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CHAPTER SIX THE IMPACT OF FREE PERSONAL CARE

Evaluation Objectives

The study will evaluate the impact that the FPC policy has had on:

• Informal care - explore whether the introduction of FPC has resulted in informal carers substituting different forms of caring for personal care and whether the switch in the balance of care towards care at home provided more opportunities for providing informal care.
• The balance of care - evaluate how successful FPC has been in meeting its aim to improve the availability of personal care services to older people at home.
• Care providers, the broader care sector and the range and availability of care services - identify whether there is a shortage or surplus of particular types of care at both a local authority and a national level and issues relating to the future capacity of the care sector.
• The quality of care received - explore service users' attitudes to the quality of the care they receive.

Informal Care

6.1 Research undertaken for the Care Development Group ( CDG) in 2001 to assess the potential impact of introducing FPC suggested that:

"the majority of carers want to continue to look after their relatives irrespective of the introduction of universal free personal care, though they felt that more help from the public sector would allow them more time to relax or 'switch off' so that they might have the energy to continue their caring role." ⁴⁰

6.2 It concluded that FPC might lead to a shift from informal (unpaid) care to formal care (personal care funded through FPC). The CDG factored into the likely costs of FPC"an increase in demand for formal services" and calculated that the level of substitution of informal for formal care could amount to between 10% - 17% of current levels of informal care. It suggested that the impact of this shift may "build up over a period of years".

6.3 The Joseph Rowntree Foundation's report on Financial Care Models in Scotland and the UK⁴¹ considered the impact of FPC on carers. Using statistical analysis of the Family Resource Survey and the Scottish Household Survey (2002 - 2004), the report concluded that "there has been no significant change in informal caring behaviour in Scotland relative to England over the two years since the introduction of FPC."

6.4 However, qualitative research (focus groups with carers) undertaken for the Joseph Rowntree Foundation study suggested that, whilst there was no evidence of 'substitution' of informal care for formal services, there has been a shift in the balance of care provided by unpaid carers from personal to non-personal care.

6.5 The evaluation's postal survey sought to provide up-to-date information on the impact that FPC has had on carers. The survey was sent to a sample of self-defined carers and people aged 65 and over identified from the Scottish Household Survey. Three hundred and eighty seven of the 1,327 respondents to the survey defined themselves as carers of people (with personal and/ or non-personal care needs) aged 65 or over.

6.6 As can be seen from Table 6.1, these carers mainly perform non-personal care tasks such as shopping (69%) and housework (56%). Four out of ten unpaid carers carry out 'service tasks' such as cooking, preparing food and/ changing bed linen (tasks that may come within the scope of FPC, depending on the needs of the client).

6.7 Less than a quarter of unpaid carers of older people who responded to the survey reported that they carry out more intimate personal care tasks that come within the scope of FPC, such as assisting with washing (24%), medication (24%), dressing (17%), and eating (13%). Less than 10% help with getting the cared for person in and out of bed or with toileting. (Table 6.1)

Table 6.1: Tasks carried out by unpaid carers

Base = 387 carers of people aged 65+
Source: 2006 Postal Survey

6.8 One hundred and eleven carers responding to the postal survey had been providing unpaid care (of any kind) prior to the introduction of FPC. The survey asked these carers whether/ how the level and type of care they provide has been affected by the introduction of FPC.

• 52% said that FPC has not affected the care they give
• 24% said that they continue to provide the same level of care but have changed the type of care they provide
• 18% said that they have reduced the amount of care they provide as a result of FPC.
• 5% said that they had increased the amount of care they provide since FPC was introduced.

6.9 The quantitative evidence from the postal survey was confirmed by the qualitative evidence gathered from interviews with social workers, care staff, service users and carers. Most interviewees reported that they believe FPC has led to a definite shift in unpaid care from personal to non-personal care but that carers are still a key component of the overall care package.

6.10 Almost all the carers interviewed for the evaluation spoke positively about the difference FPC had made to their own lives and to the life of the person they care for. FPC has generally helped carers, especially those who are themselves getting older and possibly more frail, by freeing them from tasks which in some cases they struggled to carry out, such as bathing. This has enabled them to continue caring in other ways, and many carers spoke about the value of having time for themselves and time and energy to enjoy shared activities. Respite care was mentioned by many carers and service users as being particularly important in helping carers cope with the pressures of caring for someone over a lengthy period of time.

Mrs G (Dumfries and Galloway) came out of hospital recently following a stroke. She lives with her daughter and son-in-law and has done so for some years since the death of her husband. Her daughter does all of the domestic tasks including cooking. She gets a range of personal care services each day and is very pleased with how things have been arranged. She feels that FPC has made a difference to her own life and to her daughter's life. The provision of FPC has enabled her daughter to work part time.

The Balance of Care

Balance between personal and non-personal care

6.11 The introduction of FPC has contributed to shifting the balance of publicly funded care from non-personal care to personal care.

6.12 The total number of older people receiving (publicly funded) personal care services in their own homes has risen significantly (by 74%) since the introduction of FPC, from 24,162 in July 2002 to 42,102 in March 2006 . The number of older people receiving (publicly funded) home care has also increased from 53,636 in July 2002 to 57,187 in March 2006.

6.13 When FPC was introduced in July 2002, 45% of older people receiving a home care service received FPC as a part of that service. By March 2006 that proportion had increased to 73%. Only 27% of older people who currently receive a home care service are not receiving some form of personal care. (Table 6.2) This reflects the changing balance of care from non personal to personal care with local authorities prioritising the provision of personal care. As highlighted above (Chapter 4), some local authorities no longer provide non personal care in new cases unless it is part of a comprehensive package of care including personal care.

Table 6.2: Home Care Clients aged 65+ and Clients receiving FPC (2002-2006)

Source: Free Personal and Nursing Care Scotland 2002-2005: Scottish Executive and March 2006 figures provided by the Scottish Executive

Balance between home care and residential care

6.14 FPC, and the additional funding that was made available to fund the policy, has undoubtedly improved the availability of personal care to older people at home. Dumfries and Galloway Council summarised the impact of FPC in the following terms:

"Free Personal Care has probably encouraged more take up from persons who would previously have been charged. The additional funding has been very important and definitely helped us improve our infrastructure and increase our overall services and focus these on meeting people's wishes to receive care support at home." ⁴²

6.15 The increase in the availability of personal care services to people at home has been a contributory factor in the shift away from residential care to home care. However, as was reflected in the Range and Capacity Review Group: Second Report ⁴³, other policies and initiatives have also made a major contribution to encouraging and helping older people to remain in their own homes, including:

• delayed discharge initiatives such as rapid response teams and Step Up and Step Down initiatives, which provide intensive support and rehabilitation for older people being discharged from hospital or at risk of having to go into hospital
• provision of Community Alarms
• very sheltered and extra care housing
• telecare.

6.16 Interviews with service users and carers highlighted the importance of personal care in helping people stay at home longer. However, they also suggested that the total package of care they receive - the support provided by unpaid carers, the provision of non-personal care, and the provision of equipment and adaptations, telecare, community alarms, and in some cases Direct Payments - is the key to their remaining at home rather than having to go into a care home. Packages of care provided as an alternative to a care home placement will invariably include a mixture of personal and non personal care and might also include other forms of care such as unpaid care and support from nursing staff.

6.17 In order to measure progress towards shifting the balance of care from long stay residential care (to reduce the number of older people in inappropriate hospital and care settings) the Scottish Executive has set a target to increase the number of older people receiving intensive home care to 30% of all older people receiving long term care by 2008. Intensive care is defined as a home care package of more than 10 hours per week. At this level of service clients are more likely to need personal care rather than non-personal care.

6.18 However, this measure of intensive care was questioned by senior social workers interviewed during the evaluation. As highlighted in Chapter 4, there are significant differences in what local authorities record within their Home Care statistics. For example, some local authorities do not include meals on wheels and laundry services within their home care provision, and respite care is recorded differently across local authorities. Senior social workers argued that the 10+ hours of home care measurement is a relatively low level of intensity that does not equate to a level of service that would shift the balance of care between residential care and home care. Therefore it was argued that increasing the proportion of packages of care above that target does not provide a robust measure of whether the balance of care is shifting between residential care and home care.

Care Providers

Care Homes

6.19 The care home market is dominated by the private sector which in September 2005 accounted for 73% of care home places and 74% of care home residents. Across Scotland between 2002 and 2005, whilst the number of places in care homes across all sectors remained virtually static (+0.2%), there was a slight fall in the number of local authority and voluntary sector care home places and a small increase in the number of private sector care home places. Over the same period the number of care home residents across all sectors fell slightly from 34,569 to 33,716 (-2.4%); the falls in the local authority and voluntary sector were significantly greater than in the private sector. (Table 6.3)

Table 6.3: Care Home places and residents by sector: 2002 - 2005

Source: SEHD Community Care Statistics - SCHS Return

6.20 Occupancy rates in the care home sector vary significantly across the country. The September 2005 Care Home census ⁴⁴ shows that, although the Scottish average occupancy rate is 90%, rates vary from almost 97% in Inverclyde to 81% in North Lanarkshire.

6.21 Care home capacity, measured as the number of care home places per 1,000 population aged 65 or over, also varies significantly. The Scottish average in September 2005 was 46.2 places per 1,000 population aged 65 or over, with the highest being 59.3 in South Lanarkshire and the lowest 29.5 in East Dunbartonshire.

6.22 Table A6.7 (Appendix 6) provides information on the care home capacity and occupancy rates in the six case study areas along with a summary of how the care home sector has developed.

6.23 FPC per se has had little direct impact on care homes. FPC/ FNC payments are made to residents of care homes rather than care homes. Almost all the independent care homes that responded to the evaluation's survey stated that, although FPC had been beneficial to self funders, it had had no direct impact on the care home.

6.24 However, as is evidenced by the delays by some local authorities in paying FPC/ FNC payments to self funders who cannot find a place in a care home, or the care home of their choice (see Chapter 4 and Table A6.4 in Appendix 6), the capacity of the care home sector can have a major impact on how local authorities deliver FPC.

6.25 The evaluation's survey of the number of people waiting either in hospital or at home for FPC/ FNC payments to begin after an assessment showed that more than half of Scotland's local authorities have people waiting, either because there are no vacancies in local care homes or because the there are no vacancies in the individual's preferred care home.

6.26 Even in areas where there is a relatively high capacity in the care home sector and/ or low occupancy rates (e.g. Glasgow) there may still be people waiting for care home places because the vacancies are not in the homes that they would choose to move to. This problem is particularly apparent in mixed urban / rural areas such as Stirling where, although there is a relatively high vacancy rate across the council as a whole, homes in rural areas have few vacancies.

6.27 In developing Joint Capacity Plans to plan future demand for community care and for care home places (thereby affecting the future balance of care between home care and care home provision which will have an impact on FPC), Joint Future Partnerships are having to consider and take on board a wide range of factors that both increase and reduce potential demand for care home places. For example:

Increasing demand for care home places

• The decline in long stay beds for older people in the NHS and ongoing pressure to reduce delayed discharges from hospitals
• The ageing population and the increase in the population with chronic and degenerative illnesses.

Reducing demand for care home places

• The shift in the balance of care, with higher levels of intensive home care designed to assist older people to live in their homes for longer
• The development of alternative residential based care in very sheltered and extra care housing that provides 24 hour care. This can provide an alternative to care home placement for people who require intensive levels of support
• Investment in telecare and assistive technology (devices or systems that allow people to perform tasks they would otherwise be unable to do) also assists people to live in their own homes.

6.28 The Scottish Executive's Range and Capacity Review Group's Second Report considered the trends in capacity in the care home sector in Scotland in some detail. It concluded:

"The net effect of different factors on the demand for care home places over the next few years is uncertain. It may be that the additional pressures associated with a) a sharp rise in the number of people aged 85 and over, b) continuing pressure to reduce delayed discharges, and c) a further decline in NHS beds, can be met by expanding alternative non-institutional forms of care. This is likely to require substantial investment in these alternatives, and also effective management of admissions to care homes to ensure that these places are used only for those in the highest dependency categories." ⁴⁵

6.29 The shift in the balance of care has supported people to stay at home longer, meaning that when / if they do eventually require a care home place they are likely to have higher levels of care needs. This trend, along with an increasing number of people with dementia and challenging behaviour going into care homes rather than hospitals, is leading to an increase in demand for dementia and other specialist units or beds within care homes.

6.30 This means that, in most areas, Joint Capacity Plans are planning for an overall reduction in the care home sector whilst increasing specialist provision such as dementia units. The need for changes in care home provision to meet the new demands will require concerted planning and co-operation between local authorities and private and voluntary sector care home operators.

6.31 In respect of care home provision, local authorities are operating within a market place dominated by the private sector. One way of trying to influence the market in order to increase the capacity to provide additional higher dependency beds is through pricing structures. The higher costs associated with providing augmented care or specialist dementia units for elderly mentally ill residents arise from the need to have smaller homes (or smaller specialist units within residential homes), higher staffing levels and more highly trained staff.

6.32 Local authorities have begun to recognise the additional costs required to provide augmented care for residents with more intensive care needs that fall short of nursing care by paying care homes a rate somewhere between the nationally agreed rates for residential care (£410) and nursing care (£471) for local authority funded places.

6.33 Five of the six case study councils have agreed higher fees for care home residents requiring augmented care. The augmented fee rates range from £423 in Angus to £442.10 in Argyll and Bute. These augmented rates apply to local authority funded care home residents and do not affect the £145 FPC or £210 FPNC payments made to self funders.

6.34 The non-uprating of FPC / FNC payments to take account of inflation since 2002 was an issue that was raised by many of the national and local stakeholders interviewed for the evaluation, as well as several care home residents and their relatives. As care home fees have increased, the non-uprating has eroded the financial benefit of FPC for self funders. The Scottish Executive is actively considering whether the £145 and £65 still represent the cost of delivering personal and nursing care services.

6.35 The fundamental principle behind the FPC policy is that older people in care homes who have an assessed need for personal care / nursing care to be met in a care home should not have to pay for their personal and nursing care costs. If this is to be maintained, consideration will have to be given to whether the higher costs associated with providing care for people who require a level of care that falls short of nursing care but is greater than basic personal care should be reflected in the FPC/ FNC payments.

6.36 This would have implications for assessments of need as local authorities would be required to consider augmented care needs along with personal and nursing care. However, local authorities that pay augmented rates already have procedures in place to determine eligibility for the augmented rate.

Home Care

6.37 Although the home care market is still dominated by in-house local authority provision, the latest home care statistics for all community care clients show that there has been a substantial increase in the size of the independent home care sector since the introduction of FPC in 2002. The overall size of the home care market has grown but the number of clients receiving a service solely from the local authority fell from 55,513 in March 2002 to 53,478 in March 2006; from 86% of the total number of clients to 76%. During this period the number of home care clients receiving a service solely from a private or voluntary sector provider doubled from 6,178 to 12,223; from 9% to 18% of the total. There were similar shifts in the proportion of hours of home care services provided solely by the various sectors. The percentage of hours of service provided solely by in-house local authority staff fell from 74% in 2002 to 56% in 2006. (Table 6.4)

Table 6.4: Distribution of home care clients and hours between various providers

Source: Statistics Release: Home Care Services 2006 (Scottish Executive)

6.38 Figures provided by the six case study councils show significant variations in the level of care services which they purchase from independent (private and voluntary) sector home care providers. (Table 6.5). This shows that there are two models of home care provision operated by local authorities; in-house and mixed market:

In-house

Angus and West Dunbartonshire Councils rely almost totally on their in-house home care services to provide both personal and domestic homecare.

Mixed market

In four of the case study councils, independent home care providers account for between 30% to 40% of home care provided by the local authority.

Table 6.5: Proportion of home care services provided by in-house home care staff or private/ voluntary sector providers in case study councils

Source: Case studies

6.39 Generally, mixed market care services have developed in an unplanned manner without an options appraisal or competitive tendering and are not actively managed by local authorities, although some local authorities (e.g. Dumfries and Galloway) actively consult and engage with independent sector providers.

6.40 City of Edinburgh Council has begun to address the issue of how to influence the independent sector market. In autumn 2006 it issued a tender proposal to external home care providers with a view to rationalising contracts through offering a framework agreement for services to a smaller number of providers. It hopes that the tendering process will reduce costs and allow it to develop better links between the council and the independent sector providers.

6.41 The type of contract used to engage the independent sector varies, but in most areas spot purchase or call up contracts (individual care packages negotiated with the provider) are the norm rather than block or tendered contracts. Four of the six case study areas do not have a standard rate paid to independent care providers but rely instead on spot purchase of services on a case by case basis, where the rates paid to providers may vary case by case.

6.42 The lack of block contracts and standard rates means that care managers (e.g. in Argyll and Bute) or specialist staff (e.g. Dumfries and Galloway) have to source providers and negotiate with them to deliver care packages on a case by case basis. The complexity of trying to arrange a package of care, which might require negotiating with several care providers on different types of contract, can be very time consuming.

6.43 Staff involved in arranging care packages in the case study councils reported that the factors that influence whether care packages are placed with internal or external providers include:

• Whether the in-house team has the capacity to provide the services requested in the care package
• The costs and rates charged by the in-house team compared to the external provider
• Whether specialist services are required
• The time at which the service is required and whether the in-house team is able to provide the services at the times requested.

6.44 Complex and intensive care packages that require services to be provided at evenings and weekends are more likely to involve a combination of care providers since local authorities may have to buy in services to cover for times when their own staff are unavailable.

6.45 The case study example below illustrates the range of services that might be provided for a client with a complex package of care by various service providers.

Mrs P (Angus) is physically disabled and has recently become completely blind. Her husband died a few years ago and she has family living close by. She lives in sheltered housing and has an intensive care package involving a range of service providers:

• Social Care Officers provide a range of personal care services at various times of the day, including washing and dressing and putting on support stockings every morning, visits every evening to assist with getting ready for bed; providing a shower once a week; providing breakfast at weekends (when Home Helps are not available); and, on the days Mrs P is not at Day Care helping with meal preparation (opening prepared meals)
• A Home Help comes (Mon - Fri) to make her tea and toast (breakfast) and twice weekly for cleaning and laundry
• She attends Day Care three days a week
• Meals on wheels is provided at lunch time and tea time when she is not at Day Care
• A nurse comes in to dispense eye drops twice daily
• An unpaid carer takes her out for a short while once a week
• She receives a shopping service once a week
• She also receives respite breaks in the care home where she attends Day Care.

6.46 As highlighted in Chapter 4, one of the main reasons for delays in the provision of personal care services is lack of capacity amongst care providers. The evaluation has found that this is an issue irrespective of the balance between in-house and independent provision in the local area. For example, both Angus and Stirling Councils, at either ends of the in-house/ mixed market spectrum, have reported people waiting for personal care services due to either insufficient in-house care staff or lack of external providers to deliver services in rural areas.

6.47 Problems with recruiting home care staff or finding external providers to support the provision of services are a particular issue faced by local authorities in rural areas. The limited pool of labour, travel distances, and competition from other employers present major logistical difficulties. For example, Argyll and Bute Council reported that, although it has sufficient external providers and staff in its larger towns, it has experienced problems providing services in some of its more rural areas.

6.48 The evaluation has found that both local authority in-house teams and external providers face difficulties in recruiting staff. Most of the home care providers that responded to the providers' survey stated that they have had, or are currently having, difficulties in this area. The following comments are representative of the experiences reported by independent sector home care providers in case study areas in recruiting and retaining staff:

• "Experienced and committed care workers are difficult to recruit because of low pay and status and anti social hours."
• "Cannot offer potential employees steady employment due to the erratic nature of the referral system. We are referred service users weekly and lose others back to main stream weekly."
• "Limited labour force in the area together with limited suitable applications from people genuinely interested in providing quality home care services."

The Quality of Care

6.49 Interviews with service users and carers confirmed the findings of previous research, including Audit Scotland's 'Homing in on Care: A Review of Home Care Services for Older People' ⁴⁶ and the more recent Joseph Rowntree Foundation study, 'Financial Care Models in Scotland and the UK' ⁴⁷. These show that the most important aspects of home care services for clients are:

• Staff reliability
• Continuity of care and staff
• The attitude and the general manner of care workers
• Competence of care workers in undertaking specific tasks
• Flexibility of response to changing needs
• Knowledge and experience of the needs and wishes of the user and/ or carer
• Information about the services that will be provided.

6.50 For the most part, service users were very positive about the quality of care they received and were particularly appreciative of staff being reliable, friendly and flexible and services being provided in an unhurried way. Respite care and day care services were also welcomed by users and carers. Day care centres were found to play an important role in supporting older people with personal care needs. In some areas (e.g. West Dunbartonshire), personal carers provide a bathing service at the day care centre that could not be provided in the clients' home.

6.51 However, interviews with users and carers also suggested that the introduction of FPC might have had a negative impact on the quality of care provided in three ways:

• The time allocated to providing personal care services
• The time at which services are provided
• A lack of flexibility and continuity in service provision.

Time allocated to providing for personal care services

6.52 A concern voiced by service users and carers in Angus and Dumfries and Galloway was the short time allowed for home care staff to help people with certain tasks such as bathing and dressing. With the introduction of FPC some local authorities (e.g. Angus, Dumfries and Galloway, Edinburgh and Stirling) set tight time limits on distinct elements of personal care (e.g. washing and assistance with eating: 15 minutes each). Packages might be broken down into distinct parts which are provided in short visits.

6.53 The tight time allocations are as a result of:

• trying to ensure a common level of service across the authority
• having to provide a range of personal care services at different times of the day
• having to meet growing demand for personal care services within tight budgets and staffing resources.

6.54 The evaluation found that the short time allowed for visits means that service users can feel hurried and services may not meet their needs (e.g. meal services that do not allow for the fact that the person may need help and encouragement to eat as well as to prepare the food).

Mr J (Dumfries and Galloway) lives in his own home and has a package of care, including personal care, provided up to five times a day in short sessions, for 15 minutes a session, seven days a week and for bathing twice a week. There are five care workers on a rota. He also has home help for domestic tasks, cleaning and washing up, which he pays for. He goes to day care twice a week. He is happy with his current level of care but unhappy with the length of the sessions. He feels they are too short and he feels rushed. He finds it particularly difficult that he gets no fresh food. The meals are microwave varieties as there is not enough time allocated to prepare fresh food.

The time at which services are provided

6.55 The timing of care services was also a recurring issue in most of the case study areas. Clients do not always receive services (e.g. help with getting in and out of bed or assistance with eating) at the time they wish to receive them due to the demand for services at 'peak' times and lack of staff availability to actually get round all clients at these times. Case study local authorities reported that they may not always be able to meet a client's specific preferences for a service.

6.56 Many service users and carers complained that visits seemed to be scheduled to suit the service provider rather than the service users. This was a particular issue in relation to evening and night time services. As can be seen from the following example some clients and carers reject the offered night time service because of the proposed time of the service.

Miss L (Stirling) has been caring for her relative who lives separately for nearly 10 years. Her relative has FPC every morning for getting up, washed and dressed. Although her relative needs help getting to bed, they refused this service because care workers would have come at 7.30-8 pm and this is too early. The service user likes to go for a walk on summer evenings and this is important for her health. Miss L helps her relative to get ready for bed rather than accept the early service.

Lack of flexibility and continuity in service provision

6.57 In some areas service users and carers complained about the lack of flexibility in the way that personal care is being provided, not just in terms of the time at which a service may be provided, but also in relation to the clear division between personal and non-personal care tasks which has meant that different staff may be responsible for carrying out different tasks.

6.58 Delivering a package of care through four or five short visits spread out through the day ensures that a range of services will be provided (e.g. assistance with getting out of bed and washing, assistance with lunch, housework, tea time service and assistance with getting into bed). However, delivering services in this tightly regimented way means that the care package can be inflexible in relation to timing and who will provide which service.

6.59 Clients are also particularly critical of the lack of continuity of care with different care workers, sometimes from different providers, providing care services. Service users would prefer to be able to build up a relationship with a care worker over a period of time rather than be faced with a succession of different care workers coming to their home.

Improving the quality of care

6.60 The quality of the service received and the experience of the service users depends as much on the individual paid carer providing the service as it does on the factors outlined above (paragraph 6.49). The following comments from a carer in Angus are typical of the views expressed by service users and carers about the quality of care:

"there is considerable variation in the standard of care provided by individual carers; mainly they are excellent and do the best they can in the time available, some however do not wash my husband properly, don't speak to him, avoid tasks they find distasteful and do not take proper account of his disabilities."

6.61 The local authority representatives interviewed during the course of the evaluation recognise the potential of the National Care Standards and the Care Commission inspections to improve standards, both in in-house provision and amongst independent sector providers. However, the Standards and inspections of home care providers are still in their infancy and it is too soon to say whether they are achieving their aim of driving up standards amongst care providers.

6.62 The interviews with care home residents and the survey of independent sector care homes found no evidence that FPC/ FNC has had any impact (good or bad) on the quality of care provided in care homes. The payment of FPC/ FNC to self funders did not increase the level, type or range of care provided to care home residents. As one care home manager commented:

" FPC has had no bearing at all on care standards…. Why should it?"

6.63 COSLA has recently commissioned work on establishing quality standards for care homes. In order to avoid duplication it is working closely with the Care Commission in developing standards that are consistent with the existing requirements on care service providers. The new standards will be linked to new fee rates to be paid by local authorities. The new standards and fees will be based on the principle that higher quality services will attract a higher fee. It is hoped that these new standards along with the regulation undertaken by the Care Commission will help to drive up the quality of services in care homes.

Summary and Recommendations

Informal Care

6.64 Most unpaid carers of people aged 65 or over provide non-personal care such as shopping and housework; 40% assist with cooking and the preparation of food; whilst under a quarter carry out personal care tasks such as washing, assisting with medication, getting dressed or eating or toileting. (6.1 - 6.7)

6.65 Just over half of the carers who responded to the evaluation's postal survey said that FPC has not affected the type or level of care they provide, whilst about a quarter said that they provide the same level of care but have changed the type of care they provide. Almost a fifth of carers said that FPC has allowed them to reduce the amount of care they provide. (6.8)

6.66 Qualitative evidence from interviews with users and carers suggests that FPC has generally helped unpaid carers in their caring role, especially those who are themselves getting older and possibly more frail, by freeing them from tasks they struggle to carry out, such as bathing. This has enabled them to continue caring in other ways. Many carers spoke about the benefit that FPC and respite care provided. (6.9 - 6.11)

Balance of Care

6.67 There has been a substantial increase (74%) in the number of older people receiving FPC since it was first introduced and a shift in the balance of publicly provided care from non-personal care to personal care. (6.11 - 6.13)

6.68 The provision of personal care is very important to helping older people stay in their homes longer. However, FPC is only one element of a holistic approach to care required to assist people to stay in their homes longer and shift the balance of care from residential to home care, along with informal care, domestic care, the provision of equipment and adaptations and housing support. (6.14 - 6.18)

Care Providers

6.69 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. (6.19 - 6.26)

6.70 Some local authorities have introduced a third band of payment for local authority funded care home residents to recognise the additional costs for providing augmented care that falls short of the level of care required to satisfy nursing care eligibility criteria but is greater than basic personal care. (6.29 - 6.36)

6.71 There has been a substantial increase in the size of the independent home care sector since 2002 across Scotland, but local authority provision still dominates the market and some local authorities continue to rely almost wholly on in-house provision of home care. (6.37 - 6.38)

6.72 Mixed markets of home care provision, where local authorities rely on independent sector providers for a significant proportion of home care services, have developed in an unplanned manner without options appraisal and competitive tendering. The process of sourcing care providers, especially for complex packages of care involving services being provided at evenings and weekends or in remote locations, can be a resource intensive process. (6.39 - 6.45)

6.73 There are particular problems in recruiting home care workers or sourcing independent home care providers to deliver services in rural areas and islands. (6.46 - 6.48)

Quality of Care

6.74 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. (6.49 - 6.63)

6.75 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. (6.49 - 6.63)

Recommendations

R6.1 Local authorities should use the assessment and review process to record the level and type of care provided by unpaid carers and use the information to assist in reviewing and planning to meet carers' needs (e.g. respite care).

R.6.2 A more holistic measure of the shift in the balance of care from residential to home care is needed than the current "10+ hours of home care" measure. It should take account of the criteria by which assessments of needs determine whether a care home placement is required, including factors such as the complexity of the care package and the hours at which services are required.

R.6.3 The FPC/ FNC rates paid to older people requiring personal and nursing care in care homes should take account of the real costs of providing augmented care for older people with special needs which may be higher than personal care but fall short of nursing care.

R.6.4 Local authorities should take a systematic approach to planning to meet the demand for home care services by working with independent sector providers and representatives of users and carers to better meet the changing needs and demands for person centred home care services. Best Value Reviews of home care services and workforce development planning should be used to ensure the most effective and efficient deployment of home care staff to provide high quality, person centred care services that meet national quality standards.

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