Crisis? – what crisis?

The controversy over the cost of funding Scotland’s free
personal care policy reignited last month after media reports
suggested it was likely to drive local authorities into
bankruptcy.

The figures referred to were forecast in the Scottish executive’s
range and capacity review of community care services.¹
Its report gives 15-year projections which look not only at the
likely growth in the older population, but also project the
associated possible costs and workforce needs.

Media reports immediately following the publication of the report
suggested that the cost of the free personal care policy itself was
expected to increase to a staggering £2.5bn by 2020 at today’s
prices.

Forecasting is never an exact science, but in fact the furore was
driven largely by media misinterpretation of the figures. The
reality is a little less newsworthy. In fact the £2.5bn figure
is the forecast for the total cost of care of older people in
Scotland. Currently, this figure stands at £1.4bn.

Jess Barrow, head of policy at Age Concern Scotland, says free
personal care will be “a drop in the ocean” of the total cost of
care. “On an annual basis, £2.5bn in 15 years’ time for total
care costs does not represent a huge increase. The current overall
NHS budget for Scotland is £7.5bn so that puts it into
perspective. It isn’t a crisis point.”

This is good news for a policy many people regard as decades ahead
of its time. In a letter to The Scotsman, Alzheimer
Scotland chief executive Jim Jackson said Westminster’s decision
not to introduce free personal care south of the border “has led
them into the nonsense of unseemly disputes about when personal
care (means tested) becomes nursing care (free at the point of
delivery) and decisions by the ombudsman criticising health
authorities for failing to meet their obligation to provide
continuing care. Scotland is doing better”.

However, there may yet be some humble pie on Scottish dinner
tables. Population projections for Scotland show that it will have
a significantly larger ageing population than the rest of the UK
(see review findings). This is primarily because population growth
has been declining for the past few years. And advances in
technology and treatment may allow older people to live longer,
albeit sometimes in ill health, and require more community care
services. It seems inevitable that Scotland will be paying for free
personal care for much larger numbers of people in the next 20
years.

Not everyone sees this as doom and gloom. Jackson argues that the
media have exaggerated the implications. “Why is there always a
knee-jerk reaction linking projected changes in Scotland’s
population structure with free personal care? Although age is
associated with increasing likelihood of requiring medical and
community care services, tomorrow’s older people are more likely to
be fit and active than those of a previous generation and require
fewer services. All this needs to be considered, not just the
apparent impact on a single service.”

Others are not so optimistic. Although Barrow believes free
personal care is sustainable, she says there is a question over
whether Scotland as a whole is prepared for the growth in its
ageing population and that this is not just a concern for health
and social care.

She says the first step should be a strategy for older people in
Scotland that is wider than the National Service Framework for
Older People in England, covering enterprise, housing, transport,
planning – “areas that aren’t traditionally associated with older
people”. And she insists that the Scottish executive must not view
older people simply in terms of dependency. Age Concern Scotland
research shows that if more people aged 50-69 who wanted to work
did so, it could generate about £2bn for the Scottish
economy.

The growing shortage of appropriate housing is also worrying her.
Plenty of commuter and starter homes are being built, but Barrow
questions whether they will be suitable for an ageing population in
the long term. “We need to make sure that all housing will be
suitable and that the infrastructure is there around it, such as
local community facilities and transport. If you get it right for
older people, you generally get it right for people at all stages
of life.”

The Convention of Scottish Local Authorities (Cosla) says many
councils are investigating capacity planning to determine exactly
what services they are going to need in future and where they
should be. Eric Jackson, Cosla’s spokesperson for social work and
health improvement, admits there could be difficult times ahead:
“With care in general we will have to look at the way we run
services and do some lateral thinking to keep the costs
down.”

As an example he cites the single shared assessment where health
staff can directly access social work services. “But we need to see
whether social workers can access more health services direct, for
example a consultant, rather than going through a doctor.”

Another area he envisages it will be possible to save money is in
moving hospital services to people’s homes, such as physiotherapy,
as well as a rethink on aids and adaptation. “Do they need to be
permanent, do they have to be bought in, could some be hired? We
need to look at the most cost-effective way,” Jackson says. “It’s
about not always taking people to the services but bringing the
services to them. On many occasions that can be the cheaper option
– and better for the person too.”

The review notes that local authority models of community care have
been changing, with a move away from care in care homes to
increasing use of support in people’s own homes.

A recent Audit Scotland report suggested that as many as 60 per
cent of older people in care homes did not necessarily need to be
there and their care needs could be met at home with the right
package.

So if, as the review suggests, more older people choose to stay at
home and there is improved technology to help them do that, making
sure the right housing and care infrastructures are in place is
going to be a critical issue for the executive in future.

¹ Scottish executive, First
Report of the Range and Capacity Review: projections of community
care and service users, workforce and costs, 2004

Free care facts

• Scottish local authorities cannot charge for personal care at
  home for those aged 65 or over, regardless of income, capital
  assets or marital status.  
• In care homes, residents aged 65 or over are assessed by the
  local authority. Those eligible receive £145 a week towards
  the cost of personal care and £65 for nursing care, paid
  directly to the home. 
• Payments do not cover everyday housing and living costs.

Review findings 

• The population is projected to fall by 2 per cent by 2019, but
  the population aged 65 and over is forecast to rise by 26 per cent,
  with males aged over-85 having the largest relative increase. 
• The number of recipients of each service, including private
  nursing homes, residential care homes, sheltered housing and local
  authority home care is predicted to increase by 26-40 per
  cent. 
• If this happens, the number of staff will need to rise by 26-38
  per cent.  
• Total expenditure is estimated to increase by 81 per cent to
  £2.5bn.