Scotland is pressing ahead with plans to bring free personal care to everyone. Linda Bauld was a member of the expert group set up by the Scottish executive to draw up proposals for implementing the policy. She reports on the challenge they faced.

Devolution is beginning to deliver diversity in social policy. The latest example relates to the finance of long-term care for older people in Scotland. Earlier this year the Scottish executive said that it would bring forward proposals for the implementation of free personal care for all.

Yet before change could be implemented it was necessary to consider both the costs and mechanisms required. As a result, the Scottish executive brought together a group of experts - the Care Development Group (CDG) - chaired by the deputy minister of health and community care Malcolm Chisholm. The group had a broad remit, which involved examining the quality and availability of services as well as bringing forward proposals for free personal care. The CDG report, Fair Care for Older People,¹ poses challenges for the future of community care policy across the UK, and provides a clear example of devolution in practice.

The CDG made a number of key assumptions. The first of these was that the term personal care would have to be clearly defined. The second was that the current cost of care services would need to be established before future cost projections could be made. And third, it was important to examine how free care would interact with social security benefits. Finally, free personal care would need to be placed in the context of services for older people in general, to make sure that the policy promoted rather than hindered the development of sustainable care in the future.

One of the first tasks facing the CDG was to define "personal care". The definition offered by the Royal Commission on Long Term Care was compared with the range of tasks provided as part of personal care in Scotland's local authority areas. The West Lothian definition, which proved to be a useful model for the group, was adapted slightly to include specific references to psychological support, counselling and assistance with cognitive functions.

The cost of free personal care has three dimensions. It includes paying for services for self-funders in care homes. It also involves reimbursing local authorities for charges from personal care services in the community, and covering the costs of people who pay privately for personal care services in their own home. Fair Care for Older People suggests that the average cost of personal care in a care home in Scotland is about £145 a week. When the amount paid by self-funders is combined with those paying for care in the community, the total cost is estimated to be £77m a year.

Although health expenditure is a matter for the Scottish executive, social security remains the responsibility of Westminster. Older people are eligible to receive a number of benefits, including attendance allowance. This is provided to those who have physical or mental disabilities and live at home or in care homes, although entitlement stops in care homes when an individual ceases to be self-funding. In Fair Care for Older People it is assumed that part of the £145 per week cost of personal care in care homes for self-funders will be met by attendance allowance. This means that if a person is eligible for the higher rate of attendance allowance - £55 per week - the remaining cost to the Scottish executive will be £90 per week. Whether UK ministers will accept this remains to be seen.

Fair Care for Older People states explicitly that free personal care will be worth little if adequate services are not there to meet the needs of older people in the future. Despite years of policy intended to shift the balance of care, community-based services in Scotland remain underdeveloped. As a result, a key assumption made by the CDG was the need to promote additional investment in community care.

The recommendations contained in Fair Care for Older People are expected to be implemented in April 2002. What will this mean for older people and their carers?

- For older people living at home, personal care services will be provided free of charge.

- For older people in care homes who are supported by public funds there will be no change.

- For older people entering care homes after April 2002, a new system will be in place. This will involve a mandatory assessment in order to be eligible for public support. Payments for personal care will then be made based on levels of need. This is intended as an interim measure until the work of another group -Êthat is reviewing assessment and resource utilisation measures - is completed. There will be three levels of payment, up to £90 per week.

- For older people who are in care homes and are self-funding, a flat rate payment of £90 for personal care and £65 for nursing care (if required) will be made.

- Payment for both existing and new self-funders in care homes assumes that they will continue to be eligible for attendance allowance.

In addition to these payments, Fair Care for Older People includes a number of recommendations to further develop community-based services. It recommends that £50m over three years should be earmarked for a range of provision, with early emphasis on staff training. Improvements in local authority infrastructure are also required.

Perhaps most importantly, however, Fair Care for Older People recommends that the money for free care and the expansion of community services should be ring-fenced. This will ensure that local authorities spend the new resources on services for older people, rather than using them for any other purpose.

The report outlines the projected costs of introducing free personal care over a 20-year period. The report suggests that the amount the Scottish executive had set aside to fund the policy each year for the next two years - £100m plus £25m for free nursing care -Êis reasonable. This provision will facilitate an injection of more than £50m of non-recurring investment in community services in 2002-3 to build capacity to meet the future needs of older people.

The introduction of free personal care will reveal the disparity between Scotland and other parts of the UK. While the Welsh and Northern Ireland assemblies are considering introducing free personal care, no such discussions are under way in England. This means that an older person living in Northumberland will be required to pay for services that are free a few miles north. But the CDG found little research evidence from other countries to suggest that older people will move to receive free care and there are no reliable estimates of how many care seekers will cross borders.

In addition older people receiving free personal care who have savings will still be expected to pay for living costs. In care homes, this means that the real cost of different standards of accommodation will become more visible. In the community, services such as shopping and cleaning will still be chargeable, yet there is a fine line between these "preventive" services and care needs. Also, carers who choose to help their older relative with intimate activities such as bathing may lose out, as free care will not benefit them unless they are willing to shift their energies to providing domestic help.

Finally, free personal care will, at least at first glance, benefit those who need it least. The bulk of the new resource will go to the better off - those self-funders who can afford to pay for care. It is for this reason that the most vociferous opponents of free personal care have described the policy as inequitable.

But there are different kinds of equity. One type is equity between rich and poor. But another is diagnostic equity. An older person with cancer receives free care from the NHS. An older person who develops dementia is expected to pay for care. Scotland is trying to remedy this form of inequality. Will the rest of the UK do the same?

Linda Bauld is a lecturer in social policy at the University of Glasgow. She served as a research adviser to the Care Development Group. E-mail: L.Bauld@socsci.gla.ac.uk

Reference

¹ Care Development Group, Fair Care for Older People, Scottish Executive, 2001

Background Reading

Royal Commission on Long Term Care, With Respect to Old Age: Long Term Care - Rights and Responsibilities, Stationery Office, 1999

Websites

Fair Care for Older People is available at: www.scotland.gov.uk/library3/health/cdgr-02.asp     

Further information at: www.scotland.gov.uk/health/cdg 

Royal Commission on Long Term Care report at www.royal-commission-elderly.gov.uk

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World wide worry

Icreasingly valuable resource for social workers. But as information officer Sarah Carr explains, many employers deny workplace access to it for fear it will be abused by staff.

Suggest that all staff have access to the internet and some social services directors may envisage them going wild, like new recruits at a chocolate factory, online gaming, online chatting, online shopping and, of course downloading pornography.

Anecdotal evidence suggests that these anxieties have genuinely prevented some social care organisations, and indeed whole local authorities, from allowing staff adequate access to the Internet. Recent media stories about litigation following offensive e-mails at work may also heighten this anxiety.

Figures also suggest that although the majority of councils now have a public web presence, they have been slow to give their employees access to the internet. A recent British Association of Social Workers study showed that only 40 per cent of members have internet access at work, and 45 per cent at home.¹

It is probably fair to speculate that a certain degree of invisible subsidisation is occurring, where social workers are using home internet access to supplement inadequate technology at work.

Fear and resistance to change are inevitable, but a director of social services who jokes that he "can't find anything useful on the internet" is now nearly as bad as a surgeon admitting that she is "no good at stitches".

As David Poulson commented in Community Care recently,² effective social work needs to be supported by easy access to information and effective communications systems. In this respect information and communications technology is a gift.

However, all social work staff, from director to social care worker, need to be equipped to take advantage of these routes to electronic information exchange and retrieval. Access to the internet and e-mail facilities is becoming a necessity, and public policy is compelling councils to take advantage of the proliferating resources.

The government has recognised the relevance of information technology to the social care sector and devised policies for the modernisation of social work focusing on electronic communications. There is a push for e-government and an exhortation to "use new technology to meet the needs of citizens and business, and not trail behind technological developments".³

Key policy documents from the past two years have laid out how social work departments can improve user-focused and evidence-based practice by using IT. Central to this is the establishment of the Social Care Institute for Excellence, which will "draw together and disseminate what works best in social care, in order to ensure that social services are no longer a 'postcode lottery'."⁴

But if inconsistencies are to be tackled, all social services departments will need equal access to Scie's information output. Much of this will be mediated through the internet: the electronic Library for Social Care (eLSC), including caredataWeb, the only comprehensive social care bibliographic database of its kind in the UK, and electronic Best Practice Guides.

However, the recent Social Services Inspectorate report, Quality on the Way, revealed that in many social work departments there is still a "lack of integrated and up-to-date information and communications technology".⁵

If social workers remain unable to get to these information sources at work, then there will still be inconsistencies in social work, this time characterised by a "digital divide".

While the information for social care strategy is making money available for IT, some local government decision makers also need to have their technological anxieties assuaged. It is true that allowing staff full internet access involves some risk, but there are strategies and resources to lessen the risk of abuse.

Commercial filtering software is available that can be used to restrict internet access, either by preventing access to all but explicitly approved sites, or to permit access to all but a list of unacceptable sites, according to the organisation's internet policy.

Fearful public sector organisations may need to think about negotiating an access protocol with staff, similar to those established with pupils in schools that provide internet access in the classroom. Any restriction and monitoring needs to be explicitly communicated and although employers may feel the necessity to restrict internet access, it is important that staff understand why in order not to feel a sense of distrust.

Many are still sceptical about the information resources on the internet, but the original notion of the world wide web, which was to facilitate the swift exchange of research information between academics, should not be forgotten. Invaluable sources of information are available for the academic and practitioner alike, and web space is rapidly being reclaimed for quality information.

The NHS is among the leaders in the dissemination of the clinical knowledge base through the internet. Social care is quickly catching up, particularly with the establishment of Scie and eLSC, and the wealth of online information coming from the voluntary sector. Social work web gateways make this information easy to find, and generic web search engines are getting more sophisticated and accurate.

The list here provides no more than a sample of the UK online social care knowledge bases available. With the establishment of Scie and its sister social care organisations, General Social Care Council and National Care Standards Commission, the online knowledge base is set to expand further, with easier web interfaces.

It is therefore vital that every social care professional has access to this information so that user-focused social work practice has the chance to improve universally.

Inconsistencies in social work will continue or even get worse if a significant number of social care staff cannot easily reach the web-based practice information they need.

The government's Information for Social Care document calls for a change in attitude towards the role of technology, and asserts "senior managers have a key role in leading this drive for change".

Now is the time for managers and directors to put aside their fear of allowing staff internet access, because access to the internet means access to knowledge.

Sarah Carr is information and research officer at the National Institute for Social Work.

References

¹ J Bolton, "Moving forward", Professional Social Work, August 2000

² D Poulson, "Net Gains", Community Care 6 September, 2001

³ Department of Health, A Quality Strategy for Social Care, DoH, 2000

⁴ Department of Health, Information for Social Care: Executive Summary , DoH, 2001

⁵ Social Services Inspectorate, Quality on the Way, DoH, 2001

Websites

1 The electronic Library for Social Care is at www.elsc.org.uk   This will be central for the dissemination of Scie material, including Best Practice Guides, caredata resources, an online social work library with much more to come.

2 www.researchweb.org.uk  reSearchWeb is the social work internet research and information site funded by the Scottish executive. Practitioners in Scotland can access caredata, and the site provides universal access to Scottish-focused social work research and information, including an online library and a database of structured research abstracts.

3 www.sosig.ac.uk/vts/socialworker/index.htm   An easy guide to using the internet designed specifically for social workers. If you're a beginner, start here.

www.sosig.ac.uk  The Social Science Information Gateway. A well-established web directory for online social science information, with an extensive entry for social work.

4 www.swap.ac.uk  The Social Policy and Social Work Learning and Teaching Support Network, high-quality learning, teaching and assessment in social work subject areas.

5 www.doh.gov.uk/scg/socialc.htm  The Social Care Group website at the Department of Health for all the latest social work policy, consultation, guidance and Social Services Inspectorate information.

6 www.audit-commission.gov.uk  The Audit Commission for news, publications and performance indicators.

These websites allow free access to their own bibliographic databases:

7 Centre for Policy on Aging: www.cpa.org.uk 

8 Alcohol Concern: www.alcoholconcern.org.uk

9 DrugScope: www.drugscope.org.uk  

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Across the divide

 in Northern Ireland the consequences of living in a divided society are very real. Now that we are into the school term, we see yet more images of children protected by security forces as they walk past residents "from the other side" shouting sectarian abuse.

Northern Ireland is marked by conflict and sectarianism, where segregation pervades almost all aspects of children's lives. There is an increasing body of research on the impact of this. However, this literature assumes that children are from either the Catholic or the Protestant community. There is little focus on families that have crossed the divide; particularly on children from cross-community families who have one parent from a Catholic and one from a Protestant background.

Yet these children have very particular, and often complex, needs. To give one example: Tom, a young man from a cross-community marriage in Belfast, was being brought up as a Protestant. His parents were divorced and Tom lived with his father but saw his mother regularly. When his father remarried, Tom had difficulty with his new stepmother and started to act out his unhappiness. His father was eager to have his son taken into care; a fact which did not go unnoticed by the young man. Going to live with his mother, with whom he had a good relationship, seemed an obvious solution but was rejected by Tom "because she is a Catholic".

A research study by the National Children's Bureau on planning for children in public care in Northern Ireland found that children who had parents from different community backgrounds were greatly over-represented in their sample.¹ However, there was no information available that could indicate whether this was a true reflection of the care population as a whole; nor had the issue been identified as significant by social work staff. NCB undertook a further study with the aim of identifying the prevalence across Northern Ireland of children from cross-community families among those looked after.

Information was gathered about the family background of a one-in-five randomly selected sample from the total population of looked-after children in October 1998.² Despite detailed file studies and interviews with staff, for 22 per cent of the children it was not possible to determine the backgrounds of both their parents. It was also recognised that there would be a degree of inaccuracy in the recorded information; social workers acknowledged that they often assumed parents to be from the same community.

Even so, the study indicated that 17.3 per cent of looked-after children had parents from different communities. Yet the best estimate of the number of mixed relationships within the population as a whole is 5.6 per cent.

For staff in social services, these findings came as something of a surprise. It appeared from interviews that these issues are rarely addressed or given priority when dealing with children from cross-community families. Yet the case file study highlighted some of the complicated issues that can arise, particularly in terms of the child's sense of identity, their choice of religion and hence school, contact with parents and extended family, and relationship with their siblings, half-siblings and stepfamilies.

Several studies of children in care in England found that children of mixed parentage were disproportionately represented among those becoming looked after in Britain.^{3, 4} There is little systematic account of why but explanations range from socio-economic deprivation, to family background, to institutional and individual racism on the part of social services.

The NCB is now undertaking a study in Northern Ireland, through interviews with children, their parents and professionals, which seeks to identify factors that lead children in this group to become looked after more readily and how their particular needs can best be met by service providers.

Dr Ruth Sinclair is director of research at the National Children's Bureau.

References

¹ G Horgan and R Sinclair, Planning for Children in Care in Northern Ireland, National Children's Bureau, 1997

² N McCay and R Sinclair, Mixed Needs? Children from Cross Community Families in Public Care in Northern Ireland, National Children's Bureau, 1999

³ R Barn, R Sinclair R, DFerdinand, Acting on Principle: An Examination of Race and Ethnicity in Social Services Provision for Children and Families, BAAF, 1997

⁴ A Bebbington and J Miles, "The background of children who enter local authority care", British Journal of Social Work,19, 1, 349-368, 1989

Background reading

1 E Cairns, Caught in the Crossfire; Children and the Northern Ireland Conflict, Appletree, 1997

2 E Cairns, Children and Political Violence, Centre for the Study of Conflict, University of Ulster, 1999