IN her keynote speech at the recent SNP Conference, Nicola Sturgeon made much of the importance of the “I” word to the Scottish Government. “Not that one,” she joked. The word she had in mind was “inclusion”.

Scotland has tried to play a leading role in developing modern social care policies for the last two decades, in particular with the closure of large institutions for people with learning disabilities and through the ground-breaking Same As You report in 2000 which was about supporting people to be included in society. More recently Scottish Government policies on self-directed support have tried to give people personal budgets to empower them to live full independent lives.

Health and social care integration, attempting to break down the silos between the NHS and councils, is also designed to provide services which allow people to choose to live at home, with social support for this “inclusion”.

But there have always been questions about whether resources in the community were sufficient and how care will be paid for as demand increases and expectations rise – even before austerity policies took their toll on council budgets.

It has been apparent the strain is beginning to tell as cuts often make a mockery of this rhetoric of individual control. Tactics to square the circle from cash-strapped councils have included introducing charges for many basic supports which were formerly free, shorter visits to old or disabled people and ever tighter assessment criteria restricting who is eligible for support.

Now, with varying degrees of overtness, there are signs councils are tacitly acknowledging they cannot afford to deliver on the promise of some of these policies. New clients of Perth and Kinross Council with care needs are to be denied at-home support if their care would cost 10 per cent more than placing them in a care home. In other areas social work assessments of people’s home environment as unsafe, or their own condition as too “frail”, are used to justify decisions that they can no longer be included as envisioned, but must instead live in a care home.

Health and social care integration is a work in progress, and boards are looking to transform the provision of community support. But those currently in need of care cannot be expected to wait in limbo until services are ready.

There is no intention to criticise care homes most of which are very high quality. However people who want to live independently, included in society as promised, should not be forced to choose something less satisfactory, based on budget-led decisions with half an eye, at best, on what they really need.

There is a tension here between national government policy and delivery on the front line by health boards and councils. It is too easy for the latter to blame government for funding shortages and for ministers to criticise them for failing to honour policy.

There have been repeated calls for a commission into the true cost of care. If the Scottish Government is serious about inclusion, rather than marginalising vulnerable people through an increasing use of institutional care, perhaps it is time to heed those calls.