Summary of the impact

Our research on free personal care and, subsequently, self directed support in Scotland has influenced policy across the UK. It has influenced the continuing cross-party support for free personal care (£111m during 2011-12) in Scotland, and informed recent legislation, and has influenced debates in England about how to pay for the costs of long term care in the context of population ageing. In Wales, the detailed research on the actual costs of care influenced the decision not to take forward free personal care, due to its high costs. Internationally, the continuing research on the case of Scottish policy, especially the development of the costs, has informed wider policy debates, involving stakeholders in Europe and the USA.

Underpinning research

The underpinning research was based on interdisciplinary, groundbreaking work by Bowes Rummery, Bell (Economics, University of Stirling) and Dawson. The first project (2004-5), funded by the Joseph Rowntree Foundation (JRF), was the first attempt to review the impact of the policy of free personal and nursing care (FPC) in Scotland (Community Care and Health (Scotland) Act 2002). It involved quantitative and qualitative research and compared policies and their impacts across the UK, was competitively awarded and peer reviewed at the grant awarding stage. The second project (2005) was funded by the Scottish Government — it collated baseline data to establish a benchmark for monitoring the policy, and underwent peer review at the grant awarding and project reporting stage. The third project (2006) was an update commissioned by JRF which looked at trends over a longer time period, and particularly focused on the issues faced by local authorities. The team also completed a project for the Welsh Assembly government (2006) which collected and analysed detailed data on services delivered to older people through Welsh local authorities. The research was updated to inform the Sutherland Review of FPC (2008), the Audit Scotland review (2008), and the Syracuse symposium (2011), funded by the Russell Sage Foundation (USA). Subsequently, further research was commissioned by the Scottish Government (2012) (following competitive tender) to analyse the costs of care in the context of personalisation and self-directed support (elsewhere known as direct payments). This research was both quantitative (using large scale data sets) and qualitative and included extensive work with service providers, older people and family caregivers to collect a range of perspectives: for example, the first project involved 20 key informants and 88 older people who took part in focus groups. Economic micro simulation modeling was used to provide costings, drawing on the OPERA (Older PEople's Resource Allocation) model, developed at Stirling by Bowes and Bell in ESRC funded work under the Scotland's Demography programme¹ (2005-6).

The research provided analysis of the costs of FPC, which were found not to be greatly out of line with costs in the rest of the UK, whilst rising due to demographic change and to the shift away from residential towards home based care. Qualitatively, the research raised and elucidated a number of important issues around FPC including the problematic nature of Government guidance, the variable impacts on and strategies adopted by local authorities and the variation in value for money when delivering the services, the critical role of unpaid (family) care, the lack of substitution and the lack of cross-border migration — both the latter two trends had been raised at the launch of the policy as potential problems which could inflate costs. The research was able to show that these trends did not occur, leading to a more informed public debate^2,3,4,5,6. Researching costs in Wales and Northern Ireland found these to be prohibitive⁷. In Scotland, we identified and explained the rising costs of care, particularly the impact of the increased emphasis on care at home. Issues for both service providers and service users were explored in the subsequent investigation of self-directed support, suggesting that this would not positively impact on the costs of care⁸.

References to the research

Details of research projects

2004-2005 `Financial care models in Scotland and the UK' funded by the Joseph Rowntree Foundation (Bowes and Bell) (£99,974)

2005 `Establishing the evidence base for an evaluation of the implementation and impact of the free personal care policy' funded by the Scottish Executive (Bowes, Bell, Dawson and Roberts) (£48,340)

2006 `Free personal care — recent developments' funded by Joseph Rowntree Foundation (Bowes, Bell and Dawson) (£9,993)

2006 `Estimating the cost of free home care for disabled people in Wales' funded by Welsh Assembly Government (Dawson and Bell) (£10,939)

2011 Self Directed support funded by Scottish Government (Rummery, Bell, Dawson, Bowes and Roberts) (£28,128)

Details of the impact

The research has been contributing to policy development over a lengthy period. In this case study, we focus on impact from 2008 onwards.

The `reach' of the impact has been substantial: the research findings have played a significant role in ensuring better informed public policy-making in the field of personal care provision in Scotland, England, Wales and Northern Ireland, leading to direct changes in policy (detailed below). As a guideline to the numbers of people affected by the research findings and the related policies, 33,000 older people received FPC in Scotland in 2003-4 and by 2011-12 this had risen to 46,000, with costs of £342m. This population also shows increasingly high levels of need, from 7 hours per week to 8 hours over the same period<sup>9</sup> In addition, the impact has achieved international reach, through the World Demographic Association in Switzerland and via work contributing to a Russell Sage foundation publication led by Syracuse University's Maxwell School of Citizenship, which aimed to influence implementation of the CLASS Act USA (Community Living Assistance Services and Supports) in the USA (the CLASS Act was eventually withdrawn by the Obama administration in October 2011). Influential stakeholders including LeadingAge, the Urban Institute, AARP (formerly the American Association of Retired Persons), United Hospital Fund NYC and Thomson Reuters were co-contributors. The published volume continues to contribute to the debate through the Russell Sage Foundation's commitment to `the improvement of social and living conditions in the United States'¹⁰.

The `significance' of the research findings has also been substantial. The project set out baseline information which enabled the monitoring of the FPC policy in Scotland, which was reviewed by Audit Scotland in 2008¹¹ and subsequently cited as evidence in the Sutherland review in 2008¹², of which Bell was a member. This confirmed the all-party commitment to FPC in Scotland, despite the rising costs: coverage cited the Stirling research as fundamental¹³.

The significance of the research findings was felt in the English, Welsh and Northern Ireland policy contexts. The research was cited as part of the Wanless review of various options for funding social care in 2006, which continues to inform debate and has led to the ongoing development of long-term care policies in England, including a continuing rejection of the Scottish model of FPC in the English context, most recently represented in the Dilnot report of 2011 Fairer Care Funding. The team contributed input, through JRF events to the `Caring Choices' UK wide debates on paying for care which reported in 2008 on `The Future of Care Funding'¹⁴. This initiative was focused on informing and stimulating public debate on the future costs of care and how these should be met: the JRF document which fed it (Paying for long term care — moving forward¹⁵) cites our research on the lessons of the FPC policy.

The follow-up research on expenditure on domiciliary care in Wales was instrumental in the Welsh Assembly's decision not to implement FPC for older people in Wales in 2009¹⁶. The research team gave expert evidence to the Northern Ireland government based on their findings in 2007¹⁷: this was reported to the Minister and was instrumental in the decision not to provide FPC to the over 65s in Northern Ireland, announced by Michael McGimpsey in 2009¹⁸.

More recently, the team has developed the research, using microsimulation modelling to examine the future costs of self-directed support in Scotland. The research has informed the new legislation in this area through the Scottish Parliament implementing self-directed support, potentially affecting 100,000 service users across the country¹⁹ (Social Care (Self-directed Support (Scotland) Act 2013). In May 2012, Bell contributed to and Rummery addressed the Health and Sport Committee on the subject of the research, informing the progress of the legislation. Records of the Committee discussion on 8th May 2012:20 quote Bell, particularly in relation to the need for caution about costs, and the Committee report July 2012:21 cites evidence received from Stirling University (Rummery's address) and from Bell. The Scottish Government 2012 Social Care (Self Directed Support) (Scotland) Bill Explanatory Notes, Financial Memorandum includes extensive reference to the research.

Sources to corroborate the impact

⁹http://www.scotland.gov.uk/Publications/2012/08/4156/0.

¹⁰http://www.russellsage.org/.

¹¹Audit Scotland (2008) A Review of free personal and nursing care http://www.audit-scotland.gov.uk/media/article.php?id=68

¹²Sutherland S (2008) Independent Review of Free Personal and Nursing Care in Scotland
http://www.scotland.gov.uk/Publications/2008/04/25105036/0

¹³e.g. Community Care http://www.communitycare.co.uk/articles/30/04/2008/108058/free-personal-care-workable-but-underfunded.htm.

¹⁴http://www.kingsfund.org.uk/publications/the_future_of_2.html

¹⁵http://www.jrf.org.uk/publications/paying-long-term-care-moving-forward

¹⁶Welsh Assembly government (2008) Paying for Care in Wales: creating a fair and sustainable system (consultation document) para 6.3: refers to our evidence on the costs of free personal care and states this is not currently on the agenda because it cannot be afforded.

¹⁷Meeting with civil servants at Stormont (16.10.07). Dean.Looney@DHSSPSNI.GOV.UK

¹⁸Example of coverage: http://www.communitycare.co.uk/2009/05/20/northern-ireland-free-personal-care-rejected-on-cost-grounds/

¹⁹http://www.selfdirectedsupportscotland.org.uk/

²⁰http://www.scottish.parliament.uk/parliamentarybusiness/28862.aspx?r=7054&mode=pdf

²¹http://www.scottish.parliament.uk/S4_HealthandSportCommittee/Inquiries/her-12-10w-rev-rev.pdf)

Independent verification/reference can also be provided by Audit Scotland, the JRF, the Scottish Government, the Welsh Assembly Government and Lord Sutherland.