Free personal care: No myth in Scotland

Over the past two decades, Scotland has managed to provide free long-term care to its elderly. What’s its secret?

Is there no such thing as a free lunch? Apparently, in Scotland, there is. For almost 10 years, elderly Scots have benefited from free personal care, according to authors and researchers David Bell and Allison Bowes. In the e-book, “Universal Coverage of Long-Term Care in the United States: Can We Get There From Here?” (Russell Sage Foundation 2012), policy experts examine various models for a universal long-term care financing system. In chapter 5, Bell and Bowes look at the transition of long-term-care financing in the United Kingdom, from a flawed system to one that appears to serve its elderly population. In addition, they focus on the cost and benefits of free personal care in Scotland and consider some important lessons for policy makers in the United States.

LTC in the UK: The trek forward
By 2030, about 10 percent of the population in the UK are expected to be 75 years and older, according to Bell and Bowes, who point to a 30 percent increase in this age group between 2000 and 2030. Traditionally, long-term care in the UK has been provided in a variety of residential settings, including clients’ homes, they explain. For those with greater needs, the private sector, voluntary and charitable organizations, and the local government provide care homes. In Scotland alone, local authorities provided 16.9 percent of care homes for people 65 years and over – substantially more than in England.

The cost of providing long-term care in the UK has been shared by private and public sectors, the authors point out. However, traditionally, local government has only covered about 20 percent of the costs, while the remainder has been covered by grants. In Scotland, the Scottish Parliament serves as the grant-providing body to local authorities.

In 1998, the Royal Commission on Long-term Care was established under Tony Blair. The majority report of the Royal Commission recommended that nursing home and personal care costs should be covered by the state, but that certain costs associated with care homes and home care continue to be means-tested. While the majority report argued that personal care be funded through general taxation, based on assessed need, it considered free personal care to be unaffordable. Still, it argued that personal care should be treated as if it was part of the National Health System and be free at the point of delivery. In the end, the UK government did not implement the Royal Commission’s free personal care proposal in England.

Through the years, there have been several proposals – most notably the Wanless Review in 2006 – which favored a partnership model that would entitle individuals to a minimum guaranteed amount of care, according to Bell and Bowes. But, nothing was put into place and by 2010, “the UK government [was] still searching for a sustainable and equitable solution to the problem of long-term care funding in England,” say the authors. For whatever reason, long-term care in England has appeared not to gain high political priority.
By contrast, Scotland has made some definite policy decisions, including the introduction of free personal care for those 65 years and over, they point out.

Providing free personal care in Scotland
In response to the Royal Commission, in 2001 Scottish First Minister Henry McLeish established the Care Development Group, whose job it was to explore the implementation of a free personal care policy in Scotland, according to Bell and Bowes. The Care Development Group immediately introduced legislation and a policy was implemented the following year.

Key to implementing the policy was the task force’s definition of personal care: “…care which relates to the day-to-day physical tasks and needs of the person cared for and to mental processes related to those tasks and needs.” Equally important to the passage of the policy was the assessment of potential clients, note Bell and Bowes. “A separate group was set up, the Care Assessment Group, to design a single shared assessment which was meant to streamline the way in which individuals’ care needs were assessed,” the authors report. So, whereas individuals previously were assessed by multiple groups, now there would be one shared assessment. The result: Local authorities no longer could charge for personal care. The new system also put an end to ring-fencing – where resources allocated for personal care were re-allocated to other local authority services.

The Scottish government provided local authorities with additional resources to compensate for the loss of ring-fencing, according to Bell and Bowes. And, the free personal care policy ensured the following:

  • Care homes received flat rates to compensate them for the personal care they provided.
  • As long as a need was established, there would be no charges for personal care at home. (Depending on the need, this covered modest packages to more extensive packages requiring a caregiver to stay with the ill individual.)

Among other things, the new system led to a change in the balance of care, shifting the emphasis from caring for individuals in hospitals and care homes to caring for them at home. The end result: Clients’ needs were better met at a lower cost, report Bell and Bowes, citing a 39 percent reduction in the number of geriatric long-stay beds in hospitals between 2003 and 2008. Nor was “the decline in [hospital] geriatric care beds offset by a compensating increase in care home places,” say the authors. “Instead, there was a sharp increase in the number of people receiving free personal care at home, the numbers increasing by 69 percent between 2002-3 and 2009-10.

At the same time, the total number of clients being cared for at home by local authorities decreased by 6.6 percent between 2004 and 2010, according to Bell and Bowes. “Because local authorities now had a duty to provide free personal care within the constraints of fixed budgets, they tended to reduce the provision of non-personal social care and increase charges for this type of service. The proportion of their client base receiving free personal care increased up to 2010. Thus an unintended consequence of the free personal care policy was increased charges for services associated with non-personal care, such as mobility, shopping, etc. Increased charges may also have reduced demand, with care clients purchasing services privately.” A growing trend toward care within the community meant care homes could focus on those whose needs could not be met in their own homes, they add.

Lessons to be learned
There are a number of similarities between the UK and the U.S. systems for funding long-term care, note the authors. For one, both countries rely largely on means tests rather than entitlements as the basis for allocating funds to long-term-care recipients. “In both countries the private long-term care insurance is weak,” they note. “Both systems are complex and disjointed with public funding coming from different levels of government. [And], reform has been slow due to the difficulties of establishing political consensus and urgency around long-term care.”

Most recently, Scotland has introduced “the most significant change” in long-term-care funding in the UK, they continue. True, a change in demographics and “the extent to which [the system] provides a subsidy to the relatively rich who could afford to pay for their care” present a drawback. But, reducing demands on hospitals and care homes should release resources to support home caregivers, they point out.

Shifting the balance of care in the United States would depend on strong leadership and require organizations and policy makers to work together toward common goals, the authors suggest. Finally, it is essential to draw clear boundaries between those individuals who are entitled to free personal care, and those who have the means to fund their own care.
“In Scotland, there was an unexpectedly large uptake of free personal care following its introduction,” they say. “In addition, it was not anticipated that the introduction of free personal care would lead to a reduction in the public provision of other forms of social care. Unpaid carers may now be shifting their provision towards such forms of care. Free personal care may also have stimulated the private market in non-free personal care. The lesson is that very careful planning is required before the introduction of radical change in social care policy.”

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