Section three: The role of social care
People will feel confident in identifying and agreeing the outcomes they want. Assessment and review processes will focus on these outcomes and will take a holistic, human rights based approach to individuals and family carers.
National outcomes and minimum information standards
Social care is at its best when it helps people to be independent and to feel safe. This works most effectively when people control for themselves the support they may need. Local authorities have a duty to assess, and must therefore ensure that people are assessed, under section 47 of the NHS and Community Care Act 1990; and that the assessment complies with binding policy and guidance; that qualifying carers are offered a carers assessment; that relevant local eligibility criteria are operated, and that all 'eligible needs' are met by service provision or direct payments; that financial resources are not used as a reason for not meeting an eligible need; financial contributions are assessed; and that services and support meet minimum human rights standards - most importantly, the dignity standard.
Local authorities and their health partners work within a framework where National Information standards define the nature of information used, and collected for national and local information purposes. Current assessment processes, shared or otherwise, have led to needs being responded to in time units ("Task and go"). This, in turn, has limited individuals, carers and assessing staff, compromising the provision of services focussed on outcomes, in particular those elements of soft but necessary support (contact, relationships) which mean so much to individuals.
Recent reports have consistently indicated the need to change the way in which services are provided. In particular, the Changing Lives report indicated the need to significantly change the relationship between assessor and user and carer; to enable the provision of more personalised services; and to co-production 12 of services with disabled people, their families and wider communities. There needs to be further development of alternative assessment models, including supported self assessment styles, models of co-production and e-solutions, giving more choice and control at this point, as well as when deciding on what support should be provided.
The Association of Directors of Adult Social Services ( ADASS) in England have published a paper 13 confirming that self-assessment is not legal, and local authorities cannot legally contract out eligibility, resource allocation and support planning decisions. There is however a clear role for supported assessment and pre-assessment in taking forward the principles of self-directed support.
The Talking Points Framework developed from research into individual outcomes provides a means of looking at the desired personal outcomes for individuals and for family carers within the context of the Community Care National Outcomes, while ensuring best value in the use of resources. the national outcomes are:
- Improved health
- Improved wellbeing
- Improved social inclusion
- Improved independence
The Talking Points framework is now being used, albeit in different ways across all Scottish local authorities, in some at assessment and in others in review processes.
The change outcomes, identified by individuals as being central to their needs, together with process and quality of life outcomes provide a template whereby people's needs and aspirations can be met more fully. This process effectively engages individuals in setting their agenda based on their perception of the situation.
Carers' assessment should similarly move to support planning and co-production models, having greater attention to the outcomes that carers require, including partnership, training, information, skill level, but especially the limits to the role they are able to fulfil and the support available. There is a danger that self assessment models and the right of carers to a separate assessment may be bypassed if the relationships and limits in support are not approached through a model of co-production. A co-production approach should assist the normal or natural relationships between the carer and the person for whom they care.
Choice and Means.
Following on from an outcomes based assessment, choice in how to reach the desired outcomes is more transparent. The respective roles and responsibilities of individual and carer, and responses from the assessing and provider agencies are clearer as part of a negotiated agreement. It is at this point that individuals and their carers can exercise choice about the way their support needs are to be met and how support will be provided to them.
Here, there is a clear opportunity to consider the implementation of alternative forms of provision - a Direct Payment, Individual Budget (or individual service funds lodged with a provider), or commissioned service, albeit with greater involvement from the service provider in designing how the support will be delivered in the context of the assessed "support package" and based on desired outcomes.
Risk and safeguarding
Working to achieve outcomes that promote independence will inevitably involve risk. Risk averse practice can lead to over protection and can unnecessarily inhibit ambitions and aspirations. Risk cannot be ignored, and there are statutory duties to ensure adequate protection of individuals in Adult Support and Protection, Mental Health Care and Treatment, Adults with Incapacity, and Protection Vulnerable Groups legislation. It is important to identify and manage risk in a way that is shared among the person, family and friends, the Council and the provider(s).
The shift to co-production, outcomes monitoring and risk enablement will require training for staff across the social care and health sectors, and leadership from all levels of management.
Tightening resources are a reality for all agencies and the challenge is to develop self-directed support in a way that offers people real choice whilst recognising that social work budgets may not meet all of the demands. There is growing evidence of the financial efficiencies of a focus on early intervention, prevention and (re)-ablement. Good information and advice, practical support, appropriate housing options, and joint working between health and social care can assist people in living fulfilled and independent lives, thereby reducing the number of people entering or requiring ongoing support from social and/or health care.
The contribution of health is outlined in section two. Local authorities need to work in partnership with the NHS to share investments that improve outcomes for individuals. Work is now underway to test an Integrated Resource Framework ( IRF) for health and social care in Scotland, with four partnerships (four health boards and their 12 local authority partners) established as test sites in September 2009. The objective of the IRF, which is being developed in partnership between the Scottish Government, COSLA and NHS Scotland, is to enable resources to move across the system to best meet the needs of citizens.
More economic analysis is needed to assess the extent of investment needed - from social work and community planning partners -to achieve the right balance between lower level and critical and substantial supports. As discussed earlier, many authorities have introduced eligibility criteria in an effort to manage budgets, to bring some transparency and clarity to their services and to address the feeling that there is an inherent lack of fairness.
Beginning in 2010, the Scottish Government should work with COSLA in using economic analysis to identify the best strategies available to local authorities so that they can lead a shift towards self-directed support focussing on a shift to commissioning for individuals rather than for groups.
At present, legislation provides for entitlement to have care needs met, and not to assessment of financial payments. Direct payments legislation provides a right to a payment that secures a service that meets assessed needs.
There are a number of approaches to setting direct payment rates,some through a fixed rate system for DP's and others through meeting the agency rate for the direct service provided. This in effect means that rates are often determined by agency market forces and available resources.
To move towards the personalisation of services in a measured way, local authorities will need to consider the use of a mechanism such as a Resource Allocation System ( RAS) to determine the resources available to the individual that is transparent and sustainable. IBSEN describes how in pilot sites in England there were mixed views on the RAS and devising new processes for allocating resources was particularly challenging, with no consensus on the best method. In some areas, developments of the Indicator of Relative Need ( IoRN) are shifting from the dependency focus it used for older people to an outcomes focus that can be adapted for different groups. The Government does not recommend any particular resource allocation system and believes more evidence is needed of the most effective means for delivering outcomes.
Whatever system or tools are used, local authorities are expected to develop up-front and transparent methods for the allocation of resources to eligible people. To do so, they will need to understand patterns of spend and costs for services; manage resources to deliver good quality outcomes; and be able to meet predicted demands. The Joint Improvement Team ( JIT) developed a capacity planning toolkit which allows agencies to draw together this type of information. Along with data gathering at individual level, such as the E-say learning disability database, local authorities can more readily predict future demand.
A system for allocating resources should be used as a means of giving an approximate indication of what it may reasonably cost to meet a person's particular needs according to his/her individual circumstances. It is important for councils to ensure that their resource allocation process is sufficiently flexible to allow individual circumstances to be taken into account when determining the amount of resources they are allocated in their individual budgets.
In 2010 the Scottish Government and COSLA should gather and interpret information on the evaluation of resource allocation models and systems to see which approaches best deliver the outcomes for all groups and levels of need, and whether and how systems can provide the best possible outcomes for both younger adults and older people.
Direct payments and individual budgets
In order to provide greater clarity on the range of options for directing support, we propose to use the following terminology to differentiate between emerging tools and legislative provisions.
Direct payments are defined in legislation and are payments in lieu of services provided directly to individuals assessed as being in need of community care services.
Individual budgets are an indicative allocation of funding given to users after an assessment for support. The assessment of the budget should be through a transparent process that demonstrates compliance with community care and other legislation. Where there has been a joint assessment, the budget may include money for health and educational/training needs.
Individuals have a choice on how the budget is processed. They may opt for a direct payment, commission the service directly with providers through an individual service fund or trust or leave councils with the responsibility to commission the services. Or they can have some combination. Individual budgets provide greater clarity about the financial contribution to meeting their needs.
The individual budget may combine a collection of funding streams, to support the delivery of agreed outcomes. This may include Supporting People14, Independent Living Fund ( ILF)15, and Access to Work16.
The implementation of SDS should be genuinely personalised and the funding streams it brings together should include all that are relevant to each individual - for social services, education, housing, employment and health.
What is crucial in the implementation of self-directed support is that all options are given equal weight, preventing some existing attitudes and practice that limit access to direct payments. The drive to increase the uptake of direct payments needs to be sustained, and Individual Budget pilots show this can be achieved. Information from discussion with most local authorities suggested that there is still significant scope to increase the numbers of direct payment recipients, and many areas have strategies and policies in place for doing so.
In some areas, development of personalisation programmes or self-directed support projects have been disconnected with direct payments activity. Apart from missing out on the opportunities to harness the knowledge and expertise of teams promoting direct payments, this separate focus risks diminishing the drive for real choice for citizens.
Some of the barriers to direct payments will apply equally to other uses of individual budgets, and implementation of this strategy will need to address issues such as flexibility in how budgets can be spent. Local authorities generally found existing Scottish Government and The Chartered Institute of Public Finance and Accountancy ( CIPFA) Scotland guidance helpful in relation to direct payments, and these should continue to be applied. Scotland should also aim to match the best take up rates of direct payments in the rest of UK.
Another issue of significant debate is the accountability for use of public funds. In discussions with staff at many levels in local authorities, the need for financial prudence was often raised, revealing quite polarised views on what purchases should and shouldn't be permitted.
Stories that may attract unwelcome media attention travel faster than those that aim to promote SDS. The purchase of holidays abroad, a race horse, and golf club memberships were cited by some as innovative and open minded approaches and by others as abuse of public funds.
An area attracting greater consensus on the flexible use of direct payments was respite. Indeed this was identified as the most likely service to enable short term growth in self-directed support payments. The City of Edinburgh Council has published a leaflet 17 to encourage new short breaks opportunities for older people through direct payments.
The Homer and Gilder evaluation of the benefits of direct payments includes a number of personal stories highlighting the positive outcomes that flexible use of direct payments has brought.
In Control Scotland 18, and other organisations, have worked with a number of councils in Scotland to pilot their system of self assessment and resource allocation. A review of such a pilot in North Lanarkshire 19 found people had used their individual budgets for a wide range of purposes:
- People to help (Support worker, employment of live-in carer, personal assistants)
- Cleaning and laundry
- Equipment ( e.g. computer, iPod)
- Transport (Travel to/from college, taxis, electric scooter)
- Education (Courses e.g. film making)
- Access to leisure (Museums, exhibitions, cinema, music, entertainment, clubs, shopping)
- Improving health (Gym membership, acupuncture, physio at home)
- Social life and seeing friends.
No person using individual budgets in North Lanarkshire reported a negative impact of their individual budget on any area of their life. In most areas of life, people reported highly encouraging levels of positive impact that are similar to information collected from almost 50 adults in two English counties.
It is too early to identify how the range SDS options deliver more flexible outcomes that direct payments. The earlier discussion on the unnecessary separation of the 2 mechanisms needs to be borne in mind, since the shift from process-focused to outcomes-focused support planning and review should in itself drive up autonomy and control.
Systems and processes to measure and monitor progress, locally and nationally, need to be reviewed to take account of self-directed support. These are discussed more fully in section 4.
Reducing bureaucracy and cutting red tape
The shift to self-directed support, and thereby the promotion of independent living, should aim to reduce the multiple business processes associated with current activity to bring together different funding streams. It should be possible to achieve efficiency savings by streamlining some overlapping activity of the agencies involved.
There may also be opportunities to give the citizen a single entry point into funding for independent living, and current activity to streamline ILF processes should be built upon.
By autumn 2010 the Scottish Government should meet with DWP officials to ensure that the self-directed support strategy and the benefits system funding streams, fit together in an appropriate and cost effective way, to the full advantage of those using self-directed support. An aim of this should be to seek a reduction in business processes around Charging Policy and SDS.
By December 2010, the Scottish Government should discuss with Education leads whether and how Disabled Students Allowance and other relevant funds in Further and special, and Higher education can be included in self-directed support packages.
A deterrent to direct payments for some individuals has been the prospect of onerous processes to manage resources and account for the budget. There are a number of innovative approaches to reducing bureaucracy. The Edinburgh card makes money management more straightforward for individuals and families. It is a VISA card which direct payment budgets are paid into, and from which payments are made to providers.
Carers also have concerns about the expectations on them to manage budgets. In agreeing to opt for a direct payment of an individual budget, it is important that:
- assumptions are not made about the carer's contribution, rather this is jointly agreed
- assumptions are not made that the carer will administer and manage the SDS
- a combination of arranged services and SDS are made available, as necessary
- SDS set up time is kept to a minimum
- contingency planning is in place to address any breakdown in SDS arrangements
- larger packages of care and support factor in adequate management costs
- carers are supported in any employment and administrative activities.
The growth of self-directed support should lead to greater equity of provision, and whilst local authorities will continue to apply different resource allocation formulae, their focus on outcomes and clarity about available resources should aid those who move to another area, for example in order to live or work in another area.
Equally, there is a need for clarity about the contribution of personal income and benefits to meeting agreed outcomes, and the need for clarity in how charging policies will relate to developments in SDS.
The Scottish Government should work with COSLA and the Independent Living movement on simplifying Charging Policy to make this more compatible with the outcomes associated with self-directed support.
The issue of waiting lists for direct payments will also need to be addressed in taking forward a strategy for self-directed support. Some people who are currently on waiting lists have been refused a direct payment because of a lack of resources. Some receive a commissioned service, others receive no support. Generally, demand for social work services has exceeded available budgets, as highlighted in earlier discussion on eligibility criteria.
As implementation of self-directed support progresses, the impact on waiting lists for delivering agreed support plans will need to be considered, with a view to working towards a clear target. In the short term, people on waiting lists should have the opportunity to undertake supported assessment, and to explore the options for directing their support.
In estimating the reasonable cost of securing the support required, councils should include associated costs that are necessarily incurred in securing provision, without which the service could not be provided or could not lawfully be provided. The particular costs involved will vary depending on the way in which the service is secured.
SDS arrangements need to be fair and equitable, ensuring rates for SDS packages of support are fit for purpose and take account of key quality factors such as training. There are some existing concerns over time allocations for direct payment packages, and these will need to be managed and monitored. Costing, through whatever allocation system, will need to ensure purchasers have a choice that is not significantly restricted. Local authority costs need to be factored in when establishing comparable costs in direct payment packages.
For people who elect for a direct payment it will be important to consider current practice in some areas to include a one-off start-up fund and other forms of support that might be required, such as brokerage, payroll services and Disclosure Scotland checks on employees and prospective employees.
Building on recommendation 9 above, the Scottish Government in conjunction with COSLA should commission a Scotland-wide analysis of the rates offered for individual budgets and direct payments, and the costs for equivalent services provided by local authorities and the independent sector, with a view to assessing how these meet individual outcomes.
Currently, the majority of people use a direct payment to employ a Personal Assistant ( PA). Over 51% either employ only a PA or use another service in addition to the PA20. This sector has a major role in the success of SDS. Evidence suggests that employment of PAs does not impact on the recruitment and retention of workers in other areas of social care. Despite both employers and PAs valuing the training that a PA receives, nearly half of PAs do not receive any training. Most PAs would like to access training but there are a number of barriers including availability and accessibility, and there is no dedicated support service for the PA workforce.
Providing training of employees is good employment practice, and SPAEN have a role to ensure that employers promote best practice.
The recruitment of suitable individuals provides direct payment recipients with some difficulties, and a common concern is taking on the role of employer. Appropriate support during the recruitment process ensures a better experience for the individual and helps resolve concerns, and gaps in support relate to employment advice.
For a significant number of direct payment recipients, there needs to be an attitudinal shift towards providing training for their PAs to allow people to embrace their responsibilities as an employer. Funding levels need to allow the individual to be a responsible employer and factor in elements such as training and indemnity insurance. At present, there is often no relationship between a direct payment rate, PA wages and an annual uplift for the direct payment rate. The impact over time is that it becomes more difficult to recruit and retain PAs at a competitive rate. Within this context, the previous section on Fairness also applies to PAs and should be taken forward with this perspective.
The Scottish Government should consider with SPAEN and support organisations and PAs the need to develop a national organisation to support PAs.
The Scottish Government should consider the ways in which PAs can access training, how a direct payment can be used to provide training and the range of responsibilities placed on local authorities to ensure a sufficiently training PA workforce.
The Scottish Government should disseminate the findings of the research on the PA workforce commencing in 2010. Other organisations should assist in making it readily available thereafter to both potential employers and employees.
The Scottish Government will work with local authorities and support services to be able to assist employers to proactively to comply with employment law and best practice.
In addition to these specific recommendations, implementation of the strategy will need to consider how to develop a competitive PA workforce sector that provides a real alternative, whilst offering choice and flexibility to individuals.
Employing Family Carers as Personal Assistants
Current direct payment legislation only allows DPs to be used to employ a close family member in exceptional circumstances, "…where securing the service from such a person it is necessary to satisfactorily meet the service user's assessed needs." Family carers highlight that this provision is used less in some local authorities than others, despite there being particular circumstances when applying it could bring significant benefit to the service user.
Whilst there is no drive to remove this legislative limitation on employing family members as personal assistants, it is important that this facility at councils' disposal is used where this could provide best outcomes, for example when:
- a person requires end-of-life care
- there are limitations in the availability of suitable service providers in rural or remote areas
- it is considered to be the most appropriate way of meeting an individual's cultural needs
- a feature of the person's disability is challenging behaviour towards strangers.
Among the known barriers that need to be overcome are resources tied up in buildings and block contracts, which limit the resources available to individuals.
The shift to self-directed support requires strategic commissioning that focuses on outcomes for individuals, and that ensures a good supply at an affordable cost. Some tools have been developed in Scotland to support this.
The SWIA Strategic Commissioning Guide21 is designed to help councils working with key strategic partners to evaluate their performance of strategic commissioning of care and wider support for adults, children and young people. It advocates the adoption of a long term view which considers the needs of the whole community. Commissioning should be seen as a cross-cutting activity with councils linking strategic and financial planning with assessment and care management and making decisions about how to use resources most effectively to achieve desired outcomes for people. Commissioners should be planning at least 10 - 15 years ahead and considering what mix of services and support will best meet predicted needs and self-directed support choices, whilst delivering the best value.
Providers and the social care market
Services and support are provided by local authorities or contracted out to private and voluntary organisations, with a significant proportion contracted out. These organisations include the combined membership of Community Care Providers Scotland, which supports approximately 220,000 people and their families, and managed a total annual income in 2008-2009 of nearly £1.1 billion. Of that expenditure, an average of 70% per member organisation relates to public funding. It employs approximately 36,700 staff and works in all 32 of Scotland's council areas.
The success of a care package depends on service providers and individuals having responsibility for agreeing the approach to meeting quality of life outcomes. This can only be achieved by commissioning for outcomes. Current practice has boxed both assessor and provider into inflexible time and cost based activity with more emphasis on the process inputs and outputs. Re-ablement, recovery, and rehabilitation services are demonstrating how co- production and an outcomes focus can, and does, lead to improved and valued services. The shared outcomes need to be reflected in a changing relationship between providers and commissioning staff.
The Social Care Market Place has been a focus of substantial change in recent times. This arguably has been driven by a number of factors and drivers such as:
- Procurement practices
- Delivering efficiencies and cost savings
- Delivering to high volume
- Delivering to high expectations
- Increasing complex support needs
- Person centred, empowerment and personalisation approaches
- Regulation, scrutiny and monitoring
The management of the social care market is crucial to ensuring that services develop and maintain the capacity to meet and respond to needs within local communities. Traditionally the means to securing stability and certainty of service provision has been through the procurement of block contracts of services. Undoubtedly this has helped grow an experienced, diverse and able provider sector. However, the positioning of the individual within large block contracts can impact on the development of personalised and individualised service response solutions.
A challenge exists over how to best manage and ensure the provision of responsive support services whilst moving to more person led solutions. The move away from block contracting arrangements to "spot" arrangements can enhance the positioning of the person within, the consumer will more often become the procurer.
Local authorities need to procure services in an effective way, mindful of both the needs and choices of individuals and the ability of providers to deliver good quality care. They need to have robust systems in place to monitor and review the effectiveness of procurement. They also need to put systems in place that identify and respond to regulatory bodies' assessments of the performance of regulated services.
Procurement practice will need to take account of the principles of self-directed support in that it will need to consider:
- the extent and measurement of quality of life outcomes and service level satisfaction;
- the provision of information about procurement to citizens;
- involving individuals and family carers in the development of commissioning strategies, procurement policies and individual procurement plans;
- development of the social and health care market;
- new forms of financial planning and financial management;
- balancing risks and responsibilities;
- systems to deliver direct services or purchase other services in line with personally determined support plans;
- aggregating data from support plans to inform procurement exercises;
- means to support service purchase by service users if this option is chosen;
- maintaining quality standards and ensuring cost-effectiveness;
- flexibility in service specifications and contracts; and
- contract monitoring and review.
Recently developed Social Care Procurement Scotland Guidance 22 outlines useful ways to structure and conduct social care procurement activity. The guidance is based on a set of guiding principles which, taken together, are intended to govern all social care procurement activity. The guidance considers the ways in which this National Strategy, and existing National Guidance 23 for self-directed support will influence social care procurement. It highlights the need for each council to consider the development of their social care procurement policy and their commissioning strategy in the context of advancements in self-directed support.
In applying Scottish Government guidance on social care procurement, local authorities should take account of the values and principles of self-directed support, and in turn promote independent living.
Front line staff have day to day contact with individuals and families, and their skills, knowledge and values have the most direct impact on the quality of support provided. They -and their managers - need to be actively engaged in discussions on how the shift can be achieved. The Glasgow Social Care Providers Forum recently held a 'Festival of Ideas' to bring providers, commissioners, care managers and others together over a series of workshops and events to increase knowledge and understanding of self-directed support.
During 2011, local authorities should work in partnership with providers to develop provider networks in each area. These networks should look at ways of supporting citizens to singly or collectively commission services.