INDEPENDENT FUNDING REVIEW OF FREE PERSONAL AND NURSING CARE: ME ETING AT 10.00am ON FRIDAY 18 JANUARY 2008, ST ANDREW'S HOUSE: NOTE OF ME ETING
Present: Lord Sutherland (Chairman)
Anne Jarvie
Mary Marshall
Jim Dickie
Professor David Bell
Rhona Dubery (Secretary)
In Attendance: Neil Rennick, Scottish Government: Community Care Division
Shaun Eales, Scottish Government: Community Care Division
Jenny Stevenson, Scottish Government: Community Care Division
Apologies
1. Rory Mair was unable to attend.
Introductory Remarks
2. Lord Sutherland welcomed members to the first full meeting of the Group of the new year. He noted that 3 papers/additional pieces of information were being tabled which had a bearing on the business before the group: An SG news release, which had issued that morning, announcing that the flat rate FPNC payments would be rising in line with inflation from 1 April; a late piece of evidence from Scottish Care, which related to those payments and raised the question of degree of differential between them; and details from the SOLACE, ADSW, CIPFA working group of the calculations through which they arrived at the funding gap figure of £26m, put forward in their evidence to the Review Group.
Matters Arising
3. Lord Sutherland said he had met as planned with the Cabinet Secretary for Health & Wellbeing, Nicola Sturgeon, on 7 January. The Minister for Public Health, Shona Robison had been able to join them for the meeting. He had advised the Ministers of the progress made with the Review and of some of the issues encountered, including the difficulty of getting at definitive expenditure figures, where the Review Group was awaiting the final data set from Audit Scotland's work with local authorities to try and establish more reliable expenditure data as part of its study of FPNC.
Minutes of Meeting held on 14 December 2007
4. The minutes of the fifth meeting held on Friday, 14 December 2007 (IFR-FPNC (07)5th Minutes) were approved subject to a minor amendment to the 4th bullet point of paragraph 9.
Up-date on Audit Scotland Review of FPNC (Paper IFR-FPNC(08)01)
5. Rhona said that Paper IFR-FPNC(08)01 offered an up-date on the latest position with the Audit Scotland Review of FPNC ahead of the publication of the Auditor General's report. Publication was still expected for the end of the month. It would be a joint report with the Accounts Commission, which was expected to be considered by the Parliament's Audit Committee on 6 February (in line with its remit to consider and report on any report laid before or made to Parliament by the Auditor General for Scotland). She said that the key findings of the Audit Scotland Review were set out in the box on page 1-2 of the paper; crucial amongst these was the conclusion that there was a significant and growing shortfall in funding for FPNC of between £45 and £61 million.
6. Neil said that he had provided detailed comments on the factual accuracy of the Audit Scotland report and had been discussing the financial data produced in their data survey with them and that although the verification exercise was still on-going, it would need to conclude shortly if they were to keep the review on track. The figures on which they had based their conclusions on total expenditure on, and therefore their suggested shortfall on, were significantly higher than previous estimates. This was because a number of local authorities had taken the opportunity to restate figures included in the original LFR3 monitoring forms submitted to the SG. A number of those revising their figures were large councils, with large budgets, so the scale of the changes was significant. There was also the problem of the handling of overheads which had been known about for some time, with some authorities including a proportion of overheads in their reported expenditure on FPNC and others counting only the flat rate payments against FPNC. Work was on-going to clarify the exact nature of the overheads included but Audit Scotland were expected to average these out in order to produce a percentage figure which could be added across the board in an attempt to produce a more complete picture of the total cost of FPNC over the past 4 years.
7. Audit Scotland had experienced further complications in moving to compare the expenditure figures with funding levels. This was because in addition to the new money added to councils' general revenue grant explicitly to fund FPNC there were other significant strands of government funding in the period which were relevant to older people's services, e.g. for the expansion of home care. However, it was not possible to go back and break these additions down to say how much could be attributed to the provision of FPNC directly. Therefore, the Audit Scotland estimate took no account of these other funding allocations. He said that although there were serious doubts about the basis of Audit Scotland's calculations it seemed unlikely now that they would move much from their suggested shortfall figure of a gap of between £45-61 million by year 4 of the policy. Whatever the final figure, it would be considerably higher than the suggested year 4 shortfall of £26 million submitted in evidence by the SOLACE, CIPFA, ADSW working group earlier in the month; which was close to the figure of £25 million produced by the Government's Care Costs Group.
8. The Review Group noted the latest position with the Audit Scotland study and the likely conclusion in respect of the question of whether the policy had been adequately resourced. It noted in particular the difficulties Audit Scotland had encountered and that despite the suggested shortfall, there were still a number of local authorities who were not spending at GAE level. The Review Group agreed that:
(a) It should consider the final financial data produced by Audit Scotland at its next meeting; and
(b) In terms of presentation, it would not be appropriate to offer any comment at the time of publication of the Audit Scotland report, when the Review Group would still be considering all the financial information and formulating its own conclusions.
Funding of the Policy: The Costs of Care Provision for Older People in Scotland: (Paper IFR-FPNC(08)02)
9. David said that his paper was a first attempt to pull together an estimate of the total funding going into long-term care for older people in Scotland. Some of the data involved was particularly difficult to check and the figures required some further work and verification, so for now needed to be treated as estimates of the general magnitudes involved. The exercise produced a total expenditure figure in the region of £2.2 billion for 2006. To put that into perspective, spending on the NHS in Scotland in 2006-07 was £10.2 billion; so the costs of supporting long-term care were equivalent to around a quarter of the total NHS budget. The most recent estimate available on long-term care expenditure in Scotland otherwise was in the second Range & Capacity Review of 2004, which produced a figure of £1.4 billion. The difference between the 2 figures could largely be attributed to his including direct spending by the UK government in support of long-term care needs in Scotland; principally DWP payments for Attendance Allowance and Disability Living Allowance (Care Component). Given that these payments from the public purse were explicitly intended to compensate those with personal care needs it could be argued that they should be included in any analysis of overall long-term care costs.
10. David went on to explain how his analysis of respective care costs broke down by mode of provision, as detailed in his paper:
Care Home s. Of the total expenditure on care homes in 2006, net expenditure by local authorities was about £540 million. Based on an estimate of total care home fees the total private sector contribution was around £260 million. This would come from self-funders and those paying for their own care. Self-funders comprised only around 29% of all care home residents. FPNC payments by local authorities on behalf of self-funders accounted for £100 million of total care home income in 2006-07, concentrated on 9,100 self-funding residents receiving personal care and 5,900 also receiving nursing care. The affect of these payments was to reduce the care home fees payable by self-funders from around £220 million to around £130 million. At a personal level, that reduced a self-funder's annual total bill from £24,000 to around £10,000;
Care at Home. More was now spent on care at home than care homes, with costs split between benefits paid by DWP, local authorities and the individual. Around 138,000 Scots benefited from Attendance Allowance with some 41,000 of those also receiving personal care at home. In addition, a further 16,000 individuals also received non personal care support from local authorities, with councils spending about £189 million on non-personal care; but numbers there were diminishing. Gross spending by councils on domiciliary care was around £380 million and although non-personal care was chargeable, reported charge income in 2006-07 was only around £16 million. Charging policy and practice varied widely between local authorities, in spite of the guidelines that existed on this. There had been a corresponding expansion in private spending on home care services and while local authorities still did a lot of commissioning on this front they did less actual delivery of home care services;
Housing. Another significant element of the costs of long-term care was local authorities' housing support services. Around £94 million came through the Supporting People programme (which had effectively replaced Housing Benefit), where local authorities effectively acted as agents for DWP. In addition, there was a cost to local authorities associated with the financing of supported or sheltered housing, in terms of depreciation, maintenance and service provision. That was thought to amount to about £40 million;
NHS. Contributions from NHS Boards to local authorities reduced the net cost of long-term care provision. In 2006-07 resource transfers were valued at £132 million;
Private Spending. Private contributions towards the costs of long-term care amounted to around 13 % of the total costs of long-term care. Contributions arose mainly from 4 sources: about £130 million for self-funders' contributions towards care home fees; £136 million in local authority client contributions towards care home fees; £12 million in privately purchased home care; and £16 million for local authority fees and charges.
11. David said that Table 2 on page 9 of his paper brought together the various component costs of long-term care. Of the total of £2.226 billion, about a quarter of the costs, over £500 million a year, were met by DWP, through Attendance Allowance and Disability Living Allowance (Care Component), which it paid directly and provision for the Supporting People programme which DWP paid via the local authorities. The bulk of the remaining costs were met by local authorities, supported by the Scottish Government, with the exception of small flows coming from Council Tax or from charging.
12. In discussion the following points were made:
(a) It was difficult to disentangle the costs of FPNC from the other component costs of long-term care and that would become increasingly difficult, if not impossible, under the new outcomes based local government funding arrangements;
(b) The resource transfer figure from the NHS was a "best estimate" only, as it was very difficult to establish reliable figures for this, especially in the first 6 weeks of a person's transfer from NHS acute care to long-term social care, when there was inevitably some "bleeding" of costs between the respective budgets;
(c) The provision and availability of social housing was an important consideration in terms of long-term costs and sustainability and more information was needed on this and on government policy intervention;
(d) Much of the criticism of the Government's FPNC policy centred on the original commitment to "fully fund" it and the alleged funding shortfall which had emerged in the past few years. It was hoped that the Audit Scotland study would help quantify any funding gap and the Review Group would obviously need to take a view on that. However, the difficulties encountered in attempting to separately identify the costs and the interdependence of the components illustrated in the paper backed up evidence which suggested that FPNC should be "mainstreamed" and aligned with general long-term care costs;
(e) In considering FPNC as part of that wider picture of the long-term costs of care, it was necessary to factor in the sizable resource flows coming from the UK government.
13. The Review Group agreed that it should consider a paper which set out the detailed local authority expenditure figures from the Audit Scotland study at its next meeting, along with any revisions David might wish to make to his paper on total resources as a result of further work on verification. ( Action: David and FPNC Policy Team)
Attendance Allowance: A proposal: (Paper IFR-FPNC(08)03)
14. David said that his last paper on the total costs of care provision had brought other state funding of care, through funding paid indirectly by DWP, into the equation. Having done so, this further paper considered whether the £500 million flowing from the 2 main DWP universal state benefits - Attendance Allowance (AA) and Disability Living Allowance (DLA) - amounting to around a quarter of the total costs of long-term care in Scotland might be better directed to bolster the cost of individuals in greatest need, i.e. in need of personal care.
15. There were just under 200,000 people aged 65+ with personal care needs currently in receipt of either AA or DLA in Scotland. Just under 140,000 receiving AA and about 60,000 DLA; although the age profiles of recipients were very different, with a large number of younger people receiving DLA. Of the 140,000 receiving AA around 41,000 were adults aged 65+ receiving local authority personal care at home. Attendance Allowance was not means tested or taxable and recipients were free to spend the allowance on whatever they wished. There was little evidence or research about exactly how AA was spent or indeed if claimants used it to purchase social care services at all. The inequity pointed up in the evidence offered by the SOLACE, CIPFA, ADSW working group and others should be remembered here too, i.e. in terms of disposable income, where the different treatment of AA for those receiving FPC at home and those receiving it in a care home (where AA was withdrawn after 4 weeks), meant that the latter could be left with as little as £20.45 a week whilst the former could retain about £232 a week.
16. Eligibility for AA was governed by assessed need and paid as recognition of the help that an individual needed with personal care. AA was awarded indefinitely on passing a disability test. Its award might also increase the amount of other benefits or credits an individual was entitled to. But it was thought that as many as 80% of those applying for AA and satisfying the disability test would not satisfy the local authority assessment for FPC. Two key differences in qualifying for FPC and AA were the:
¨ Assessment process (the benefit being assessed by GPs/DWP and FPC by local authority social workers);
¨ Demand-led nature of the latter, which was clearly a universal provision (whereas demand for FPC services was currently being managed in many instances, with eligibility criteria and waiting lists common place and individuals receiving different levels of service depending on where in Scotland they lived).
17. The Review Group noted the position on AA and agreed that:
(a) As it stood, the 2 separate funding systems, AA benefit and FPC, did not sit well together. AA was poorly targeted and it was not clear how that money was used (this had been highlighted in the Wanless Social Care review of 2006 and was likely to be raised in the UK Government's forthcoming social care green paper) and FPC was inequitable as long as variations continued across the country in how serious a condition had to be to qualify for free care and/or in the amount of care an individual was offered. The 2 separate assessment processes added to individuals' confusion over entitlement;
(b) Neither system sat well with the personalisation or direct payments/self-directed support agendas which sought to promote equity and freedom of choice in their care services. Take-up of self-directed support had been slow in Scotland but an extension of that system (similar in some ways to the use of vouchers as in Germany) might offer an alternative which sat much more comfortably with personalisation and ensured that resources were better targeted on need; and
(c) The latest policy position on Self-Directed Support should be checked and set out for the Group's consideration of its draft report. (Action: Rhona)
Report on the Views of Social Workers Undertaking Assessment and Care Management with Older People: (Paper IFR-FPNC(08)04)
18. Mary introduced the report on the outcome of the exercise which she had conducted along with Jim, gathering the views and experience of front-line social workers involved in the implementation of FPC. During the process they had spoken on a confidential basis with some 30 front-line staff across 8 local authority areas (in a spread of rural/urban and wealthy/poorer areas) who were involved in the assessment and care management of older people (there was still the prospect of one further local authority being involved). Mary and Jim highlighted some of the most significant aspects coming out in their study:
On the positive side:
¨ There was unequivocal widespread support for FPC as a "right", subject of course to assessed need and the status of FPC as such was thought to have diminished the stigma some older people and their families had associated with receiving social care in the past;
¨ In line with the Joseph Rowntree research, there was little evidence of any retreat from involvement by carers as a result of the introduction of FPC;
¨ Problems with the operation of Ordinary Residence arrangements were not perceived as a huge issue. One local authority felt strongly about Ordinary Residence issues and problems caused by inconsistent application of the regulations by councils. In some areas problems could be exacerbated by the quality or otherwise of their care home estate and an individual's right to choose the care home they lived in;
On the negative side:
¨ That wide-spread support was off-set by wide-spread mis-understanding or lack of awareness of the detail of the policy and what an individual was entitled to. Much of the confusion stemmed back to the use of the term "free" personal care and the misconception that an individual's whole care package was free, rather than just the "personal" element for self-funders. Social workers reported difficulties in clients or their relatives' understanding of the different components of social care;
¨ In practice mechanisms for managing and prioritising provision of care were evident in all the authorities looked at. Critically in some areas the priority systems in place were seeing only those assessed as "critical" receiving FPC;
¨ Use of eligibility criteria was widespread but meant different things to different authorities; it ultimately meant that everyone was entitled to an assessment for FPC but not everyone entitled to a service - even those assessed as in "substantial" need in some areas;
¨ The "authorisation" procedures which operated in most areas for FPC at home, usually through a "panel" type arrangement, effectively controlled budgets but for individuals it meant that at best there was a delay in them getting the care they needed or at worst, there were groups of people excluded from getting their care at home because of "ceilings" on the cost of care at home. Either way there were quality of life and equality issues for the older people concerned;
¨ The level of collaboration between local authorities and NHS Boards was an important factor in the ability of the system to respond quickly and flexibly to the care needs of older people;
¨ There was quite a degree of concern about the retreat from domestic or preventative services in a bid to balance budgets and meet the statutory obligation not to charge for FPC services;
¨ There was also concern about quality of personal care services in the light of increased demand stimulated by the introduction of the FPC policy and the skills and recruitment/retention issues faced by the care industry and the pressure on social workers' workloads;
19. In discussion of the report and the recommendations it made at paragraph 4 the following points were made:
(a) The problems around assessment reaffirmed the conclusion reached in discussing paper IFR-FPNC(08)03 above around the need for a single transparent assessment process which took place within a specific timeframe;
(b) The importance of strong partnership working could not be overemphasised. Rationing tended to be a symptom of the poorest performing partnerships, where the balance of care was often still tipped in the direction of residential care and partners less progressive or imaginative in their approach to service design;
(c) The findings also reaffirmed the idea of a minimum Scotland-wide standard of entitlement put forward in some of the evidence the group had taken over the past few months;
(d) Setting barriers to accessing funding was counter to the founding principles of FPC and to the Government's personalisation agenda for public service delivery. It was also counter to the other current policy priorities in social care set out in "Changing Lives" (the 21st Century Social Work Review); and
(e) The universities operated a tried and tested "Ordinary Residence" policy and greater consistency of interpretation of the guidance in respect of paying for the cost of accommodation and care for older people ought to be achievable.
20. The Review Group agreed that the proposed recommendations set out in paragraph 4 of paper IFR-FPNC(08)04 should be included in its report, i.e that:
(a) FPC funding should be up-rated on an annual basis;
(b) The guidance should be developed to resolve "fuzzy" issues and minimise the inconsistencies in implementation;
(c) Greater consistency in "Ordinary Residence" interpretation should be promoted;
(d) Efforts should be made to improve public information and understanding of the policy; and
(e) A framework should be developed to ensure that those with personal care needs, both at critical/substantial level and at lower levels receive services.
21. The Group also agreed that its final report should include a reference to the labour market/recruitment difficulties which contributed to the use of waiting lists and eligibility criteria in some areas - rather than funding issues alone - and to the likely impact of workforce demographics which would see the problem worsen. It should also, where possible, contain examples of better performing local authorities who were managing to deliver services within the resources available, often by turning to innovative approaches or adopting new technology as a feature of their service delivery. (Action: Rhona)
Future Plans
22. Lord Sutherland noted that only one further meting had been scheduled - Friday, 15 February - for the Group to conclude its work and in terms of what remained for consideration he anticipated a further 2 meetings beyond that may be necessary to ensure that the Review's work concluded in time to report to Ministers before the end of March. He further noted that Rory had indicated that the meeting on 15 February now looked very difficult for him. In terms of additional meeting dates and scheduling of work, the Review Group agreed:
¨ That the meeting currently scheduled for Friday, 15 February should be brought forward by a day to Thursday, 14 February (10.00 - 2.00 in SAH) in the hope that Rory would be able to attend;
¨ That 2 additional meetings be arranged for Friday, 29 February and Friday, 14 March, both from 10.00am to 2.00pm;
¨ That the 14 February meeting should:
- Re-visit the question of total level of resources for FPNC - informed by the Audit Scotland expenditure data and whether the quantum has been adequate;
- Consider David's paper on allocation of resources and any revise of paper IFR-FPNC(08)02 on total costs of care for older people which may be necessary in the light of further verification of the figures used;
- Consider a paper/papers on the latest demographics and the cost projections those produce and therefore the future level of resources and sustainability of the policy;
- Consider the draft sections of the report on Attendance Allowance and on Key Recommendations (as far as they have been developed by that point) and any other sections Rhona had drafted in the time available. Recommendations should be anchored as much as possible in broader social care policy, recognising current government policy and the direction of travel;
¨ It would return to the SOLACE, ADSW, CIPFA working group submission and in particular the "Opportunities"/possible ways forward set out in its submission discussed with the Review Group on 7 January and its calculation of a funding gap now tabled; and
¨ It would also return to consider the late submission on the flat-rate FPNC allowances from Scottish Care, also tabled.
Any Other Business
23. The Review Group agreed that the detailed anonymised reports of the interviews with social workers which informed paper IFR-FPNC(08)04 should be circulated to members for information. ( Action: Mary & Rhona)
Independent Funding Review of Free Personal & Nursing Care
Secretariat
January 2008