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

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CHAPTER SIX DAY TO DAY WORKING

INTRODUCTION

This chapter focuses on LACs' daily activities, workloads and perceived achievements and outcomes. Attention is paid to distinctive features of LAC and to the values which drive and underpin much of the work. Most of the data are drawn from interviews with LACs although two items from the Information Sheets are included. The chapter begins by looking at the various ways in which LACs work with people.

"Introductions"

As noted in the previous chapter, most LACs spent the first weeks or months of their job meeting people, networking and raising awareness of their new role. In this process, many had made contacts that led, direct or indirectly, to finding people to work with. In three authorities, however, LACs had deliberately kept publicity low key because they did not have the capacity to work with many people. The most frequent route to working with people was through 'referrals' from agencies. Social work departments provided most referrals but schools, health care professionals including GPs, supported employment agencies, voluntary organisations, community centres and in one case an organisation of people with learning disabilities had also identified potential users. In 10 authorities, LACs stressed that they did not take 'referrals' in the conventional sense and preferred to think in terms of 'introductions': they could only work with people who invited them in.

"I mean basically it's like the ethos of the LAC as well, that we only go and visit people if they want us in their life, you know, so it's totally at the person's invitation. It's not seen as, you know, like your social work…maybe the person doesn't want [a social worker] or whatever. It's always at their invitation that we go in and we would withdraw if they wanted us to withdraw."

The second most frequently mentioned introduction route was through word of mouth and the third, self referrals. Some LACs believed it advantageous that they had previously worked in the locality and were already well established and known to both agencies and service users. A few had carried on working with some previous 'clients' in their new capacity as LAC. However, one manager sounded a note of caution about staying within a 'comfort zone'.

In contrast, in two authorities LACs could only work with people who had gone through the 'normal' social work referral and allocation system while in a further two authorities, a line manager 'gate kept' or 'checked out' which referrals were appropriate for LACs. On taking up appointment, a fifth LAC found that a named group of individuals attending a resource centre had already been identified for him to work with.

Numbers of people LACs work with

In the Information Sheets, LACs were asked how many people they were currently working with. The number of families with whom individual LACs were working ranged from a minimum of two to a maximum of 47 while the number of individuals (as opposed to families) ranged from one to 42.

Table 4.1 Number of individuals and families LACs work with

Number of LACs

Families

Number of LACs

Individuals

26

2-9

20

1-9

9

10-19

7

10-19

7

20-47

16

20 -42

Twenty-six LACs reported working with fewer than 10 families, nine were working with between 10 and 19 families and seven were working with 20 or more. Twenty LACs were working with fewer than 10 individuals, seven with between 10 and 19 individuals and 16 with 20 or more individuals. Even allowing for the fact that some LACs had not been in post very long, the numbers show considerable variation with a substantial proportion of LACs working with fairly low numbers of people. This was largely due to local practice issues and LACs acknowledged that they had envisaged having contact with relatively large numbers of individuals and families, rather than intensively supporting a small number of people. One experienced LAC had this to say about numbers:

"My judgment was after I had ended up supporting 50 odd people I had to go to the Strategy Group and say this is becoming unmanageable for me. My judgment was that the maximum that somebody could support would be about 35 people. Eddie Bartnik said 'no, between 40 and 60' so I was exploring with him about what does that mean? He said … 'you don't want an individual LAC becoming complacent in the role and just meeting folk for the sake of meeting folk. They should be thinking about the supports that they are providing for the person.' So…he convinced me that, maybe OK, my judgment was 35 but you are not that far away you know. But what he said is there is no way somebody could work with 60 intensively."

LACs estimated that an average of almost 40% of the individuals they worked with also had allocated care managers/social workers (with a range from zero to 100%).

Proportion of time spent on different activities

On the Information Sheets, LACs were asked to estimate the time per week typically spent on different activities. The overall average was 37% working with individuals, 25% with families, 13% with community groups, 15% with service providers, 7% on administration and 2% on other tasks such as supervision. However, there was considerable variation between respondents. Time with individuals was said to vary from 5% up to 100%, time with families had a maximum of 60%, as did time with other service providers, while time with community groups had a maximum of 30%.

Day to day activities

In the interviews, LACs were asked to describe a typical day. This usually evinced detailed accounts of busy days filled with a wide range of activities. One respondent gave us a written account which is reproduced, with her permission, in Annex Seven. Despite the diversity of work, a number of common features can be identified.

Many people's first response to this question was along the lines "there's no such thing as a typical day!" This was not just due to the variety of tasks undertaken but also

"Diverse - I think because it is needs-led and it is dictated by the individual."

Another sense in which LACs do not have 'typical' days is that working hours can vary to include evenings and weekends, with some regularly attending evening events.

There were also similarities in the mix of work described. Most LACs started the day in the office, responding to messages and following up work from the previous day, for example, finding out information for someone or making relevant connections. Most tried to keep administration to a minimum and 'typically' divided their time between visiting and meeting up with individual service users and their families, networking with community groups and, when necessary, attending meetings. Many specific examples were given of supporting individuals and families. One LAC reported that the previous day, after calling in to the office, she had transported a young man with a degenerative condition to the local supermarket where he works in the mornings. Having seen him settled in, she went away, returning a couple of hours later to take him home, where she talked to his mother about supporting him to travel independently. In the afternoon, the LAC took a disabled single mother to her first trampoline class, 'staying in the background' herself. On returning to the family home, the LAC spent some time engaging with the woman's four young children, all of whom have learning disabilities. For this LAC, working intensively with a couple of people was a fairly typical day. Others described a combination of short term and long term work or, as one respondent put it, "sometimes it's full on and sometimes it's not." She continued:

"Sometimes we'll be going with people to do the things that they said they would do, like going to a course or going to a class, going to a hospital appointment, going to a graveside, all the things that…sometimes sadly going to hospital appointments to see them because they get ill. We do the follow up work in the office. We'd be going out looking to see what other people in the area are doing, what other professional people are doing in the area, finding out. We would be doing training."

Although there were more similarities than differences in LACs' accounts, there was some disagreement about the type of activity appropriate to the LAC role. For example, two LACs had been invited by local schools to attend all Future Needs Assessments Meetings. One had welcomed this as a 'way in' to identifying youngsters likely to need support in the transition from school to adult life; the other had declined the invitation on the grounds that the young people did not know her, had not invited her to attend and she should not routinely spend time in meetings. She was however happy to offer support to individual pupils if particular needs were identified which fell within her remit. Another activity which attracted very different views was setting up groups, as discussed shortly.

LACs' activities were also mediated by the environment they worked in. For example, working in large rural or island authorities carried implications in terms of time and logistics. One LAC used his car as an 'office' and occasional meeting place because the distances involved were too great to keep popping back to his base. In order to attend a learning disability partnership meeting every six weeks, a LAC in an island authority left home at 6.30 am to catch the early ferry, then drove for an hour and 20 minutes to the meeting. In the winter, the last ferry home was at 2pm so she had to stay on the other island overnight.

Outcomes and achievements

Work with individuals and families

LACs were asked about the impact of their work on people and communities. They all identified some positive outcomes: their responses fall into three broad categories - a better overall quality of life for people, specific examples of difference in individual lives and areas of work which LACs believed showed improvement. Concern was expressed about the use of quantitative measures such as the number of 'natural friendships' developed (see Bell, 2005) to assess results in some authorities: these were not considered compatible with the qualitative outcomes LACs were trying to achieve.

In terms of quality of life, several LACs reported that people with learning disabilities whom they worked with had grown in confidence and self-esteem. Knowing they had an ally and were no longer 'alone' made them feel stronger. They found it easier to speak up and make their views known. People were said to enjoy greater choice and opportunities than before, to be more included - and benefit from - collective activities and to occupy socially valued roles by attending mainstream college, volunteering or taking up paid employment. A few LACs reported comments made to them by families:

"Some of them have said they would have left home leaving their disabled children and husband if we hadn't gone there. Some of them have said they would have had a nervous breakdown. Some of them have said 'thank you very much, that's all we need to know and that's been great' but it feels to me in talking to them that they really value the service."

"One 80 year old that I met during that period who had a 45 year old Down's Syndrome son said to me quite early on, she said 'you are the first person that has come into our lives that has talked positively. All my life professionals have said to me no, no, no, can't, can't, can't.'"

There were plenty of examples of work with individuals or families where LAC was said to have had significant positive impact. It is noticeable that most of these were not crisis situations but, again, revolved around supporting people - often young people - with a poor quality of life to gain the confidence to extend their horizons, venture outside their safety zone and try something new. There were various instances of LACs spending time getting to know individuals who were leading very isolated and apparently impoverished lives, accompanying them on one to one outings or supporting them to join in group activities and then withdrawing or planning to withdraw when the person had settled in. It was stressed that what might seem, to outsiders, a relatively small or unremarkable development in a person's life might have great significance for that individual or their family:

"The impact can be huge, but I think wee things are what make the difference."

One young man who was said to have spent 'the best part of the previous three years in his bedroom' was now attending college. Another man aged 22 had been used to his mother doing everything for him, including washing, dressing and cooking: as a result of the LAC slowly but persistently working with his mother, the young man was now much more independent, and looking towards independent travel. In another authority, a LAC had been working intensively with a school leaver who became homeless, was overdosing on drugs and self harming. The LAC reported:

"The [hospital] said she has made remarkable progress and she had a job over Christmas; it was only a seasonal job but she is looking for another job again. Relationships with her family have really improved. She is bidding for a house now."

Some LACs chose to identify specific areas of work where they felt they had made an impact. These included transitions to adulthood, work with families, welfare benefits, long-term planning with people and raising awareness of disability issues among the wider community. In two or three authorities there was evidence that LAC activity had reduced the number of people with learning disabilities on the social work waiting list or (where LACs were in effect care managers) done away with it altogether. There were few references to the cost benefits of LAC - although these respondents were not specifically asked about value for money. However, one LAC recounted how she had set up a tenancy arrangement locally for a young man who previously lived in a care home for older people and had been at risk of having to move 25 miles to a residential facility for people with learning disabilities:

"The guy in [town], the support I set up for him with the social work department was £80 a week. Now [that's] £90 a week cheaper than what it used to be in the older people's home. So because we used ILF and Supporting People obviously the money came from other budgets."

Community capacity building

Only six LACs identified community capacity building as an area of significant achievement. In 17 of the 24 authorities where interviews took place, LACs admitted that so far they had made limited progress in community capacity building. A number of reasons were cited, the most common being that time spent on work with individuals and families left little scope for wider capacity building. A related consideration was the length of time it takes to build community capacity which, as several LACs emphasised, is a long term task. However, disinterest or even resistance within local communities was also a barrier. A minority of LACs reported there was little community spirit in their local areas, another reported a lack of informal community resources, while a few identified 'ignorance and prejudice' towards people with learning disabilities as significant problems:

"This is my experience, that I think that we are a long way off… because I think a hundred years ago adults with learning disabilities were supported by their local communities, because communities were so small and extended families were so big. Um…but I think we have moved away from that. And I think we are a long way from it ever coming about again."

Other LACs attributed difficulty getting into communities to the fact that they were based outside the areas they worked in, had no drop-in facility, did not live in the community or had to cover too broad an area. One LAC appeared unfamiliar with the concept of community capacity building, responding in terms of working with community based as opposed to institutional services.

LACs in six authorities described capacity building as a particular focus of their work, believed they were making good progress and gave examples to evidence this (a seventh LAC felt she had made some progress). These included working with a theatre group to include young people with learning disabilities, supporting a group of people with learning disabilities to create a sensory garden in a town centre for the enjoyment of all citizens, introducing one individual to a local bowling club and another to a first aid group which in both cases led to wider inclusion opportunities, and helping with a food co-op stall run by people with learning disabilities, through which a number then became volunteers for other local groups. Thus, it was claimed that people with learning disabilities had become much more visible through their participation in a range of employment, volunteering and leisure opportunities. This in turn made the community more aware of and responsive to them. In contrast to the view that communities were not ready or willing to include, here is a comment from a LAC who had supported the setting up of a community café where people with learning disabilities were trained in catering, and which had proved popular with local people:

"I also think in the rural areas there is a lot of potential to develop things as well, a lot of goodwill to kind of get things going. Just like the café is a really good example of that and I could see that you could do lots of other things as well. People are quite happy to help and get involved. I think there is a lot more potential."

Another success factor identified by this LAC was her location in a Community Learning base rather than a social work office. The other LACs who were focusing on community capacity building all had bases within their communities and although not all had drop-in facilities, none was based in a social work office. Another common factor which may have helped promote community building in these authorities was that LACs had previously worked in the area, in three cases with a community development remit. One of the latter suggested it was important to have a specific reason for contacting a community group, such as trying to find a suitable resource for a particular individual, rather than making connections more broadly 'for the sake of it'. He also argued:

"We shouldn't be the all knowledgeable only person around. We need to pull in the other resources that are in communities, the other key contacts. And that's what we need to know, who they are, or where they are, or how you contact the individual."

Distinctive features of LAC

Throughout the interviews, it was very clear that LACs' day to day work was closely informed by a strong set of underlying values. LACs often identified what they saw as distinctive about LAC and referred to its guiding principles. They were also asked to comment on the usefulness of the LAC ethos and whether they had found anything problematic in it.

Person-centeredness was seen as the bedrock of LAC in theory and practice. This involved focusing on the individual's 'needs, wishes, dreams and aspirations', not on services. Priority was given to taking time to build up a trusting relationship with the person and often the family. It meant being on their side, taking a positive attitude to what people can do and achieve, and acknowledging individuals and families as the experts. Person centeredness also required LACs to enable and empower but not to 'fix it' for the people they work with. One LAC summed it up as follows:

"To me the main things are…seeing people as individuals who all have strengths and we all have weaknesses. And just recognising what is there for people and recognising that they do all have strengths. They do all have abilities and focusing on the positives and the negatives for people. Just having a genuine respect for people and individuality."

LAC was also seen as distinctive because of its informal non-bureaucratic approach. As already discussed, people can self-refer, and most LACs (although there were exceptions) do not carry out formal assessments or reviews. One respondent described how she had been able to work with a father and son who had refused social work intervention:

"A social worker was trying to go in and do some Future Needs planning with them but they were just not having anything to do with it. When the dreaded word 'assessment' was mentioned they threw her out of the house. She told me about this and gradually, it has been a very gradual process, but I have got in there and I have been developing a relationship with these two men. I don't go in and mention assessment …and I don't label them. I don't think the man actually believes he has a learning disability and maybe he doesn't, I don't know. He is a fascinating man. He might not have a learning disability but does it matter really? I don't need to put people in categories in order to help them plan for their future."

This account illustrates the flexibility which other LACs described as integral to their approach. The reference to long-term planning also highlights the important preventive aspect of LAC, a point made by several respondents. LACs' ability to spend time with people, get to know them well and strengthen their informal support networks were all seen as important ingredients in helping forestall future difficulties. This was repeatedly contrasted with the social work task which was seen as crisis driven, often with little or no time to build relationship with clients.

A further aspect of LAC, which some respondents expressed more explicitly than others, is, as one person said, to 'rock the boat'. Another respondent pointed out that LAC will only work if it transforms the services around it. It will take time for other professionals to understand and accept this and to change. Part of the LAC role was to present that challenge 'in the nicest possible way':

"I also say to managers 'could I appeal to you before you do your service plan for next year, or before you do your restructuring, could you pause for a wee while and think what it means for the individual and family you are meant to…?' and I think that has worked. I think I have managed to avoid anybody shutting the door on us, and I think that's really important, and I had to learn a lot of diplomacy skills along the way…As soon as you changed the whole social policy of how we support people with learning disabilities of sixty years or so… we had to be understanding of that. And I think if you are understanding of that and you can be diplomatic and you can challenge in the nicest possible way, I think you can get people to come along with you. And I would say that has been my experience."

A number of LACs also identified what was distinctive about the LAC role in terms of activities not perceived as appropriate. However, there was disagreement on some points. For example, LACs from eight authorities spoke at some length about groups they had set up. Their accounts highlight the diversity of approaches to - and views about - promoting inclusion, a fundamental aim of LAC. In two authorities, LACs described 'inclusive' groups, in one case a youth club, in the other, an art group. Both believed it was very important that these were not segregated activities but while one group was run by the LACs, in the second authority LACs did not see that as an appropriate part of their role and were applying for funding to appoint a worker.

In contrast, LACs in six authorities recounted setting up groups which were only attended by people with learning disabilities (although one LAC added "that's not stopping anybody else coming into the group"). These were mostly social/ recreational groups although one was a consultation forum on social work services. Most of these LACs admitted feeling some ambivalence or discomfort about this aspect of their work, knowing that LAC principles were based on inclusion, but at the same time they argued there was a need to fill a perceived gap in support. One person argued that some people with learning disabilities feel more comfortable being with others with similar intellectual abilities and life experiences and that people should be able to choose whom they wanted to associate with. Another LAC explained how she had adopted a pragmatic approach to helping four people achieve what they wanted:

"I have been going with four individuals, meeting up in the pub before the [football] match and going to the game with the hope that they will be able to meet up and go to the game when I am not there. That is the hope. A lot of the advice we got was that maybe I should have been working with them individually and individually finding out how they could be supported to go to a supporters' club for example and make links there and it is not a group, they are still going as individuals. I understand what they [people giving advice] are saying and I understand what I am saying and I think they might well be right but I am still wanting to get these people to go to the football. That was the objective rather than being purist and theory. The theoretical debate for me was less important; it was 'these people really want to go and watch the football - how can we achieve that?"

An experienced LAC in another authority took a different view again. He worked with a middle aged man who wanted to become a first aider but others had assumed he would not be capable. The LAC found a first aid course due to start in a community centre, approached the community centre and the man was enrolled. The LAC also introduced him to a couple of people he knew who were doing the course:

"Just introduced him that was all and they supported him in the course; they didn't do his exams or anything for him. What they did was after each night they said 'how did you get on with that, did you enjoy that? Is there anything you weren't sure about?' You know that kind of stuff and at the end of it the guy … got his certificate, he is a first aider, that's the first big thing."

This LAC emphasised that his role was to introduce and support but not to attend the course and certainly not to set it up:

"I shouldn't be putting the adult learning class on, you know, I should be getting the adult learning team to put the adult learning class on."

Views about the LAC ethos

Most respondents declared strong allegiance to the LAC ethos, describing it, for example, as 'brilliant' and 'absolutely essential.' Several reported that they regularly read through the LAC principles. Interestingly, respondents in two authorities described these as being 'like our bible', while a LAC elsewhere commented:

"I find them absolutely crucial to every single day that we do our work. I really do... It's meat and drink every single day."

Many LACs identified what they saw as the main elements of the ethos. As well as those discussed in the preceding section, key aspects included respect for people, confidentiality, choice, giving a one stop service, having a 'can-do' attitude and:

"It's about common basic rights of people…And it's really just about supporting people to get a good life that we all take for granted, you know. So I don't think it's anything special."

The main problems relating to the LAC ethos were first, getting other professionals to understand and accept it and, secondly, putting it into practice within the structural constraints many LACs faced. In relation to the ethos itself, LACs in four authorities expressed some reservation. This ranged from the observation expressed by one respondent, whose overall orientation was favourable to LAC, that the ethos was 'a bit idealistic', 'very airy-fairy' and 'open to different interpretations' to the minority view expressed by someone with serious doubts:

"I find a lot of the ethos a wee bit kind of um…a wee bit altruistic and ambitious although that's not what I mean, I just mean unrealistic. And…a lot of parents say 'yes this is what we want' but a lot more parents say 'we want services'. And a lot of people with learning disability…want whatever you are offering them. Don't know what they want. And…as I was saying before I sometimes think society isn't ready for what LACs are trying to do. And I sometimes think that is unfair on the people we are working with because we are kind of exposing them to the rejection."

Two areas of practice raised questions about the LAC ethos for a minority of LACs. One was the issues associated with setting up groups, discussed above: the other was working with families. For most LACs, this was a key part of their role and their holistic approach was sometimes contrasted with social work practice, which was described as focusing on individual family members and, allegedly, failing to see 'the bigger picture'. At the same time, some LACs acknowledged the difficulties involved when different family members had conflicting views and needs, for example, when school leavers were looking for more independence from the family, or in households where older parents were reluctant to let go of middle-aged sons or daughters. While LACs spent many hours working to reconcile differences, or help families move forward, sometimes it became necessary to support one member 'against' the wishes of another. An example was given of a LAC enabling an eight year old child to make a choice which her mother disagreed with. Other examples were given of working with a person who did not want the wider family involved or even aware of the contact, and the LAC having to avoid meeting the parents. In one urban area, LACs found that the goal of long-term planning was unrealistic due to the level of poverty and social disadvantage families faced:

"We are working with quite a few people whose families don't want to know them. If you have got a family that are supportive and the poverty issues are kind of not too big, then it works fantastically well. If you have got…I don't know, all these other difficulties, then people are just too busy dealing with the kind of hand to mouth. And looking at that bigger picture, where they want to be, and working towards a goal, I mean their goal could be just to have enough food for the rest of the week."

These LACs pointed out that they worked with a number of single parent families, and others who rejected or abused their learning disabled member. Their experiences, had in some cases, led them to question the considerable focus on families within the LAC ethos.

SUMMARY

Most individuals and families were introduced to LACs by service providers. Word of mouth and self-referrals also played a part. In a minority of authorities, people had to go through the social work allocation system or a similar 'vetting' procedure to access local area co-ordination. This is at odds with the LAC ethos of easy, informal access. There was considerable variation in the numbers of people LACs work with, ranging from 2 to 47 families and from 1 to 42 individuals. One experienced LAC suggested that 35 people was the upper limit a LAC should work with.

There is no typical day for a LAC but the emphasis was very much on spending time with individuals and families rather than in meetings or on paperwork. Overall, relatively little time was spent on community capacity building. In only six of the 24 authorities did LACs claim to have made significant progress in that area. Apart from lack of time and the fact that community building is a long term process, disinterest and sometimes resistance was reported among some local communities. Where progress had been made, this may be linked to more welcoming communities, the LACs having a strategic base in the area, their previous knowledge of the locality and/or their community development background.

LACs identified several distinctive features of their role, not least its person-centred value base (although many other workers in human services would lay claim to that). The non-bureaucratic and preventive aspects of LAC and its remit to challenge where appropriate were also highlighted. All the LACs were agreed on the importance of promoting inclusion, but there were different understandings of what that meant and how it should be achieved. Most were fully signed up to the LAC ethos - indeed for some it almost seems to be a more of a vocation than a job. However, a small minority thought there was an idealistic, even an unrealistic, strain within the ethos. Some LACs struggled at times with the emphasis on promoting family support which, for a range of reasons, was not always feasible or desirable.

LACs identified a number of positive outcomes from their work with individuals and communities including a better overall quality of life for people, specific examples of difference in individual lives and areas of work which they believed showed improvement. Several LACs reported that people with learning disabilities whom they worked with had grown in confidence and self-esteem and felt supported through the LAC role. People were said to enjoy greater choice and opportunities than before, to be more included - and to benefit from - collective activities and to occupy socially valued roles by attending mainstream college, volunteering or taking up paid employment.