The prophets of doom have been circling the Scottish executive
since it implemented the Royal Commission on Long-term Care’s
recommendation that nursing and personal services for older people
should be free.
Doubters said the costs of providing such a service to more than
750,000 older people would bankrupt local authorities. Only a
shoestring service would be remotely affordable. And with no
similar policy in England and Wales, Scotland would face a deluge
of pensioners, charging over the border in search of free long-term
But 15 months into the new system, the policy of free care appears
to be holding up quite well. True, its launch had to be delayed
from April until July last year while local authorities and other
care providers ensured they had the right assessment and delivery
mechanisms in place. Then the executive’s expert group on the
health care of older people warned that its initial cost estimate
of £125m a year to implement the policy would rise to
£227m by 2022.
There were also rumblings of discontent within local authorities.
Aberdeenshire Council claimed it was facing an £800,000
funding shortfall after the executive incorrectly estimated the
number of people paying for their own care in care homes in the
But on the one test that really matters – whether free care is
benefiting older people in long-term care – the new policy appears
to be delivering.
Maureen O’Neill, director of Age Concern Scotland, says the policy
is bedding down well. “We certainly haven’t been inundated by
complaints and the system hasn’t run out of money,” she says.
“Nor have we had thousands of people from England heading over the
border on their Zimmer frames. People don’t do that when they are
in their nineties, they don’t want to move away from home.”
Jim Jackson, chief executive of Alzheimer Scotland, agrees that
free personal and nursing care is reaching its target. “It has gone
remarkably smoothly,” he says. “Yes, there were one or two
hiccoughs early on – two or three local authorities were concerned
that they didn’t have the funding – but those problems seem to have
been sorted out.”
Jackson believes the biggest beneficiaries of the new system are
those who had found themselves just above the cut-off line used to
means-test services provided by local authorities. “It’s been of
particular benefit to those people on modest incomes. You don’t
need to be particularly wealthy to become a self-funder, so free
care has benefited those who previously lost out on means-testing
and felt they had been hard done by.”
He claims the introduction of free care has also facilitated the
formation of joint service agreements between health and social
services, a move stalled in the past because health services were
free but local authority services were means tested.
Even the local authorities are satisfied that free personal care
can be delivered within current budgets. A Convention of Scottish
Local Authorities spokesperson describes the overall picture as
“very positive” throughout Scotland. “CoSLA and the executive are
content that the joint working and monitoring arrangements
established are adequate and our partnership with the executive
will deliver an effective management of the policy.”
However, he adds that the executive is not complacent and the
implementation and impact of the policy are being closely
monitored. “Arrangements are in place to measure the uptake of free
personal care,” he says.
Perhaps one of the reasons that the portents of financial meltdown
have failed to materialise is that the phrase “free care” is
somewhat misleading. Although the new system entitles anyone older
than 65 to free nursing and personal care, this does not extend to
non-personal care such as day care, meals on wheels and help with
housework and shopping. Residents of care homes continue to
contribute towards their accommodation charges and living costs
where they can afford to do so, and those wishing to claim
assistance for these non-care costs have to undergo the same
assessment process as under the previous system.
According to Jackson, this distinction between care and non-care
costs has caught a number of older people by surprise. “There was
some confusion early on which was not helped by some of the
newspapers implying that everything would be free, including hotel
charges for those in care home accommodation.”
Indeed, lack of information is one of the key criticisms that
emerged from a study of the early days of the free care policy.
Published last March by Age Concern Scotland, the research surveyed
local authorities and the charity’s own member groups. It found
that, although some authorities had made strenuous efforts to
publicise the new policy, others had not. As a result “there was a
lack of clarity about what is meant by personal care, what services
are to be included and what still has to be paid for.”
Other issues highlighted by the study included the concern that, in
order to meet their obligations to fund personal care, some local
authorities were cutting back on other major services highly valued
by older people. There was also a worrying variation across
Scotland in access to services and in the length of time it took
many authorities to conduct assessments. “Of course these were all
issues even before the free care policy came in,” says O’Neill.
“But the continuing success of free personal and nursing care is
dependent on an adequate community care system.”
The executive’s decision to extend the policy even to those
Scottish residents who move to care homes in England has put
pressure on Westminster to follow Scotland’s lead.
Such a move is backed by nine of the royal commission’s members,
who last month accused the government of “betraying” millions of
older people by refusing to accept its recommendation.
How free care works
- All local authority charges for personal care services are
abolished for those aged 65 or over.
- The services provided are based on a care needs assessment by
the local authority.
- They are not means-tested. Free personal care is available
regardless of income, capital assets or marital status.
- Non-personal care is still charged for. This includes community
alarms, day care, lunch clubs, meals on wheels and help with
shopping and housework.
- Anyone moving to Scotland as a permanent resident has the same
entitlement to free personal services as any other Scottish
In care homes
- To claim free personal and nursing care payments, residents
aged 65 or over must first undergo a full assessment of their needs
by the local authority. Those who moved into a care home before 31
March 2002 are not required to undergo assessment.
- Those eligible for payments receive £145 a week towards
the cost of personal care and £65 for nursing care. This is
paid directly to the care home.
- Payments may be made to Scottish residents who wish to move
into a care home outside Scotland.
- Payments do not cover everyday housing and living costs. In
practice residents have to pay the balance of care costs after the
deduction of £145 or £210 a week.