Scotland tries to contain costs of free personal care for older people

Evidence shows that rationing is being introduced in Scotland to control rising demand for free personal care for older people.

Three quarters of Scottish local authorities have introduced eligibility criteria or set priority levels for access to the service. Scotland is the only part of the United Kingdom that provides people older than 65 with free personal care, which includes help with washing, dressing, and feeding.

A review by Audit Scotland has found that central funding for the policy now fails to meet the costs borne by councils, with the shortfall estimated at £46m-63m (€62m-€85m; $91m-$125m) in 2005-6. The report warns that costs will rise further as the proportion of elderly people in the population rises.

The provision of free personal and nursing care was one of the main recommendations of a royal commission that was set up by the UK government in 1997 to examine options for the long term care of elderly people (BMJ 1999;318:622 www.bmj.com/cgi/content/extract/318/7184/622). Scotland introduced the policy in 2002 but only free nursing care is available in England and Wales.

The policy has proved controversial, and concern has been expressed about its long term affordability. It was also opposed by some leading politicians, who claimed it was an expensive policy that subsidised richer people because poorer people already qualified for free support. It has proved popular with older people, however, and by March 2007 about 72 000 people were receiving the service.

Audit Scotland estimates that the policy cost a total of £1.8bn in its first four years, but councils would have spent £1.2bn anyway in providing free care for people who were already eligible. The real additional cost is, therefore, £600m, but central funding is failing to keep pace with demand.

“Councils are using a variety of approaches to manage demand,” says the report. “Differences in the use of waiting lists and eligibility criteria mean that older people may receive different levels of service depending on where they live. Older people are unclear about what free personal care means in practice.” Eight councils charge for food preparation, for example, but that is provided for free elsewhere.

Audit Scotland says that the policy was introduced without any outcome measures, which, together with other changes implemented at the same time, makes it difficult to evaluate its impact. Ambiguity in the legislation and guidance has also led to variations in implementation.

Audit Scotland recommends that

• A national eligibility framework is drawn up to ensure transparency in access to care

• Projections of cost are updated

• Clear information is provided to older people about what is covered by free personal care and who is eligible to receive it.

Robert Black, Scotland’s auditor general, said, “Free personal and nursing care is an important policy for older people in Scotland. It is well documented that Scotland has a growing older population, and demand for free personal care will grow. There needs to be better planning and better funding of this policy.”