We are testing a new beta website for gov.scot go to new site

Free Personal Care Reference Group Strategy to Evaluate the Implementation and Impact of the Free Personal Care Policy

DescriptionStrategy Document
ISBN
Official Print Publication DateNovember 2006
Website Publication DateNovember 03, 2006

Listen

ISBN 0 7559 1277 2 (Web only publication)

DATE: 14 JULY 2005
AGENDA ITEM 4: Strategy document
PAPERS: Attached

This document is also available in pdf format (161k)

Background

1. The attached Strategy document is designed to deliver a comprehensive policy evaluation of the operation and early impact of the policy, allowing the Department to identify and disseminate good practice and informing further development of the policy.

2. The evaluation is expected to be a flexible document that can be adapted to the research findings as they become available. The aim is to produce a series of reports throughout the evaluation, culminating in the publication of the final report in late 2006. A three-phase approach is proposed:

  • Phase 1 will be concerned with establishing the baseline. By late summer 2005, we will provide some initial analysis on current costs, unmet need and future cost projections.
  • Phase 2 will be concerned with evaluating the operation of Free Personal Care. Most of this work will take place between this summer and the middle of 2006.
  • Phase 3 will be the compilation of the overview and final report by autumn 2006.

Issues arising

3. We need to be sure that the strategy (a) reflects all the key issues identified under agenda item 3; (b) sets out an approach to the work that is likely to deliver in practice; and (c) is sufficiently clear to its potential users.

For discussion

4. Is the strategy a sound basis on which to launch the policy evaluation? For example:

  • Does it cover the agreed issues (agenda item 3)?
  • Is it a clear reference document for potential users?
  • Is the phased approach to the work suitable/ realistic?
  • Are the timescales realistic?

For decision

5. The Reference group is invited to agree the overall strategy, taking into account the conclusions from the previous item agenda on the use of the Care Development Group model to ascertain future projected costs.

SEHD
July 2005

THE STRATEGY IN FULL

INTRODUCTION

1. Free Personal Care was introduced in Scotland in July 2002 together with Free Nursing Care. The operation of this flagship policy has generated substantial interest in the UK and beyond and now that the policy has bedded down, the Scottish Executive Health Department wishes to evaluate the implementation and impact of Free Personal Care in Scotland. Associated with this, SEHD wish to examine the interaction of the Free Personal Care policy with Free Nursing Care provision in care homes. Ministers are strongly committed to the policy and are anxious to ensure that it continues to operate in an effective way to give all older people in Scotland access to appropriate and high quality long term care services.

2. This paper sets out a flexible strategy for evaluation of the implementation, operation and impact of Free Personal Care in Scotland with the aim of informing future development of policy and practice on long term care of older people. It gives a brief review of the policy background, the existing evidence base, the initial aims and objectives of the evaluation and it outlines the strategy itself including arrangements for management, timing, resources, outputs and dissemination.

BACKGROUND

Policy background

Free Personal Care policy development

3. In 1999, the Royal Commission on Long Term Care, established to examine the funding of long-term care for the elderly, recommended that personal care should be provided free of charge both in residential settings and at home. The Care Development Group was set up in 2001 to take forward the recommendations in the Royal Commission report 1 in Scotland, the purpose of the Care Development Group being to ensure that older people in Scotland have access to high quality and responsive long-term care, in the appropriate setting, and on a fair and equitable basis. At this time, charging for personal care services was means tested which meant that a number of older people received personal care services without charge, whereas others were required to pay for the services they received. In some cases, personal care services were already provided free of charge to older people assessed as requiring them, without means testing.

4. The Care Development Group report Fair Care for Older People 2 was considered by the Scottish Executive and in September 2001 an announcement was made by the First Minister to accept the Care Development Group's recommendations in full, including the implementation of free personal and nursing care in Scotland. The Free Personal and Nursing Care policy was implemented in July 2002, enabling eligible older people to receive personal and nursing care services free of charge, without means testing. Guidance 3 for local authorities, the NHS and other service providers was published in April 2002 (see Annex 1) and has been kept under review and revised.

5. The aims of the policy are to:

  • improve the availability of personal care services to older people at home;
  • encourage and help older people to stay in their homes for as long as possible where it is practicable and reasonable to do so;
  • provide older people throughout Scotland with the same range and standards of personal care services in the same circumstances, irrespective of where they live;
  • provide personal care services on a fair and equitable basis based on an assessment of people's needs and to provide these without charge to everyone that required them;
  • provide nursing care free for all who need it;
  • remove discrimination caused by charging for care provided to elderly people in the community, bringing that care into line with the NHS where the principle of free care based on need is accepted and applied.

6. The implementation of Free Personal Care resulted in:

  • the provision of payments for personal and nursing care for those aged 65 and over who meet their own care costs (self funders) in care homes on the basis of an assessment of need (those self-funders already in care homes as at 31 March 2003 did not require an assessment under transitional arrangements);
  • the provision of personal care services at home without charge to those assessed as requiring them;
  • self-funders in care homes paying the remaining living or accommodation costs; and
  • those receiving non-personal care services at home paying for them.

7. The Care Development Group estimated that costs for implementing Free Personal Care would be £125m in each of the first two years. These figures included £37m in 2002/03 and £19m in 2003/04 to cover non-recurring costs to local authorities in implementing the policy. Since July 2002, payments for personal and nursing care in care homes have been fixed at £145 and £65 respectively and are paid on contract by local authorities directly to care homes with self funders paying the remainder of their care charges directly. In some cases, Free Personal Care does not apply to older people placed in care homes, for example by the NHS on a continuing care basis. The anticipated costs of providing personal care services at home without charge acknowledged that many people did not pay for personal care services as a result of means testing or local policy and local authorities were already receiving funding to cover the provision of community care services. COSLA has introduced guidance for local authorities on charging policies for non-residential care services to ensure greater consistency between local authorities 4. The funding available for the introduction of Free Personal Care was intended to cover the additional costs of the policy. Further information on the development of cost projections is available in the Care Development Group report.

8. A Joint Group of officials from the Scottish Executive, the Convention of Scottish Local Authorities ( COSLA), the Association of Directors of Social Work ( ADSW) and the Society of Local Authority Chief Executives ( SOLACE) was set up in 2002/03 to manage the implementation of the Free Personal and Nursing Care policy. Their remit was to manage information on the implementation of Free Personal and Nursing Care; identify any problems and address them with the local authorities involved and to seek a consistent approach to media enquiries. The Group provided a forum for working constructively with local authority partners to resolve any local concerns with the implementation of the policy.

The Wider Policy Context

9. Implementation of Free Personal Care is a dynamic process which is affected by and in turn affects the development and implementation of other policies and ways of working. The introduction of Single Shared Assessment for older people from April 2003 as part of the Joint Future Agenda provided an opportunity to streamline assessment processes and the development and roll out of the Indicator of Relative Need ( SSA- IoRN) also has potential to assist in planning care services for older people. Implementation of 'Supporting People' also cuts across the implementation of Free Personal Care. From April 2005, Direct Payments will be rolled out to older people and other community care groups potentially offering people more choice and control in the provision of services which they are assessed as requiring. Although local authorities are charged with implementation of Free Personal Care, moves towards joint working, management and funding with the NHS are likely to impact on implementation in different ways depending on the local context.

The Evidence Base

10. Development and implementation of Free Personal Care has been underpinned by a range of evidence which has allowed some monitoring of progress and will contribute to the evaluation by providing baseline data and identifying emerging issues to be explored in more depth. In addition, a number of studies are being conducted by other bodies which will contribute to evidence base for the evaluation. Some of the available evidence is outlined below.

11. Commissioning Community Care Services for Older People5, published in 2004 by the Auditor General for Scotland, looks at the way in which councils plan, purchase and review their older people's services. It also looks at the implementation of national policy by councils and their health partners, and concludes that councils and their health partners should redouble their efforts to ensure there are sufficient services to meet the future needs of Scotland's ageing population. In addition, the report recommends that the Scottish Executive should monitor whether its policies are being effectively delivered and ensure that information is available and used to plan for the future.

12. The Scottish Parliament's Audit Committee has just published their Report on Community Care6 (21st March 2005) of their enquiry into the findings of Commissioning Community Care Services for Older People and another report from Audit Scotland, Adapting to the future: management of community equipment and adaptations 7. In this report, for which the SEHD provided evidence on Free Personal Care based on currently available information, the Committee recommends that SEHD should review the cost of implementation of its Free Personal Care policy, in order to 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. This strategy addresses this and other recommendations noted in the report, by proposing, for example, to review the cost of Free Personal Care implementation, calculate cost projections, and investigate the monitoring processes in place in Local Authorities in relation to Free Personal Care expenditure.

Care Development Group

13. The Care Development Group developed their recommendations on the basis of a thorough examination of available evidence and analysis at the time and they also commissioned a programme of research which was published in 2001 8 (for further information, see Annex 2). The supporting research included work investigating public attitudes to Free Personal Care, independent home care providers' perspectives on Free Personal Care, the demand for and use of personal care services and informal care of older people. The research findings raised a number of issues including:

  • what services Free Personal Care should cover;
  • concerns about the quality of services;
  • mixed opinion about whether the provision of funding for personal care for the elderly should be means tested;
  • the extent of unmet need; and
  • how far people would switch from informal to formal care if personal care services were available without charge.

Statistics

14. The research conducted for the Care Development Group provides a partial baseline against which implementation of Free Personal Care can be evaluated. The following statistical data is also available, and provides further evidence to fill out the baseline and to monitor the implementation of Free Personal Care:

  • The numbers of people currently receiving personal care without charge;
  • Expenditure by local authorities on Free Personal Care;
  • Scottish Household Survey;
  • Details of home care charging policies;
  • The care home survey; and
  • Delayed discharge quarterly publications by ISD

15. Work is proposed to begin in 2005 to identify a new statistical formula for 2008/09 onwards to replace the historic caseload distribution between local authorities of certain elements of residential care funding provision. This includes funding for free personal and nursing care in care homes. The new distribution formula(e) should reflect the distribution of additional demand for services between local authorities which these resources are intended to fund. It will be important for this research to inform that work.

Research currently underway

16. As part of its Policy and Practice Development Programme on Long Term care of Older People, the Joseph Rowntree Foundation is currently funding a study entitled 'Financial Models of Care in Scotland and the UK' which is being conducted by David Bell (who was a member of the Care Development Group) and Alison Bowes at the University of Stirling. The study is examining the practical issues encountered during the implementation of Free Personal Care and will consider its longer term sustainability. These issues will be examined in the context of developments in the funding of long term care for the elderly in the rest of the UK. The final report is due in July 2005 and both Angela Campbell and Sarah Campbell ( HD: ASD) are members of the Research Advisory Group for the project. The study includes:

  • Modelling work and long term projections;
  • Analysis of Scottish Executive data on Free Personal Care;
  • Interviews with professionals at strategic, tactical and operational levels, focusing on issues about the implementation of Free Personal Care; and
  • Focus groups with older people and carers recruited from 6 organisations and in 5 care settings to explore the consumer perspective.

17. Whilst it is clear that the JRF study at Stirling University is covering similar ground to that proposed in this draft strategy, it is not intended to provide a comprehensive evaluation of the implementation of FPC in Scotland. It will be important to monitor progress with this work and build on it in implementing the strategy for the evaluation. More detail on the links between the aims of this strategy and the JRF study can be found in Annex 3.

18. The Office for Public Management Ltd ( OPM) has recently completed a review on behalf of the Scottish Executive Education Department, which explores the available literature on informal care. OPM is also working with the Scottish Executive examining the future of unpaid carers in Scotland. This work will examine the future role of informal care in the delivery of health and social care services. It will also consider the main factors influencing the development of services to support informal carers over the next 10 years, and its findings will be highly relevant to this evaluation.

19. The Department of Health, the Scottish Executive and the Welsh Assembly are supporting the development of a Social Care Workforce Research Initiative. This project aims to commission research to examine a wide range of issues relevant to the current operation and future development of the social care workforce. It will support efforts across the UK to address recognised workforce issues in areas such as: workforce composition, recruitment and retention; training and qualifications; and organisation of work and the work environment. The research will provide valuable information to the National Workforce Group 9, HR group and Workforce Intelligence Group about the effectiveness of particular strategies. It is anticipated that this programme of work will commence in April 2005 and continue for 4 years.

20. The Kings Fund launched research in January 2005 into the long-term demand for and supply of social care for older people in England 10. The Wanless Social Care Review will examine the demographic, economic, social, health, and other relevant trends over the next 20 years that are likely to affect the demand for and nature of social care for older people (aged 65 and over) in England, and identify the financial and other resources required to ensure that older people who need social care are able to secure comprehensive, high quality care that reflects the preferences of individuals receiving care..

21. The findings of this and other relevant research and analysis will inform the evaluation of Free Personal Care as they become available.

Current requirement

22. Following the announcement in 2001 that the Care Development Group's recommendations on the Free Personal Care policy had been accepted, SEHD moved quickly to develop guidance for its implementation in July 2002 based on the best available evidence. While the longer term implications of the policy were difficult to assess at the time, it was recognised that it would be necessary to review its operation and early impact once the policy had had time to bed down in order to ensure it continues to operate effectively. Experience to date and statistical information published by SEHD indicate that the implementation and operation of Free Personal Care varies across Scotland and has proved complex as related policy and practice in health and social care have been developed and implemented. Publication of the 2001 Census has provided further evidence about demographic change which needs to be taken into consideration in developing policy and practice to make sure that Free Personal Care is effective in the future.

23. Now that three years have elapsed since the first elements of the Free Personal Care policy were implemented and other policies and developments have come on stream which directly affect its operation (for example, single shared assessment for older people), this is an appropriate time to undertake an evaluation of its operation and early impact to inform a review of the policy. The evaluation strategy outlined in this paper is designed to provide a flexible framework to support Ministers and the SEHD in reviewing Free Personal Care in consultation with key stakeholders. As well as providing a comprehensive evaluation of the implementation and early impact of Free Personal Care to focus review of the operation and impact of the policy in the longer term, the strategy will deliver shorter term research and analysis to support Ministers and SEHD in addressing high priority issues as they arise, building on analysis and the findings of relevant research as they become available.

AIMS AND OBJECTIVES

24. The main aims of the strategy are:

  • to evaluate the implementation, operation and impact of Free Personal Care,
  • to identify and disseminate good practice in the operation of the policy, and
  • to consider any implications for the further development of policy and practice within the wider policy context, reflecting both the care home and care at home sectors.

25. The specific objectives have been grouped together to reflect four main aspects of the evaluation:

  • Free Personal Care implementation and operation;
  • Free Personal Care assessment processes;
  • Individual and carer experiences of Free Personal Care; and
  • Funding and management of Free Personal Care.

26. These groups are not intended to be watertight and information collected under each heading will be cross referenced. While these wide-ranging objectives are intended to cover the ground in terms of the key issues which the evaluation will address, they will be worked up in more detail as specifications are developed for the various elements of the strategy and they may be refocused or extended in the light of emerging findings and on the advice of key stakeholders. Annex 3 provides an overview of how existing or forthcoming evidence will contribute to meeting the objectives of the evaluation.

1. Free Personal Care implementation and operation

27. The evaluation will provide a descriptive account of the implementation and operation of Free Personal Care from the perspective of key stakeholders in order to identify issues arising and how they have been addressed. The baseline against which the policy was implemented will be established and updated in the light of new evidence not available at the time the policy was developed. The policy and operational context will be mapped out to inform a review of the operation and impact of the policy. The aim is to:

  • describe the implementation and operation of Free Personal Care in Scotland from 2002, from the perspective of the local authorities, service providers, service users, Scottish Executive Health Department, and other relevant organisations;
  • analyse available statistical, economic and other evidence to provide a baseline as at July 2002 against which progress with implementation and the impact of the policy can be measured;
  • map out and explore the relationship between Free Personal Care and other relevant policies; and
  • explore public opinion on the Free Personal Care policy.

2. Free Personal Care assessment processes

28. Some of the variation in operation of the policy stems from differences in definitions and in processes used in assessing eligibility for Free Personal Care. These objectives are intended to explore the extent and impact of this variation on the policy. The aim is to:

  • describe the definition of 'personal care needs' and 'level of need' used by local authorities for assessing eligibility for receiving personal care services without charge in both care at home and care homes, highlighting variations and similarities;
  • describe the definition of Free Nursing Care used to assess whether care home residents are eligible to receive Free Nursing Care;
  • describe the information (for example, leaflets, web sites) available from local authorities about Free Personal Care and the methods used to publicise this information;
  • identify the processes currently in operation across Scotland to assess people's eligibility to receive personal care services without charge, such as single shared assessment, and evaluate the impact the various processes have on the outcomes of the assessments;
  • examine whether all those who are eligible to receive personal care services without charge do so;
  • examine why those who are eligible may not receive personal care services without charge;
  • identify the methods used to assess older people for Free Nursing Care, and examine whether people are assessed prior to moving into a care home or when they are already living there;
  • examine what services local authorities deliver under the remit of Free Personal Care and how the services are provided; and
  • explore the concept of unmet care need in Scotland, assessing where possible the level of unmet need before and after the introduction of Free Personal Care.

3. Individual and carer experiences of Free Personal Care

29. In order to understand whether the objectives of the policy are being met, it is essential to examine the views and experiences of people receiving personal care services at home or in care homes and those of their carers. It is a key priority for Ministers to ensure that service user and carer perspectives are at the heart of health and community care policy. The aim is to:

  • explore people's experiences of being assessed for receiving personal care without charge under the remit of Free Personal Care, examining the impact of varying assessment processes and definitions on the outcomes of the assessments;
  • examine what services people are receiving under the remit of Free Personal Care, highlighting whether their receipt of these services is new or displaces previous informal or formal services, who provided the previous services, and any costs involved;
  • examine whether those who receive Free Personal Care are likely to also receive Free Nursing Care (and vice versa) and highlight any practical difficulties experienced through receiving services from separate providers;
  • explore the decision making processes of service users, their families and carers leading to their application for personal care services without charge;
  • examine what changes have occurred to the financial situations of those receiving personal care services without charge, including changes in benefits received (particularly Attendance Allowance);
  • explore people's experiences of the benefit of Free Personal Care over time;
  • explore the experiences service users, and their carers and families, have of Free Personal Care and of receiving personal care services without charge under this remit, highlighting both positive experiences and any difficulties encountered; and
  • explore service users', their families' and carers' opinions about the quality of services received through Free Personal Care, highlighting changes to service quality since implementation, and any changes experienced to quality of life as a result of Free Personal Care.

4. Funding and Management

30. The costs of Free Personal Care were originally assessed by the Care Development Group on the basis of the best available information at the time. However it is now necessary to review current and future costs in the light of experience and more recent evidence. There is some evidence that local authorities tasked with management of the policy may have approached this in different ways which may have an impact on service providers, including care home providers, and the way in which they provide and charge for services. The aim is to:

  • examine local authorities' and care home providers' experiences of the implementation of Free Personal Care, highlighting both the challenges they faced and examples of good/ innovative practice;
  • examine and describe the allocation of expenditure by local authorities on Free Personal Care, showing how this relates to expenditure on community care more generally (this should describe expenditure on personal and domestic care prior to and following FPC, distinguishing between expenditure on home care and care home sectors, and should outline how non-recurrent costs available to LAs in the first 2 years of the policy were allocated);
  • describe and evaluate the methods used by local authorities to monitor and evaluate the uptake and expenditure on Free Personal Care;
  • examine the impact of Free Personal Care on home care and care home charging policies, and the subsequent impact on those receiving personal care services without charge;
  • examine the implications for the future costs of Free Personal Care, in terms of changes in healthy life expectancy, and workforce developments, for example;
  • consider the wider workforce implications of Free Personal Care;
  • explore the impact of the supply of community care and nursing home places on the operation of Free Personal Care, and the impact of Free Personal Care on the supply of care home places and community care;
  • examine whether Free Personal Care has had an impact on the numbers of people who experience delayed discharges in Scotland, and the associated costs;
  • explore whether the projected cost of Free Personal Care established at its implementation has so far proved accurate, examining which factors have had the most impact on costs and whether there is anything that can be done to reduce the costs of these factors;
  • calculate the cost of implementing Free Personal Care based on current cost and future projections (over and above the cost of the care), taking account of the cost of related policies; and
  • provide evidence to ensure that the new statistical formula to be established for the distribution of funding for free personal and nursing care in care homes for the 3 Year Settlement Group reflects the distribution of additional demand for services between local authorities which these resources are intended to fund.

SCOPE OF THE EVALUATION

31. The evaluation will explore the implementation, operation and early impact of Free Personal Care on both the home care and care home sectors from the perspective of:

  • people who currently receive personal care without charge and their carers, as well as wider public opinion;
  • those who administer and manage the Free Personal Care policy (including front-line staff and local authority managers);
  • service providers (including voluntary organisations, local authorities and private/commercial care service and care home providers).

32. It will examine the concept of unmet need and will involve modelling work to facilitate projections of the cost and extent of Free Personal Care in the future. The evaluation will also explore understandings and definitions relating to the policy of providing personal care without charge, examining variations in interpretation and measurement (such as variations in definitions of personal and nursing care, assessment processes or differing approaches to the use of community care and Free Personal Care resources). It will include an examination of workforce issues arising from implementation of the policy.

33. Whilst the main focus of this strategy is the Free Personal Care policy, it will also address the interaction of Free Personal Care with Free Nursing Care in care homes. The evaluation will also map out and explore the relationship between Free Personal Care and other relevant policies. The evaluation will be set in the wider policy and practice context, considering the impact of the development of other policies and their cross cutting aspects, examining whether the policies facilitate or work against successful implementation of Free Personal Care.

THE EVALUATION STRATEGY

34. The evaluation strategy is intended to provide a flexible framework to ensure that key issues for the operation of Free Personal Care can be addressed as they emerge taking into account the perspectives of key stakeholders. The strategy will build on and contribute to the evidence base at it develops to identify good practice and provide a basis for development of the policy and practice in the future.

35. A three phase approach is proposed for the evaluation as follows:

Phase 1 - Establishing the baseline

36. This will bring together available evidence which informed the initial implementation of Free Personal Care, identifying and filling any gaps and updating on the basis of current evidence. It will also review the information currently available from statistics and research on the implementation and management of Free Personal Care since 2002, to inform the main stage evaluation. It is proposed that some initial analysis is undertaken on costs and unmet need using available quantitative and qualitative evidence, including an update of cost projections based on currently available information.

Phase 2 Evaluating Free Personal Care

37. The main stage evaluation will:

  • evaluate the implementation, operation and impact of Free Personal Care from the perspectives of local authorities and care providers (including voluntary organisations and commercial/private service providers), examining definitions of Free Personal Care, assessment processes, management arrangements, charging policies, costs and projections; and
  • examine service users' and carers' experiences of Free Personal Care.

38. This stage will be informed by the baseline work, emerging findings from other relevant research and the views of key stakeholders.

Phase 3 Overview

39. The final phase will bring together and review the findings of the baseline and main stage evaluation, drawing out the implications for the future development of the policy and practice in providing long term care for older people.

40. Annex 4 outlines the work proposed for each phase of the evaluation recognising that this may be subject to review in the light of advice from key stakeholders and findings from the initial phases and from other relevant research or analysis. It is recognised that this is a substantial task, and whilst some elements of this evaluation may be undertaken in-house, most aspects will require to be externally commissioned. It will be essential to establish a comprehensive evidence base and develop links with other relevant research to ensure effective use of limited resources, bring added value to the evaluation, avoid duplication and limit the burden on potential respondents. The involvement of key stakeholders in the design and management of the strategy is also essential to facilitate future policy development and implementation. Proposals for management of the strategy, outputs and dissemination, resources and timing are outlined below.

MANAGEMENT ARRANGEMENTS

41. As the evaluation is intended to inform review of Free Personal Care to ensure that it continues to operate effectively, it is important to involve key stakeholders and expert advisors as appropriate. We envisage a core internal Free Personal Care team to manage the strategy, a wider Reference Group to ensure effective liaison with stakeholders, and specific Research Advisory Groups as necessary.

42. The Free Personal Care team will be responsible for management of the strategy. It will meet periodically to oversee progress and determine the specific operation of the strategy. It will comprise key officials from HD: ASD and Care of Older People Division.

43. The Reference Group will focus on the objectives of the evaluation and consider the implications of the findings of the 3 phases for policy development, facilitating the implementation of any changes and dissemination of good practice emerging from the evaluation. The group will meet at key points during the evaluation (see Annex 5 for suggested timing). It will include representatives of:

  • SEHD key policy areas-Care of Older People, Community Care Division, Primary Care;
  • SEHD Analytical Services Division;
  • service providers and managers - ADSW. COSLA, local authorities, private and voluntary care home and home care providers;
  • service users and carers; and
  • key agencies and external organisations - Care Commission, Social Work Inspectorate Agency

44. Expert advisors will be invited to contribute to the group as appropriate, including members of the Care Development Group, to provide continuity.

45. Research advisory groups will be established to oversee the larger, more complex elements of the strategy, in particular the projects commissioned as part of the evaluation stage. The main role of these groups is to provide an interface between policy colleagues, researchers and external stakeholders, to oversee progress with the research and provide advice and support to the research contractors. The research advisory groups will involve key internal and external stakeholders with relevant expertise and experience, and there will be a link between each research advisory group and the reference group to ensure effective communication on progress with individual elements of the evaluation. The HDASD will be responsible for day to day management of the research projects which make up the strategy.

OUTPUTS AND DISSEMINATION

46. The main outputs from the evaluation will be as follows:

  • Overall evaluation report drawing together the research and analysis conducted for the evaluation and summarising the key implications for future policy and practice development due autumn 2006;
  • Reports of the individual pieces of work (research, economics and statistical analysis) comprising the evaluation as completed;
  • Regular reports of progress with the various elements of the evaluation and of the strategy as a whole; and
  • Statistical bulletins (these will be published to the agreed GSS timetable and will feed directly into the evaluation)

47. Effective dissemination of information on the strategy will be essential as a means of maintaining the commitment of key stakeholders and participants in the evaluation and of facilitating the review of the policy and the implementation of any changes. In the early stages of the evaluation, a dissemination strategy will be developed and implemented by HD: ASD and Care of Older People Division in liaison with the reference group. A possible approach would be to establish a website for the evaluation which would provide a dedicated resource on Free Personal Care containing relevant policy documents, research references, statistics and information on progress with the strategy including publication of outputs. It could also provide a forum for the exchange of information on good practice.

TIMETABLE AND RESOURCES

48. It is difficult to provide accurate timing and costing at this stage - the timetable and costings provided in Annexes 4 and 5 are based on currently available information and should be treated as provisional. It is envisaged that the three phases of the evaluation will run consecutively to allow the findings of each stage to inform the following phase. However each phase will overlap with the next phase to ensure that the challenging timetable for delivery of the evaluation is met and to provide the flexibility to respond to emerging issues over the life of the evaluation. Where feasible, it may be possible to bring forward specific pieces of work contributing to the evaluation should early information be required. Annex 4 contains further detail of the work that will make up each phase of the evaluation and Annex 5 outlines the timetable for all aspects of the strategy.

49. Most of the research outlined in the strategy will be externally commissioned, however the evaluation will draw on data collected in-house (see annex 5 for timing) and there may be scope for ASD to contribute directly to some economic and statistical analysis to support the evaluation as follows:

  • Unmet need as reported in Scottish Household Survey;
  • Quarterly monitoring of the numbers of people receiving personal care without charge, in care homes and care at home;
  • allocation of expenditure by local authorities on Free Personal Care; and
  • 6 monthly care home survey on the supply of care home places.

50. It is anticipated that the costs for this work will be largely met by the Community Care Research budget over the period 2005/6 and 2006/7. We will ensure best value for money by making best use of the existing evidence and building links with relevant ongoing research. Where appropriate, we will explore the possibility of joint funding and draw on existing arrangements with bodies such as the Health Economics Research Unit ( HERU) at Aberdeen University and the Centre for Research on Families and Relationships.

Health Department Analytical Services Division
May 2005

ANNEX 1
FREE PERSONAL CARE GUIDANCE

1. The guidance on Free Personal and Nursing Care stipulates that the implementation of free care can be put into 2 broad categories:

  • Care in care homes - arrangements for flat rate payments for personal care for those aged 65 and over in care homes who are able to meet their own care costs and flat rate nursing care payments both for over and for under 65s in care homes who are able to meet their own care costs.
  • Care at home - arrangements for adjusting local authority systems for home care charging to individuals to take account of Free Personal Care.

2. The key aspects of the policy are:

For those living in their own home

  • Personal care without charge is available to those aged 65 and over.
  • All eligibility for receiving personal care without charge is subject to an assessment of need by the local authority.
  • No local authority charge will be made for such personal care services after 1 July 2002.
  • Eligibility for receiving personal care without charge is made irrespective of income, capital assets, marital status or the care contribution currently made by an unpaid carer.
  • Non personal care services will continue to be subject to charges at the discretion of the local authority.
  • Eligibility for and payment of Attendance Allowance and Disability Living Allowance are not affected by the introduction of Free Personal Care.

For those living in care homes

  • The provision of payments towards nursing and personal care will apply to those who pay their own care costs (self-funders).
  • Transitional arrangements applied for those already in residential or nursing homes on 31 March 2002. For those people no assessment of need was required and they were eligible for a payment of £145 a week for personal care and if receiving nursing care of a further £65 per week.
  • For those self-funders entering a care home after 31 March 2002, an assessment of need is required before they become eligible for personal or nursing care payments at the rates above.
  • Self-funders pay the remainder of their own costs, often described as living or accommodation costs.
  • Attendance Allowance and Disability Living Allowance are not payable to those receiving personal care without charge in care homes (but are payable for the first 4 weeks).
ANNEX 2
RESEARCH ON FREE PERSONAL CARE

Research to inform the Care Development Group:

Machin, D and McShane, D Providing Free Personal Care for Older People: research commissioned to inform the work of the Care Development Group (November 2001) Scottish Executive Central Research Unit

Chapter 2-NFO System Three Social Research/ MORI Scotland 'Public attitudes to the provision of free personal care: telephone survey'

Chapter 3- Jones, L, Ridley, J and Anne Robson (Scottish Health Feedback) 'Public attitudes to the provision of free personal care: focus group research'

Chapter 4- Dewar, B, O'May, F and Walker, E (Queen Margaret College) 'Public attitudes to the provision of free personal care: older people's focus group research'

Chapter 5- Matthew, D and Rimmer, L (United Kingdom Homecare Association) 'Providing personal care to older people in Scotland- the perspective of independent home care providers'

Chapter 6- Stearns, S C and Butterworth, S (Health Economics Research Unit, University of Aberdeen) 'Demand for and utilisation of personal care services for the elderly'

Chapter 7- Leontaridi, R and Bell, D (University of Stirling) 'Informal care of the elderly in Scotland and the UK'

Ongoing research:

Bell, D Financing long-term care in Scotland and the UK (ongoing work for the Joseph Rowntree Foundation due December 2005)

As part of its Policy and Practice Development Programme on Long Term care of Older People, the Joseph Rowntree Foundation is currently funding a study entitled 'Financial Models of Care in Scotland and the UK' which is being conducted by David Bell (who was a member of the Care Development Group) and Alison Bowes at the University of Stirling. The study is examining the practical issues encountered during the implementation of Free Personal Care and will consider its longer term sustainability. These issues will be examined in the context of developments in the funding of long term care for the elderly in the rest of the UK.

Statistical publications:

First Report for the Range and Capacity Review: Projections of Community Care Service Users, Workforce and Costs, Scottish Executive 16 July 2004
http://www.scotland.gov.uk/library5/health/pccswc-00.asp

Statistics Release: Free Personal/Nursing Care, Scottish Executive September 2004
http://www.scotland.gov.uk/stats/bulletins/00368-00.asp

Benefits and tax credits in Scotland: report for February 2004 National Statistics Publication for September 2004 http://www.scotland.gov.uk/library5/government/btcsfeb04.pdf

Home Care Services, Scotland 2004
http://www.scotland.gov.uk/stats/bulletins/00387-00.asp

Care Homes, Scotland, September 2004
http://www.scotland.gov.uk/stats/bulletins/00406-00.asp

David Clark, Amy McKeon, Matt Sutton, Rachael Wood Healthy Life Expectancy in Scotland On behalf of the HLE Measurement in Scotland Steering Group March 2004
http://www.isdscotland.org/isd/files/HLE_report_2004.pdf

Economics related publications:

Wittenberg, R, Comas-Herrera, A, Pickard, L and Hancock, R (2004) Future demand for long-term care in the UK: a summary of the projections of long-term care finance for older people to 2051 Joseph Rowntree Foundation
http://www.jrf.org.uk/bookshop/details.asp?pubID=624

Glendinning, C, Davies, B, Pickard, L and Comas-Herrera, A (2004) Funding long-term care for older people: lessons from other countries Joseph Rowntree Foundation
http://www.jrf.org.uk/bookshop/details.asp?pubID=626

ANNEX 3
TABLE OF AVAILABLE EVIDENCE

Objective

Available evidence

1. Free Personal Care implementation and operation

Describe the implementation and operation of Free Personal Care in Scotland from 2002, from the perspective of the local authorities, service providers, service users, Scottish Executive Health Department, and other relevant organisations.

Records maintained by relevant organisations about the implementation and operation of the Free Personal Care policy.

Analyse available statistical, economic and other evidence to provide a baseline as at July 2002 against which progress with implementation and the impact of the policy can be measured;

Quarterly monitoring of the numbers of people receiving personal and nursing care services without charge, in care homes and care at home (internal). Relevant research.

Map out and explore the relationship between Free Personal Care and other relevant policies

Explore public opinion of the Free Personal Care policy.

Research conducted to inform the Care Development Group (see Annex 2) provides a baseline.

2. Free Personal Care Assessment Processes

Describe the definition of 'personal care needs' and 'level of need' used by local authorities for assessing eligibility for receiving personal care services without charge in both care at home and care homes, highlighting variations and similarities;

This information should be on local authority websites, but it may not be comprehensive and further investigation will be required.

Describe the definition of Free Nursing Care used to assess whether care home residents are eligible to receive Free Nursing Care;

Describe the information (for example, leaflets, web sites) available from local authorities about Free Personal Care and the methods used to publicise the information;

Local authority websites will again provide some of this information but further investigation will be required.

Identify the processes in operation across Scotland to assess people's eligibility to receive personal care services without charge, such as single shared assessment, and evaluate the impact the various processes have on the outcomes of the assessments;

Examine whether all those who are eligible to receive personal care services without charge do so;

Examine why those who are eligible may not receive personal care services without charge;

Identify the methods used to assess older people for Free Nursing Care, and examine whether people are assessed prior to moving into a care home, or when they are already there;

Examine what services local authorities provide under the remit of Free Personal Care;

Records maintained by local authorities.

Explore the concept of unmet care need in Scotland, assessing where possible the level of unmet need before and after the introduction of Free Personal Care;

Partial exploration through Scottish Household Survey data (who requires help and who provides help) (internal). Some analysis in chapter 7 of Older people in Scotland: results from the Scottish Household Survey 1999-2002 11. Literature reviewed in Older people and community care in Scotland (chapter 2) shows that there is often a gap between the support people need and care services offered.

3. Individual and carer experiences of Free Personal Care

Explore people's experiences of being assessed for receiving personal care services without charge, examining the impact of varying assessment processes and definitions on the outcomes of the assessments;

Some information on service users' experiences of general assessments, including single shared assessment, can be found in chapter 3 of O lder people and community care in Scotland: a review of recent research 12

Examine what services people are receiving under the remit of Free Personal Care, highlighting whether their receipt of these services is new or displaces previous informal or formal services, who provided the previous services, and any costs involved;

Some baseline information in Chapter 4 of CDG report on services received and service users' plans for the future. Also in chapter 7 about informal care. There may also be some relevant data in the Scottish Household Survey- see chapters 4 and 7 of the Older people in Scotland report.

Examine whether those who receive Free Personal Care are likely to also receive Free Nursing Care (and vice versa) and highlight any practical difficulties experienced through receiving services from separate providers;

Explore the decision making processes of service users and carers leading to their application for personal care services without charge;

Some baseline information in Chapter 4 of CDG report (see above).

Examine what changes have occurred to the financial situations of those receiving personal care services without charge, including changes to the benefits they receive (particularly Attendance Allowance);

Stirling University will explore this in a small number of interviews with service users, carers and families. Significantly more depth will be required.

Explore people's experiences of the benefit of Free Personal Care over time;

Explore the experiences service users and their carers and families have of Free Personal Care and of receiving personal care services without charge under this remit, highlighting both positive experiences and any difficulties experienced;

Stirling University will explore this in a small number of interviews with service users, carers and families.

Explore service users', their families, and their carers' opinions about the quality of services received through Free Personal Care, highlighting changes to service quality since implementation, and any changes to quality of life as a result of Free Personal Care;

Stirling University will explore this in a small number of interviews with service users, carers and families.

4. Funding and management

Examine local authorities' and care home providers' experiences of the implementation of Free Personal Care, highlighting both the challenges they faced and examples of innovative practice;

Stirling University's research will look briefly at this, through stakeholder interviews, but more in depth work will be required to meet this objective.

Examine and describe the allocation of expenditure by local authorities on Free Personal Care, showing how this relates to expenditure on community care more generally (this should describe expenditure on personal and domestic care prior to and following the implementation of Free Personal Care, distinguishing between expenditure on home care and care home sectors and should outline non-recurrent costs available to Local Authorities in the first 2 years of the policy were allocated);

CC Stats collect information on actual expenditure for 2002-3, CC division have information on allocations for each year (internal).

Describe and evaluate the methods used by local authorities to monitor the uptake and expenditure on Free Personal Care;

Examine the impact of Free Personal Care of home care and care home charging policies, and the subsequent impact on those receiving personal care services without charge;

Some baseline evidence on home care charging in the CDG report- chapter 5.

The statistics expenditure survey asked for information on charging policy for home care prior to FPC and after FPC. COSLA issued guidance on home care charging. CCD also ran survey on home care charging and whether LAs were adopting COSLA guidance (internal). Information on the quality of home care can be found in the Audit Scotland report Homing in on care: a review of home care services for older people 13. This will also be addressed by Stirling University's work.

Examine the implications for the future costs of Free Personal Care, in terms of changes in healthy life expectancy and workforce developments, for example;

Stirling University's work will be looking at this. Also see JRF reports Future demand for long term care in the UK and Funding long-term care for older people.

Consider the wider workforce implications of Free Personal Care;

Explore the impact of the supply of community care and nursing home places on the operation of Free Personal Care, and the impact of Free Personal Care on the supply of care home places and community care;

Community care statistics conducts a 6 monthly care home survey in March and September, Range and Capacity Review (internal), and HERU is also doing some work on care home capacity.

Examine whether Free Personal Care has had an impact on the numbers of people who experience delayed discharges in Scotland, and the associated costs;

ISD publish delayed discharge figures quarterly.

Explore whether the projected cost of Free Personal Care established at its implementation has so far proved accurate, examining which factors have had the most impact on costs and whether there is anything that can be done to reduce the costs of these factors;

Baseline information on costs, including the cost of replacing informal care in Scotland, in chapters 6 and 7 in the CDG report- David Notman (health department ASD) is currently doing some work clarifying the cost estimations pre- FPC implementation.

Stirling university's work will also be looking further at costs.

Calculate the cost of implementing Free Personal Care (over and above the cost of the care), taking account of the cost of related policies, now and in future projections.

Stirling University's modelling work will be looking at the future costs of Free Personal Care (by Local Authority area), but will not be taking costs of other policies into account.

Examine whether the new funding proposal drafted for the 3 YSG reflect the distribution of additional demand for services between local authorities which the additional resources are intended to fund.

The new proposed funding is yet to be established- see page 4.

ANNEX 4
PROPOSED PROGRAMME OF WORK

1. The programme of work proposed below is flexible and there is scope to add additional pieces of work to the programme and amend the timetable for the work in response to changing priorities and questions over the course of the evaluation.

Phase 1- Establishing the baseline

2. One project will be commissioned in phase 1 of the evaluation over the period June to November 2005. Initial work on costs and projections will be conducted in house from May 2005, with the reference group contributing to decisions about additional work to be conducted on costs.

i) Establish the baseline for the implementation of Free Personal Care, bringing together relevant evidence used to inform the initial implementation, identifying and filling gaps where possible. This should include relevant evidence relating to costs, statistics, social research and the policy context. Establish what evidence is currently available, relating to the policy context, statistics and social research, on the implementation of Free Personal Care, and the quality of this information. This work will also identify any gaps in the available evidence base, in order to inform the main evaluation of Free Personal Care (June to November 2005).

ii) In-house work on costs relating to Free Personal Care, providing updated cost projections if possible, based on currently available economic evidence (May 2005 to October 2005).

Phase 2- Evaluating free personal care

3. 4 pieces of work will be commissioned to complete phase 2 of the evaluation. These pieces of work form the main stage of the evaluation and the anticipated timing is outlined below:

i) Investigation of local authorities' experiences of implementing and managing Free Personal Care, including an examination of the definitions of Free Personal Care used by Local Authorities and the methods they use to assess people for personal care services without charge. (August 2005 to June 2006).

ii) Investigate care home providers' experiences of implementing and managing Free Personal Care. This is required to include voluntary, local authority and private care home providers, generating evidence about charging policies and general experiences of the implementation of the policy. (December 2005 to April 2006).

iii) Explore service users' and carers' experiences of Free Personal Care and of receiving free personal care services without charge, including changes in financial circumstances and in the quality of care received. (December 2005 - March 2006)

iv) Explore public opinion on the Free Personal Care policy, following on from the research conducted on behalf of the Care Development Group (January 2006 - March 2006).

Other work in phase 2:

4. Additional work may be required on the costs involved with the implementation and operation of Free Personal Care. Information should be available from statistics collected by the Scottish Executive, ISD and the work conducted by HERU and David Bell (Stirling University).

Phase 3 - Overview

5. An overview of the evaluation evidence will be commissioned as the main output of the strategy:

A report of the evaluation of the implementation of Free Personal Care, bringing together the findings of research and analysis from the baseline and evaluation stages of the strategy. The report will describe the conduct of the evaluation and summarise the evidence base, addressing the aims and objectives, discussing the findings and setting them in the wider research and policy contexts. The implications for the development of the policy will be discussed.

A dissemination strategy will run concurrently with the 3 phases, with a series of reports produced throughout the evaluation, culminating in the publication of the final report in late 2006.

Annex 5- Proposed timetable for the strategy to evaluate Free Personal Care

Gantt Chart Proposed timetable for the strategy to evaluate Free Personal Care