HOW DOES THE COMMUNITY CARE? PUBLIC ATTITUDES TO COMMUNITY CARE IN SCOTLAND
The advent of the Scottish Parliament provides an opportunity to focus more specifically than in the past on defining elements of Scottish policy and the extent to which this differs from other parts of the United Kingdom. A critical element of such debates is whether those living and working in Scotland have different perspectives on issues in the policy arena from those living elsewhere. In order to explore the extent of any such differences, the long established British Social Attitudes survey has been supplemented in the last three years by the Scottish Social Attitudes Survey. In the third of these surveys, 2001, the Scottish Executive funded a module of questions designed to explore the attitudes of the public in Scotland on key issues relevant to the support of individuals with particular needs within the community. The module focused on
- where individuals with a range of disabilities should live and the ways in which support should be provided
- preferred options for older people in the balance of care between care home and care at home
- the perception by people in Scotland of individuals with support needs as full citizens with rights and responsibilities
- the views of people on Scotland on whose responsibility it should be to fund the provision of care
- priorities for government expenditure, including expressed willingness to incur higher levels of taxation.
The survey of public attitudes was considered timely for three main reasons:
- the need to change public attitudes if social inclusion is to be fully achieved
- the need to assess the extent to which policy proposals are supported by public attitudes, priorities and preferences
- the need to monitor the way in which the public is responding to changes in the delivery of community care support services.
Since this survey was commissioned, the Scottish Executive has launched a National Programme for Improving the Health and Well-Being of the Scottish Population. A high profile anti-stigma campaign forms part of the Programme. The findings of this survey complement those of the Scottish Public Attitudes Survey linked to the National Programme.
The questions on community care were asked in face-to-face interview as part of the 2001 Scottish Social Attitudes Survey. A national probability sample of adults aged 18 and over living in private households is drawn from the Postcode Address File. Interviews were achieved with 1605 individuals, with 86% returning the supplementary self-completion questionnaire. Data from the survey is weighted to ensure that results can be considered representative for the population of Scotland as a whole. The forty questions for the community care module, addressing the issues outlined above, were devised following consultation with a range of stakeholders in the field. Attitudes were explored through the use of four vignettes, each portraying a community care scenario. These were designed to represent a frail older person, a person with learning disabilities, an individual with mental illness, and an older person with dementia.
There were significant differences in how comfortable respondents said they would feel living next to the different individuals portrayed in the vignettes. Three quarters would be comfortable living next to the frail older person and six out of ten next to the person with a learning disability. More than half, however, expressed some disquiet about living next to the person with dementia or with a mental illness. This last vignette produced the only instance where gender differences were evident, female respondents being significantly less comfortable when the person depicted with a mental illness was male.
Support for the policy of individuals living within the community was high, ranging from 58% for the person with dementia to 88% for the person with a learning disability. Support in the latter case was particularly high amongst younger people. Less than a quarter of the respondents endorsed individuals with mental illness and learning disability serving on a jury.
WHO SHOULD PROVIDE CARE?
Views as to the best individuals or agencies to provide support varied depending on the particular needs which had been highlighted in the vignettes. Over half of respondents selected a paid nurse or home carer as the best source of support for the frail older person needing help with shopping and cooking. This rose to three quarters of respondents in the case of the person with dementia requiring bathing and checking and the person with mental illness requiring medication. In respect of the person with a learning disability, however, the need highlighted was to be taken to a club once a week; one third of respondents selected a family member to do this, a quarter a volunteer, and a quarter a paid worker. The large majority of respondents would go either to the social work department or to the GP in order to access support, although one fifth of respondents were unable to answer this question.
WHO SHOULD PAY FOR CARE?
The survey predates the introduction of free personal and nursing care for older people in Scotland and was conducted during a period when this policy was the focus of high profile debate. The respondents to this survey supported by a large majority the government paying for the provision of support, irrespective of individual income. This response was given by just under three quarters of respondents in respect of the person with mental illness and just under two thirds for the other three vignettes. Those dissenting thought in the main that payment should depend on income; very few considered that the individual should pay, regardless of income. Support for state funding was higher amongst those with personal experience of receiving or providing care and those with lower incomes.
THE BALANCE OF CARE
There was strong endorsement of the elusive community care policy of attaining a shift in the balance of care for older people from institutional to domiciliary base. Three quarters favoured an individual being supported at home, should they wish, even if it cost more than a care home placement. This option was most strongly supported by respondents aged 35 and over and by those with experience of care provision or receipt. There was strong support for equity of access: the proposition that those able to pay for it should be able to access higher quality support was rejected by three out of four respondents.
This study of public attitudes in Scotland found high levels of support for additional government expenditure on welfare issues, even if this were to mean higher tax levels. Nine out of ten favoured higher levels of expenditure on health, eight out of ten on supporting older people at home and three quarters of respondents on pensions and on older people in care. Endorsement for spending 'much more' rises as income levels decline and is higher amongst the older age groups and those who have been in receipt of care. Asked to select overall priorities for additional government spending on older people, respondents chose the following 3 options (in order of preference): home helps, special housing provision, and district nurses.
The results of this survey suggest a number of barriers to the attainment of social inclusion for individuals with community support needs. The levels of discomfort and unease implied may reflect a complex mix of concerns with risk rather than stigma; nonetheless, while the majority of respondents appear happy to endorse the principle of individuals being supported within the community, at the current time they appear more reluctant to fully endorse the rights of individuals to full participation as members of that community. Some areas of uncertainty may arise from lack of awareness, both generally of community care needs and specifically of the potential of individuals to contribute; information and education on these fronts must continue. The promotion of 'joined-up policies', key to current government, should enhance the potential for the development of more inclusive policy, planning and service strategies.
Social work and GPs are the agencies currently perceived as the key access points. As the profile of community support services changes, embracing for example the development of Direct Payments, it will be important that these agencies collaborate effectively with other sources of information and referrals, for example Direct Payments Scotland and other routes within health. In the development of 'one-stop shop' models, care is necessary to ensure that barriers to accessing primary care are addressed.
The findings of the survey are in line with those of surveys of public attitudes carried out for the Care Development Group of the Scottish Executive on who should pay for care. Respondents also express support for higher rates of taxation in order to fund higher levels of government expenditure in key welfare areas.
Recent policy initiatives designed to accelerate the shift in the balance of care for older people are also given a vote of confidence by the results of the survey. Indeed more radical expenditure on community-based options would be endorsed by the survey finding that three quarters of respondents would opt for an individual to be supported in their own home even when that was a more expensive option than a care home.