INDEPENDENT FUNDING REVIEW OF FREE PERSONAL AND NURSING CARE: MEETING AT 2.00pm ON MONDAY 22 OCTOBER 2007, ST ANDREW'S HOUSE: NOTE OF MEETING
Present: Lord Sutherland (Chairman)
Mary Marshall
Jim Dickie
Professor David Bell
Rory Mair
Rhona Dubery (Secretary)
In Attendance: Neil Rennick, Scottish Government: Community Care Division
Shaun Eales, Scottish Government: Community Care Division
Carolyn Smith, Audit Scotland: Portfolio Manager ( for item 3 only)
Nick Hex, Audit Scotland: Project Manager ( for item 3 only)
Apologies
1. Anne Jarvie was unable to attend.
Introductory Remarks
2. Lord Sutherland welcomed members to the third meeting of the Review Group and introduced Carolyn Smith and Nick Hex from Audit Scotland who had agreed to offer an over-view and up-date to the Review Group on the Audit Scotland Study on Free Personal and Nursing Care.
Minutes of Meeting held on 21 September 2007
3. The minutes of the second meeting held on Friday, 21 September 2007 (IFR-FPNC (07)2nd Minutes) were approved.
Matters arising from the Minutes
4. Lord Sutherland advised that there were only 2 matters arising which were not covered elsewhere on the agenda: the interim report letter to the Cabinet Secretary for Health & Wellbeing and the question of further calls for written evidence. He said that on the first, he had received a reply from Nicola Sturgeon that week, which thanked him for the initial progress report and agreed that a meeting around the turn of the year would be useful. Rhona would follow that up with the Cabinet Secretary's office with the aim of getting a date in diaries quickly.
5. Where further calls for evidence were concerned, he had now written to "other stakeholders", i.e. those organisations which had given evidence on FPC to the 2006 Health Committee Care Inquiry. He had also written on the same date (8 October) to the Conveners of the 3 Parliamentary Committees with the greatest interest in the funding of free personal care: Health & Sport, Audit and Finance, to draw their attention to the independent review and to give members the opportunity to offer views on the key aspects if they so wished. It was hoped that the comments from both groups would be received in good time for the review group to consider an overview on the evidence received at its November meeting. The Review Group noted the position on both matters.
Audit Scotland Study: Free Personal & Nursing Care
6. Nick Hex and Carolyn Smith gave a presentation on the Audit Scotland Study into Free Personal & Nursing Care and the progress with their fieldwork and the analysis of data they had been able to carry out to-date. Copies of the audit tools had been provided to Rhona already and the detailed results of the field work, including those from the local authority data request would be shared with the Review Group in due course. In terms of approach and progress made to-date, the presentation covered the following:
Methodology & Progress
6.1 The methodology for the study employed a number of different techniques aimed at getting a broad perspective as to how the policy was working in practice, including: the review of published data; a data survey of all local authorities; detailed interviews and document reviews with a sample of 6 councils; care package tracking of 50 older people, to track their experiences and look how packages may have changed over the past 5 years; Interviews with Scottish Government and COSLA officials; interviews with care homes; a data survey of a sample of care home providers; a review of care home brochures; analysis of income level scenarios; and focus groups with older people. Twelve focus groups were being conducted across the country by Age Concern Scotland. These would involve a broad-range of individuals and in some case, their carers, with different backgrounds and needs.
Local Authority Data Survey
6.2 The survey was a key element of the field work and included details on: financial planning and monitoring; information on local policies, including charging policies, application of eligibility criteria and waiting lists, details of what their interpretation of food preparation had been and whether charges had been made, costs and funding and home care services. The data request had issued to all 32 local authorities on 31 August and 26 returns had been received to-date. Validation of completed returns was on-going and a final chase of outstanding returns was being carried out that week, as Audit Scotland hoped to complete its analysis and validation by 31 October.
Local Authority Interviews, Document Reviews and Care Package Tracking
6.3 Another key element was the detailed interviews and work was on-going with a sample of 6 councils - North Lanarkshire, Glasgow, Edinburgh, Shetland Islands, Aberdeenshire and West Lothian - to follow-up more detailed and qualitative issues. Although the interviews were still taking place it was expected their value might be limited to some degree due to factors like changes in personnel in the 5 year period. Supporting evidence, such as minutes of Council meetings had been sought and was awaited in a number of cases. The aim was to complete the analysis by early November.
Other Key Areas of the Study
6.4 Other key areas included the care home survey and economic analysis. The response to the care home survey had been disappointing at only 15%, despite follow-up reminders and the support of Scottish Care. However, the response rate may have been affected by the pressure to complete other information requests falling at the same time. The economic analysis, which David had been asked to conduct by the end of October, would look at cost estimates of FPC and future projections and income scenarios, tracking those through to consider the impact of the policy on older people.
Reporting
6.5 The end product of the study would be a national report and key messages paper which was expected to publish by the end of January. Timing was extremely tight, with internal drafting and editing of the report expected throughout November as analysis of information was still on-going; with the draft going to the Accounts Commission in December and to the Scottish Government for clearance in terms of factual accuracy in December or early January. The team hoped to be able to share an early draft with the Independent Review in confidence around the end of November.
7. In a follow-up discussion the following points were made:
(a) Getting a genuine assessment of the actual net cost of delivering FPC would be challenging given the past problems with accuracy of data returns and the difficulties experienced in the past with local authorities' different recording and reporting systems. Difficulty in extrapolating costs of FPC from the rest of the social work or care budget was also a problem anticipated. But inconsistencies in data were being followed up and councils were being asked to restate their figures where these were inconsistent or where it was unclear as to whether or not they included overheads. Where data was not readily available alternative ways of getting the information required were being considered; and
(b) Possible alternative sources of information on actual costs of FPC included: the Care Commission and the 2003 Pricewaterhouse Cooper's research commissioned by the Northern Ireland Executive. The Audit Scotland Project Advisory Group for the study was due to meet later that week and it could prove helpful is getting under the surface of some of the issues emerging.
8. The Group thanked Nick and Carolyn for the up-date on progress and agreed that it would be helpful if the Audit Scotland team could return to the Review Group's next meeting on Friday, 23 November to offer a further up-date on findings ahead of sharing the early draft of their report around the end of November. (Action: Rhona and Audit Scotland Team)
Scottish Government/COSLA Working Groups: On-going Work in response to Hexagon Research (Paper IFR-FPNC (07)08)
9. Neil Rennick introduced paper IFR-FPNC(07)08, which in response to the request made at the last meeting, provided information on the 2 Scottish Government/COSLA working groups established to look at the specific policy and implementation issues highlighted in the Hexagon Evaluation Report and elsewhere. The issues around the broader aspects and difficulties of implementation of FPC policy were well documented and the work was aimed at producing joint remedies and greater clarity and would be another important strand in ensuring FPC was on a sure footing in the long-term. He said that the COSLA President and the Minister for Public Health were due to meet to discuss the political context for advancing work on these issues on Tuesday, 6 November. That meeting was expected to set parameters within which the issues could be progressed at official level. Although it was unlikely that all these complex areas of difficulty could be resolved at once, it was hoped some early progress could be made, so that the output of the 3 major strands of work on-going on FPC might emerge around the same time next spring.
10. The Group noted the information on the joint working groups. It also noted that the 3 major strands of work coming together at once would call for careful handling, not least in terms of clarity of recommendations, timing of proposed changes and public perception of the policy and future plans (given some of the criticisms of the past around lack of clarity and ambiguity). A further complication was the timing of the 2007 Spending Review (covering the 3 years 2008-09 - 2010-11) the outcome of which was not now expected until mid-November, with year 1 commencing 1 April 2008.
Written Evidence from Local Authorities: Report on Responses Received To-date (Paper IFR-FPNC (07)09)
11. Rhona introduced paper IFR-FPNC (07)09 which provided an overview of the written evidence she had received to-date in response to Lord Sutherland's letter of 14 September inviting local authority Chief Executives to contribute to the review. She tabled an up-dated version of the table at Annex A of the paper and noted that as at Friday, 19 October 19 responses had been received from local authorities. A reminder to authorities had been sent immediately before the deadline for comments but although that was now past, a final reminder could be sent to encourage any remaining respondents in order to gain the fullest possible picture from the local authorities' perspective.
12. She said that as might be expected, returns varied considerably in terms of style and detail offered. The most common issues of concern focused on overall level and distribution of resources and ambiguity of definitions. Where distribution of resources was concerned there were contradictory views expressed on GAE methodology from local authorities, often it seemed, dependent on levels of deprivation in their area; some being in favour of the pending change to the Personal & Nursing Care for Older People GAE (the main GAE line for FPC offered in care homes) where the intention was to move to a formulae-based distribution, rather than one based on historic caseload data from 2008-09 on (pending Ministerial/COSLA leaders' approval).
13. In discussion the following points were made:
(a) In view of the conflicting views from local authorities on the distribution of resources through the GAE mechanism and the wide variations evident in expenditure and therefore per head cost of provision, it might be useful to seek the view of SOLACE (the Society of Local Authority Chief Executives) and enquire what evidence they may have;
(b) The comments from a number of respondents to the effect that FPC has been funded at the expense of other home care and preventative services was disappointing but not unexpected given that authorities had a statutory obligation to provide FPC to those assessed as eligible whereas they had more discretion in the provision of other support services;
(c) In terms of actual costs of personal care, the inability to establish robust figures on the cost of care at the outset had been a failing which was thought to have manifested itself in the large variations in the cost of provision which were now apparent across authorities. The Audit Scotland data would reveal more on that front and although not directly comparable, cost figures from the Welsh and Northern Irish might be useful to see if, as thought, they had commissioned studies to analyse the cost of providing personal care and what figures they had come up with;
(d) In considering the cost of provision and the variations in spend across Scotland it was also necessary to look at quality of provision and performance issues and at supply side issues like the care market and labour market costs and availability. The quality of partnerships established and the management in place locally were also relevant in terms of local authorities' ability to deliver FPC successfully; and
(e) Social work budgets used to be skewed towards children's services and it would be interesting to see from the Audit Scotland work whether there had been any movement towards services for adults and older people in the past 5 years as a result of the FPC policy.
14. The Group agreed that:
(a) Additional evidence should be sought for the Group's consideration in due course on the:
¨ Adequacy of Legislation & Original Policy Intent: The policy papers setting out the Government's original policy intent and finance intentions should be re-examined and clarified for the next meeting;
¨ Actual cost of FPC: In addition to the Audit Scotland Study, the Northern Ireland Assembly and Welsh Assembly Government should be asked if they would share any information they have from work commissioned to establish the actual costs of providing FPC;
¨ Shift in the Balance of Care: The Government's Joint Improvement Team or other sources should be approached for evidence on the shift in the balance of care over the 5 years since FPC was introduced in Scotland and for information on any capacity planning work they may have done or work on tracking resource savings accrued to the NHS, as a result of the policy and of other policy interventions, like that to tackle bed blocking;
¨ Demand side issues: In quantifying demand, an up-to-date picture of the demographics would be required. That needed to include healthy life expectancy and other issues affecting the client group. Cross-border movement/issues should also be considered; and
¨ Supply side issues: Information should be sought from SWIA and others on supply side issues, including the care market and how it divided up in terms of share of the market; private sector issues, staff training, numbers and any evidence on quality and performance issues.
(Action: Rhona and FPNC Policy Team)
(b) A final reminder should be sent to those local authority Chief Executives yet to respond to the Group's open invitation to offer their views. That reminder should make clear that the views of SOLACE were also to be sought and a letter seeking the SOLACE position should be prepared; (Action: Rhona)
(c) The Chief Social Work Inspector should be approached to see what evidence SWIA might to offer on quality, performance and supply side issues; (Action: Rhona)
and
(d) The tight timeframe for the review made oral evidence taking difficult but a view on what further oral evidence might be required from local authorities should be deferred until the remaining evidence (including the Audit Scotland data) had been analysed and possible gaps/areas in need of clarification identified. (Action: Review Group)
Withdrawal of Attendance Allowance: Background Paper (Paper IFR-FPNC (07)10)
15. Shaun introduced Paper IFR-FPNC (07)10 which had been produced by the FPNC Policy team at the Group's request. The paper offered background information on the current position on the question of payment of Attendance Allowance to older people in receipt of FPC in Scotland. He said that the SNP Government's Manifesto had clearly indicated its intention to re-open the issue with the UK Government and preliminary official level discussions had taken place, with the prospect of more to follow. However, this would not be an issue easily resolved or likely to be addressed in the short-term. That said, and the situation in Scotland aside, it was bound to be brought to the fore again by any plans that the Northern Ireland Assembly had to introduce FPC there and by the reforms of social care and support for older people which the UK Government had announced in the 2007 Pre-Budget Report.
16. It was noted that in terms of up-take of Attendance Allowance, this was increasing rapidly on a UK level, but had slowed in Scotland since the introduction of FPC in 2002. There were currently around 140,000 individuals in receipt of the Allowance in Scotland. Of those around 57,000 were home care clients and 9,300 were self-funding care home clients receiving free personal care. The latter no longer qualified for Attendance Allowance since they were now receiving FPC. That still left a group of more than 60,000 individuals in receipt of the benefit, (intended as assistance with the "extra costs" associated with their disability-related needs) but not FPC. But there was little information available about who this group were and what they used the allowance for. Those for whom Attendance Allowance had been withdrawn (the 9,300 self-funders) or would be withdrawn after 4 weeks of taking up a place in a care home were no worse off in real terms though, as the Executive had made up personal care payments to a flat rate of £145 a week, to allow for the withdrawal of Attendance Allowance. The Group noted the current position on withdrawal of Attendance Allowance and agreed to revisit this aspect of its remit before reporting to Ministers in March and in the light of further developments in the intervening period.
Initial Outline of the review's Final Report to Ministers (Paper IFR-FPNC(07)11)
17. Rhona introduced paper IFR-FPNC(07)11 which she said responded to the request made at the last meeting when the Group asked her to give some early thought to the shape and format of its final report to Ministers, which was expected in March 2008. The Group noted the proposed framework for the report and offered a number of comments, including:
¨ The need to be clear on the "net" costs and savings in the section on Current Costs and Funding - which it was hoped the Audit Scotland field work would help establish;
¨ In setting the context, the position on payment for care for the client group in the other 3 countries of the UK needed to be set out; and
¨ In quantifying demand, the picture was more complex and it would be necessary to take a broader view. Looking at the demographics alone was not enough, as the future demand for care for older people would be determined by other changes, including: age specific levels of ill-health or dependency and healthy life expectancy, on which increasing levels of long-term conditions like diabetes and dementia was expected to impact.
Social Work Inspection Agency: Possible Input
18. Mary said that she and Jim had met informally with the Chief Social Work Inspector, Alexis Jay on 1 October to see whether and how SWIA might assist the Independent Review through the knowledge and understanding built up by the agency in the 18 social work department inspections it had undertaken to-date. A brief note of the meeting, which flagged a number of issues which Alexis considered critical to the Review Group's deliberations, had been circulated. The Group noted that as per the discussion at paragraphs 11 to 13 above, there could well be valuable evidence that SWIA could input, especially on delivery issues and indicators of best and poorest performance. It agreed that there would be value in inviting Alexis Jay to offer early oral evidence and that a formal invitation should be issued to that effect. (Action: Rhona and Lord Sutherland)
Any Other Business
Outcome of Judicial Review - Argyll & Bute Council and the Scottish Public Service Ombudsman: Free Personal Care (Paper IFR-FPNC (07)12)
19. Lord Sutherland said that Paper IFR-FPNC (07)12 was not on the agenda but had been prepared by the FPNC Policy Team in the past few days to offer the Group some background and a note on the position on Lord Macphail's ruling of earlier that week on the Judicial Review of the SPSO's decision. The Group noted the paper and the Government's position, i.e that the judgement did not impact on older people's entitlement to FPC and nursing care support and was consistent with existing guidance and the way in which local authorities had operated the legislation. It was noted that a number of authorities could well chose to seek legal interpretations as a result. Where the operation of waiting lists was concerned, although the ruling provided clarity on this, some concerns were expressed about it leading to a possible shift to other more covert forms of "rationing".
Media Attention on FPC
20. The Group agreed that given the renewed media focus on FPC in the light of Lord Macphail's judgement it would be useful if arrangements could be set in hand for press coverage of FPC issues to be monitored and any press cuttings circulated to the Group on a daily basis. (Action: Rhona)
Independent Funding Review of Free Personal & Nursing Care
Secretariat
November 2007