In 2002, the Scottish Government introduced the Community Care and Health act, setting out provisions for the charging, and non-charging of community care services to individuals over the age of 65, generally referred to as ‘free personal care’ (FPC). This was furthered once more in 2019 with the extension of free personal care to individuals under the age of 65; meaning that where assessed as requiring the provision of such care, any adult above the age of 18 will be entitled to the provision of free personal care in the community. In theory, FPC is a brilliant step towards making social care services accessible to all. It fails, however, to deliver in a more holistic manner and causes a significant divide between the issues of the mind and body.
The introduction, not only of FPC to over 65s but also its extension to under 65s has been heralded by many as ground-breaking legislation in the field of social policy and it continues to receive heaps of praise in contrast to neighbouring England and Wales (where social care is still a chargeable service regardless of age). Indeed, as a social work practitioner in one of Scotland’s busy local authorities in a world where I have only ever known there to be free personal care, I am appalled at the concept of charging someone to access support and assistance in the pursuance of their most basic needs. However, I don’t have to look too far to find a very clear example of this.
Legal context of free personal care
For context, local authorities have a duty to assess individuals where they are made aware that the individual may require the support and assistance provided by such an authority for the purposes of promoting social welfare. Leaving aside the screening process which goes on in all local authorities for the purposes of determining urgency and of course, the criteria we use as a judgement as to whether someone is ‘entitled’ to an assessment of need, provision of support occurs in two distinct categories: personal care and housing or social support.
Unlike FPC, housing support is not legislated for by the Scottish government and it is a chargeable service. This means that where a local authority assesses someone’s needs for housing support, they can conduct a financial assessment to determine what the contribution of the client is, based on their income. This ultimately leads to a significant amount of interpretation by each of the local authorities who can determine what can be classed as chargeable and non-chargeable services.
What is meant by personal care?
If I were to ask any of my colleagues in adult care services in Scotland what is meant by free personal care, there is little doubt that they would reach for the rather classic idea of FPC; support to wash, dress, eat, drink, go to the toilet, and help with medications. They would be correct in doing so because, as stated within the Community Care and Health Act, these areas are stipulated as being ‘personal care’ services which must not be chargeable. However, an often forgotten aspect to this piece of legislation is the inclusion within Schedule 1, section 5, where, with regards to the persons general well-being, “behaviour management and psychological support” are also classed as personal care. This causes significant difficulties for senior managers and budget holders who are dogmatic in their approach to what should be free personal care, not just in the context of older adults but in mental health, learning disabilities, substance misuse and so on.
A recent example of this was for one of my own clients – someone with no physical difficulties but with a diagnosis of an autism spectrum disorder. In this case, the individual requires a significant amount of face-to-face support to reduce their anxiety, provide reassurance and encourage them to take part in activities which are beneficial to their mental health. Without this, they would not be able to access support in the community, would likely be more withdrawn and isolated, or suffer significant emotional distress without that level of specialist support in place. According to the relevant budget-holders, this is housing support, therefore it is chargeable.
Turning down support
As I said before, housing support is not legislated for in the same way that personal care is, but it is generally accepted as providing support to maintain a tenancy or a home to boost social welfare. None of the above support takes place in the home, let alone for the purposes of maintaining a tenancy or a home environment for that particular client – it all relates to the ‘behaviour management and psychological support’ of trained staff members to benefit their well-being. So why would we charge for this? In some instances, clients are more than happy to pay for their care in this context, but others decline altogether. Factor in UK-wide government policy on the ‘tapering’ of state benefits and the ongoing cost of living crisis and we begin to understand why such critical services are being declined by our clients.
The implication for workers and clients
There has been a concerted effort by many western governments over the past decade or so to prioritise the mental health and wellbeing of its citizens (with varying success I should add). It is unmistakable that it is certainly the most used buzzword for public figures across a huge spectrum. With such a focus on this, how can we promote the mental well-being of our clients when we make such marked delineations between issues of the body and mind in such a materialistic and brutal manner?
From a practitioner’s perspective, where we work with clients in more acute settings (hospital discharge being one) we find that our assessments clearly fall into the category of the physical rather than the broader sense of well-being which we all seek to promote. Where the pressure to move people from hospital beds is the key priority, we find ourselves constrained by our environments, the pressures of which dictate the provision of basic care and hack away at what should be a more holistic assessment.
A united and progressive approach
I believe that the Scottish government’s bold plans for many of these progressive approaches to the health and well-being of its most vulnerable is absolutely right, and I fully agree with the concept of free personal care. I also agree with many of the Scottish Government’s attitudes towards social welfare, however from a practitioner’s perspective, its implementation in the above ways, frustrates and disheartens me about the way it is implemented on a practical level. Regardless of my own feelings, of course, the people who suffer the most from this approach are the most vulnerable in society; those who should trust us in providing them with the necessary means to live their lives as independently, and with as much dignity, freedom and choice, as they possibly can. My concern is unless there is a more united front from practitioners about the application of a critical piece of legislation, it misses the potential to be something that truly benefits the people we work for.
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