Summary of the impact

Stirling research has provided new data, identified key issues and influenced policy outcomes in the management of long-term care, one of the major challenges associated with population ageing. Professor David Bell has researched the costs of provision of long-term care since 2001. He has presented research findings to policy-relevant audiences in Scotland, England, Wales, Northern Ireland and the USA. He was a member of Lord Sutherland's committee which reviewed the policy of Free Personal Care in Scotland. His research has directly influenced social care policy in Wales and Scotland. Most recently, he has provided research for the Scottish Government in relation to the policy of Self-Directed Support and gave evidence to the Health Committee of the Scottish Parliament on the bill to implement this measure. His research has also been influential in improving the quality of data relating to long-term care.

Underpinning research

The underpinning research was based on a series of interlinked projects for which Prof David Bell (Stirling Management School) and colleagues from the Stirling School of Applied Social Science were leading Investigators. The first project (2004-5), funded by the Joseph Rowntree Foundation, was the first attempt to review the impact of the policy of free personal and nursing care in Scotland. It involved quantitative and qualitative research and compared care 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 update by Joseph Rowntree Foundation which looked at trends over a longer time period, and particularly focused on the issues faced by local authorities. Professor Bell also completed a project for the Welsh Assembly government (2006) which collected and analyzed detailed data on services delivered to older people through Welsh local authorities. The research also informed the Sutherland Review of Free personal care (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 analyze the costs of care in the context of self-directed support (elsewhere known as direct payments). Bell's contribution focused on the provision of cost estimates based on demographic projections and microsimulation modelling. This work has been further developed through Stirling's role in the ESRC-funded Centre for Population Change based at the University of Southampton.

One key output of the research was estimates of the costs of free personal care in the constituent countries of the UK. These were forecast to rise due to demographic change, but the shift away from residential towards home based care moderated this rise, which in turn had consequences for the housing market and for unpaid (family) carers. The research on free personal care raised and elucidated a number of important issues including the problematic nature of Government guidance, the apparently variable impacts on local authorities and the variation in value for money when delivering the services, the critical role of unpaid care, the lack of substitution between formal and informal care and the lack of cross-border migration — both the latter two trends had been raised at the launch of the free personal policy in Scotland as potential problems which could inflate costs. The research showed that these trends did not occur, leading to a more informed public debate. Analysis of the costs of introducing free personal care in Wales and Northern Ireland led to decisions not to proceed, partly as a result of their higher levels of disability than Scotland.

Another consequence of the data analysis at the local government level has been the realisation that data on the linkages between health, social care and housing are inadequate throughout the UK. Bell has successfully applied to the US National Institute of Aging to work with the Scottish Government to improve the quality of data linkage in Scotland.

References to the research

Details of research projects

2004-2005 `Financial care models in Scotland and the UK' funded by the Joseph Rowntree Foundation (Bell and Bowes) (£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 (Bell, Bowes, Dawson and Roberts) (£48,340)

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

2006 `Estimating the cost of free home care for disabled people in Wales' funded by Welsh Assembly Government (Bell and Dawson) (£12,536)

2009-2012 "Rural Ageing and Migration" sub-project of the ESRC Centre for Population Change based at the University of Southampton, ESRC Grant RES-625-28-0001 (£230,000)

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

Details of the impact

The impact relates to five interlinked projects conducted by Bell in association with colleagues in the School of Applied Social Science. These were funded by the Joseph Rowntree Foundation, the Scottish Government and the Welsh Assembly Government and examined long-term care costs with a particular focus on the costs and benefits of providing free personal care for older people in Scotland and Wales. The impact began in 2005 when Bell's analysis of the costs of free personal care in Wales led to an abandonment of this Assembly Government policy. Here 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 and practice. As a guideline to the numbers of people affected by the research findings and the related policies, 33,000 older people funding received free personal care in Scotland in 2003-4 and by 2011-12 this had risen to 46,000, with costs of £342m. In addition, the impact has achieved international reach, through the World Demographic Association in Switzerland (Bell is a Fellow of this organisation) and via Bell and Bowes contribution 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 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'

The `significance' of the research findings has also been substantial. The project set out baseline information which enabled the monitoring of the free personal care policy in Scotland, which was reviewed by Audit Scotland in 2008 and subsequently cited in the Sutherland review in 2008. This confirmed the all-party commitment to free personal care in Scotland, despite rising costs. The significance of the research findings was felt more acutely 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 (and a continuing rejection of the Scottish model of free personal care in the English context, most recently represented in the Dilnot report of 2011). The follow-up research on expenditure on domiciliary care in Wales. The research team gave expert evidence to the Northern Ireland government based on the research findings in 2008, which was reported to the Minister and was instrumental in the decision not to provide free personal care to the over 65s in Northern Ireland.

More recently, the team has developed the research, using microsimulation, 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 country (Social Care (Self-directed Support (Scotland) Act 2013). In May 2012, Bell addressed the Health and Sport Committee on the subject of the costs of Self-Directed Support. And as a result of his previous research, he is now working with the Scottish Government on a US National Institute of Ageing project to improve the quality of data on long-term care clients.

Sources to corroborate the impact

Audit Scotland (2008) A Review of Free Personal and Nursing Care
http://www.audit-scotland.gov.uk/media/article.php?id=68

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

Welsh 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 that this is not currently on the agenda because it cannot be afforded. Bell's influence on the Welsh decision not to proceed with free personal care is referenced here
http://news.bbc.co.uk/1/hi/wales/4717144.stm and here
http://www.bbc.co.uk/radio4/youandyours/transcripts_2006_07_thu_01.shtml

Scottish Government 2012 Social Care (Self Directed Support) (Scotland) Bill Explanatory notes, Financial memorandum includes extensive reference to the research which is informing the new legislation). Bell gave evidence on the costs of the policy to the Scottish Parliament —
http://www.scottish.parliament.uk/parliamentarybusiness/28862.aspx?r=7054&mode=pdf

Scottish Government Self Directed Support in Scotland website:
http://www.selfdirectedsupportscotland.org.uk

Russell Sage Foundation: http://www.russellsage.org/.

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