Carefree Scotland, by David Scott

13 Jul 06
One of devolved Scotland's first major policies was free personal care for the elderly. Four years on, how has it fared and does it offer any lessons for the rest of the UK? David Scott reports

14 July 2006

One of devolved Scotland's first major policies was free personal care for the elderly. Four years on, how has it fared and does it offer any lessons for the rest of the UK? David Scott reports

Free personal care for the elderly, the Scottish Executive's flagship policy, has been the subject of renewed controversy in recent weeks. Councils have been criticised for failing to honour the promise given to thousands of elderly people by putting them on lengthy waiting lists. A series of reports by politicians and academics has examined whether the system is working and is being properly funded, and whether there are lessons for south of the border, where the future of social care is back on the political agenda.

Free personal care was first proposed by Sir Stewart Sutherland (now Lord Sutherland of Houndwood) in his Royal Commission report on long-term care of the elderly, published in 1999. Concerned about the cost implications, the UK government rejected the idea. However, the ruling Labour-Liberal Democrat coalition in the Scottish Executive – anxious to demonstrate how devolution could make a difference – took the bold and controversial step of putting it into practice.

The go-it-alone policy for Scotland means that, irrespective of income, all people aged 65 and over are entitled to the free personal care element of their care costs either at home or in a residential establishment. Personal care includes services such as help with washing, dressing, hygiene and eating. The Executive pays £145 per week for each qualifying person to local authorities, who then pay the care provider. Nursing care is also free but, for those who can afford it, the 'hotel' costs of living in a care home (accommodation and food) must be paid for.

The recent row over waiting lists arose because a number of councils claimed they were facing a serious shortfall in funding. A national survey carried out by the Scottish Executive, based on a statistical snapshot taken in February this year, revealed that almost 5,000 elderly people in 21 of Scotland's 32 councils had been left waiting for free personal care.

The local authorities argued that they had no alternative but to draw up waiting lists because the amount they were paid by the Executive had failed to keep pace with large increases that had occurred in care costs since the policy was first implemented in 2002. They say that the overall shortfall in funding is about £70m.

'Free personal care is a good policy and has benefited a lot of people and we want to see it continue, but there are still a lot of grey areas that need to be sorted out,' says Eric Jackson, social work spokesman for the Convention of Scottish Local Authorities.

Argyll and Bute Council is one of the authorities with a lengthy waiting list. Jim Robb, its head of service for integrated care, believes a change is needed in the way the Executive funds councils for care services, which is via the Grant Aided Expenditure system.

'We need to move to a position where it is decided that free personal care is a national policy and is implemented as such,' he suggests. 'Under the present system, each of the 32 councils have different versions of the policy and are trying to implement it in different ways. How can you have a national policy based on a funding stream that is not consistent across Scotland?' he asks.

The Scottish Executive argues that it gave councils £153m in 2005 specifically to cover the extra costs of providing free personal care for everyone over 65. The sum was increased to £162m for 2006/07 and is due to rise to £169m for 2007/08.

In general, it seems that the policy has been a success. A June report by the Scottish Parliament's health committee found that it had provided greater security and dignity to many elderly people; had allowed them to be cared for more readily at home; had assisted their carers and had reduced delayed discharges, thus freeing NHS resources.

However, the committee found problems too, including the funding formula; the operation of waiting lists; the Executive's failure to produce clear guidance on key aspects of eligibility, such as the preparation of meals; a funding level that was not increasing in line with inflation; and continuing confusion over what was covered by the policy.

The Joseph Rowntree Foundation, following an independent assessment carried out on its behalf, concluded last year that the system provided important lessons for the rest of the UK, though it warned that the transfer of the policy to England, Wales and Northern Ireland would not be simple or straightforward.

A study carried out for the Scottish Executive, published last month, highlighted 'broad support' for free personal care but also found there was a need for greater clarity on how to calculate the costs.

A team at Stirling University carried out the research for both reports. One of the researchers, Professor David Bell, says the costing is extremely problematic because of different recording systems in different authorities, with varying priority given to good data collection. He also describes the way the cash goes to the councils as being 'quite complicated'.

Bell and his colleagues found that older people now consider the care arrangements to be more equitable and an improvement on the past, although confusion remains among many about what they are entitled to. 'People in care homes don't have to pay as much as they used to but hotel charges – for accommodation and food – can still cost up to £300 a week,' he says.

Andrew Sim, policy and research officer for Age Concern in Scotland, also considers the policy to have been operating well but points to some 'significant problems'. These include the lack of a consistent application of care policy around the country, including disputes over whether councils should pay for food preparation. Many of the problems could be easily resolved through clearer guidance, Sim suggests.

Sutherland himself believes the Scottish policy is 'going in the right direction'. He warns that the lack of a policy is what is causing most of the problems south of the border. 'It's evident they don't have a policy that works. That is causing all sorts of problems because there isn't a strategy that can deliver,' he adds.

He welcomes the work carried out by Sir Derek Wanless, whose social care review argued for an end to means testing for care services and a move to a partnership model, whereby the costs of care are shared between the individual and the state.

'This report plus the Rowntree report have shown that the government can't back away from this in the way they have been doing,' Sutherland warns. He recalls that his own solution was to create a single budget and put all of the responsibility in the hands of primary care trusts.

'If the government say they can't afford that and we can't afford a health service as we see fit, then let's be honest and put one pence on national insurance or have compulsory insurance for individuals, to cover the additional costs. That is perhaps thinking the unthinkable but it needs to be thought about.'

He says it is quite wrong that people who are suffering from dementia or another condition are not considered as having an illness and are charged for care. 'I think the present arrangement is disproportionate and unfair.'

In a further report, Paying for long-term care: moving forward, the Rowntree Foundation said Scotland had taken a promising step forward.

However, it proposed a series of more modest changes for south of the border. These, it said, would start moving care funding forward to a better settlement but would not replace the need for more fundamental reform.

Donald Hirsch, a special adviser to the Rowntree Foundation, believes Scotland has led the way in pioneering free personal care. 'But it doesn't represent the final solution,' he adds.

That's a sentiment that will no doubt be echoed by a number of leading figures who are concerned about social care and believe it is a problem that the rest of the UK must now tackle urgently.


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