Report on Community Care

The Committee reports to the Parliament as follows—

INTRODUCTION

This report sets out the Committee’s findings in relation to the reports of the Auditor General for Scotland (AGS) entitled “Commissioning community care services for older people” and “Adapting to the future: Management of community equipment and adaptations” (AGS/2004/8 and AGS/2004/9).

Remit

At its meeting on 9 th November, the Committee agreed to examine two key processes in developing and implementing cross-cutting policies, namely:

• ways in which Executive departments work together in developing cross cutting policies such as joint working between health and local government

• how the Health Department supports, monitors and evaluates the implementation of community care policies at a local level, with specific reference to recent policies on free personal and nursing care and community equipment and adaptations.

Evidence

The Committee held an oral evidence session on 23 November 2004. The following witnesses gave oral evidence to the inquiry:

• Mr Ian Gordon, Head of the Scottish Executive Health Department and Chief Executive of NHSScotland (Acting), Dr Peter Collings, Director of Performance Management and Finance, and Ms Fiona March, Policy Officer, at the Scottish Executive Health Department.

• Written evidence received by the Committee can be found at Annexe B.

Findings and Recommendations

The Committee’s main findings and recommendations are set out at Appendix A.

The Committee was pleased to note from Mr Gordon that SEHD has accepted all of the recommendations addressed to it in each report¹. CoSLA has also accepted the findings of both reports and accepts their responsibility to address areas that require to be improved².

POLICY ON FREE PERSONAL AND NURSING CARE

Whilst focusing on free personal and nursing care, the Committee acknowledges that this is only one element of care that is provided for older people. The future costs of care for older people is a significant issue given the impact of demographic change. The recommendations in this report therefore may be relevant to other aspects of care for older people.

SEHD implemented its free personal and nursing care policy in July 2002. Implementation was originally planned for April 2002, but was delayed to allow Councils sufficient time to prepare, including the training of staff, development of IT systems, and the estimating of take up in order to bid for funding from SEHD.

The AGS report on Commissioning community care services for older people pointed out that “even with this extension, councils reported that the timescale for implementation was tight”³.

The Committee noted from Ian Gordon’s oral evidence that SEHD’s initial emphasis, when introducing the policy, was “to ensure that the policy was implemented promptly….the emphasis was on getting the guidance out and on helping local government to prepare itself for implementation of the policy”⁴.

The Committee recognises the political imperative at the time for the speedy introduction of the free personal care policy and that SEHD was working to a tight timescale set by Ministers for its introduction. The Committee considers that this short timescale, coupled with the lack of robust information, is likely to have undermined SEHD’s ability to cost the policy accurately.

Financial Planning

Councils and their NHS partners need to plan now for the likely increase in demand for community care services for older people, and an expected shortage of carers, both paid and unpaid. Good financial planning therefore is vital to ensure that appropriate funding is made available so that services match need.

How Costs Were Estimated

In projecting the cost of the free personal care policy, Dr Collings indicated that following work carried out after the publication of the Sutherland report, SEHD’s initial estimate for the year 1 cost of the policy was £125m⁵. The Care Development Group subsequently estimated that the policy would cost £125m for each of the first 3 years following implementation (2002-2004), rising to £137m in 2007, £161m in 2012, £189m in 2017, and £227m in 2022. The Committee notes the co-incidence in the estimated cost figure (£125million), and SEHD’s explanation of how both costings were arrived at. The Committee wishes to emphasise that allocations must be made on the basis of a realistic and accurate assessment of need – estimated costs must not be calculated to fit allocations.

A detailed summary of the projected costs of the policy was included in written evidence to the Committee from Ian Gordon, and this is attached at Appendix B⁶. These estimates were increased following clarification that Attendance Allowance would not be payable to people in care homes who were self-funding and in receipt of free personal and nursing care payments. The revised estimates are attached at Appendix C.⁷

In terms of financial allocations, SEHD allocated £250million for free personal and nursing care over the period 2002/03 and 2003/04, £40million of which was for non-recurring expenditure on community care infrastructure costs⁸.

Future costs

One of the most important questions in relation to implementation of the policy is how much it is going to cost in future. A further £300million has been allocated for 2004/05 and 2005/06. The Statistical Release on free personal and nursing care ( 28 September 2004) showed actual expenditure for the first 9 months of the policy at £126million against an estimate of £107million from SEHD’s revised costs.

Assuming that the most current information from the Executive about expenditure in the first 9 months is accurate; then on this basis, expenditure to 05/06 could be greater than estimated by SEHD.

Existing Expenditure by Local Authorities

Mr Gordon however, considered in comparing the £107m cost estimate for the first 9 months of the policy, with the £126m outturn figure for the same period, the Committee was not comparing like with like. He explained that this was because, prior to the introduction of the policy, local authorities had already been spending money on providing personal care, but he did not quantify the level of local authority expenditure⁹. After the policy was introduced, local authorities were only able to provide SEHD with estimated personal care costs making it impossible to identify with certainty how much of the £126m expenditure could be accounted for by existing spend by local authorities.

The provision of estimated data by councils is of concern to the Committee. The Committee was informed that 12 councils were inconsistent in providing data¹⁰ - Dumfries and Galloway, East Lothian, Glasgow City and South Lanarkshire had problems in providing good estimates for personal care at home, although East Lothian is now providing this; a further 8 councils returned less than half of the quarterly returns sought by the Executive, and these were Shetland Islands, Inverclyde, West Dunbartonshire, Aberdeen City, Moray, East Renfrewshire, Angus and Falkirk; and 3 councils have returned no information to the Executive – Eilean Sar, Perth and Kinross and Scottish Borders.

Given the limitations of the information provided by local authorities, SEHD could not know with any certainty how much local authorities were spending on personal care, it seems therefore that the Department is not able to determine how much the policy has cost to implement.

The Committee is concerned that in providing regular data to SEHD a number of councils continue to provide either no information at all, or estimates. The Committee considers this to be an unacceptable position and is concerned that SEHD has continued to accept this.

The Committee recognises the difficulty of separately identifying local authority expenditure on free personal care prior to the implementation of the free personal care policy.

However, it is extremely regrettable that the Department is not able to separate out the costs to show local authority spending on care prior to implementation of the Bill, so that like for like comparisons can be made.

Following implementation of the policy, with its emphasis on the assessment of individuals, local authorities should be able to supply this information.

The Committee recommends that SEHD, together with councils, puts in place measures to ensure that all councils provide accurate data as and when it is required; that information on the older population is used to plan and develop services; so there can be confidence that service delivery will meet needs, and that financial allocations to councils are appropriate.

The Committee considers that SEHD has failed to monitor the actual cost of the free personal care policy following implementation.

Range of estimates

Given that SEHD was aware that the information it was receiving from councils was not robust and there was some uncertainty about information on issues such as demand and unmet need, the Committee would have expected it to have carried out a risk assessment on the consequences of inaccurate estimates. This would have included close monitoring across the range of variables such as the move from informal to formal care, the number of self-funders and unmet need. This information could have been used to produce a more realistic range of estimates.

The Committee was concerned to note that SEHD undertook no systematic risk assessment on the consequences of inaccurate estimates. Projection of a range of estimates would have been better than a single estimate given the uncertainty involved.

Post implementation Review of Estimates

The Committee notes with some concern that SEHD did not undertake any modelling exercise following implementation to review the estimated costs of the policy, or to revisit the assumptions it had made initially, despite the fact that the costs of the policy were higher than had originally been estimated.

In a wider context, the Committee is conscious of the impact that poor estimating and financial planning information can have on service delivery. Inaccurate information can, for example, affect the allocations councils receive in order to provide community care services. Inadequate allocations can then impact on users who do not receive the services they need. This may, in turn, lead to waiting lists arising, and indeed in its submission to the Committee, CoSLA indicated that they were already aware of waiting lists in some areas¹¹.

The Committee recommends that SEHD should review the cost of implementation of its free personal care policy, which will help ensure that future cost projections for the policy are based on accurate information, and will help make sure that financial allocations to councils are matched with needs.

Evaluating the impact of the policy

The Committee considers that in the case of free personal care, SEHD’s focus was more on supply rather than on outcomes. Ian Gordon, in oral evidence to the Committee said “From our point of view, the priority was to ensure that the policy was implemented promptly and effectively. For that to be done, the key measure that is to be measured is take-up of the policy”.¹²

The Committee is concerned that no consideration was given by SEHD at the outset of how the impact of the free personal care policy would be evaluated. No success criteria, beyond the level of take-up, appears to have been put in place at the outset which would measure whether the policy was making an impact. Furthermore, SEHD has not undertaken any measurement since implementation of the policy, making it difficult to evaluate whether the policy is delivering what it set out to do, or whether it is achieving value for money.

The Committee agrees with the point made in the AGS report on Commissioning community care services for older people, that a “more detailed review is needed which should involve looking at the numbers receiving this service, how it has affected their quality of life and the cost of the policy”¹³. As acknowledged in the AGS report, it is difficult without information like this to assess the impact of this policy and forecast future expenditure.

Mr Gordon indicated that SEHD plans to commission research in 2005, which will assess the impact of the policy and evaluate future costs. Whilst the Committee welcomes this commitment, it remains very concerned that this will be carried out 3 years after the policy was introduced. It considers that monitoring and ongoing evaluation procedures should have been put in place at the outset, and that these should have been carried out as a matter of course since then. In the Committee’s view, such procedures should be in place for any policy introduced by the Executive, given its responsibilities for the distribution of public funds.

The Committee notes that the research exercise has not yet been scoped, therefore it is difficult for it to form a judgement at this time about whether this will address its concerns in relation to measuring the impact and costs of the policy.

Given the Committee’s concerns about the robustness of the data that the Executive receives from councils, it considers that there is a danger this exercise will not be meaningful. For it to be worthwhile, SEHD must use accurate data and, as suggested above, take steps with councils to improve the quality of data it receives.

In terms of the types of data required, it was clear to the Committee that SEHD does not collect data on a regular basis on such issues as changes in pensioner and household incomes and the disposal of property to fund individuals’ care¹⁴. The Committee considers that SEHD has not been as alive as it should have been to the implications of demographic change on the cost of older people’s care.

In a wider context, the Committee recommends that comprehensive criteria to assess the impact of a policy should always be put in place at the outset of all policy development in the Executive to allow the impact of all policies to be measured.

The Committee requests details from SEHD of the scope and timetable of its research exercise which will assess the impact of the free personal care policy.

In assessing the impact of the policy on people who are receiving care, the Committee recommends that SEHD should collect appropriate demographic information on a regular basis. This would allow SEHD to be in a position to update the assumptions underpinning the costs of free personal care when demographic projections change.

COMMUNITY EQUIPMENT AND ADAPTATIONS

The Committee recognises the importance placed on community adaptations and equipment as outlined in the AGS Report¹⁵:

“Community equipment and adaptations are an important part of an integrated community care service. They support people with a wide range of needs to live in their own homes and can enhance the quality of people’s lives. They can reduce demands on other health and social care services by preventing unnecessary admissions to hospital; speeding up discharge arrangements from hospital; and reducing or eliminating the need for other community care services”.

The Committee acknowledges that the organisation of these services remains largely fragmented, and the split in responsibilities between social work, councils and the NHS is unhelpful for users and providers alike. The Committee considers that joint working between these bodies is vital if the policy is to be a success, with users being able to have access to the services as and when needed. Better co-ordination, in the Committees’ view, would undoubtedly lead to better service delivery.

Joint Working

The Committee noted that a number of steps are being taken to improve joint working. For example, the Executive’s Joint Future Agenda extends councils’ and the NHS’ legislative duty to co-operate with each other (NHS (Scotland) Act 1987 s.13), and introduced new powers for councils and NHS trusts to set up pooled budgets to facilitate the delivery of joint services (Community Care and Health (Scotland) Act 2002).

The Committee welcomed evidence from SEHD that local partnerships, involving the NHS and councils, are currently developing Local Improvement Targets (LITs) for joint community care services; and that a Joint Improvement Team is being established to support partnerships¹⁶. It was also pleased to note that in March 2004, SEHD announced national outcomes and local improvement targets for joint working between local authorities and their NHS partners; that interim monitoring procedures are in place; and that full reporting procedures will operate from 1 April 2005¹⁷.

The role of the Department in encouraging and disseminating best practice is vital to successful joint working. The Committee recommends that SEHD should put in place incentives and support mechanisms which encourage partnerships to provide better, and ensure greater, joint working at a local level.

This should be supported by current and appropriate national guidance. The Committee welcomes SEHD’s acceptance of the AGS report recommendation that guidance be updated. In a wider context the Committee recommends that guidance should be reviewed prior to new policies being implemented to ensure consistency.

The Committee is aware of the important role that housing plays in community equipment and adaptations, but was concerned to note that the Scottish Executive Development Department appeared to have only limited involvement in developing joint working on this policy, despite its statutory responsibilities for housing. The Committee considers that, given the fragmented local organisation of services, the Executive should have been showing a lead to councils and NHS bodies by promoting joint working between its own departments.

The Committee is concerned that in many areas there is evidence that local authority services and community health services are still not properly joined up around equipment and adaptations. The pace of implementation in relation to joint working initiatives is too slow.

The Committee should be kept informed of how the Joint Future Agenda is being taken forward by the Executive in making joint working work.

The Committee welcomes moves to encourage joint working, however, given the lack of involvement of the Development Department in developing joint working on community equipment and adaptations, it considers that there is still work to be done by the Executive to ensure a more integrated approach across Executive departments where a policy is cross-cutting. It also notes that CoSLA accepts that there is “room for improvement” in terms of joint working between local government and the NHS.¹⁸

APPENDIX A

KEY FINDINGS AND RECOMMENDATIONS

The Committee’s key findings and recommendations are set out below:

Free Personal and Nursing Care

• Whilst focusing on free personal care and nursing care, the Committee acknowledges that this is only one element of care that is provided for older people. The future costs of care for older people is a significant issue given the impact of demographic change. The recommendations in this report therefore may be relevant to other aspects of care for older people. ( Para 6)
• The Committee recognises the political imperative at the time for the speedy introduction of the free personal care policy and that SEHD was working to a tight timescale set by Ministers for its introduction. The Committee considers that this short timescale, coupled with the lack of robust information, is likely to have undermined SEHD’s ability to cost the policy accurately. ( Para 10)

Financial Planning for free personal care

• Allocations to councils for free personal and nursing care must be made on the basis of a realistic and accurate assessment of need – estimated costs must not be calculated to fit allocations.( Para 12)
• Assuming that the most current information from the Executive about expenditure in the first 9 months of the policy is accurate; then on this basis, expenditure to 05/06 could be greater than estimated by SEHD. ( Para 16)
• Given the limitations of the information provided by local authorities, SEHD could not know with any certainty how much local authorities were spending on personal care, it seems therefore that the Department is not able to determine how much the policy has cost to implement. ( Para 19)
• The Committee is concerned that in providing regular data to SEHD, a number of councils continue to provide either no information at all, or estimates.The Committee considers this to be an unacceptable position, and is concernedthat SEHD has continued to accept this. ( Para 20)
• The Committee recognises the complexity of separately identifying local authority expenditure on free personal care prior to the implementation of the free personal care policy. ( Para 21)
• However, it is extremely regrettable that SEHD is not able to separate out the costs to show local authority spending on care prior to implementation of the Bill, so that like for like comparisons can be made. ( Para 22)
• Following implementation of the policy, with its emphasis on the assessment of individuals, local authorities should be able to supply this information. ( Para 23)
• The Committee recommends that SEHD, together with councils, puts in place measures to ensure that all councils provide accurate data as and when it is required; that information on the older population is used to plan and deliver services; so there can be confidence that service delivery will meet needs, and that financial allocations to councils are appropriate. ( Para 24)
• The Committee considers that SEHD has failed to monitor the actual costs of the free personal care policy following implementation. ( Para 25)
• The Committee was concerned to note that SEHD undertook no systematic risk assessment on the consequences of inaccurate estimates. Projection of a range of estimates would have been better than a single estimate given the uncertainty involved. ( Para 27)
• The Committee recommends that SEHD should review the cost of implementation of its free personal care policy, which will help ensure that future cost projections for the policy are based on accurate information, and that financial allocations to councils can be matched with needs. ( Para 30)

Evaluating the impact of the free personal care policy

• The Committee agrees with the point made in the AGS report on Commissioning community care services for older people, that a “more detailed review is needed which should involve looking at the numbers receiving this service, how it has affected the quality of life and the cost of the policy”. As acknowledged in the AGS report, it is difficult without information like this to assess the impact of this policy and forecast future expenditure. ( Para 33)
• In a wider context, the Committee recommends that comprehensive criteria to assess the impact of a policy should always be put in place at the outset of all policy development in the Executive to allow the impact of all policies to be measured. ( Para 38)
• The Committee requests details from SEHD of the scope and timetable of its research exercise which will assess the impact of the free personal care policy. ( Para 39)
• In assessing the impact of the policy on people who are receiving care, the Committee recommends that SEHD should use updated demographic information as it becomes available. This would allow SEHD to be in a position to update the assumptions underpinning the costs of free personal care when demographic projections change. ( Para 40)

Community Equipment and Adaptations

Joint working

• The role of the Department in encouraging and disseminating best practice is vital to successful joint working. The Committee recommends that SEHD should put in place incentives and support mechanisms which encourage partnerships to provide better, and ensure greater, joint working at a local level. ( Para 45)
• In a wider context, the Committee recommends that guidance should be reviewed prior to new policies being implemented to ensure consistency. ( Para 46)
• The Committee is concerned that in many areas there is evidence that local authority services and community health services are still not properly joined up around equipment and adaptations. The pace of implementation in relation to joint working initiatives is too slow. ( Para 48)
• The Committee should be kept informed of how the Joint Future Agenda is being taken forward by the Executive in making joint working work. ( Para 49)
• The Committee welcomes moves by the Executive to encourage joint working, however, given the lack of involvement of the Development Department in developing joint working on community equipment and adaptations, it considers that there is still work to be done by the Executive to ensure a more integrated approach across Executive departments where a policy is cross-cutting. It also notes that CoSLA accepts there is “room for improvement” in terms of joint working between local government and the NHS. ( Para 50)

APPENDIX B

Care Development Group projected costs of Free Personal Care based on personal and nursing care costs of £90 and £65 per week.

Note: components may not add to totals due to rounding.

APPENDIX C

Revised projected costs of Free Personal Care policy based on a delayed introduction of Free Personal and Nursing Care in Year 1, with personal and nursing care costs of £145 and £65 per week¹⁹.

* This figure is for 9 months only, 1st July (when the policy began) to the end of the financial year.

Footnotes:

¹ Col.811

² Letter 23 December 2004

³ p13, para 32

⁴ Col.813

⁵ Col.818

⁶ Letter 17 November 2004

⁷ Letter 17 November 2004

⁸ Letter 17 November 2004

⁹ Cols.820-821

¹⁰ Letter 22 December 2004

¹¹ Letter from CoSLA 23 December 2004

¹² Col.813

¹³ p13, para 35

¹⁴ Col.832

¹⁵ p3, para 1.1

¹⁶ Letter 22 December 2004

¹⁷ Letter 17 November 2004

¹⁸ Letter from CoSLA 23 December 2004

¹⁹ Subsequent to the Care Development Group projected costs of free personal care (Appendix B), the Department of Work and Pensions advised that Attendance Allowance would not be payable to people in care homes who were self-funding and in receipt of free personal and nursing care payments; and the figures were revised to compensate for this. These are the figures used in the table above.