Care provision in Scotland: background, policy context and research.

Demographic changes present considerable challenges to the way that health and social care for older people are funded and organised (Bernard and Phillips 2000). They mean not only an increase in the number of older people using services, but also significant changes in the kind of services they require. The standard of care offered to older people in the UK has caused increasing concern within the last decade (King’s Fund 2001a, Lothian and Philp 2001). Specific anxieties have been raised about the quality of assessment for older people (Clinical Standards Advisory Group 1998), the fragmentation of care, the sharp increase in the use of residential and nursing home provision (Audit Commission 1997) and the quality of care in care homes. The latter has occurred as the responsibility for long-term care has shifted from hospitals to care homes (Morris and Bowman 1999). In response to these concerns, the future health care of older people has become a priority on the political agenda (Royal Commission 1999, Scottish Office 1998, Scottish Executive 2000a, 2000b). Central to the NHS and Community Care Act (Department of Health 1990) was the promotion of choice and independence for individuals, and the cost effectiveness of service provision on the basis of needs assessment. The financial implications of this act have led to ongoing debate about what constitutes health and social care: the boundaries between the two shift as social and policy definitions change (Twigg 2000). Whether individuals contribute to the cost of their care or not has, until now, depended on who provides that care: continuing care provided by social services is means tested, while continuing care provided by the NHS is free at the point of delivery (Royal College of Nursing 1997). A key proposal made by the Royal Commission into Long Term Care (1999) was that free nursing and personal care should be provided to everyone in both care homes and the community. In Scotland, the Scottish Executive has responded to this report by stating that it would implement this recommendation in full – that is, free nursing and personal care for all. The development of these proposals has presented a number of challenges to policy makers and service providers. Following detailed assessment and analysis to address these challenges, implementation of free personal care is now underway. Part of the process of developing these proposals for free personal care included consultation with older people. The government is committed to building a health service that is responsive and sensitive to the needs of patients and the wider public (Department of Health 2000). Indeed, working with service users can often provide a different view of issues and provide important information for the development of innovative quality services (Barnes 1999). Without this input, there is a danger that service provision will be driven by a professional and political agenda which may not always be consistent with the needs and requirements of the users themselves. This could have financial and resource implications – for example, there is already substantial evidence to suggest that even when services are provided, they are often not used (Williams and Fitton 1990, Antonson and Robertson 1993), as well as resulting in a failure to meet users’ needs. The Care Development Group was established to examine how free personal care could be delivered, taking into account public perspectives. The study presented here was commissioned as part of the Care Development Group’s examination of the implementation of free personal care. It elicits the views of older people in receipt of residential and community care on the provision of free personal care and the design of future services. The data complement those Health and social policy Service planning Elderly services Patient empowerment Research methods key words