A two tier system of care for elderly people was introduced in the United Kingdom's national health service last month when Scotland starts providing free personal care for those aged over 65.
From 1 July, people in Scotland who are assessed as requiring personal and nursing care will have their costs met by the state if they live at home and will receive payments of £145-£210 ($216-$313; a225-a327) a week, depending on their needs, if they are in care homes.
It will leave elderly people in Scotland better off than those in the rest of the United Kingdom, where personal care will continue to be means tested. People with assets of more than £11 500 have to pay a proportion of the costs whereas those with assets of £18 500 or more--which can include the family home--have to pay the full amount.
The financial burden facing older people in paying for their long term care has become a big issue in the United Kingdom. Average nursing home fees cost about £17 500 a year, and many older people have had to sell their homes to pay the costs of care. Earlier this year the provision of free long term care was voted the number one health issue by viewers who responded to a poll conducted by the BBC as part of a day long series of programmes on the NHS.
However, Scotland remains the only part of the United Kingdom to have accepted the recommendations of a Royal Commission that was appointed in 1997 to report on the long term care of elderly people. The commission concluded, in March 1999, that all nursing care should be free and that personal care that includes bathing, feeding, and dressing should also be free according to assessed need. The Royal Commission rejected private and compulsory insurance schemes and recommended that the costs be met out of general taxation (BMJ 1999;318:622).
The changes in Scotland will see a substantial reduction in care home fees for elderly people. Those with the highest level of dependency will benefit from payments of almost £11 000 a year. In England, elderly people get help with nursing care costs and qualify for payments of £35, £85, or £110 a week on the basis of low, medium, and high care needs--a maximum of £5720 a year.
The new policy has not found universal favour in Scotland, with some Scottish Labour party politicians seeing it as a subsidy for the better off. It will cost Scotland £125m a year, with costs expected to rise in future years.
The Scottish decision leaves English ministers with an embarrassing problem. They have made it clear they are not prepared to pay the £1bn that it would cost to introduce a similar scheme but are under strong pressure from organisations representing elderly people to ensure equitable treatment across the United Kingdom.
How different countries organise care for older, disabled people
- Germany and the Netherlands have adopted compulsory insurance to pay for it
- Women have borne the main burden of caring for elderly people in many countries, but this is breaking down in some places, such as Spain, as more women go out to work
- Better off, middle aged people in the United States are taking out insurance for long term care
- The quality of long term care is a cause for concern in many countries, such as Germany
- Most governments provide subsidies for long term care for those who cannot afford it. This varies widely--for example, £6500 ($9800; a10 000) a year in the Republic of Ireland, £11 000 a year in Scotland, and £22 000 a year in Australia
