Abstract
Providing care for the elderly requires particular coordination in Britain, where the seats of government at Westminster and Holyrood differ at times on the National Health Service's responsibilities. This article details the review of the implementation of the policy of Free Personal Care in Scotland published by the Scottish Government in April 2008, which focused on demographic projections and public funding. The Royal Commission found that demography projections were faulty and, consequently, public funding inadequate. It recommended stricter accountability as well as a longer term political vision. Only with a broader vision can the NHS plan for the changing nature of society and the inevitable consequences.
Background
The first and most important point is the focus of this issue of European View–-changing demography. The United Kingdom is subject to the consequences of this phenomenon, though not quite to the extent of some European countries. A primary consequence of extended longevity is the increasing costs of long-term care, not least those associated with forms of dementia. It has been the case that significant expenditure on health care is occurred at the later stages of life, and this is now compounded by the fact that the later years of life bring with them an increased risk of dementia.
The second, more general point, is that in the United Kingdom, the National Health Service has a status which makes politicians very wary in the processes of policy formation and implementation in this and related areas; yet it is evident to all reflective persons that for a variety of reasons, including demographic change, increasing expenditure in the area of care services on a ‘demand’ rather than rationed basis has significant dangers.
In the legislation setting up the National Health Service, what was provided by way of personal and social care was excluded from the provision of a free (at the point of delivery) National Health Service. Instead, local authorities had the responsibility for making appropriate provision but without the guarantees associated with a ring-fenced full-cost allocation of resources from national taxation.
By the 1997 election it was clear that there was a problem to be confronted, since the 1948 settlement was no longer adequate to deal with changing demographic patterns. The Labour Party was no braver than the others in making pre-election promises about expenditure, but it did promise to appoint a Royal Commission to enquire into and make recommendations on the provision of personal and nursing care for the elderly. To the Party's credit, it began the process of implementing this promise within weeks of coming to power. The Commission met for the first time in December 1997 and published its report, With Respect to Old Age, in March 1999. Ten members supported the recommendations and two submitted a Note of Dissent disagreeing with certain central recommendations.
In July 2000, the Westminster Government decided not to accept the most contentious of the recommendations, namely, that personal and nursing care should be free at point of delivery, but that living costs for those in residential care should be means-tested.
However, as a result of quite separate government initiatives, there was a new and very significant factor at play–-devolution. Differing powers had been devolved to new parliaments in Scotland and Wales. This paper tells the story of the reception in Scotland of the Royal Commission recommendations on long-term elderly care. 1
Currently the provision of long-term care in the United Kingdom is the responsibility of four different parliaments–-in Scotland, Wales, Northern Ireland and England–-each of which operates in different ways with different levels of provision.
The provision in Scotland
Following much passionate political debate, and much to the irritation of some senior politicians in Westminster, all four main political parties in the Scottish Parliament accepted the recommendation to implement the provision of personal and nursing care free at the point of delivery, while accepting the system of a means-tested co-payment for the living costs of those in residential accommodation. The appropriate legislation was put through the Parliament by the coalition Labour/Liberal Democratic cabinet, but with the support of all other parties.
The cost to the Scottish Parliament in the first full year of operation (2003-2004) was £143 million [4, p. 51, Table 3]. There was a saving, for various accounting reasons, to the Westminster Government of £30 million, but this was retained in Westminster rather than devolved via the Scottish block grant, as many had reasonably hoped. There is currently no rigorous way of establishing the net cost to public expenditure, since, for example, it is not possible to compute savings made to the National Health Service as the number of cases of deferred discharges from hospital beds (so-called blocked beds) continues to drop as a consequence of this policy.
Five years on
As was suggested in the original Royal Commission Report, it was appropriate to carry out a review of the implementation of these policies after 5 years of operation, and this was proposed in the manifesto of the Scottish National Party for the 2007 election. In the event, the SNP won the largest number of seats and, upon forming a minority government, commissioned an independent review [4].
The review focused initially upon a number of points that caused irritation; for example, degrees of different and, therefore, perceived inequity of provision from one local authority to another. There were variations of provision evident in three main areas: in the use of waiting lists; in the stringency of the criteria of eligibility used to evaluate need; and in charges made for food preparation for those receiving care in their own homes, which some local authorities applied and some did not.
However, the number of complaints reaching the desk of the Public Ombudsman were few in number, 2 and the generally good reception for the policy was confirmed. These points were addressed in a series of recommendations stressing the need for publicly stated and common assessment and commissioning procedures. In addition, an increase of public funds of £40 million on the 2007-2008 provision of £169 million, to be up-rated annually for inflation over 5 years, was also recommended.
Whereas complaints on this matter to the Ombudsman of the Scottish Parliament numbered in single figures per week, her counterpart in England, the Health Ombudsman, received several thousand.
These and other more detailed recommendations have all been accepted by the Scottish Parliament.
The longer perspective
Equally important, however, were the recommendations that look beyond the next 5 years. These were stimulated by two lines of enquiry pursued by the review. The first was the uncovering of the basis of the demographic projections on which current policy is based. The second was the analysis of the many streams of public funding that are devoted, not always consistently, to the needs of old age.
A key element in any projection of the future costs of long-term care is the projection of demographic change. The basis used by the 1999 Royal Commission report for estimating the future costs of care was the 1991 Census and its predecessors [3, pp. 13-14, Figures 1, 2]. This was accompanied by the then reasonable assumption of no overall population growth. By the time the Scottish Parliament was conducting its own ‘due diligence’ on costs in 2001, the Registrar General had issued new projections for Scotland based on 1998 information. The Independent Review in 2008 had the benefit of a new update in these latter figures based on 2006 information. In each change in the statistics there were two key features: the numbers and proportion of the ‘oldest old’ were predicted to rise increasingly steeply. There was also a hint of what is now more firmly based, that the population in Scotland, rather than decreasing will in fact be subject to increase, though less sharply than some other parts of the UK. In particular the former of these two points has significant impact on cost projections [4, pp. 75-77,
The relatively sharp swing in demographic projections between 1998 and 2006 led us to recommend the following:
Review and remodel. The uncertainty associated with projecting future costs of long-term care means demand must be reviewed and re-modelled regularly and be reflected accurately in future local government finance settlements and capacity planning by local authorities and their health partners. (Recommendation 10; [4, p. 9])
Clearly other factors will have to be taken into account at the same time–-not least the progress in developing preventative and ameliorative treatment for various forms of dementia. However, as a Report of the House of Lords Select Committee on Science and Ageing [2] made plain, other forecasting tools have to be refined, such as rigorous means of projecting years of healthy living against years of survival.
The second line of enquiry that led to major recommendations focused upon the total costs of all long-term care of which the costs of personal care are a proportion.
It became clear that there were several streams of public funding which together met the demands of providing long-term care.
Figures for 2005-2006 (the latest that were comprehensively available) showed that local authorities spent £987 billion on long-term care. Of this, £284 billion was spent on domiciliary care, of which personal care totalled £168 billion. There were several other expenditures; for example, equipment and adaptations, sheltered housing and so on. Also, there were several other streams of public funding via the Department of Work and Pensions including attendance allowance, £374 billion, and disability allowance, £129 billion. The National Health Service spent £343 billion while private, local authority and NHS spending on residential care amounted to £791 billion.
We drew a number of conclusions from these figures. 3 The first was that there was no overall coordination of spending and particularly of the criteria of eligibility exercised in these varied streams of funding. To say the least, this leaves open questions of the proper exercise of accountability over this very large area of public spending–-currently about 1.5% of GDP.
For a more detailed picture, see [4, p. 71, Table 15].
The 11th recommendation
These conclusions led to our 11th recommendation:
Review public funding arrangements. There should be a holistic review over the next few years of all the sources of public funding for long-term care of older people, including health, social care and housing support, but also UK government benefit funding, in particular through Attendance Allowance and Disability Living Allowance. [4, p. 9]
We had no doubt that the public and political context in which the policy of free personal and nursing care was discussed was the wrong one. Negative reactions were always based upon the claim that the cost is astronomically high and will get even higher. That costs will rise is not in contention. Predicted demographic change alone would ensure that. Our first recommendation on this point asks that the resource allocated under this heading be seen in context. The first part of that context is that it has simply been added to a series of funding streams already operating in the same area of need–-long-term care. Rationalisation of these funding streams in terms of common criteria of need and single commissioning of care packages to deal with housing needs and disability as well as other forms of frailty is required. Equally, attendance allowance, which continues for those on home care packages but not for those in residential care, should be seen as part of a single pot including the other streams of funding available separately to those in need.
It will require political vision which is long rather than short term to begin to sort this, as well as the political nerve of a Beveridge to begin to cast policies for the future.
An even more striking outcome of our review of the financial consequences of long-term care needs was that the element of publicly funded personal care costs which we estimated to arise in 2006-£256 billion–-was approximately 10% of total costs of the actual expenditure on all aspects of long-term care in Scotland across all government departments in Holyrood and Westminster [4, p. 80, Table 18].
Also noted
It is incorrect to expect that changing or removing this policy would cause a very substantial reduction in the overall costs of long-term care. This is because a significant proportion of those that receive free personal care at home, who comprise around 80% of all those receiving long-term care, would be unable to pay for the cost of this care [4, p. 80,
That is to say the costs of most of what counts as personal care would fall to the public purse even in a means-tested system. A recent study of the situation in Wales, where the cost of personal care is means-tested, estimated that only around 14% of the costs of personal care are recovered in charges [1].
Our contention is that the debate about the policy of free personal and nursing care is being carried in the wrong terms. The debate focuses on the question of whether in Scotland the inflation-related figure of £256 billion is affordable; the real question has two parts.
The first is whether rationalising further the actual expenditure on long-term care, which is ten times that sum, could begin to make feasible the future costs of demographically led change in care costs.
The second is whether the rather shrill debate about financial doom as opposed to a fair and humane society is the best way of discussing the policy of free personal care. What it does is divert attention from the much more daunting challenge of dealing with demographic change in all its manifestations.
This brings me to the final recommendation of the Independent Review:
In the longer term, Government at all levels should take a comparable sufficiently long-term view of planning for the future shape of our society. It should seek to establish a vision for dealing with challenge of demographic change, not just for long-term care but also for pensions, employment, housing and other key aspects of public policy. [4, p. 42]
In the introduction to the review, I pointed out that if demographic change of the kind predicted does take place (and in policymaking that is the prudent way to bet), much else besides long-term care will have to be part of the picture. Included in this are the costs of health care, the adequacy of current pension provisions, the patterns of work-life balance, changing patterns of retirement dates, the availability of sufficient people of working age and fitness, patterns of housing need, changes to transport systems, new patterns of lifelong learning and education, and the research and research support needed for such a new future.
Nothing less than a new vision of the changing nature of such a society and of the possible directions which it might take is required. We do have time to engage in such an examination of future options and there is plenty of evidence of the need for it.
In such a context, planning for and funding personal and nursing care is only one element of a much wider picture. It is rather like climbing a Scottish mountain. Having reached the vista provided by one horizon, we realise that a much larger lies before us for which we must prepare.
Health warnings
There is no such thing as free personal care. In Scotland, personal and nursing care are free for many at point of delivery. Someone–-often the taxpayer–-pays.
The principle of means-tested co-payment for the living costs (heat, light, food, etc.) of those in residential care has been adopted. This principle was part of the package of recommendations made in the Report of the Royal Commission on Long Term Care [3].
Footnotes