distribution of future funding allocations. They highlighted demographics and other particular issues/needs impacting on individual local authority areas. Some suggested that a new assessment of need across local authorities was required to re-base the funding. Another suggested that a "national reserve" of funding for FPNC should be established, which local authorities could draw on if and when local demand exceeded expectations.
16.2 Care Market. Four of the other groups and individuals that responded reported difficulties due to instabilities in the care market, including the affect of churn in care service contracts, resulting in unnecessary change/instability for clients. It was also suggested that the procurement system of reverse e-auctions put larger companies at an advantage as economies of scale meant they were able to provide care services at lower prices and were better placed in terms of risk.
16.3 Ring Fencing. Three of the other groups and individuals that responded raised the issue of 'ring fencing' government funding for FPNC and favoured a move to 'that model. These respondents where concerned that the unhypothicated nature of general revenue funding had been implicit in the situation reached by 2005-06 when 27 out of Scotland's 32 councils spent below GAE on older people's services; directing funds instead to other services.
16.4 Direct Payments. Two of the other groups and individuals raised the issue of low take up in 'direct payments'. These responses suggested there was a lack of information and support to members of the public about self-directed support from both central and local government, coupled with a system that was not user friendly due high levels of bureaucracy. One of the responses also suggested that while individuals were usually content to take up the direct payment option when a family member would be providing the care they were usually reluctant to do so where they had to employ someone due to the added complications associated with liability insurance etc.
16.5 Inflation. Two of the other groups and individuals that responded raised the issue of the affect of inflation on funding of the policy and the fact that the level of the weekly flat rate payments had remained static since the policy was introduced. They were concerned to ensure that any increases in the payments which the new government made in 2008 reflected inflation over the period since introduction in 2002 and that inflationary up-lifts should, in future, be an annual event.
16.6 Mutual Accountability. One of the other groups and individuals who responded raised the issue of 'mutual accountability' for funding and provision of FPNC between central and Local government and suggested that to avoid a "spiral of blame" over funding levels, a more progressive approach was needed in accepting responsibility and agreeing a way forward which best served the interests of vulnerable elderly people.
To summarise what respondents said in evidence about the total level of resources to fund FPNC:
They asked the Independent Review Group to consider:
¨ Examining a system of resource transfer to take account of savings accrued by the NHS as a result of the shift of provision of care into the community and into local authority responsibility;
¨ Funding FPNC as a demand-led service, in line with the 'housing benefit' model;
¨ Pressing for a review of eligibility and assessment of the criteria for NHS Continuing Care;
¨ Conducting a new needs assessment with local authorities to set new baselines for FPNC;
¨ Recommending that a national reserve of funding be established as a means of coping with unexpected local demand for FPNC;
¨ Establishing a system of funding to local authorities which 'ring fenced' FPNC funding;
¨ Recommending annual up-rating of the flat-rate payments for FPNC to account for inflationary pressures;
¨ Recommending that self-directed support be made more "user friendly"; and
¨ Pressing central and local government to move quickly to address the problems with the policy by accepting their mutual accountability.
Responses regarding the DISTRIBUTION of Resources
17. The SOLACE, ADSW and CIPFA Working Group's response along with 14 of the 21 local authorities individual responses highlighted a number of significant areas regarding the distribution of resources for FPNC. First, they stressed the importance of resolving the fundamental issue of whether the policy was a universal one (subject to assessment of need) and therefore 'open-end demand-led' care or if not whether councils were entitled to "ration" care within finite resource. They suggested that all other issues of how local authorities distributed their resources were secondary to that point and could not be resolved until it was clarified. The point was made that if local authorities were to implement FPC within a 'limited budget' prioritising their resources according to local needs, then it must be acceptable for them to manage demand for services through the use of tools like waiting lists, eligibility criteria etc to ensure that care is delivered in line with greatest need.
18. The Joint Working Group's response also suggested that in view of the significant increases in the numbers of older people projected (and particularly those in the 85-plus group who often require more resource-intensive care packages) and the increasing numbers receiving care at home, one possible solution on the affordability front was to implement a 'funding ceiling' for care at home. Although they recognised that this solution may not be a palatable one, they suggest it "would reduce inequities for service users, and help mitigate the financial deficit associated with the policy".
19. Means Testing. The Joint Working Group's response and 4 of the local authorities' individual responses also identified the issue of 'universal funding versus targeted funding', and some advocated a return to means testing, as a way of ensuring there was adequate funding available for those that needed it most.
20. Local authorities raised the 5 following points in their individual responses highlighting concerns about the distribution of resources for FPNC. Again, in descending order:
20.1 Resource Allocation. Six of local authorities raised their concern that they were having to divert resources from other services to fund their FPNC obligations and highlighted the detrimental effect on services this was having.
20.2 Waiting Lists. Five local authorities suggested they had no choice but to operate waiting lists in order to provide the care required within their budgets which they were required by statute to balance.
20.3 Assessment of Needs. Two local authorities reported they needed to be able to critically assess the level of needs required. This was to ensure that personal care was received by the elderly individuals in most critical need.
20.4 Food Preparation. Two of the local authorities highlighted their concerns that they were not able to charge for food preparation and as a result had less resources to fund FPNC. The serious financial implications of refunding charges already made were also raised.
21. The Scottish Public Service Ombudsman reported 4 main areas of complaint relating to the distribution of resources for FPNC:
21.1 Assessment of Capital. The assessment of capital assets for clients requiring personal care in a care home was one of the most common areas of concern drawn to her attention; with increasing numbers of individuals who purchased their home under the 'right to buy' policy coming into the cohort. The problem was compounded by inconsistencies across the country in the formula used to assess individuals' capital assets.
21.2 Variations in Eligibility Criteria and in Charging for Food Preparation. Local authorities use of eligibility criteria was another source of disquiet, as was their different interpretation of the legislation and guidance in relation to food preparation where different local authorities took different positions on charging. These accounted for a large volume of the complaints received.
21.3 Delayed Assessments. Delays in assessment were also a problem, with no standard time scales set for assessment the length of time this took varied considerably from area to area.
22. The Chief Social Work Inspector's evidence on the distribution of resources highlighted 2 main issues:
22.1 Financial Split. The CSWI reported concerns about what might be considered as an "ageist system" operating in the prioritisation of social work resources and services. This was demonstrated in the expenditure figures with the bulk of social work resources allocated other client groups and adult and older people's services seen as the "Cinderella" service.
22.2 Care Planning. Within the broad context of care planning the CSWI highlighted 4 specific areas of concern:
22.2.1 Personalisation. Broadly speaking, the quality of care service was considered to be good. However, there were still concerns about limitations in the choice available to individuals and the low take up of self-directed care.
22.2.2 Dementia. Services provided to individuals with dementia were still not as good as they should be.
22.2.3 Informal Carers. Despite their contribution to caring for the elderly, only around 40% of informal carers reported they had been offered a carer's assessment.
22.2.4 Care Plans. While there had been significant progress with implementing care plans for individuals being discharged from hospitals in recent year there was still too many instance where local authorities were failing to set care plans in place in good time.
23. Of the 14 responses from other groups and individuals 10 commented on the distribution of resources. This section summarises their responses which focussed around 4 specific issues. Again, in descending order of importance:
23.1 Assessment of Needs. Nine of the other groups and individuals that responded stressed their concerns about the assessment process for FPC. Concerns related mainly to the lack of consistency nationally in how and when individuals are assessed by the local authorities as eligible for FPC services. With most local authorities operating eligibility criteria focussed around "critical" or "substantial" needs only and having a lesser commitment to clients with moderate needs.
23.2 Waiting Lists. Five of the other groups and individuals that responded raised their concern about the waiting lists implemented variously by local authorities for FPC. These responses reported their concerns that after being assessed as in need of care local authorities were delaying the provision of services in order to manage their budgets or effectively "rationing" of services in spite of an identified need.
23.3 Time Allocated. Three of the other groups and individuals stressed their concern about the adequacy of time allocated to provide services; with some local authorities not allocating enough time to provided personal care and prepare food for individuals cared for at home; another form of "rationing".
23.4 Hotel Costs. Two of the other groups and individuals that responded highlighted the issue of billing of self-funders for 'hotel' costs. They noted the following concerns:
23.4.1 That care homes were over charging self-funders for their 'hotel' costs as a flat rate fee was sometimes charged regardless of whether individuals required nursing care or not.
23.4.2 That self-funders in local authority care homes could be getting charged more for their 'hotel' costs in local authority care homes than in private sector care homes.
23.4.3 Concern over the billing process i.e. that 'hotel' costs were not transparent enough and that care homes should provide detailed breakdowns of costs they were billing for.
To summarise what respondents said in evidence about the distribution of resources to fund the FPNC.
They asked the Independent Review Group to consider:
¨ Defining the terms of FPNC i.e. "demand led" or "budget limited service";
¨ Implementing a 'funding ceiling' for FPNC at home;
¨ Implementing a form of 'means testing';
¨ Removing all charges for at home care;
¨ Clarifying the position of 'food preparation' and on refunds of charges already made in that regard;
¨ Issuing national guidance on assessment and treatment of an individual's capital assets;
¨ Issuing national guidance on standards of care, time limits for assessments and eligibility criteria for FPNC;
¨ Pressing for greater transparency in 'hotel' costs levied in care homes.
Responses regarding ATTENDANCE ALLOWANCE
24. Of the 4 strands of the Group's remit, respondents had least to say about the impact of the withdrawal of Attendance Allowance following the introduction of FPC in Scotland.
25. The Joint Working Group's response along with 2 of the 21 local authorities individual responses and 3 of the 14 other groups and individual responses highlighted issues regarding withdrawal of attendance allowance to individuals receiving FPC, mainly in relation to inequity of treatment:
25.1 Cross Border Issues. One local authority suggested there was inequity in DWP's treatment of elderly people in care homes in Scotland where Attendance Allowance is withdrawn after 4 weeks whereas in England older people still receive their attendance allowance.
25.2 Two of the Other groups and individuals' responses commented on the allocation of attendance allowance. These responses suggested there was a need to allocate attendance allowance regardless of whether individuals where receiving care at home or in a care home. One of these responses also reported concerns about the inequality between individuals who receive personal care at home from those who receive care within a care home.
Responses regarding the SUSTAINABILITY of Free Personal Nursing Care
26. The sustainability of FPNC was the issue attracting the most responses, The Joint Working Group; 19 of the 21 local authorities; the Scottish Public Service Ombudsman; Chief Social Work Inspector; and all of the 14 other groups and individuals responded on this topic. There were 4 main areas of concern highlighted:
Demographic Trends
27. The Working Group's response along with 13 of the 21 local authorities individual responses highlighted the issue of demographic trends and how this reflects FPNC which they felt the review group should consider. They demonstrated with population growth estimates the number of elderly individuals will increase and live longer. Significantly, they predicted that as individuals live longer their personal care needs will become more complex therefore having to rely on these services for longer periods of time. Local authorities highlighted the financial implications of this increase in demand of care services as they needed to balance between affordability and the care services they provide.
28. Local Demographic Trends. For example, the Highland Council demonstrated a notable increase of 62% in the elderly population estimates for individuals aged 65 years and over between 2005 and 2024. Moreover, they project 118% increase over the same time frame for elderly individuals aged 85 years and over. The Highland Council therefore stress the need not only to increase the funding available to them to provide this care but also to maintain affordability within the policy, with a funding ceiling on the level of personal care provided to individuals who received their care at home.
29. Levels Of Care. The Glasgow City Council also stressed the need to recognise the level of care that is required particularly as their local population tend to have increased care needs from a younger age, i.e. approximately two years lower than the Scottish average. They demonstrate this as they report individuals living in Glasgow suffer from strokes at a younger age which often leads to higher levels of care needs.
30. Chief Social Work Inspector's evidence to the review group also suggested that a factor to the increasing costs with FPC has been with the 'unmet need' of care being provided by the family. FPNC has eliminated the stigma associated with receiving care as it is now considered to be a 'right' and families are now more willing to take up the care needed.
31. Other groups and individuals. 7 of the 14 that provided evidence commented on the demographic trends, which cover 2 main areas. Firstly, they too question whether this policy is affordable in the longer term considering we have an aging population. However, they felt the policy can not continue if funded by cutting other budgets locally. Secondly, they advised there had been an unmet need of publicly available personal care, as they suggested this has been largely been provided within the family. It was therefore advised that more care homes, trained staff, and respite care was required. However, to ensure the affordability of the policy it has been suggested that a scale of available funding is implemented and not just a flat rate.
To summarise what respondents said in evidence about the Demographics.
They asked the Independent Review Group to consider:
¨ Implementing a 'funding ceiling' for FPNC at home; and
¨ Introducing a scale of available funding, i.e. not just a flat rate.
Legislation
32. The Working Group's joint response along with 14 of the 21 local authorities individual responses reported they felt further clarity needs to be provided on a number of issues through re-visiting the original legislation. They have suggested at this stage providing further guidance would not resolve the issues as these matters needed to be clarified in legal terms. The Working Group's response suggested the review group should consider clarifying the legislation to provide consistency across Scotland in regards to waiting lists, eligibility criteria, and food preparation. The individual local authorities' responses, on the other hand, also reported on 4 specific issues they have experienced and feel needed to be clarified in legal terms. Below is a summary of the responses from local authorities on the issue of legislation. However, as some issues have been expressed by more than one local authority responses, again in descending order:
32.1 Eligibility Criteria. Eleven of the local authorities that commented on legislation have reported that further clarity was needed for consistency of eligibility criteria for FPNC services. Specifically, what level of care would be considered to need FPNC? Which personal care and nursing would be provided free and what services would to be charged for?
32.2 Food Preparation. Eight of the local authorities that commented on legislation have specifically mentioned further clarity on the issue of food preparation. They suggested that a legal definition is now required and not simply further guidance. 2 of the local authorities also expressed their concern about refunding the charges that where made for food preparation.
32.3 Funding Ceiling. Six of the local authorities that commented on legislation reported they felt a legal definition of what the upper limit of personal and nursing care that was to be provided to an individual at home must be specified. They suggested that if an upper limit was to be effective this could not be done with guidance.
32.4 Assistance With Medication. One of the local authorities that commented on the legislation recommended a definition of 'assistance with medication'. This was reported as different local authorities have a different understanding of this term i.e. to be considered as reminding individuals to take their medication or actually helping the individual in administering their medication etc.
32.5 Ordinary Residence. One of the local authorities that commented on legislation reported their concerns regarding the issue of cross border and cross boundary placements. Therefore they recommended a legal clarification of the term of 'ordinary residence'.
33. The Scottish Public Service Ombudsman's findings on the issue of legislation cover this last point on a legal clarification of the term 'ordinary residence'. The Ombudsman had received complaints where disputes fall into two categories i.e. cross border and cross boundaries. Significantly, different local authorities both in Scotland and in England have varying understandings of what this term means. However, if local authorities can not agree what the term means it leaves an unresolved situation over which local authority would fund the individuals care needs and can lead to a situation where individuals care needs are under- funded.
34. Other groups and individuals, 5 of the 14 responded on legislation issues which covered 4 issues these are listed below, again in descending order:
34.1 Charges For Services. Four of the other groups and individuals that responded on legislation commented on the need for a clarification on charges for services in relation to food preparation. 2 of these also suggested further clarifications issued to the local authorities about refunding for the services previously charged for.
34.2 Demand Lead. One of the other groups and individuals that responded on legislation suggested legal clarification on whether FPNC was demand lead or subject to budget constraints.
34.3 Nursing Care. One of the other groups and individuals that responded on legislation recommended a definition of the criteria for nursing care that is to be funded under FPNC. Specifically, was nursing care to be considered as on call nursing or nursing for specialist care needs?
34.4 Assistance With Medication. One of the other groups and individuals that responded on legislation recommended a definition of 'assistance with medication'.
To summarise what respondents said in evidence about the legislation for FPNC.
They asked the Independent Review Group to consider:
¨ Defining the terms of FPNC i.e. "demand led" universal or "budget limited" service
¨ Defining the terms of what is to be allowed under 'waiting lists';
¨ Defining the terms of 'eligibility criteria' more clearly;
¨ Clarifying the position of 'food preparation', and any refunds of charges already made;
¨ Defining the upper limit of FPNC that would be received at home;
¨ Clarifying the term 'ordinary resident';
¨ Clarifying what level of nursing care is to be provided under FPNC; and
¨ Clarifying the position of 'assistance with medication'.
Equality
35. On the issue of equality there where 4 main issues that have been reported, listed below is a summary of these issues with the most concerns raised first following on in that order.
36. Two Tier System. The Working Group's joint response; 5 of the 21 local authorities; the Chief Social Work Inspector's evidence; and 4 of the 14 other groups and individual responses reported the wider implications of inconsistently allocating FPNC. It was their view the current stance on the allocation of FPNC was contributing to a two tier system, or a perception of a two tier system. These concerns fall under two distinct topics i.e. where individuals receive their care, and whether they are self-funders or fully funded local authority clients.
36.1 Where Care Is Received. This was demonstrated as there are concerns regarding the differences in the level of funding available to provide care depending on whether individuals receive their care at home 'at home' or in 'care home'. Specifically, are self-funders able to receive more choice in the care they receive.
36.2 Socio-Economic Groups. There was also a concern raised about the distribution of resources and questions where raised as to whether FPNC was having adverse affects in widening the gap between socio-economic groups.
37. Availability. Four of the local authorities and 3 of the other groups and individuals that responded highlighted the question as to whether FPNC should be available to all individuals that need it and not restricted to those over 65 years of age. These responses highlighted two questions i.e. could the Scottish Government afford to fund FPNC for all individuals that need it? If they did not provide this care service to all individuals could they face legal action over age discrimination laws?
38. Quality Of Care. Four of the other groups and individuals that responded reported their concerns about the varying levels of care available across Scotland. They suggested this inequality in services provided could be rectified by implementing a national criteria for services and a national standard of personal care individuals could expect.
39. Hotel Costs. One of the other groups and individuals that responded highlighted their concern about why mentally ill elderly individuals where having to pay for the 'hotel' costs of their care home as they felt this should be funded through the NHS.
To summarise what respondents said in evidence about equality
They asked the Independent Review Group to consider:
¨ Reviewing assessment procedures for FPC to address issues around a two tier system;
¨ Reviewing the method of allocating FPC to ensure it does not adversely impact the gap in socio-economic groups;
¨ Ensuring FPNC is available to all who need it;
¨ Recommending national criteria for care services; and
¨ Calling for a review to the criteria for NHS continuing care.
Other
40. Other issues of concern that has been raised during the review process which has been suggested will effect the sustainability of the policy vary over 7 topics. Listed below is a summary of these issues with the most concerns raised first following on in that order.
40.1 Public Understanding. Six of the local authorities and 8 of the other groups and individuals that responded reported their concern at the lack of understanding members of the public have about this policy. One response proposed the implementation of a free hotline which members of the public could call for information about FPNC.
40.2 Available Data. Five of the other groups and individuals that responded reported it was difficult to analyse the policy effectively due to the lack of data available. They suggested this absence of monitoring and reporting had implications over how they where able to determine whether best practice and value for money was being achieved. One response proposed the implementation of 'outcome agreements' which could be monitored to check if they where being met.
40.3 Quality Of Care. Four of the other groups and individuals that responded suggested there was a lack of care home places and trained staff. The responses reported on the issue of trained staff they felt the reasons for this was due to low moral, low pay, and poor working conditions.
40.4 Hotel Costs. Two of the other groups and individuals that responded highlighted their concern that self-funders may need to sell their house to fund their 'hotel' costs of their care home placement.
40.5 Type Of Resources. One of the local authorities that responded proposed an increase in telecare and extra care housing as a means of making the policy of FPC more affordable.
40.6 Care Regulations. One of the other groups and individuals that responded highlighted the need to improve care regulations and provide protection for individuals who complain against their care service provider.
40.7 Audit Scotland. One of the other groups and individuals that responded recommended the review group consider the Audit Scotland report.
40.8 Impact Of Other Policies. The Chief Social Work Inspector reported the need to consider the impact of other policy developments on FPNC. This was significant as it could impact the availability and quality of services.
To summarise what respondents said in evidence on other issues
They asked the Independent Review Group to consider:
¨ Calling for the establishment of a free hotline for FPNC to provide a central point of information for members of the public;
¨ Seeking the development of robust 'Outcome Agreements' to improve monitoring and reporting on FPNC;
¨ Calling for an improvement to the pay and conditions for care staff;
¨ Seeking an increase in the use of 'telecare' and 'extra care housing'; and
¨ Calling for a tightening to care regulations.
Independent Review Group
April 2008