6 Atitudes to Providing and Funding Particular Services
6.1 This chapter summarises:
- The level of public support or opposition for (a) charities and (b) private companies providing care for older people
- Views on whether individuals should be charged for some services - specifically personal care for older people, meals while in hospital, individual music lessons in school and school trips.
6.2 The difficult economic context in which the 2011 SSA survey took place has been noted repeatedly in this report. The Christie Commission set out the scale of the challenge posed for the future delivery of public services in its final report, published in June 2011:
"The pressure on budgets is intense and public spending is not expected to return to 2010 levels in real terms for 16 years. In addition, new demographic and social pressures will entail a huge increase in the demand for public services. The economic downturn will also intensify and prolong demand.
Unless Scotland embraces a radical, new, collaborative culture throughout our public services, both budgets and provision will buckle under the strain."
(Christie Commission, 2011)
6.3 The need to restructure and maximise value from limited public sector budgets has lead to increasing debate across the UK about (a) the potential role of the private and voluntary sector in delivering some public services and (b) areas in which service users might reasonably be expected to make a contribution to the costs of the services they receive (co-payment).
6.4 In relation to the former debate, supporters of diversity of provision have long argued that by creating a 'quasi-market environment' in the provision of public services, providers will have an incentive to meet users preferences while keeping costs down (see discussion in Le Grand, 2003, 2007). In response, critics have argued that the private sector is insufficiently committed to a public service ethos, and that they may cut costs at the expense of service quality (see discussion in Curtice and Heath, 2009). More negative arguments about public service ethos are perhaps less frequently applied to third sector organisations. However, more generally it has been argued that the public may not be sufficiently well informed to choose between different providers, and that therefore the supposed benefits from provider diversity (whether involving the private or voluntary sectors) are unlikely to occur (see discussion in Curtice and Heath, 2009).
6.5 Introducing co-payment for some public services is one possible reaction to budget constraint and to the increasing demands users place on services. However, moves towards charging for services that were previously free inevitably attract extensive debate around fairness and equality of access. For example, the issue of charging university students tuition fees attracts heated debate in the UK. On the one hand, supporters argue that asking students to pay towards the costs of an education which, on average, is likely to lead to higher lifetime earnings is fairer than paying for this solely out of general taxation. On the other, it is argued that tuition fees restrict access to university, particularly for children in 'middle income' groups, and may undermine social mobility.
6.6 This chapter discusses attitudes to diversity of provision in the area of care for older people in particular. It then discusses attitudes to users paying for different elements of public services - specifically, personal care for older people, meals in hospital, individual music lessons in school, and school trips.
Who should provide services for older people?
6.7 The Christie Commission has identified 'Maximising scarce resources by utilising all available resources from the public, private and third sectors, individuals, groups and communities' as a priority. An obvious way of utilising resources in the private and voluntary sector is to involve them in delivering some public services. In fact, the private and third sectors have long been involved in delivering elements of public services - for example, both private companies and charities have been involved in providing care for older people across Scotland. However, previous public opinion research evidence has suggested that the involvement of private companies in particular in providing public services can be controversial, even in areas where they are already involved. For example, the 2007 Scottish Social Attitudes survey found that 51% of people in Scotland (compared with 43% in England and 50% in Wales) were opposed to private companies providing care. Across Britain as a whole, only 31% of people supported private companies providing government funded personal care for older people, while 43% were opposed (Curtice and Heath, 2009). In comparison, support in Britain for charities providing such services was higher, at 53%.
6.8 The 2010 Scottish Social Attitudes survey repeated these questions for a second time. As described in Ormston and Reid (2011), support in Scotland for organisations other than the state providing care for older people had increased significantly since 2007. Support for charities delivering such services in particular increased very substantially, from under half (44%) in 2007 to three quarters (74%) in 2011. Meanwhile, although still a minority position, support for private companies providing care also increased significantly, from 28% to 35%. The report concluded that "while private sector involvement in public services clearly remains a controversial issue, with respect to personal care services for older people there now appears to be a consensus that the voluntary sector is well placed to provide these services, whether alongside or instead of the state."
6.9 Rather than repeat these questions again, the 2011 survey attempted to explore in more detail public perceptions of the relative merits of voluntary sector and private sector providers vis-à-vis the public sector on two key dimensions - cost effectiveness and service quality. Focusing again on views about services for older people who need regular help, the survey asked people four questions, covering:
- Whether private companies or government would be better at running services for older people more cost effectively
- Whether charities/other 'not for profit organisations' or government would be better at running services for older people more cost effectively
- Whether private companies or government would provide the best quality service for older people who need regular help, and
- Whether charities/other 'not for profit organisations' or government would provide the best quality service for older people who need regular help.
6.10 In each case, the question asked people to answer on the basis that the service would be free to the people who use them, to focus responses on questions of provision rather than funding. Half the sample was asked questions about private companies first, and half was asked about charities first.
Perceptions of private sector and not-for-profit providers of care
6.11 The findings show that it is not the case that people view the private sector as more cost effective but reject private involvement in public services because of concerns about quality. In fact, people appear to prefer the government over the private sector on both grounds. Fifty-six per cent felt that government would definitely or probably provide the most cost effective services, compared with 39% who thought the private sector would do so (Table 6.1). Similarly, 60% felt government would provide better quality services, compared with 33% who thought the private sector would deliver higher quality. So while the public is slightly more likely to believe the private sector is best placed to deliver cost effective services than they are to think it will deliver best quality, in fact a majority think that the government would provide better services for older people than the private sector on both criteria.
6.12 In contrast, the public appear to rate third sector service providers more highly than government on both measures. Fifty six per cent said charities would provide more cost effective services, while 54% felt they would provide better quality services for older people who need regular help.
|Private companies vs. government||Charities vs. government|
|Most cost effective||Best quality||Most cost effective||Best quality|
|Probably private companies /charities||30||26||46||42|
|Definitely private companies /charities||9||7||10||13|
Who is most likely to favour private care providers over government?
6.13 Further analysis looked at which groups of people were most likely to favour private companies and/or charities or 'not for profit' providers on each of these measures. Those who were most likely to feel that private companies could provide a more cost effective service for older people included: younger people, those on higher incomes, those with higher levels of educational qualification, private sector employees and the self-employed, and those who are more right wing in their general political beliefs (Table 6.2). In more detail:
- Younger people were more positive than older people about the relative ability of private companies to deliver cost effective services for older people. Over half (52%) of 18-29 year-olds felt private companies were more likely than government to provide the most cost effective services, compared with just 30% of those aged 65 and older. The fact that older people - who are most likely to use such services either at the moment or in the near future - were more negative about the relative merits of private sector involvement reflects findings from earlier years of SSA and BSA (see Ormston and Reid, 2011 and Curtice and Heath, 2009).
- Those on higher incomes were more likely than those on lower incomes to believe that private companies would provide the most cost effective services - 48% of those with household incomes over £44,200 felt this, compared with 35% of those with annual incomes of £14,300 or less.
- Those with higher levels of educational qualification were also more likely to think this - 43% of those with degrees and 43% of those with Higher level qualifications felt the private sector would provide the most cost effective services, compared with just 26% of those with no qualifications.
- Those who work for the private sector or are self-employed were, perhaps unsurprisingly, more likely than public or third sector employees to feel that the private sector would provide the most cost effective service (43%/44%, compared with 32%).
- Those who are generally more left-wing in their political beliefs were less likely to feel the private sector would provide a more cost effective service for older people than would government (27%, compared with 45% of those on the right).
6.14 Variations in attitudes towards whether or not the private sector or government would provide the best quality service for older people generally followed similar patterns to those described above. However, variations by income were not significant. The pattern of responses by education was somewhat different - it was those qualified to Higher level who were most positive about the private sector on this measure (42%), while both graduates (30%) and those with no qualifications (26%) were less likely to feel private companies would provide better quality services than government.
6.15 In combination, these findings indicate that some groups - for example, older people and those who are more politically left wing - may simply have a preference for government rather than private companies providing services for older people. In contrast, others - including graduates and those on high incomes - appear to draw distinctions between the perceived ability of private companies to provide more cost effective services and their ability to provide better quality services.
Who is most likely to favour not-for-profit care providers over government?
6.16 There were fewer significant variations in attitudes to the relative cost effectiveness of charitable service providers compared with government. In particular, there was little variation by how left or right wing people were or by occupational sector. This suggests that where the involvement of private companies in delivering services may divide people depending on their political beliefs, the involvement of voluntary sector organisations may be less politically contentious. Meanwhile, while patterns by age and income followed a similar pattern to those noted above, differences were less pronounced and were not statistically significant.
6.17 Education was, however, significantly related to thinking both that charities could provide a relatively more cost effective service and that they would provide the best quality service. The difference here was primarily between those with no qualifications - who were less likely to feel charities could provide more cost effective or better quality services than government - and those with any level of educational qualification. Meanwhile, younger people and those on higher incomes were again significantly more likely than older people and those on lower incomes to feel that charities would provide better quality services than government. Sixty-five per cent of those aged 18-29 felt this compared with 45% of those aged 65 or older. Similarly 65% of those with incomes over £44,200 a year said this, compared with 50-54% of those on lower incomes.
|Private companies vs. government||Charities / 'not for profit' vs. government|
|% private companies/ charities definitely/ probably provide MORE cost effective/ better quality services||Most cost effective||Best quality||Most cost effective||Best quality||Sample size|
|Annual household income|
|Up to £14,300||35||38||51||50||322|
|Over £14,300 to £26,000||38||32||54||53||208|
|Over £26,000 to £44,200||43||31||60||54||233|
|Highest educational qualification|
|No recognised qualification||26||26||47||43||284|
|Public sector / Charity||32||27||57||54||391|
|Position on political left-right scale|
6.18 In summary, younger people appear more positively disposed than older people to the relative merits of both private companies and charities as service providers for older people, while those with no educational qualifications were less positive about both. Public sector employees and those who are more politically left-wing in general were more negative than private sector employees and those who are more right-wing about private companies, but not about charities. Graduates and those on higher incomes appear to draw distinctions between the ability of the private sector to deliver more cost effective services and its ability to deliver better quality services for older people. However, they did not appear to make similar distinctions with respect to charities.
Who should pay for services?
6.19 As discussed above, the issue of involving users in paying for public services is almost inevitably a contentious one. Yet against a back drop of limited public sector budgets, the question of whether there are some services people might reasonably be expected to make a direct contribution towards is unlikely to disappear. Public attitudes towards co-payment may be affected by a range of considerations, including:
- the likely level of payment required
- how 'essential' the service is perceived to be
- which groups of users are affected - people may perhaps be more supportive of charging for services they themselves do not currently use; equally, there may be some groups of users who are viewed more sympathetically than others
- understanding of current policy - people may be more willing to continue to pay for areas where charges already exist than to start paying in new areas.
6.20 SSA 2011 included questions about funding in four areas:
- Personal care for older people.
- The cost of meals while in hospital
- The cost of individual music lessons in schools, and
- The cost of school trips to local museums.
6.21 The latter three questions were prefaced by statements that 'one way of helping to fund the NHS is to charge people for certain things', and that 'one way of helping to fund state schools is to charge parents for certain things'.
6.22 Free personal care is an area where the current position in Scotland is both different from that in England and different from policy in Scotland just over a decade ago. Personal care - such as help with washing and eating - was made free for everyone over 65 in Scotland in 2002. Meanwhile, in England such care continues to be means-tested. While hospital meals are free for all NHS in-patients, policy on who pays for individual music lessons and school trips (where these are not part of the curriculum) can vary between local authorities. The issue of charging for school musical instrument lessons hit the headlines in mid-2011, when a survey by teaching union EIS suggested that 25 of 32 local authorities in Scotland would be charging pupils up to £400 per term for lessons and instrument hire - reported as an increase of nine authorities on the previous year (Scotsman, 4 June 2011).
Who do people think should pay for personal care for older people?
6.23 Respondents were asked who they thought should pay for regular help for older people who need help looking after themselves. Figure 6.1 shows responses to this question in 2011 and in 2007, when it was included in SSA as part of a module of questions on public services funded by the Economic and Social Research Council (ESRC). The findings suggest that the issue of whether personal care should be provided free of charge on a universal basis or whether it should be means tested divides the Scottish public. In 2011, 51% felt that the government should pay for such care, no matter how much money a person has. However, almost as many (46%) thought it should depend on how much money the person has - in other words, that it should be means tested. The slight decline between 2007 and 2011 in the proportion saying that personal care should be provided freely on a universal basis was not quite statistically significant. However, it is clear that it would only take a small further shift for the balance of public opinion to be reversed in favour of means testing rather than universal free personal care.
Base: All respondents.
Sample size: 2007 = 1,508; 2011 = 1,197
Differences in attitudes to who should pay for care
6.24 Table 6.3 shows how views on who should pay for personal care for older people vary between different groups in Scottish society. In interpreting this table, it is important to note that where views on an issue divide roughly down the middle, differences need to be bigger before they are statistically significant. Thus while it may appear that women are more supportive than men of universal free personal care and that support for this policy increases with household income, in fact these differences are not statistically significant. Differences by age, education and how politically left or right wing people are were significant, however. Those aged 30 or older were more likely than those aged under 30 to believe the government should pay for personal care for older people, no matter how much money a person has (52-56% of those aged 30 or older thought this, compared with 41% of those under 30). Support for universal free personal care decreased with level of education, while support for means testing increased. For example, 68% of those with no qualifications felt the government should pay for care for all older people who need regular help looking after themselves, no matter how much money the person has. This figure falls to 39% among graduates. Finally, those who are more politically left-wing were more supportive of personal care being funded on a universal basis - 59% of those on the left said this, compared with 42% of those with more right-wing beliefs about the role of government.
|Government, no matter how much money person has||Person, no matter how much money he/she has||Who pays should depend on how much money person has||Don't know||Sample size|
|Annual household income|
|Up to £14,300||55||2||44||*||322|
|Over £14,300 to £26,000||51||2||46||1||208|
|Over £26,000 to £44,200||49||3||48||*||233|
|Highest educational qualification|
|No recognised qualification||68||2||29||*||284|
|Position on political left-right scale|
Attitudes to charging for hospital meals, school trips, and musical instrument lessons
6.25 Figure 6.2 shows attitudes to charging for meals in hospital and for school-based individual musical instrument lessons and school trips. There was strong opposition to charging patients for their meals while in hospital - 76% were either somewhat against or strongly against this idea. However, opinion on charging parents for school-based activities was more divided. While 45% were against charging for individual musical instrument lessons, 41% were in favour of this. Meanwhile, a narrow majority (51%) favoured charging parents for the cost of a school trip to a local museum. These differences perhaps reflect a greater tendency to view these school-based activities as 'additional' to the 'core' service schools deliver. In contrast, the fact that opposition to charging for hospital meals was so strong may suggest that meals are viewed as an essential part of the service provided by hospitals. Alternatively, perhaps, as suggested in paragraph 6.19, people are simply less willing to pay for services that are currently free (like hospital meals) and more supportive of paying for services that are already more commonly charged for (like school trips).
6.26 These questions were also included in a 2007 module on attitudes to public services, funded by the ESRC. There has been relatively little change in views on these issues in the last four years (Table 6.4). To the extent that views have shifted, they have moved very slightly in favour of charging for hospital meals (from 10% in favour in 2007 to 16% in favour in 2011) and charging parents for the cost of school trips (from 45% in favour in 2007 to 51% in 2011). However, the amount of change over time is perhaps less than might be expected given the dramatic changes in the economy and the widely reported impacts on public sector budgets that occurred between 2007 and 2011. The economic downturn does not, therefore, appear to have resulted in many more people in Scotland feeling that charging for public services is an appropriate way of dealing with the budget deficit.
|Neither in favour nor against||7||8|
|Individual music lessons in school|
|Neither in favour nor against||14||13|
|School trips to a local museum|
|Neither in favour nor against||13||9|
Differences in attitudes to charging for hospital meals, school trips, and musical instrument lessons
6.27 There were relatively few significant differences in support for charging for each of these services between different groups in Scottish society (Table 6.5). Views did not vary significantly by age or income, while those with and without school aged children were equally likely to favour charging for the two school activities. However, there were a few significant differences of opinion, primarily in relation to charging for in-school musical instrument lessons:
- Women were slightly more likely than men to favour charging parents for the costs of school-based individual musical instrument lessons (45% compared with 37%)
- Those with no recognised educational qualifications were less likely to favour charging for musical instrument lessons (34%, compared with 42-44% of those with some form of qualification)
- Those who were more politically left-wing in terms of their general beliefs about the role of the state were less likely to favour charging for hospital meals (12%, compared with 20% of those with more right wing views) or school-based musical instrument lessons (35%, compared with 48% of those on the right).
|% strongly support/somewhat support charging||Meals while in hospital||Individual music lessons in school||School trips to a local museum||Sample size|
|Annual household income|
|Up to £14,300||11||38||46||322|
|Over £14,300 to £26,000||18||41||53||208|
|Over £26,000 to £44,200||15||40||59||233|
|Highest educational qualification|
|No recognised qualification||16||34||46||284|
|Position on political left-right scale|
|School-aged children in the household|
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