England could learn from the consequences – both intended and unintended – of Scotland’s free personal care scheme before implementing its own version
One of the big measures in the Queen’s Speech, the Personal Care at Home Bill, has just received its third reading. The aim of the Bill is to give free personal care in England to the most vulnerable people in their own homes, regardless of personal wealth (‘Social care comes in from the cold’, January 12).
While the details are not yet clear, it appears that assistance will include every aspect of day-to-day living, from food preparation to dressing. The policy does not cover residential care: a prime aim is to help people remain in their homes. Health Secretary Andy Burnham estimates that 400,000 pensioners will be eligible, and that the policy will cost £670m a year.
Scotland introduced a policy of free personal care for elderly people in July 2002. What lessons from that experience can England learn?
In 2003/04, the first full year of the Scottish programme, 32,870 elderly people received free personal care in their own home. By 2007/08, this had risen to 44,660: an increase of 36%. Expenditure on free personal care almost doubled between 2003/04 and 2007/08, from £128.6m to £256.7m.
If the pattern of need in England is similar to Scotland’s, we might expect 300,000 people to be eligible in the first year of operation, rising to just over 400,000 over a five-year period. The average number of hours provided each week might be around 2 million in the first year rising to around 3.1 million in five years. And the increase in expenditure might possibly begin around £580m, rising to £1.73bn in real terms over five years.
These crude estimates depend on a lot of underlying assumptions, and are only indicative. But in one important respect they might well understate the likely growth of demand in England.
When the policy of free personal care was introduced in Scotland in July 2002, it covered not just recipients of personal care living in their own homes, but also those in care homes – unlike the proposed policy for England, which will apply only to those living at home.
The broader scope of the Scottish policy is likely to have displaced some of the demand for care at home – so take-up by those with some savings in England might increase even faster than implied by Scottish trends.
The second lesson from the Scottish experience is the importance of looking out for unanticipated, and possibly adverse, consequences of the policy, particularly at a time of public sector financial restraint.
In Scotland, people receiving general care in their homes from councils – such as cleaning, helping with lighting fires and getting groceries – saw their services squeezed to pay for personal care.
The Scottish figures also indicate that net expenditure on home care that is not free personal care has fallen by 24% in the last two years, despite a rising elderly population.
The final lesson from the Scottish experience is the vital importance of estimation and monitoring. The initial costings of the policy were based on mistaken estimates of the size of the potential pool of recipients: in fact, the size of the elderly disabled population was underestimated by 50%.
The statistical systems for monitoring the implementation of the policy in Scotland still do not yield consistent figures on how it is operating.
Estimates of the cost per hour of free personal care in the home, based on the most recently published Scottish data, range from £8.14 in one authority to £32 in another – a range that strains credibility.
These sorts of problems make it very difficult to budget appropriately – and to interpret what is actually going on. England would do well to learn from Scotland’s good – and bad – experiences.
Margaret Cuthbert and Jim Cuthbert are members of the Public Interest Research Network at the University of Strathclyde
