Home free?

“Scottish solutions to Scottish problems” was the bold cry of
Scotland’s new parliamentarians more than three years ago when the
Scottish parliament was “reconvened” after a hiatus of nearly 300
years. The reality has rarely been as distinctive or distinguished
as supporters of devolution hoped. However, there have been clear
dividing lines in social policy – the most significant being the
decision to provide free personal care implementing the
recommendation of Lord Sutherland’s Royal Commission. This is now
one of the flagship policies of the Labour and Liberal Democrat
coalition that controls the Scottish executive, Scotland’s
government.

Under first minister Donald Dewar the executive initially followed
the policy lead of the Westminster government – offering to extend
support to cover only the health care elements of long-term care.
After Dewar’s death the new first minister Henry McLeish signalled
his desire to reopen the debate and, backed by a majority in the
parliament, swept aside the objection of some of his Labour cabinet
colleagues.

During 2001, a care development group met to develop the plans for
implementing free personal care. Drawing on substantial expertise
in economic modelling, demographic trends and the practicalities of
social care, they produced a blueprint last summer which was the
basis for the Community Care and Health (Scotland) Bill which was
passed in February 2002. The original intention had been full
implementation by April 2002, though this was delayed until July to
allow local authorities time to get fully prepared. Even with these
three months’ delay the new legislation has had to be introduced at
breakneck speed.

At the centre of the new policy is the introduction of flat rate
payments to those in care homes who are self-funding. These
payments are £145 for those who need personal care with an
additional £65 taking the total to £210 for those who
need nursing care. This is supplemented by strategies to maintain
older people’s independence in the community through the abolition
of all charges for personal care in the community and additional
funds to local authorities so that they can increase the range of
provision supporting people in their own homes. Personal care has
itself been defined almost entirely in line with the Sutherland
Report’s suggestions to include:

• personal hygiene;
• continence management;
• food and diet including assistance with eating and special
  diets;
• help with immobility;
• counselling and support services;
• assistance with medication; and
• personal assistance such as help with dressing and getting up
  and going to bed.

A huge public information campaign was launched in April to
highlight the main elements of free personal care with national and
local newspaper advertising and a massive leaflet drop to GP
surgeries, care homes and advice centres. Malcolm Chisholm, health
minister in the Scottish executive, praised local government for
“making every effort to ensure that free personal care is
introduced with minimal disruption to recipients”. In response,
councillor Ronnie McColl, health and social services spokesperson
for the Convention of Scottish Local Authorities claimed that
“implementation is on track across local authorities and will be
effective and sustainable. Scotland’s councils have moved mountains
in getting to this stage.”

A predictable response, perhaps. However, the evidence is that
despite the speed of implementation things are, at least initially,
going well. These are early days, but there have been no real
complaints to advice agencies, and hardly any “shock, horror”
stories in newspapers.

But it is already becoming clear that the impact of free personal
care is serving to highlight fundamental, structural weaknesses in
the market for providing residential care in Scotland.

Before free personal care was implemented it was apparent that the
residential care sector was in a substantial crisis. Providers
ranging from small family run homes through to the large
not-for-profit providers like the Church of Scotland were
complaining that the fees they received from local authorities were
uneconomically low (and in some cases substantially below the
amounts that local authorities paid to their own care homes).

Just as in England, when money came in to provide support for the
nursing care element of residential care, Scottish providers have
taken the opportunity of new resources to adjust their charges
upward. (Though, having perhaps learned from the outcry that met
fee changes in England, the increase is not blatantly equal to the
total of the new money in the system.) This will, in reality, only
delay the crunch for residential care providers.

They still face the increased costs of improved care standards,
rising wage bills in what is the tightest labour market Scotland
has experienced for over 25 years, and the inability of current
income to cover fully capital expenditure and depreciation. In
certain places – such as Edinburgh – the booming housing market
adds a further twist to the knife. Property prices have risen so
giddyingly high that many are tempted to cash in on the increased
capital value of their homes.

The resulting reduction has led Edinburgh Council to consider and,
at least currently, reject, the notion of taking over hotels to use
their beds for intermediate care. In the end, it is the user who
suffers. Self-funders going direct to providers are finding higher
prices for the non-nursing and non-health care elements of
long-term care. And where they attempt to obtain a placement via a
local authority, and gain the benefit of the lower costs associated
with block contracting, they find that they have to join a waiting
list.

The quiet revolution has been in the abolition of charges for
personal care in the community. For the first time local
authorities have a duty to make direct payments available. This has
not yet taken off to any degree but as it does it will empower
older people and transform services around individual needs.

Initially though, the main issue is about the interpretation of
what constitutes personal care. The one real controversy has been
about what form of food preparation can be charged for and what
must be free. This could be a simple argument about the
interpretation of executive guidance by one particular local
authority (in this case Borders). However, some observers believe
it goes to the heart of how effective the executive’s information
campaign has been.

Jess Barrow of Age Concern Scotland points out that the row only
erupted when a niece asked precisely what free personal care her
aunt was receiving. On finding that it excluded food preparation
she pointed to the legislation. Initially, the social work
department cited the executive’s guidance, but has since backed
down. What happens to people who don’t have a pushy relative, asks
Barrow, and are those people being charged improperly?

So, success or failure? It is too early to tell. Local authorities
can be pleased that they engineered a rapid and relatively smooth
transition to the new system. Labour and Liberal Democrat ministers
and backbenchers can be pleased that they have found a widely
popular policy to boast of as an example of how things can be done
differently – and better. For older people, direct payments may be
the long-term route to creating customer-focused social care, but
they can feel pleased that an injustice that still afflicts older
people in the rest of the UK has been ended in Scotland.