INDEPENDENT FUNDING REVIEW OF FREE PERSONAL AND NURSING CARE: MEETING AT 10.00am ON FRIDAY 14 DECEMBER 2007, ST ANDREW'S HOUSE: NOTE OF MEETING
Present: Lord Sutherland (Chairman)
Anne Jarvie
Mary Marshall
Jim Dickie
Professor David Bell
Rory Mair
Rhona Dubery (Secretary)
In Attendance: Neil Rennick, Scottish Government: Community Care Division
Jenny Stevenson, Scottish Government: Community Care Division
Alexis Jay, Chief Social Work Inspector ( for item 3 only)
Introductory Remarks
1. Lord Sutherland welcomed members to the fifth meeting of the Review Group and thanked Alexis Jay, the Chief Social Work Inspector for making the time to join the Group that morning and offer her input.
Minutes of Meeting held on 23 November 2007
2. The minutes of the fourth meeting held on Friday, 23 November 2007 (IFR-FPNC (07)4th Minutes) were approved.
Matters arising from the Minutes
Attendance Allowance
3. Rhona said that she had agreed with David that the Group's consideration of his paper on Attendance Allowance should be deferred to the January agenda to allow more time for discussion and ideally so that it could be considered alongside the paper he was preparing on the total cost of care provision for older people.
SOLACE/CIPFA/ADSW Working Group Oral Evidence
4. Rhona said that as agreed at the last meeting, the oral evidence taking meeting with representatives of the SOLACE/CIPFA/ADSW Working Group had been arranged for the morning of Monday, 7 January. The Working Group, led by Alex Linkston, was expected to present a more detailed joint submission to the Independent Review, although sight of that in advance of the meeting was thought unlikely given the proximity to the Christmas holiday period. The Review Group noted the arrangements and that Rory would not attend that particular session.
Chief Social Work Inspector: Overview of FPNC from SWIA Perspective
5. Alexis Jay said she appreciated the opportunity to offer her views to the Independent Review, not only from the perspective of her current position as Chief Social Work Inspector, but also because of her considerable past interest in FPNC. In the period 2001-2002 she had been a member of the Care Development Group and had Chaired the high level Implementation Group established to drive forward the practicalities of implementation of the policy. Looking back at that, she wanted to remind the Review Group of the extreme political pressure that existed at the time and drive to deliver FPNC in Scotland. She also wanted to stress the scale of achievement on the part of all those involved (central and local government and others) in introducing the policy in Scotland by July 2002. The time afforded for implementation of such a complex policy change was extremely tight and although the policy had had its problems (which had received a very public airing and suffered as a result of mis-conceptions) she felt these should be kept in proportion as overall it represented a huge step in the right direction.
6. In her evidence to the Review Group Alexis Jay said that since SWIA was established in May 2005 it had carried out performance inspections in 18 out of Scotland's 32 local authorities and SWIA inspectors were working with councils to ensure resulting action plans were put into effect. Through these inspections they had already built-up a unique overview of the consistency and standards of Scotland's social work services. She expected SWIA to complete its national inspection programme by mid-2009.
7. In addition to that main programme of activity, SWIA had also carried out a number of other pieces of work, including a pilot multi-agency inspection of older people's services in Tayside which it had led in partnership with NHS Quality Improvement Scotland and the Care Commission. Using a methodology devised by a Task Group comprised of representatives from the 3 agencies, the pilot focused on how the agencies in Tayside (NHS Tayside, Angus, Dundee City and Perth & Kinross Councils) worked together to provide joined-up and integrated services for the client group, rather than on specific services. That multi-agency inspection was a very rigorous process and enabled inspectors to drill-down further and look objectively at the nature of the service delivered for older people in the area. The inspection was one of 3 inspections piloting the approach, which SWIA hoped to roll out more widely and she expected that the knowledge derived would enable SWIA not only to improve the quality of services but also to expand the contribution it made to social work policy development in the future.
8. Alexis said that provision of social work services could be split roughly 10%/70%/20% between criminal justice services, adult and older people's services and children and young people's services. The first year of performance inspections had enabled SWIA to build up a substantial body of evidence on services and overall, the picture was reasonably positive; but the client group tended to rank satisfaction more highly than other groups and that contributed to what might be perceived as an "ageist system" of provision, with the bulk of social work resource flowing to the other 2 groups and older people's services still seen as the "Cinderella" service. Where older people's services were concerned, she made the following points:
¨ Care planning was still not as good as it could be;
¨ Although integrated working had moved on in recent years, it still had some way to go;
¨ As part of its work, SWIA had surveyed older people across Scotland and broadly speaking they regarded the quality of service provision as good however, in the largest part, the model in place was still a traditional one, with most people still not afforded a choice in the delivery of their care or even the more straight forward components of that, like provision of meals. The take-up and promotion by agencies of the direct payment option in Scotland was at much lower levels than in England;
¨ There was still not enough personalisation in the delivery of older people's services;
¨ Services for those with dementia were still not as good as they should be; and
¨ Despite their huge contribution to caring for the elderly, informal carers still found themselves quite poorly supported, with only around 40% saying they had been offered a carer's assessment.
9. In discussion the following points were made:
¨ Disparity in cost and quality of provision. Evidence to the Review showed huge variations in total spend on provision of FPC and spend per head in different local authorities across the country and on the ground variations in practice between councils was also quite striking. SWIA assessments were carried out in a consistent fashion, resulting in actions plans which Inspectors followed up with each council. However, matching 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 behind the increasing use of rationing. There was evidence to suggest that the use of eligibility criteria as a means of controlling budgets was common and in some areas clients needed to be assessed as "critical" in order to receive FPC;
¨ Care Plans. A number of councils were also failing to put in place care plans in good time and there was a direct correlation between the absence of adequate care plans and failures to meet people's needs. Where discharging the elderly from hospital was concerned, performance had improved greatly over the past 5 years and poor practice (which in the past had led to frequent re-admissions to hospital) was no longer coming out as a big issue in inspections. Where problems arose, it tended to be with sudden discharges or in the case of people with complex needs;
¨ Provision of funding through the GAE mechanism. Although SWIA inspections did not normally comment on the resourcing of specific services through GAE it had done so in published reports in a few cases where it appeared that resources had been skewed greatly from the original cost estimate of providing the service (the GAE) and large sums diverted elsewhere or where there was evidence of significant waiting lists operating;
¨ Perception of impact of FPC. Although it was difficult to evidence, there was a perception amongst some front line staff (which Mary and Jim's study of social workers' views was expected to reaffirm) that rationing was leading to a 2-tier system of care, where the wealthy had their needs met and were afforded the benefit of choice and provision for those with lesser means was increasingly restricted to those in "critical" need;
¨ Unmet Need. The levels of unmet need which had transpired since 2002 was a key contributing factor to the increasing costs and the extent of rationing of services being seen, with demand for FPC services (especially at home - where there was no "cap" on costs) far exceeding that originally envisaged by the Care Development Group. General levels of awareness had also been raised through the media focus on the FPC policy, as had service users' expectations. It was also thought that the removal of councils' ability to charge for personal care had also removed any perceived stigma, with more older people or their carers viewing care as a "right";
¨ Impact of Other Policy Developments. The interface between FPC and other simultaneous policy initiatives was relevant too, with action to address delayed discharge and the introduction of Supporting People grant impacting on the same client group in the period since 2002. The availability and quality of housing support for older people in different areas was also very relevant;
¨ Joint Working/Joint Budgets. There has been huge improvements in partnership working in the past 10 years or so, in line with the shift in the balance of care towards caring for the elderly in the long-stay geriatric hospitals of the past and caring for people in their own homes. However the transfer of resources, which the then Health Boards held in relation to that provision was virtually impossible to track and support for these services in the community did not get off on the surest footing. This was most acutely seen in the case of client groups like those with dementia, on the cusp of service provision, falling between both health and social care. In a number of areas joint working and in some, pooled budgets, were proving the best way of addressing the difficulties. The SG's Joint Improvement Team (JIT) was seeking to progress integrated working and commissioning and had issued a tool kit/workbook in 2007 to assist councils in that respect. There were examples of good practice in areas like West Lothian and Angus, but there was still huge scope for improvement and there was a perception that for many the JIT tool was unwieldy and too complex to implement; and
¨ Commissioning Services/Capacity Planning. Local authorities varied widely in their approach to commissioning care home places or services for care at home. The more progressive councils had range and capacity plans but realistically were still only able to look up to 15 years ahead. At worst, councils focussed their commissioning efforts on driving prices down with no eye to the changing needs of the client group. Overall though, the impression was of increasing sophistication which could well continue in line with the drive for public bodies to share common services like procurement and the new emphasis on outcomes.
10. The Review Group thanked Alexis for her time and valuable input to the Independent Review.
[ Alexis Jay left the meeting]
Aspects of Free Personal & Nursing Care: Discussion of Report for Audit Scotland by Prof. David Bell (Paper IFR-FPNC(07)17)
11. Lord Sutherland said that David Bell's economic modelling paper, prepared for the Audit Scotland study of FPNC had been circulated to the Group for discussion. The report submitted in November, was still classed as a draft. He said that it had also been possible that morning to table copies of the draft Audit Scotland Report itself. He stressed that the report was still a draft and was shared with the Review Group in strict confidence. It was subject to further changes that week as the Audit Scotland verification process went on and ahead of formal submission to the Scottish Government for clearance for its factual accuracy on 19 December.
12. David introduced his paper. He said he had been asked to carry out the economic modelling for Audit Scotland's study, examining the overall current and future costs and funding for the implementation of the policy in Scotland and evaluate its impact. Although the bulk of the report focussed on the costs and funding, he said that Audit Scotland had been very interested in local authorities' charging policies, hence the individual examples given at the end of the report.
13. He said that part 1 of the report looked at the history and development of the policy, as well as the methodologies used to determine costs (including the work of the Care Development Group (CDG) and Range & Capacity Review). It looked at major sources of the rapid expansion of demand for social care and the increasing costs of supplying it. It considered unmet need and the supply of informal care and the demographic projections. In both cases the picture now looked somewhat different to the forecasts made by the CDG in 2001-02, with the costs to local authorities still rising. Where healthy life expectancy was concerned, at the time it was thought that changes would be small relative to the effects of demography but subsequent work by Aberdeen University showed that it had been increasing at the same rate as life expectancy for people aged 65+. It was now clear that although the numbers in the client group had not changed dramatically in the past 5 years or so, the proportion of clients receiving FPC and of those requiring more intensive care packages was increasing.
14. The report also acknowledged the impact of other factors, such as other government policy initiatives and benefits. The successful work to tackle the problem of delayed discharge had impacted on demand for social care and the numbers requiring nursing or personal care in the community. The Right to Buy policy and resulting increases in home ownership in recent times had also increased the proportion of self funders among care home clients. In terms of other government benefits, the numbers receiving Attendance Allowance and the withdrawal of that DWP benefit to care home based recipients of FPC also had an affect on costs and the numbers still in receipt of the benefit was possibly an untried determinate of unmet need. He was looking at this separately for consideration by the Review Group in January.
15. David said that part 2 of the report went on to discuss other recent reviews and investigations into FPNC and the funding of the policy and variability in costs and spend. All the work carried out in evaluating the policy had so far been compounded by problems with the available data to monitor it effectively. Ageing was a major strategic issue for Scotland and the UK as a whole and it was surprising that the data and monitoring was not at least as good as that for other contemporary strategic issues and priorities, such as climate change.
16. Based on what data was available and bearing in mind the "health warnings" it carried, David could see no clear explanation for the huge variability in the clients costs of FPC between Scottish local authorities - as shown in table 4 and Figures 3 and 4 of the report. Variations in client costs were much less dramatic in the work he had done on costs for the Welsh. Historic service provision pre-FPC had a bearing but factors like rurality, which might be expected to influence cost and offer an explanation were not always evident. On funding, the report considered the evolution of GAE for older people and FPNC and actual expenditure by local authorities but this too was a complex picture; not least because of the need to take into account councils' expenditure on personal care at home prior to the introduction of the FPNC policy. But also because you were not comparing like with like comparing GAE with expenditure, when GAE was not actual funding, but rather represented provision to spend. Also, the Government often made additional allocations to local authorities mid-year, which did not appear in the GAE allocations.
17. Part 3 of the report then looked at possible means of projecting the cost of personal care at home in the future, for which David said he had used a survey conducted by the Welsh Assembly Government, as individual information on personal care clients was not available in Scotland. One of the more startling conclusions of the modelling related to levels of need was that 40% of the total hours of care and therefore of the cost of care was accounted for by just 10% of users. The number of individuals receiving more intensive and therefore more expensive packages of care had increased in line with the shift away from long-term care in residential homes and hospitals and the demographics, which projected large increases in the numbers of people over 75 by 2031 and in the most needy and frail, suggested that would continue to grow significantly.
18. The Review Group noted the report and that David planned to do further work and a paper on the costs of care and on the latest demographic position which the Group would consider early in the new year.
Free Personal & Nursing Care: Funding of Policy: Papers IFR-FPNC(07)18 (a) and (b)
19. Rhona said that the 2 papers on funding were presented to assist the group in coming to a view on the first strand of its remit, i.e. on the total level of resources made available to local authorities for implementation of FPNC since the policy was introduced. Paper 18(a) responded to the request made at the November meeting, for a paper which completed the picture (presented in Paper IFR-FPNC(07)15) on the Government's original policy and financial intent by setting out the policy developments post implementation and details on funding intent and provision. Paper 18(b) summarised the overarching picture on total financial allocations and expenditure for FPNC. The Review Group noted paper 18(a).
20. Neil introduced paper 18(b) which the SG FPNC policy team had drawn together with the assistance of Analytical Services colleagues. He said that the total financial provision for the cost of FPNC was calculated on the basis of the Care Development Group's projections and that the policy had been 100% funded by central government, i.e. there was no expectation by the then Scottish Executive that any part of the costs would be met from local council tax income. In the first 3 years of the new policy, 2002-03, 2003-04 and 2004-05 new money in the form of additional resources added to general revenue grant was £107 m, £143m and £147m. However, to gain a full picture on funding for FPNC you needed to add to those figures the sums local authorities were already receiving (prior to the FPNC policy) through the GAE mechanism to cover the cost of personal care services for older people at home. These costs were estimated as around £65m by the CDG and estimated expenditure in 2002-03, 2003-04 and 2004-05 was £68.4m, £75.8m and £81.9m. That addition brought funding in those first 3 years to a minimum of £175.4m, £218.8m and £228.9m.
21. In addition to the specific increases made to total grant provision, the then Executive made other significant additions to total revenue funding in the period, a number of which were relevant to older people's services. They included additional funding for care home fees, the expansion of home care services and the transfer of former preserved rights clients from the DWP to Scottish councils. But it was not possible to separately attribute the proportion of these resources which benefited the provision of FPNC.
22. Although, for reasons explained at the Group's first meeting (IFR-FPNC(07)02), it was not strictly possible to compare GAE allocations with local authority expenditure i.e. because GAE allocations were not budgets and to do so took no account of local authorities' freedom to spend their resources in line with local priorities, in the circumstances it was the only means of making any comparison of funding and expenditure since the policy was introduced. Also the individual expenditure figures returned were based on different accounting procedures, with some authorities including overheads and others not.
23. Neil said that the paper showed that for Scotland as a whole, over the first 3 years of the FPNC policy, provision was greater than expenditure by local authorities. However, by year 4 expenditure began to move ahead of the explicit funding provision to spend. That amounted to £19.4 m in year 4, 2005-06. That "deficit" contrasted with the bigger picture when you considered spending on older people as a whole, where expenditure by local authorities now fell significantly behind the growth in GAEs, amounting to £73.3 m in 2005-06. The post implementation figures revealed a shift in local authority spending away from non FPNC towards FPNC and 2 factors which stood out over the period since 2002 were: the decreasing number of local authority "fully-funded" clients and the reduction in non-personal home care services.
24. The Review Group noted the paper and that the difficulty of not being able to compare like with like (i.e. income in the form of GAE allocations with local authority expenditure) and the changing pattern of care provision between non-personal and personal care since 2002 would make it very difficult for it to come to a firm conclusion on the adequacy of the overall quantum of resources available for the policy.
25. The Review Group also noted that the verification process of the data return by local authorities in response to the Audit Scotland Study might produce more robust expenditure figures but that that process was taking longer than originally anticipated, so the data from the exercise which the Auditor General had agreed to share with the Review Group had yet to be made available. Although early indications were that the complexity involved in trying to determine the actual costs and financial impact of the FPNC policy, may prevent Audit Scotland coming up with a firm figure on actual costs and a firm view on whether or not the funding provided by government has been adequate.
26. In the light of the discussion above, the Review Group agreed that it would be useful to consider the costs of care provision as a whole and David agreed to prepare a paper looking at total resources (to include NHS resources) for consideration at the Group's January meeting. ( Action: David Bell)
Any Other Business
27. The Review Group noted that Rory would not attend the oral evidence taking meeting on 7 January, when the Group would hear from SOLACE, CIPFA and ADSW representatives.
28. The Review Group agreed that the time planned for its next full meeting on Friday, 18 January should be extended from the original 2 hours. The meeting would commence at 10.00am as planned and should conclude by 2.00pm. (Action: Rhona)
Independent Funding Review of Free Personal & Nursing Care
Secretariat
January 2008