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EXECUTIVE SUMMARY
Aims of the Research
This evaluation of Free Personal Care was commissioned by the Scottish Executive to provide information on its operation and impact and set out how the policy could be further developed to deliver cost efficient and high quality Free Personal Care ( FPC) for older people in Scotland.
The research examined the four key stages of the operation of FPC:
- the application process
- the assessment process
- the provision of FPC and care services
- reviewing and monitoring FPC.
An additional objective was to evaluate the impact that the FPC policy has had on:
- informal care
- the balance of care
- care providers, the broader care sector and the range and availability of care services
- the quality of care received.
The research aimed to present a picture of the operation of FPC across Scotland. It had an explicit focus on the practical operation of the policy, and included a range of specific objectives (highlighted at the beginning of each chapter), which investigate in detail issues which may impact upon the successful delivery of the policy. These objectives focus on those areas of the operation where improvement may be required in order to enhance the delivery of FPC to elderly people across Scotland.
The funding and cost of FPC was not within the remit of this evaluation as the Scottish Executive has established a working group to analyse the cost of FPC and the wider costs of care for older people at a national level.
Research Methods
A broad range of research methods was used to address the aim and objectives of the evaluation:
- a comprehensive literature review of background information on the implementation of FPC
- interviews with a range of national stakeholders
- the collection and analysis of information on policy and practice from all Scottish local authorities
- a survey of all Scottish local authorities gathering a range of information, including a survey of the number of people waiting for the delivery of FPC
- two Public Attitudes Surveys - a 1,000 person telephone survey and a postal survey of 4,000 older people and carers
- six in-depth case studies involving interviews with over 100 local authority staff involved in strategic and operational management and frontline delivery of FPC, and 134 users and carers who have first hand experience of FPC; and a survey of independent sector care homes and care home providers
- a stakeholder workshop which considered an early findings paper.
Summary of Key Findings
The primary aim of FPC is to remove discrimination against older people who have chronic or degenerative illnesses and need personal care by bringing their care into line with medical and nursing care in the NHS, where the principle of free care based on need is almost universally applied and accepted. FPC has achieved that aim.
Around 9,000 self funders aged 65 or over are currently receiving £145 per week as a contribution to meeting their care home costs without means testing, and around 6,000 of these self funders are also receiving £65 per week towards their nursing care costs. Over 42,000 people are now receiving personal care services at home at no charge and without being means tested.
The vast majority of people receiving FPC under the Community Care and Health (Scotland) Act 2002 have received their FPC payments or personal care services without undue delay or complication. The process through which an individual moves through the community care system from first contact with the local authority (referral) through to assessment, and delivery of services (or payments) is well defined within the legislation and guidance that governs the delivery of Community Care, and the system works well in the vast majority of cases.
Public Awareness, Understanding and Support for FPC
Levels of awareness of FPC amongst the general public are relatively low. Most people's knowledge of FPC is informed by the media rather than by personal experience. People generally have a low understanding of the operation of the policy and of what services are covered by FPC.
There is strong public support for both personal care (e.g. washing and bathing) and non personal care (e.g. shopping) being provided free to all older people who need help. A majority of people (over 60%) believe that frail older people should be "offered FPC to help them continue living in their own home, as long as they choose, whatever the cost to the public purse."
The Application Process and Referral Practices
Across local authorities there is significant variation in the source of referrals for assessment. However it is clear that the NHS is a major source of referrals for care assessments. There is no evidence to suggest that the source of referral has any bearing on outcome. The majority of referrals are triggered by either a deterioration in an individual's health or a withdrawal of unpaid care.
Groups not Applying for FPC
There is very little, if any, systematic research carried out by local authorities to assess unmet need/ demand for care services, either among the general older population or within specific groups such as black and minority ethnic groups. However, the research did identify a significant proportion of older people who rely solely on unpaid carers for the provision of personal care.
The Assessment Process
Target times for completion of assessments, based on factors such as risk and need, vary considerably across Scotland. Local authorities use a range of different assessment tools to undertake assessments but there is no evidence to suggest that the assessment tool used has any significant impact on outcome.
Users and carers reported that their relationship with the professional carrying out the assessment is more important in determining their satisfaction with the process than the assessment tool that is used.
Delays in Assessments
A number of definitional and data collection issues need to be resolved in order to provide a robust measure of the number of elderly people waiting for assessments (that may result in FPC) to begin or be completed, or of the time taken to complete them.
Some local authorities backdate the payment of FPC/ FNC to self funders in care homes if their assessment is delayed beyond their target time for completing assessments, contrary to the guidance on FPNC that states that FPC/ FNC payments should not be backdated.
Reasons for Delays
Around half of Scotland's local authorities reported operating waiting lists for assessments to be completed, mainly due to a lack of staff to meet the demand for assessments. No local authority reported that assessments are being delayed because of funding pressures on their budget for providing FPC.
Local authorities use a number of approaches to reduce the number of people waiting for assessments and to manage waiting lists, including screening and prioritising referrals, reviewing and monitoring waiting lists, taking a proactive approach to staff recruitment and retention, reviewing services and restructuring social work teams.
Improving the Assessment Process
The assessment process works well for most people in most areas. However there are legitimate concerns about the delays in completing assessments in some areas. Full implementation of Single Shared Assessment ( SSA), the principal means by which assessments for people who might receive FPC are undertaken, should improve the speed and effectiveness with which assessments are carried out.
Prioritising Service Provision
More than half of Scotland's local authorities have a threshold for determining whether an assessed need will be met by the provision of care services. In most local authorities that operate thresholds, people with personal care needs will be in priority categories that will receive access to services. However, some local authorities may restrict access to FPC services for people if their personal care needs can be (and are being) met by unpaid carers or other service providers.
Delays in Delivering Free Personal Care
Differences in eligibility criteria 1 between local authorities mean that it is difficult to collect comparable data on the number of people waiting for local authority provided FPC services. A snapshot survey of local authorities carried out in December 2006 found the following totals of people waiting six weeks or more following an assessment of need:
- 38 self funders in care homes (in six local authorities) waiting for FPC/ FNC payments to be provided
- 192 self funders (in 20 local authorities) requiring FPC/ FNC in a care home waiting for a care home place and payments to begin
- 31 people ready for discharge from hospital (in 10 local authorities) waiting for personal care services to be put in place at home
- 391 people (in nine local authorities) waiting for any personal care services to be delivered at home
- 13 people (in four local authorities) waiting for Direct Payments for personal care services.
Lack of vacancies in care homes was reported by local authorities as the main reason for people having to wait for a care home placement following an assessment. Lack of capacity to provide personal care services at home, either in the location or at the specific time of day requested, was reported as the biggest factor contributing to people having to wait for all or part of their care package to be delivered. People waiting for local authority FPC services were having their personal care needs met by informal carers and other service providers. The majority of people waiting for services were already receiving some personal care services from the local authority.
Four local authorities directly attributed delays in service provision/ payments at the time the latest survey was carried out to a lack of available funding.
Only five local authorities did not report anyone waiting for FPC payments or services. However, most local authorities reported only one or two people waiting in any category and only nine local authorities reported more than 12 people waiting for either FPC payments or services.
Limiting or 'capping' Care Packages
Nine local authorities operate a 'cap' or limit on home care packages and a further five local authorities operate a formal process to review the cost of home care packages that reach a threshold level. The cap on home care packages is usually set at around the gross cost of a care home place. Local authorities operating caps on care packages apply these flexibly, reviewing each case on its merits and trying to accommodate the needs and wishes of the client and family.
Unmet Need
Few local authorities currently collect and analyse information about unmet need arising from assessed needs not being met in full. However, such information can be used to identify and address areas of unmet need in home care, respite care and day care places. At a more strategic level it can be used to help develop Local Improvement Targets and joint commissioning strategies.
Involving Carers and Offering Choice
Unpaid carers are crucial to the effective delivery of community care. Whilst carers are being involved in the assessment process, few have a formal Carer's Assessment carried out. Some carers and users voiced concern that their views and needs were not reflected in resulting care plans.
Local authorities are not required to offer choice to users and carers and offer limited choice about the type and level of service and who will deliver it. However, the level of choice that can be offered is often constrained by lack of service capacity. This is particularly the case in more rural areas and at peak demand periods.
Contractual Arrangements for Self Funders in Care Homes
The majority of self funders in care homes are on Route 2 contracts. 2 Local authorities prefer the Route 2 contract since it reduces their liability and is simpler for them to administer. Care homes prefer the Route 2 contract since it gives them greater flexibility in setting charges. Care homes are reluctant to accept Route 3 contracts for self funders.
Self funders and their relatives were unclear about the different contractual options and may not have been given sufficient information to allow them to make an informed choice.
Monitoring and Reviewing Individuals' Needs
Home care workers and staff in care homes play a key role in monitoring the needs of individuals who receive personal care. All local authorities have policies in place for monitoring and reviewing individuals' needs and target times for undertaking reviews. However, there is no national monitoring of whether reviews are carried out as scheduled and within target times. Where local authorities may be experiencing problems undertaking assessments they also reported delaying 'non-urgent' reviews. Users and carers reported varying experiences. Some were happy that their case was reviewed as required. Others reported long periods without review.
Informal Care
Informal carers undertake a wide range of tasks for the individuals for whom they care. FPC has helped to support carers in their caring role, especially those who are themselves getting older and possibly more frail, by freeing them from tasks they may struggle to carry out such as bathing. This has enabled them to continue caring in other ways.
Monitoring and Evaluating Free Personal Care
Few local authorities have developed a systematic approach to reporting and monitoring the implementation, impact or cost of FPC. Whilst local authorities do produce substantial amounts of statistics for the Scottish Executive on some aspects of home care these statistics provide only a partial picture of the implementation of FPC.
A large number of local authorities still lack community care information systems that can readily produce robust statistical information on key aspects of the operation of FPC. There is limited collection and analysis of information about key issues such as numbers of people waiting for FPC payments or services, unmet need, and the level and type of support provided by unpaid carers.
Balance of Care
There has been a substantial increase (74%) in the number of older people receiving FPC at home since it was first introduced and a shift in the balance of publicly provided care from non-personal care to personal care. The provision of personal care is very important in helping older people stay in their homes longer. However, FPC is only one element of the holistic approach to care required to assist people to stay in their homes longer, along with informal care, domestic care, the provision of equipment and adaptations and housing support.
Care Providers
There are major differences in care home capacity across Scotland. High occupancy rates in care homes in some areas are contributing to waiting lists for care home places and hence for FPC/ FNC payments.
There has been a substantial increase in the size of the independent home care sector since 2002 across Scotland but some local authorities continue to rely almost wholly on in-house provision of home care. Mixed markets of home care provision, where local authorities rely on independent sector providers for a significant proportion of home care services, have generally developed in an unplanned manner without options appraisal or competitive tendering.
Quality of Care
The majority of service users interviewed for the evaluation were generally very positive about their experience of receiving personal care and the dedication of care staff. The most important aspects of home care services for users are staff reliability, continuity of care, the manner and attitude of staff, and the competence and knowledge of staff. Users' and carers' concerns about the way home care services are provided centred around the length of time allocated to providing specific tasks, the time at which services are provided, and lack of flexibility and continuity in the way services are delivered.
Potential Barriers to the Sustainability of FPC
Guidance
Different interpretations of the guidance on 'assisting with the preparation of food' has led to local authorities adopting different policies on charging for food preparation. The Scottish Executive has provided revised guidance but most local authorities still believe there is ambiguity about which services should be provided free of charge.
Assistance with medication is another area of the guidance that some local authorities have suggested should be clarified.
There is a strong view amongst local authorities that the guidance on FPNC lacks clarity and transparency on the key issue of whether/ how local authorities are able to take resources issues into account in determining access to care services and FPC.
Staffing/ Workforce issues
Staffing and workforce issues are a major constraint on how FPC is being delivered. Shortages of staff have contributed to delays in assessments and in the delivery of home care services, and inefficient working practices and staffing structures have restricted home care services' ability to meet demands for services.
Relationship with the NHS
The relationship between local authorities and their NHS partners is a crucial determinant of how FPC operates now and in the future. Three issues need to be considered: the interface between personal and nursing care; the need to implement SSA; and funding, principally 'resource transfer'.
A full list of recommendations arising from the report is contained in Chapter 8.
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