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Evaluation of the Implementation of Local Area Co-ordination in Scotland

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CHAPTER FIVE CASE STUDIES: STIRLING AND MIDLOTHIAN

Introduction

In this chapter, two further case studies are presented. Both were selected due to the distinctive features of local area co-ordination in practice that they provide. Stirling provides an example of LAC working across traditional service user boundaries, while Midlothian illustrates LAC situated in the voluntary sector,

STIRLING

Introduction

Stirling was chosen as a case study because here the LACs work across traditional service boundaries. It is the only authority in Scotland to work with people 'from cradle to grave' and across 'service user groups' (people with learning disabilities and those with mental health issues) although the latter is a fairly recent development. When we conducted the case study in May 2006, there were three fulltime LACs: a fourth, part-time post with a focus on transitions, was due to start in June.

The LACs cover the entire Stirling Council area, which runs to 848 square miles and has a population of 86,370 (Stirling Council, 2006). Over 31,000 people live in the city of Stirling, with much of the remaining area sparsely populated. The proportion of people describing themselves as White Scottish or White British is 95.5%, mirroring the national picture. Household tenure is similar to the Scottish average, with 67% owner occupied and 20% rented from the local authority. Unemployment, at 2.1%, is a little lower than the national average of 2.6%, while the age profile reflects that throughout Scotland, although the number of older people is projected to grow. The Scottish Index of Multiple Deprivation (Scottish Executive, 2004d) shows that, overall, Stirling does not rank highly in relation to other local authorities in terms of income and employment deprivation, although there are pockets of disadvantage, with eight data zones in Stirling city falling within the 20% ranked as most deprived in Scotland.

The case study was spread over 2.5 days during which time the research team met with:

  • the three LACs
  • four senior managers, (Director of Community Services, Head of Service for Sport, Youth and Support for People, Head of Community Care/ Chief Social Work Officer, and Service Design Manager, Community Care)
  • five individuals (separately)
  • four family carers (separately)
  • 10 members of a self-advocacy group (together) supported by a project worker
  • the project leader of a youth group
  • the manager of a supported employment scheme run by the council.

Background to implementation of LAC

In 1999, Stirling Community Services embarked on a redesign of services to people with learning disabilities. At first, senior managers were unsure whether local area co-ordination, recommended in The same as you?, would add anything to their existing plans - the closure of a traditional day centre and the introduction of Streets Ahead (a 'without walls' day service), and a supported employment scheme. However, on attending a presentation by Eddie Bartnik, "the penny dropped", as one senior manager put it. The first appointment, made in January 2003, had several distinctive features. First, it was a LAC Development Manager post pitched at Service Manager level. Secondly, it was not located in Community Care but instead was a strategic and independent appointment in Community Services. Thirdly, the post holder reported directly to the Director of Community Services. These strategic decisions were intended to send out a number of messages: LAC was distinct from social work and care management; it was set to expand and develop, and it was to have value, status and 'the power to open doors'. A second LAC was appointed in 2004 and a third in 2006. Our findings suggest that these decisions have proved effective. There has been one recent change. Following the retirement of the then Director of Community Services, and a recognition that LAC was well established, LAC is now located in Sport, Youth and Support for People (part of Community Services) and the LAC Development Manager reports to the Head of Service.

Overview of role and remit

The Development Manager has a mixed remit - part practice, working with individuals and families, part strategic, 'influencing and challenging at senior level'. The principal purpose of the other posts is:

"By using person centred approaches [to] support individuals and families to identify their own needs, interests, aspirations; to encourage the full participation of people with disabilities in all aspects of community life by enhancing, developing and co-ordinating relevant supports." (Stirling Council, 2005)

The LACs work with people at the latter's invitation and do not carry out assessments. They have developed a User Questionnaire, printed in bright colours with illustrations, which they complete with individuals. It seeks information about the person's current use of services and perceived needs or desire for other supports or activities. Before the other LACs were appointed, the Development Manager was asked to identify and work with 35 people. The team is currently working with about 130 people as well as various community groups and other projects.

Stirling is the only authority in Scotland (at the time of writing) where the LACs have a shop front, as in the Australian model. They can access budgets to support their work, for example, for office equipment, training and hospitality. They can also access other budgets through negotiation with the budget holder, such as Quality of Life funding for a youth inclusion project. The Stirling same as you? Implementation Group acts as a steering group, although its remit is wider than local area co-ordination alone. It has representation from parents' groups, a self-advocacy group of people with learning disabilities and statutory and voluntary organisations.

Individuals and families views of LAC

The nine individuals and family carers we spoke to all had a good understanding of LAC. One individual described a LAC as someone "who helps you do things and knows where to go...a one stop-shop person." There was evidence of the LACs going to some trouble to ensure that people were well informed about LAC, for example, by giving a presentation to the management committee of the self-advocacy group and inviting parents to attend the Eddie Bartnik seminar. One individual described the LAC information leaflet as "very clear". However another, who lived in rural Stirlingshire and had heard about LAC through word of mouth, experienced some difficulty "tracking it down". She commented that the LAC leaflets were not on display in GP surgeries or other healthcare premises locally.

Without exception, people were very positive about the quality of support received from the LACs, described by one as "absolutely brilliant" and another, "a tremendous help". One person said he trusted his LAC "to help in the right way." The LACs were said to respond quickly to requests for help and to keep people in touch with progress. A wide range of support had been provided to the people we spoke to, including:

  • helping several people secure their own tenancies
  • arranging home care
  • supporting people to apply for benefits and other entitlements, eg: a bus pass
  • supporting a family experiencing serious problems with their child's school
  • helping one young man transfer from school to college
  • persistently pursuing an OT to assess for and arrange a much needed extension to a family home
  • when one man moved house, introducing him to the neighbours and postman.

People saw the LACs as 'on their side': this mother's comments were typical:

"I could boil it down in a couple of words: basically he's on our side. He doesn't question what we say; he doesn't question the validity of my son's opinions on anything. He's there for him and he's the only one who's there for him. He's not on the school's side, the council's side, he's not on anyone's but my child's side; he's there for him."

At the same time, the LAC role was seen as supporting families to gain information, obtain services, tackle practice they were unhappy with and so on - not to do these things for them. For example, one mother explained that while she would write or phone agencies about an issue, the LAC would send them an email letting them know that he was also aware of the matter and that the mother would be in touch, thus reinforcing but not replacing her action. One individual said she usually only rang the LAC in an emergency, for example, when the washing machine broke down and she did not know what to do while another said that, having received support from the LAC with filling in forms, she now tries to do tasks like that herself and only contacts the LAC if it proves too difficult:

"When I had the social workers, they were telling me what to do and they were taking over and doing it for me, so to me I wasn't really learning anything."

This was reinforced by a senior manager, who described the LACs' remit as:

"Working alongside people, helping them to make the choices and decisions and all the rest of it, the whole capacity building in the community thing, but they're not thinking they can be therapists. And if you do have that level of intensity, then you're not doing it [ LAC] as it was designed to be."

None of the people we spoke to expressed any reservations about LAC support. While some had also benefited from social work help, a few strongly favoured the support provided by LAC. One parent contrasted the fact that the LAC took her seriously with what she considered to be dismissive attitudes of education and health professionals, for example, some of whom had been "terribly terrible brutal" in the way they spoke to her family. Individuals contrasted the LACs' informal and positive approach with the type of response they had received elsewhere:

"It's different from social work, these professional people. Professionals kind of put you down but [the LAC] stands alongside you and helps you."

Working across traditional service user boundaries

From cradle to grave

From the outset, LAC in Stirling has been offered to people of all ages. Although the work is funded through Adult Services, it was decided to include children because building up long-term trusting relationships from an early age, without disruption during the transition to adulthood, was seen as key. It was not expected - and has not been the experience - that individuals will need support all the time but they are likely to need it at certain key points. Managers recognised that public services often let people down through breaking off relationships, so consistency is vital. One LAC is currently working with people aged from 9-89. The wide remit did not appear to have caused any difficulties. While some different skills and knowledge may be required to work with such diverse age groups, the LACs felt that the core principles apply in the same way to everyone. The ease of access to LAC in Stirling was highlighted when one LAC tried to arrange local area coordination support for a person aged 37 moving to another authority, where LAC was only available to people aged 10 to 24.

As noted above, a fourth LAC was about to take up post in Stirling, with a focus on transitions, primarily from school to adult life but also from primary to secondary school. Although Stirling Council has a transitions strategy in place, it has been recognised that this works better for some young people than others. Senior managers noted a tendency to 'put people on a treadmill' of college courses which may not be appropriate for every individual.

Across service user groups

According to senior managers, the expansion of LAC in Stirling was "well thought out, targeted and focused." The decision to include people with mental health issues was largely based on feedback from individuals and families about the type of support they wanted. The Service Redesign Team then saw a funding opportunity in Section 26 of the Mental Health (Care and Treatment) (Scotland) Act 2003, which places a duty on local authorities to promote well-being and social inclusion, through cultural and recreational activities, training and help in securing employment. A proposal for a LAC post was accepted by the Mental Health Steering Group. Although different funding streams require each post to focus on a certain area, because working across traditional service boundaries is part of the LAC ethos, the LAC Development Manager was keen to avoid 'pigeon holing' people by having particular LACs working with individuals purely on the basis of diagnosis or 'label'. Therefore decisions about whom each LAC works with are made on an individual basis, an arrangement which senior managers said they were 'content with'. One suggested that part of the reason why this worked well was the mix of disciplines within the LAC team - community education/development, psychology and social work/mental health. Asked if there were any particular challenges in engaging people with mental health issues in LAC, the worker with main responsibility for that area suggested that motivation was sometimes a factor. However, while people may not see themselves as needing a social worker, the relationship with a LAC is different, not least because the latter has no statutory role and engages with people at their invitation.

Looking towards the future, senior managers also see a role for LACs working with older people. One respondent noted that while various models for working with older people have been tried, such as Better Government for Older People, none, in her view, had been successful. She believed that LAC "could blow a hole through a lot of current practice with older people." It was also suggested that ideally LAC would eventually be on offer to 'people with support needs' generally, so long as this did not conflict with the authority's statutory responsibilities or structural arrangements.

Outcomes for individuals and families

As noted above, there was plenty of evidence of people having access to more supports and services than before. These included practical, financial and emotional supports, the introduction of care managers, advocates and support workers and help with transport, housing and educational support. However it was also striking that in some cases LACs' intervention had resulted in individuals requiring less formal support than before. For example, one man who now has a paid job had reduced his care package from 50 to 5 hours a week. Another now had the confidence to say that he could manage with two hours a week help with cleaning instead of four. Senior managers had asked the LAC Development Manager to begin recording quantitative outcomes, noting that where people were diverted from entering the care system or an informal or voluntary sector support was provided in place of a statutory one, this freed up resources for other people. Managers are also keen to estimate financial savings associated with LAC. Notional costs have been put on differing levels of care management support and the plan is to assess what level of support a person using LAC would have received had they also, or solely, been a care management client.

It was clear that individuals and families were generally better informed, in some cases significantly so, about services and support available. The LACs were seen as a useful source of information, particularly about how 'the system' worked and who to contact for help with specific matters. After years of trying to source information and support, this was a welcome relief for some parents:

"When you need something, you never know where to go. [The LAC] is there to find out for you who provides that service. And when you first find out that your child is disabled in some way, you don't know who to go to. Nobody tells you. You go to the hospital and they say 'this is what your child's got - goodbye'. And you think 'now what?' …And to have someone say 'right, this is me; I'm going to arrange everything that you possibly could need' would be a great idea."

An individual pointed out that not only did the LAC give him information, she explained what it meant and how it applied to his situation. People also appreciated the LACs' advice although one added that decisions were not made for him.

Individuals and families reported that the LACs had presented them with options and encouraged them to make choices, for example, about social activities and where to live. One person commented that he had "got everything he had asked for". However a couple of parents pointed out that choice was restricted by the resources available, with one mother highlighting the lack of activities for young people on the autistic disorder spectrum. Senior managers recognised this kind of limitation on choice, while also suggesting that growing capacity led to increasing choice. Finding a resolution to one person's issue could widen the known options for others: a recent example concerned support looking after pets.

Examples were found of increased social activity for people and also in some cases, new friendships and improved family relationships. The LACs had supported a number of people to go out socially and join in community groups and this in turn could lead to wider social inclusion. For example, one man had always wanted to try bowling on grass. The LAC identified a local bowling club and introduced the person to the secretary. After attending the club for the season, this individual found that people were now speaking to him in the street, whereas previously they had only waved. He had commented: "I used to be in the community, but now I feel part of the community." Another good example of new friendships comes from an initiative whereby the LAC supported several young people to join in a Youth Club which wanted to be more inclusive. An Employability manager highlighted the social benefits of work now being enjoyed by a couple of people who had been supported, by him and the LAC Development Manager, to obtain paid jobs:

"It's providing employment for two guys whose lives have been changed by employment, which happens - people forget there's more to employment than just like financial gain. It's all about meeting other people and going to the works night out and things like that- and this is what's happening to these two guys now."

As illustrated above, the LACs have helped develop new day opportunities for a number of people, notably paid employment. Working closely with EmployAbility Stirling, for example, the two jobs referred to above were created to solve the problem of disposing confidential waste within the council. The LAC Development Manager and EmployAbility Stirling have also agreed a pilot project with the Council whereby, when certain ring fenced posts fall vacant, they will be referred to EmployAbility Stirling. Any likely candidate on their books will have an informal interview with the relevant Manager, a work experience trial and, if all parties are satisfied, secure the paid post. This is an example of positive discrimination which will also save the Council money. A third example of collaboration between the LACs and the supported employment project concerns the employment of cleaners for the LAC office. This three hour a week paid job is allocated to different EmployAbility clients for six months each, thus allowing a number of people to gain work experience. Two people who have occupied the post now have full-time jobs.

Along with the wide range of new supports and activities for people has come an increased sense of confidence and well-being. This was reported by the LACs, the senior managers and colleagues in other agencies but, most importantly, by families and individuals themselves. One mother said the LAC "took a weight off me" while people with learning disabilities said they felt more capable, more able to speak up and more sure of themselves. These important outcomes can be attributed to the feeling of being valued and respected by the LACs and encouraged to try new things for themselves. The project leader of the youth group commented:

"[ LAC] makes them think they're worth more than what people have given them credit for; they're hugely to be admired."

Equally important, one mother described her son as 'much happier' following the LAC's support.

Outcomes for Communities

The LACs have contributed to raising awareness of disability issues in the community in various ways but perhaps two projects stand out. First, they supported the local self advocacy group, the Quality Action Group ( QAG), to develop and deliver disability equality training to front line staff in several settings. The training was also delivered to an audience of 150 people at an annual meeting of the Scottish Union for Supported Employment, with 'fantastic feedback'. Senior managers now want Human Resources to include the training within induction for all Council staff. If that happens, it could provide three jobs for people with learning disabilities.

Secondly, the LACs introduced some young people to Braehead Youth Group and this had led to the filming of a DVD about bullying and inclusion, starring six disabled and non-disabled youngsters. The project, funded by the Council, was launched at an evening event in a high profile local arts centre to an audience of over 200. Again, there was a positive response with group members receiving appreciative emails from the Chief Executive of the Council and the Chief Constable of Central Police Force. Current plans centre on taking the DVD, as part of a presentation, to schools, youth clubs and uniformed organisations to demonstrate, the Project Leader said, that "just because you're disabled doesn't mean you're not able to get a job or drive a car."

Both projects show evidence of the LACs helping develop leadership among disabled people. The young people involved in the DVD had completed Evidence Folders to qualify for a Youth Achievement Award from Youth Scotland. There was an estimated core of about 30 disability activists in Stirling, a relatively high number. While many of these were supported by the Quality Action Group, its staff and members highlighted the important role of the LACs in introducing people to the group and finding individuals to support them attend its activities. The LACs also supported three QAG members to attend the local same as you? Implementation Group.

The Stirling LACs have not set up any support groups as such. The Development Manager did not think it appropriate for his team to set up groups 'for' people with learning disabilities. Priority is given to enabling individuals to join mainstream groups and supporting the latter to become more inclusive.

As already evident, the LACs had developed links and networks across a range of agencies and groups. With some, they worked very closely on specific projects; others they liaised with on behalf of individuals and families as required. They also supported people to raise issues about gaps in services or poor professional practice, or did so themselves if necessary - described by one senior manager as "making appropriate challenge". In one manager's view, the LACs' approach, which sometimes provided an alternative perspective on people using services, had enhanced the 'person-centeredness' of other services, including care management.

DISCUSSION AND CONCLUSIONS

There are a number of strengths in the way Stirling has implemented LAC. It has remained close to the core principles, for example, working across traditional service boundaries of age and 'client group', setting up an easily accessible 'shop front' and focusing on community capacity building as well as work with individuals and families. The only obvious deviation is the large geographic area the LACs cover, although this was not identified as problematic. Everyone we spoke to gave a positive account of the LACs' activities in relation to both process and outcomes. Stirling's success appears to be the result of a number of key factors coming together:

  • real commitment to LAC on the Council's part from the outset
  • strategic positioning of the LAC Development Manager, in terms of level and location
  • the council structure does not have 'departments', facilitating work across boundaries
  • political support
  • enthusiastic, imaginative and experienced individuals employed as LACs
  • the diverse professional backgrounds of the LAC team
  • the LAC Development Manager has a community development background
  • the presence of other progressive, user-focused projects eg: EmployAbility Stirling and the Quality Action Group
  • clear understanding of the difference between LAC and care management and energy put into developing a complementary relationship
  • commitment to build capacity in individuals, families and communities - to support them to do things for themselves rather than doing things for them.

MIDLOTHIAN

Introduction

Midlothian was selected as a case study area because it is one of three authorities in Scotland where the LACs are employed and managed by a voluntary organisation. Midlothian covers an area of over 35,000 hectares and has a population of nearly 80,000. The geographical area covered by the LACs in Midlothian includes Bonnyrigg/Eskbank, Dalkeith/Woodburn and Mayfield/Easthouses 18. In Midlothian overall, there is a higher incidence of limiting long-term illness, unemployment and drug and alcohol misuse than the national average. Midlothian also has the second highest ratio of adults (aged 16 and over) with learning disabilities: 6.4 per 1,000 populations. There is a high rate of claims for Incapacity Benefit, Severe Disablement Allowance, Disability Living Allowance, compensation awards for mining-related diseases and Income Support in the areas covered by the LACs, thus exemplifying the levels of poverty, disability and social exclusion present in those particular communities. These areas also have higher than average rates of social work referral compared to Midlothian as a whole 19.

There are three FTE posts in Midlothian, covered by four LACs, two of whom job share. One of the LACs is a manager/practitioner who provides the day to day management and supervision of the service. She herself is managed by the Director of Services for the Thistle Foundation, an organisation which works directly with people with learning and/or physical disabilities, and which holds the three year contract to deliver a LAC support service in Midlothian.

The case study visit by the research team was spread over 2.5 days and included shadowing one LAC on a visit and face-to-face interviews with the following people:

  • the four LACs
  • the Thistle Foundation manager
  • a representative of a church social group
  • the manager of a community network support service
  • 4 individuals living within the family home
  • 4 family members (one partner and three mothers)

The case study also draws on the Information Sheet and two original interviews, one with the Social Work Department Planning Officer for Learning Disability in Midlothian and the other with the LAC manager/practitioner.

Background to the implementation of LAC

LAC in Midlothian started in 2003 as a result of the implementation of The same as you? recommendations. Partnership arrangements already forged between Social Work and The Thistle Foundation over previous projects within the Authority, led to the commissioning of The Thistle Foundation to provide local area co-ordination because it was recognised that the value base of the organisation matched those of the original concept of local area co-ordination as it is practiced in Australia. It was always envisaged that LAC in Midlothian would adhere to the 'across the board' model of disability adopted in Western Australia. This model of LAC also encouraged a certain distancing from the statutory sector in order to support and facilitate alternatives, choices and strategies for people, and to emphasize capacity building within local communities. The Thistle Foundation already had close links with local communities and their value base was seen as highly complementary to that of LAC.

Overview of role and remit

Although the Thistle Foundation manages the contract with the LACs in Midlothian, the LACs' office base is within the grounds of a residential home for older people run by the Social Work Department. Although they do not have the potential 'stigma' of being based in a social work office, the LACs are nevertheless not readily accessible to the local communities they serve, and their premises have limited wheelchair access. They generally meet people in their own homes or in cafes or other public places. Service users who live locally to the office base and who are mobile will often spend time on the premises. The office base is also used extensively by other specialist professionals in the area who are involved with the same service users, as they feel they are in a familiar and comfortable space. This has included counselling services, social workers and other support organisations in the area.

The remit of LAC in Midlothian is to work with people from birth up to the age of 65, across the whole of the physical and learning disability ranges. The three year contract with Midlothian Council states that the LACs would aim to work with 20 'cases' in the first year, 40 in the second and 60 in the third. At the time of writing, the LACs were working with, on average, 54 individuals and 20 families, although it should be borne in mind that when working with individuals, there is an inevitable overlap with the wider family. Although they have links with a number of community groups, the LACs have specific involvement with six currently. Each LAC has his/her own geographical area to cover, and this arrangement seems to work well, not least because each LAC can immerse themselves in their own locality and make useful individual and professional contacts. However, from conversations with individuals and their families, it seems that all the LACs are known to the families irrespective of who is the named worker and this has obvious advantages when LACs are on holiday, for example, and an individual or family requires assistance or advice.

However, the role of LAC generally is not clearly defined. One LAC suggested that this may have some advantages:

"Every time I go in to meet a new individual, it's a person-centred situation for me. I do not know what's going to be required of me till I go and speak to somebody. Sometimes it's a straightforward request for information and sometimes it's about building through trust and empowerment to a point where a service user is aware of options and how to access them. These things may not happen immediately - they might be worked out over time."

Individuals' and families' views of LAC

Whilst some of the individuals or carers we spoke to had known the LAC team for almost the duration of the project in Midlothian, others had known them for less than a year; however, they had only positive things to say about their involvement with LAC. One of the most valued aspects of the LAC role was the companionship, the getting alongside people that the workers could offer: "I had someone to speak to for the first time in ten years". The LAC worker was also described as: "an extra pair of ears"; "somebody to moan at"; and "someone different to talk to", albeit a professional set of ears. One carer summed up the mood of many when she said:

"More than anything, she's a friend and that's what I want. She's got the knowledge and all this, but I still want her to be 'come on, you're alright."

Other traits mentioned by individuals and families were that they could share confidences with the LAC, felt supported and could trust them. The LACs were also said to be caring and compassionate, approachable, enthusiastic, respectful and person-focused. Carers were also conscious of the fact that the LAC could be there for them as opposed to just being interested in supporting the person that they were caring for. Indeed, in some instances, the focus for LAC support was purely on the carer rather than the disabled person for whom they were caring.

The majority of people interviewed in this case study had been introduced to LACs through social workers. It was not possible to interview social work staff for this evaluation and it is therefore unclear why social workers had introduced people - whether for positive reasons (i.e., the LAC input was deemed more appropriate) or for more expedient reasons (i.e., social workers either did not have the time or the resources to work with individuals themselves). Comparisons were made between the time and commitment that LACs put in to their involvement with users and families and the time and commitment that social workers were able to provide, based on pressures of work. The LACs were seen as always being available and on the end of a phone, whereas social workers tended to be perceived as 'too busy' and unable to respond immediately to calls for help. One carer, whose son had high support needs and was about to leave school, indicated that she had to take her concerns to senior management level in the social work department before this young man was finally allocated a social worker:

"It seems to be all young ones in the social work. This is the most important time in my laddie's life, with leaving school and going on to something else. I felt as though I needed someone with a bit more experience."

This mother, amongst other carers, spoke highly of the advice, guidance and friendship that the LAC could offer, not least in accompanying her to visit potential services for her son as he became older. The LAC's indicated that they are aware of the need to deliver a service with a light touch, one which uses all their experience and training, whilst genuinely working to empower the individuals they are involved with. They suggested that this can often give rise to tensions around perceptions of what they actually do.

The LACs indicated that as a team, they spent a great deal of time considering ways of supporting people which would empower them as individuals, and families. This is done by working in person centred ways and employing a range of skills. Diverse tactics are employed for different people, situations and occasions. This can include solution focused therapy, person centred plans, physically accompanying people, acting as advocates or key workers, or sourcing appropriate information as required. As one LAC pointed out, tensions can result from other professionals perceiving them as 'befrienders' when they consider their interventions to be based on 'empathy coupled with a dynamic approach'.

Voluntary Sector Management of Local Area Co-ordination

The Thistle Foundation has values very similar to those of LAC, and their value base and dynamic and person centred approach was considered appropriate for managing LAC. Indeed, the manager at the Foundation described the LAC role as a sometimes "quiet, peaceful, respectful intervention", along with a vigorous person centred approach to the work. This appropriately sums up not only the ethos of LAC generally but also the work being undertaken in Midlothian.

It was suggested in interviews with staff that a small voluntary organisation like the Thistle Foundation is ideally placed to undertake LAC work along the lines envisaged by Eddie Bartnik in Western Australia. Such organisations are well suited to community development models and approaches of empowerment, building relationships within local communities and empowering individuals and communities. The statutory sector, on the other hand, especially in relation to community care, was increasingly perceived as care management oriented and less able to work with rather than for families and communities more generally. It was suggested that the statutory sector tended to work reactively with 'problems', rather than proactively with 'opportunities for change'.

With many statutory services, involvement with a service user can be around specific areas, usually when a situation is reaching some sort of crisis, after which the case is closed; however, with LAC, the involvement can be ongoing, as long as the individual desires it. Staff in voluntary settings are often considered to have fewer formal qualifications than statutory workers (for example, not necessarily requiring a social work qualification). However, the Thistle Foundation is a well-established and well-resourced voluntary organisation, thus enabling the LACs to access a wealth of training that is relevant and often customised to their particular needs, training which might not be available or affordable to staff in the statutory sector.

One of the potential tensions that may arise for LAC being placed in the voluntary sector is the issue of funding. It may be hard for a local authority to justify funding a voluntary organisation to do a piece of work when that local authority itself may be cutting back on budgets or making staff redundant. Indeed, several respondents described LAC as 'the icing on the cake' of local authority provision. Whilst such a tension has not yet arisen in Midlothian, LACs suggested that social workers often commented on the scope and intensity of the work that the LACs can do with individuals and families, wistfully recalling that such work was what 'traditional' social work used to be all about but that it had been superseded recently by more of a 'hands-off' case management role.

Voluntary sector organisations tend to be seen by the general public as more informal and accessible. Many users have suggested to the LAC workers and Thistle Foundation staff that they were perhaps more approachable than the statutory sector because they do not have statutory, or financial gate keeping powers over the people that they work with. This could mean they were not perceived as having any 'hidden agendas' in terms of control of funding and access to choice. Users and their families also viewed their experiences with LAC staff within the voluntary sector as significantly different to those experiences with some statutory sector staff. Whilst several individuals and families interviewed in Midlothian voiced concerns about the capacity of social work and other statutory agencies to have either the time or the resources to listen and respond to their ongoing concerns, they were almost unanimous in praising the approach of the LAC staff as being empowering and facilitative. As one LAC worker explained:

"They see the approach as different and they appreciate the approach… We're there to find out what it is they might be looking for, rather than telling them what we've got."

Community capacity building was described by one professional as "helping people to find the answers to their problems, because, they're the experts", but also includes, helping people access the correct information at the right time to enable them to find their own answers; helping communities to access information and advice, to 'demystify' disability, to break down barriers, to make connections within and between communities and to build the strength and knowledge of those communities. At the outset of their involvement in a given community, the LACs in Midlothian do a 'mapping exercise' of the area, and become intensive 'networkers' in order to identify what services and facilities are available, what local activities and groups are present in the area and where gaps exist in service provision. The workers visit local agencies and groups, often giving talks or handing out leaflets about their work. They are also members of various disability or mental health committees as well as attending local groups. This kind of representation within the local community was seen as all the more important given the fact that they are not officially working within the statutory sector: the LACs felt it was strategically beneficial to be more involved in statutory as well as voluntary sector policy and practice initiatives in order to remain influential. This part of the LACs work was described as painstaking and perpetual, involving much diplomacy. Since success for a service user often relies on the workers ability to support people to make beneficial connections, it is an essential component of the work that other professionals in the area have good positive working relationships with the LACs and vice versa.

Although the Midlothian LACs indicated that they want to increase their involvement in community capacity building, the workers currently estimate that 20 per cent of their time is focused on this aspect of the work, with 80 per cent being more person or family-focused. Nevertheless, their involvement in one-to-one work inevitably impacts on the wider community and indeed may involve the wider community. For example, several agencies are now considering involving disabled people or those with mental health issues as volunteers or workers and LACs have been instrumental in widening the remit of several informal groupings to include disabled people. The Thistle Foundation itself is also involved in a campaigning role more generally in Scotland in relation to, for example, disability awareness, access issues, employment rights, and so on and encourages the LACs to do similar work in Midlothian. The LACs do not want to change communities or individuals so much as to "strengthen people where they are", as one LAC worker put it, in order to empower them to better negotiate their own worlds.

LAC in Midlothian was originally guided by a Steering Group, comprising: LACs, the voluntary organisation manager and two members from the local authority. Individuals and families were not represented on the Steering Group as the local authority was seen as initially 'reluctant' to involve them, "until it was felt their inclusion was natural and meaningful". LACs felt that they now knew several people who could play a meaningful role. The Group has been in abeyance for the last few months. However, if it can be resurrected in the near future, there is a strong desire from the LACs and the Thistle Foundation that individuals and families are represented. Meantime, however, there has always been and will continue to be user involvement in recruiting LAC staff.

Outcomes for Individuals and Families

There will always be some tension between local authority requirements for 'hard' outcomes to allow continued support for a service, and the reality that for many of the individuals and families that LACs work with, it may be the intangibles that bring about the biggest changes. For example, the way in which a person is communicated with, a sense of empowerment brought about by being addressed as an expert in their own life. While stories and anecdotes are often regarded as 'soft' evidence, they are often perceived to be the best way for people using person centred approaches to document changes in people's lives. They do however remain, difficult to define or identify. Whilst the LAC team is working on formulating ways of identifying and measuring what they do so as to be better able to provide 'hard' evidence of effectiveness, there is an inherent dilemma for LACs about how to measure and communicate the effectiveness of their work, as the following quotation illustrates:

"People find it hard to grasp, what is LAC? What does it do? And because it doesn't have the hard outcomes attached to it, what difference is it making? And what Eddie Bartnik is saying is that the more you know what LAC is doing, the harder it is to actually grasp what it does, because it's just doing it. It's hard to actually say what it is."

With that proviso in mind, the following sections attempt to formulate the views of respondents about the outcomes of LAC for not only individuals and their families, but also for communities more widely.

Specific outcomes for individuals and families to date have been both practical and personal. In terms of practical outcomes, LACs have been able to encourage families to arrange holidays or short-term care, have helped individuals to travel within the local community independently, to find employment or voluntary work and to gain their own tenancy. One family felt increasingly unable to get out and about because of their relative's increasing physical impairment. The LAC in this case gathered useful information about the implications of that condition, thus helping the family understand it better, and encouraged them to plan a long-earned holiday. In another case a school pupil had been told by her school that she was unable, because of her impairment, to be included in mainstream activities. The LAC set up a meeting between the mother of the girl, the head teacher and the education department's integration service. There followed a successful intervention by an educational psychologist, and ongoing support to the family from the LAC, which resulted in successfully breaking down the barriers, to the pupil's desire for greater integration and interaction with her fellow schoolmates.

More personal outcomes have included increased self-confidence or self-esteem because of being able to feel more in control of their own lives and improved opportunities; increased access to information which can help people to make positive and informed choices; one to one work to overcome feelings of claustrophobia, depression or isolation; and greater access to mainstream opportunities that did not require a 'service' as such, whereas before individuals and families assumed that there were only 'special' services available to them through statutory channels.

Other less easily defined outcomes could be that many people who contact LAC would not otherwise have received any support because they would not have approached the social work department, for example. Equally, many individuals have been referred on to social work or occupational health so that they can access services which they would otherwise not have known about. LACs have also been asked to support an individual and in doing so have found that the wider family is also in need of support, thus identifying needs which may not otherwise have been picked up.

Although LAC support can increase choice for individuals and families, this can only be achieved within the confines of what services are actually available, and several respondents commented on the limited scope for choice or change given the availability of services currently in the area.

Outcomes for Communities

If outcomes for individuals and families are seen as difficult to pin down, outcomes for communities could be seen as even more nebulous. However, various examples are given here which illustrate the potential of LAC for community capacity building and strengthening social capital. As mentioned above, the LACs 'map' the area at the start of their involvement in a community and they can then share that information with the community, both with individuals and professionals and can often act as mediators or facilitators in establishing community and agency links. For example, in one instance the LAC put one agency in touch with another so as to enable them to combine resources and share the financial responsibility of organising transport to and from a holiday caravan site for various service users. A walking group was also set up by an individual who wanted increased social contact and activity. This piece of work was an example of a complex web of communication, networking, empowerment and community building by the LACs, which has resulted in an apparently 'spontaneous' forming, of a very cohesive group, whose activities touch on health, well being, self help and social interaction. The woman in question had been encouraged by the LAC to attend a coffee morning at the local church where various strategic connections had already been made, this resulted in other people joining her and a natural group began to form which involved some existing church group members as well as other people from the area who were experiencing physical and learning disability, depression and other mental health issues, bereavement, and social isolation. As well as being described by one member as a group of people that can "meet, just to discuss, to have a cup of coffee, to cry together", the main thrust of the group has been walking and active self help. The group members have also been involved in fundraising activities for themselves and other charities. Whilst LACs have joined the group on many occasions, it is increasingly becoming self-sufficient and there is still some connection to the church coffee morning membership.

Barriers to successful outcomes, both at an individual and community level often revolve around attitudes, both professional and lay. Disability awareness is often limited amongst the general public and apathy was cited as a possible barrier to improving the scope for inclusion of disabled people within mainstream services. Equally, where there is no appropriate service identifiable for an individual or family, the LACs may have to work creatively to overcome financial or practical constraints. It was suggested by the LACs that both service users and their families can create barriers, however unwittingly, to improved opportunities for themselves because of a fear of the unknown or a preference for the status quo. Individuals may also have low expectations of what they can achieve, based on previous experience of a seemingly limited scope for change for disabled people.

Barriers to successful outcomes for communities in Midlothian are partly similar to those barriers for individuals - attitudes of the public to disability, apathy and resource constraints. However, one other barrier which respondents mentioned in relation to Midlothian is more historical or cultural - territorialism. The area is made up of former mining towns where people tend to 'look after their own' and have little involvement in the wider community. Groups therefore tend to be highly localised and exclusive and there is often limited scope for intermingling of groups or individuals between geographical boundaries.

DISCUSSION AND CONCLUSIONS

The geographical area and remit of the LAC workers in Midlothian is expanding rapidly, helped not only by the good reputation of the workers among both professionals and families alike, but also by the thorough mapping exercises and networking that the LACs undertake during the initial stages of involvement in a given community. The workers are managed by a voluntary organisation but nevertheless see themselves as working first and foremost for Midlothian service users, an attitude encouraged by the Thistle Foundation, and being somewhat at arms length from the statutory sector serves to enhance their independence and autonomy. Equally, whereas social workers have the capacity to work around specific problems, LACs have the capacity and resources to work more holistically, focusing on the person rather than the 'problem' and starting from where the person is at rather than from where the worker expects them to be.

Although capacity building at both individual and community levels is increasing, further involvement of users and carers and arguably the wider community would further enhance the LAC ethos of being community-based and person-focused. The project is also well placed within the Thistle Foundation to take on a greater campaigning and advocacy role within the wider community alongside individuals and families.

The LACs are seen as valued members of the local community by individuals and families alike. LACs in Midlothian are aware of the need to more closely monitor and evaluate their work so as to satisfy the needs of funders and policy makers and to this end are currently involved in discussions and training about how to differentiate the more tangible parts of LAC, how to evaluate their work to ensure that their objectives are being met and how to identify the differences between what LAC can deliver that is different from and complementary to other services in Midlothian.