CHAPTER TWO LITERATURE AND POLICY REVIEW
This chapter sets out the research and policy context for the evaluation of LAC across Scotland 7. The aims of the literature and policy review were:
- To conduct a critical analysis of evaluations of LAC
- To review other research relating to LAC
- To map the current policy context for LAC, including a number of significant developments since the publication of The same as you?
Individualised funding and support schemes
Individualised or personalised funding allows direct payments to be used by adults with a disability or by families caring for a disabled child. Direct payments are provided as an alternative to services for people eligible for support, with the intention of allowing them greater choice and some control over how their support is provided.
Lord et al (2000) (cited in Lord and Hutchinson, 2003) examined 10 individualised support and funding schemes in Canada, Australia and the United States. Lord and Hutchinson (2003) provide case studies of three of these schemes: first, the Individualised Quality of Life Project (Options) run by the Family Service Association in Toronto; secondly, what the authors call Local Area Coordination and Direct Consumer Funding in Western Australia and, thirdly, the New Hampshire Self-determination Project. The Toronto project conducts person centred planning with people with learning disabilities and provides funds and community resource facilitators to support the plans. The New Hampshire project aims to identify and develop new forms of community support for people with learning disabilities, supported by 'fiscal intermediaries' - independent agencies which help people manage their money. The authors relied heavily on written documentation and existing evaluations of the services although they also conducted interviews with project co-ordinators to fill in gaps in information. They did not talk to service users or families.
Lord and Hutchinson identify a number of common themes across the projects they evaluated. First, they report that 'values and principles mattered', particularly those relating to self-determination and community participation. Disability support was seen as a right; there was a belief that strong informal networks enhance health and inclusion while formal services were seen as having anomalies and limitations. Second, regional differences in service delivery were minimised where projects were part of a larger national or provincial policy framework. This is an interesting finding given concerns about the varied implementation of LAC in Scotland. The projects which showed most coherent implementation had been introduced through pilots and in phases, allowing opportunities for evaluation, learning and change. They began working with small numbers of people in small localities. All but one of the ten initiatives studied had set up a separate independent infrastructure in which to operate, free from any possible conflict of interest from service providers and government.
Thirdly, the roles of facilitator, broker, network builder and so on which were pivotal to these projects were clearly distinguished from the care management role. The latter was seen as more limited, with larger caseloads, often affiliated to one agency. It was also found that the most effective facilitators were those with broad community experience as opposed to staff who had spent many years working in the more traditional disability service sector. Fourthly, individual funding was viewed as a means of enhancing quality of life but finding an equitable way of allocating it was challenging for several projects and different approaches were developed. Lastly, the projects adopted a 'learn as you go' approach, necessitated by the fact that they were working in new and largely uncharted territory in which they had to learn from their own and other people's experience.
The authors acknowledge there may be concerns that individualised funding is essentially market driven and might lead to privatisation, uncertainty and a low wage sector. However, they argue that it might equally enhance the not for profit sector and that government should maintain a key role in setting standards and wages for staff. The authors conclude that the way forward for individualised support and funding schemes is to develop capacity building, not service reform.
Overview of previous research on LAC
Since LAC is relatively new, and was confined to Australia until 2000, it is not surprising that few studies have taken place to date. There have been three major evaluations of LAC in Western Australia. Below, we look at the most recent, published by the Disability Services Commission (Bartnik, 2003): this was a wide ranging review comprising various studies. There has also been a two year evaluation of the LAC programme in Queensland (Chenowith and Stehlik, 2001).
The Australian evaluations
As part of its commitment to improve public services, the government of Western Australia commissioned a review of local area coordination (Bartnik, 2003), to assess whether the programme was clear, achievable and provided value for money. The review was directed by a 13-member Steering Committee and consisted of various different studies using a range of methods. This included a review of previous evaluations of LAC, a comprehensive overview of the current programme, a value for money analysis and consultations with a wide range of stakeholders, using face to face and telephone interviews, focus groups and surveys. The review reported that LAC had grown significantly over the years and that LACs' workloads had increased substantially. Western Australia was found to compare very favourably with other states in regard to service uptake, cost and user satisfaction. Overall, the main strengths associated with LAC were identified as:
- An empowering value base
- Capacity to develop flexible and respectful personal relationships
- The localised nature, accessibility and relevance of the service
- The 'hands-on' practical approach.
Although views overall were very positive, the following areas of concern were also identified:
- Some perceived inconsistency in quality and level of service
- The way dissent was managed between key participants
- The high turnover of LACs, especially in rural areas
- Expansion of the role and high workloads, resulting in less direct work with users.
The review concluded that although LAC was highly valued by service users, its full potential remained unrealised. LACs were being asked to carry out an increasingly diverse range of functions and this was reducing their ability to concentrate on the core functions - and perhaps values - of the role. Indeed the report suggests this may threaten the medium to long term sustainability of LAC, unless steps are taken to refocus the programme on its original principles, goals and functions. This is an important point, given that similar concerns about a possible dilution of the LAC role have been expressed in Scotland (Curtice, 2003).
As part of the evaluation, Chadbourne (2003) carried out a review of research on LAC in Western Australia. Over the previous 12 years, 24 evaluative reports had been produced, 17 of which were included in Chadbourne's review. The remainder took the form of 'ongoing operational work' rather than research. Chadbourne's review summarises the main findings of these 17 studies and provides an assessment of their methodological strengths and weaknesses.
The overwhelming message of these studies, as described by Chadbourne, is that LAC is a 'success story', the benefits of which far outweigh any difficulties or drawbacks. Given that the 17 studies reviewed were spread fairly evenly across 12 years, Chadbourne (2003: 1) concludes that "positive evaluations of LAC can be regarded as continuous, enduring, long term and consistent over time". Specific aspects of the LAC process which are commended include:
- Its role in promoting user choice
- The relevance, flexibility, quality, short and long term value and continuity of services and support
- Combination of practical and instrumental support, information provision, advocacy and emotional support
- High degree of trust between LACs and families
- The many roles LACs have, including advocate, guide, supporter, broker, consultant, community worker, partner and others
- Accessibility, reliability and quickness of response.
Specific outcomes attributed to LACs - in relation to individuals and their families - included greater peace of mind and security, increased optimism about the future, better functioning and well-being, enhanced self sufficiency and ability to organise their own supports, more choice and control of services and a more diverse range of support tailored to individual needs. In relation to the broader community, the outcomes claimed for LAC included making society more inclusive; increasing community acceptance of people with learning disabilities; enabling people to stay in their own homes and local communities rather than moving into residential accommodation in a distant urban centre; helping set up community organisations and employment opportunities; attracting additional funding from a range of sources and, finally, making better use of scarce resources and being cost efficient.
The research reviewed also raised some concerns about LAC. Many of these relate to funding arrangements while others appear to be relatively minor procedural or localised matters. Chadbourne notes that some reports raise 'virtually no concerns or problems regarding LAC'. He calls for evaluations of LAC to be conducted from alternative perspectives, and should be conducted with a critical overview. He also suggests that future evaluations of LAC should be more explicit about their theoretical, conceptual and ideological frameworks.
With regard to the methods used in these evaluations, Chadbourne argues that the credibility of research findings increases when they are based on large amounts of well analysed, high quality, independently collected evidence derived from multiple sources and when they have been validated by tests of trustworthiness. While noting that by and large the evaluations were based on a substantial amount of evidence, used sound sampling and data collection methods and employed various means of validating their findings, Chadbourne reports that little information is generally offered about how the data were analysed and that some evaluations were conducted internally, lessening their claims to be independent and thus unbiased. However, internal evaluations can usefully inform operational decisions while external studies may have implications for broader policy settings.
Another substantial Australian study worth considering is an evaluation of the LAC programme in Queensland by Chenowith and Stehlik (2001). A pilot LAC project was set up in Queensland in 1999, with nine LACs appointed in six sites. These areas were selected on a number of criteria including rurality and remoteness from services, presence of or proximity to an Indigenous community, identified unmet need and little infrastructure. There were a number of differences from the original Western Australian model, notably that community capacity building would be given as much priority as work with individuals and families. Chenowith and Stehlik made 18 visits to the six pilot areas. Data collection included participant observation, a survey of individuals and families registered with the LACs and another of community organisations in contact with LACs. Thirty-nine in-depth interviews were carried out with individuals and families and social network maps drawn up with 28 of these people.
The authors found that:
"[ LAC]has made a significant impact on the lives of people with disabilities and families and is beginning to impact on those communities where LAC is operating…The LAC programme is building the capacity of individuals, families and communities across Queensland." (ibid, p.viii).
Significant claims are made about the achievements to be expected of LAC in the future, but these are largely speculative.
Chenowith and Stehlik (2001) do raise some critical questions in their research. For example, they note a certain blurring of professional and personal boundaries in the relationships LACs had with some clients. Service users valued the more personal commitment LACs made to them when compared to their interactions with other human services staff; the authors suggest that such solid relationships are a firm foundation from which to develop inclusion. However, they also raise the question of the sustainability of relationships which were sometimes quite intense, potential conflicts of interest, especially when LACs work within relatively small communities, and the possibility that service users' high satisfaction with LAC could be due to a halo effect: at least something was now being offered where previously nothing was available, or nothing which families found useful.
There is an emphasis throughout the report on the important role of families in supporting disabled people: this is presented as a 'good thing'. However, research and practice experience shows that in some cases - for a variety of reasons - it is not realistic to expect families to support their disabled members, while in others, family care may not be good care and can even be abusive (eg: Brechin et al, 2003). In addition, some parents are over protective of their adult sons and daughters: developing an 'ordinary' life with age appropriate activities is likely to involve a move away from the family home. Nevertheless, there is an ideological preference within the Australian LAC ethos for family care and/or individual responsibility for welfare, as opposed to using support provided by formal services.
The Scottish Evaluations
Four Scottish evaluations were sent to the research team by members of the LAC network: these were undertaken in Fife, South Ayrshire, Glasgow West and Edinburgh. The Fife report was conducted by an external consultant (Connor, 2005) and was intended to inform decisions about the future development of LAC in Fife. It relied heavily on data supplied by the two LACs, both in relation to their own views about local implementation and in the sense that they were responsible for collecting data from those they worked with. Connor concludes that disabled people and their families are reaping various benefits from LAC, including feeling valued and listened to, feeling 'empowered', continuity of support, improved access to services and the fact that LAC support complements that received from other services. People found the LACs more approachable than other staff. Connor also identifies a number of outcomes for 'other services' and for communities. However, it is not always clear what evidence such statements are based on, whether findings from the Fife study, findings from other studies or the author's own opinion. Claims are made (again, as in some Australian research) about the likely future achievements of LAC, for example: "staff are working in ways that are likely to lead to long term benefits for people with disabilities and their families" (Connor, 2005: 19).
The Glasgow West report, called an 'interim evaluation', was written by the LAC, who is a community development worker on secondment (Bell, 2005). It reports on the first six months of a pilot project, which works with adults with learning disabilities. Process recording is used to measure attainment in five previously agreed 'critical success factors', such as that 20 organisations are informed about LAC and become keen to be involved in the future, 10 'small examples of where LAC has made a difference to people's lives' and so on. It is not clear how these factors were chosen nor by whom, but they involve measuring variables which by their very nature, it could be argued, do not easily lend themselves to quantification. For example, 'natural friendships' are measured in hours per week. The author of the Glasgow West report rightly highlights the difficulty of trying to measure long term outcomes within a short time frame. Nevertheless, the report concludes that 'marked progress' has been made in linking local people and agencies to LAC and that LAC is 'starting to make a difference in people's lives.' This report is to be commended for including an accessible summary for people with learning disabilities.
An evaluation of LAC in South Ayrshire was carried out by Scottish Human Services Trust (2005). This research covered a considerably longer period than the others - two years - although all the data were collected during the course of seven visits to South Ayrshire when meetings were held with a group of parents and people with learning disabilities, sometimes joined by local professionals. SHS used a Participatory Action Research approach, which supports people directly involved in an issue - or service - to carry out their own research. It included secondary data reviews, observation, interviews, stakeholder discussions, force field analysis and use of graphics and diagrams. The study concluded that LAC in south Ayrshire was 'mostly a success story' with evidence of change in individuals' lives and in the community. A number of issues were identified needing further attention, including varying awareness and understanding among local agencies about the LAC role, role conflict (especially in relation to social work services), and the need for more robust support mechanisms. A distinctive aspect of this evaluation is its emphasis on community capacity building. Points raised by individuals are linked to wider social issues such as prejudice and lack of awareness about disability, local strategic planning matters and wider financial decisions which affect availability of funding for LAC. Some powerful individual 'stories' are included although ambitious claims are also made about changes within local communities.
The Edinburgh document, described as a 'progress report', gives a useful account of the work of two LACs, one in North West Edinburgh and the other, in the south central area of the city (Dale and Dunne, 2005). They have a specific remit to work with two groups of people with learning disabilities - those approaching the transition to adulthood and those aged 45 and over living with their parents. Both workers had been in post less than a year when they wrote this paper, drawing on agency records and their practice experience. An impressive list of 'community connecting' initiatives is given but overall the Edinburgh report is more modest than the other evaluations in the claims it makes for LAC to date. This reflective report offers a useful summary of the main issues arising and makes constructive suggestions about how to tackle them.
Community capacity building
A Home Office report on community capacity building defines it as:
"Activities, resources and support that strengthen the skills, abilities and confidence of people and community groups to take effective action and leading roles in the development of their communities." (Home Office, 2004).
Community building is a core element of the LAC philosophy and activity, described by Disability Services Queensland (2001: 5) as "doing what it takes at the community level and with the individuals and families being supported" to create neighbourhood, local and community resources as part of natural supports, development of leadership skills among community members and full inclusion of disabled people and their families in all aspects of community life. Chenowith and Stehlik (2001) identified a number of outcomes for communities from capacity building, namely heightened awareness of disability issues, leadership development among people with learning disabilities, their families and allies, the establishment of support groups, links with other disability agencies and groups, and economic development. The last point relates to the increased numbers of people staying in their local communities rather than moving into residential or institutional settings elsewhere which, the authors suggest, also encourages the return of others who had moved away.
The work of John O'Brien and Connie Lyle O'Brien has had a significant influence on thinking about community capacity building in relation to people with learning disabilities. O'Brien and O'Brien (2005), discussing ways of overcoming social barriers which separate disabled people from others, identify five different forms of 'commitment' between individuals: one person may act as an anchor, ally, or give assistance to another, may involve another in associations (social structures formed to further collective interests) or develop shared agendas. The O'Briens argue that those who make and share such commitments and nurture them over time create new ways to build and be a community. The authors acknowledge some potential tensions in community building, for example, there is a view that genuine community is not something that can be deliberately or artificially created: it should occur spontaneously or not at all.
Another early pioneer of capacity building with people with learning disabilities was John McKnight who highlighted the 'associational life of communities' as a driver for promoting inclusion and changing attitudes. Carle (2005), drawing on McKnight's (1995) concept of asset-based community development ( ABCD), argues that all communities, including disadvantaged ones, have a significant pool of strengths including 'the skills and entrepreneurial ideas of local residents' and organisations. 'Learned optimism' is a key part of this approach, in contrast to the more traditional problem-based focus. Carle identifies the ingredients of ABCD as the gifts and talents of citizens, the power of local associations and organisations, the resources of public, private and non-profit institutions, the physical and economic resources of neighbourhoods, and community as a geographic boundary. Like LAC, ABCD is underpinned by a clear set of principles.
Johnson (2004), who is the founder and manager of the Communications Resource Centre in Melbourne, outlines an example of capacity building with people with complex communication needs. This was a process involving several stages:
- community mapping 8 - to identify needs, gaps and opportunities within local communities
- planning - in which objectives for increasing inclusion were defined and actions identified
- networking - with individuals, groups and organisations, with the aim of building structures capable of bringing about 'lasting change'
- partnership working
- educating and developing people - building the capacity of others to be more inclusive of people with complex communication needs
- enhancing policy, practice and systems of organisations and communities
- building resources.
Johnson stresses that reflection is a key element of community capacity building.
A good example of capacity building involving 'allies', one type of commitment identified by O'Brien and O'Brien above, is circles of support (see Falvey et al, 1993). An early and much celebrated example of a circle was the group of friends and supporters which developed around Judith Snow when she moved into the community after spending many years in a Canadian institution, (Pearpoint, 1990). Neville (undated) describes a circle of support as:
"The bringing together of a group of people who care about and love the person who has invited them along. Most people have a personal and natural network; the unusual thing about circles is that they bring those networks together to work actively with the focus person."
Gold (1994) used participant observation and unstructured interviews to explore the ethos of a 'circle of friends' in Ontario. They supported a 26 year old woman with learning disabilities (although the circle 'refused to label'), living with her mother and two sisters. Gold found that group members strove to present their activities, which mainly consisted of offering emotional support and problem solving, as 'natural' and 'normal'. Each circle member valued his or her friendship with the young woman but the group itself did not lead to new friendships, leading Gold to ask how friendships can be supported 'in typical ways in typical places.' She also raises the issue of whether or not "friends should be providing social services such as job development and job coaching" (Gold, 1994: 450) and identifies some confusion between the practical and social aspects of the group's functions.
The notion of social capital, integral to community capacity building, appears to be almost absent from the LAC literature. Putnam (1993: 167) defined social capital as
"Features of social organisations, such as trusts, norms and networks, that can improve the efficiency of society by facilitating co-ordinated action."
As Riddell et al (2001) note, social capital is increasingly seen as a central driver of the health and well-being of individuals and communities. These authors suggest that the review of services to people with learning disabilities in Scotland could be seen as supporting the latter's access to social capital:
"If people with learning difficulties occupy valued social roles and merge as closely as possible with the rest of the community, they will be accorded social value and will be able to draw on and contribute to the stock of social capital." (ibid: 144)
The Policy Context
It was noted in the previous chapter that the introduction of LAC sprang from the review of services to people with learning disabilities (Scottish Executive, 2000a). In this section, we place LAC in the wider policy context, briefly outlining the following initiatives - modernising government, joint futures, the 21 st Century Review of social work, support to unpaid carers, direct payments, relevant changes within the NHS, integrated children's services and community planning, learning and development.
In 1998, the Scottish Office Social Work Services Group issued a document entitled Modernising Community Care: An Action Plan (Scottish Office, 1998). The focus of this initiative was to promote more effective joint working between relevant agencies - social work, housing, health boards, NHS trusts and Scottish Homes (now Communities Scotland) - with the dual aims of involving service users in planning and delivering community care and ensuring better outcomes. The Action Plan forms part of the wider Modernising Government initiative which aims to transform services, 'to support innovation in the public sector, to address policy priorities for modernisation and particularly to support and promote joined up working' (Scottish Executive, 2006b: p1). This theme was also echoed in the document A Partnership for a Better Scotland (Scottish Executive, 2003a), which set out plans for the work of the Scottish Parliament over the next four years. Improving public services is a key theme, to be achieved through increasing personalisation of services, which in retrospect helped pave the way for the introduction of LAC.
The Joint Future agenda
In 2000, Susan Deacon, then Minister for Health and Community Care, set up the Joint Future Group. Its remit was to provide a lead in promoting better joint working:
"Our task was specific. It was not to develop new policy but to identify ways of making existing policy work better." (Scottish Executive, 2000b, 1.9).
Since its inception, the Joint Future Group has spearheaded a number of major policy developments, including the introduction of single shared assessment and a review of care management. The latter drew on research which found huge variations in the practice and policy of care management throughout Scotland, confirming the view that care management should be targeted at service users whose needs were complex, rapidly changing or fluctuating (Stalker and Campbell, 2002). This is relevant to the current study, first, in terms of the difficulties which polices can run into when there is great variation in implementation, for example, by leading to inequities across the country. Secondly, the research concluded that care management should be aimed at those needing intensive support, while other service users should be offered 'care co-ordination'. It is this group which may appear most suited to local area co-ordination (although this is not care co-ordination by another name) 9. More recent work by the Joint Future Group has focused on outcomes for service users, with four national outcomes identified for community care 10. Mclean (2005) comments that the Joint Future agenda is held in 'equal measure of positive and negative regard', the latter relating to its adoption of service targets seen as simplistic and overly prescriptive, something which LAC has thus far avoided.
The 21 st Century Review of Social Work
In February 2006, the Scottish Executive launched Changing Lives, the report of the 21 st Century Social Work Review (Scottish Executive, 2006c). A helpful paper written for the review group ( ROSW, 2005) outlines developments in social work in Scotland since the Kilbrandon Report of 1964, some of which may have lessons for the introduction of LAC. The Barclay Report of 1982, for example, recommended the development of neighbourhood or patch social work, which would draw on a community development model and focus on prevention. Robert Pinker, a member of the Barclay Committee, submitted a dissenting paper: he believed that too 'rosy' a view was being taken of the capacity of communities to provide care, especially in deprived areas. In practice, the patch approach met limited success: ROSW (2005: 2) attributes this to a variety of factors, including:
"the challenges of developing effective local participatory democracy and the potential conflicts of interest to which successful community development approaches seem to lead."
The introduction of care management, following the NHS and Community Care Act (1990), took social work in a very different direction, with social workers arguably acting as gate keepers, form fillers, budget holders and managers of care packages. Despite the reported benefits of care management, particularly in the early pilot projects, perceived 'failings' in this model contributed to the recommendation to introduce LAC in Scotland (Scottish Executive, 2000a). On a more positive note, the community care legislation enshrined the rights of services users to be consulted about the support they received and the accompanying guidance placed great emphasis on 'user empowerment', a theme strongly reflected in LAC. Similarly, ROSW (2005) notes that the Scottish Parliament has made social justice and inclusion important priorities. Overall, however, the early ambitions for social work both to offer a preventive service and to develop the capacity of individuals and communities to tackle difficulties have not been achieved.
The 21 st Century Review was carried out against this backdrop. Its report (Scottish Executive, 2006c) makes 13 recommendations, six of which are particularly pertinent to LAC:
- The introduction of more personalised services, with users and carers exercising choice and acting as co-creators of services
- Better focused use of social work skills
- A focus on capacity building, in communities, families and social work services
- Dissolution of boundaries between professions, and between services and users
- Early intervention and preventive work
- More devolved authority to front line staff.
LAC is cited as an example of the more flexible services that should be developed. Indeed, much of the vision outlined for social work in the future, or more specifically for para-professionals around social work, resonates with the LAC role and ethos: thus, the findings of the present study may have implications beyond LAC itself.
Overall, the review report, and the Scottish Executive response (Scottish Executive, 2000d) have been widely welcomed. Both documents rely heavily on the concept of personalisation (based on Leadbetter, 2004) which involves matching services to the needs and aspirations of the people who use them, described by the Minister as "an entirely positive and unstoppable trend" (Scottish Executive, 2000e: 6). This statement is somewhat at odds with the Executive's drive for evidence based policy since, as it admits elsewhere in the report, there is limited evidence to date about the benefits of personalisation. Concern has been expressed that the emphasis on people finding their own solutions to problems could result in individuals being held responsible for their own welfare - or well-being, the preferred term in the report - potentially paving the way for local authorities to withdraw support (Ferguson, 2005). The recommendations are designed to avoid 'creating dependence on services' but some people have needs, conditions and/or circumstances which mean that at times, in some cases for a lifetime, they will be dependent on others for their support. It may be possible that the language of 'dependency' will make them feel a 'burden'. In addition, as Pinker has warned, communities may not have the capacity to offer sustained care and support to vulnerable members, a warning which appears to have been borne out over the twenty years since the Barclay report.
Another document prepared for the 21 st Century Review with relevance to LAC, given the latter's emphasis on family support, deals with the future of unpaid care in Scotland ( OPM, 2005). Again this report should be seen in the context of a substantial literature on carers and caring and a series of policy and legislative measures to support carers over recent years. The thrust of the OPM report (2005: 1) is that carers should be given not just recognition but substantial rights, for example, to:
"Flexible employment practices; adequate financial support and planning; accessible information and technology; practical support; regular breaks from caring; adequate housing, training and health care; good transport links; accessible leisure and recreational opportunities."
This does, however, beg the question of what rights service users will have: for example, regarding when, where and indeed whether to take a 'short break'. Similarly, the report's recommendation that cash payments should be available to carers to purchase support - rather than to service users - suggests there may be a risk of perpetuating individuals' dependence on their families as opposed to having the option to use support from elsewhere, or become more independent of their families. Twigg (1989) developed a typology of carers' relationships to the service system: the OPM report strongly reflects her concept of carers as 'service providers'. The report could be seen as naïve in its assertion that, in future, people will be able to choose 'when, how and if they care' and that "those not already caring will view unpaid care as a positive life choice, which is underpinned by the human conditions of love, empathy and devotion to fellow human beings" ( OPM, 2005: 1). In April 2006, the Scottish Executive announced a 10 year 'vision' for supporting carers based on the report's recommendations (Scottish Executive, 2006f).
An integral part of LAC in Australia is the provision of individualised direct funding, enabling local area co-ordinators to purchase support for service users. There is considerable variation in the extent to which local area co-ordinators in Scotland hold budgets and, even where these are available, they are usually modest. However, this should be seen within the context of the availability of direct payments. First introduced as a power, not a duty, for local authorities, through the Community Care (Direct Payments) Act 1996, and aimed at people with physical and sensory impairments, learning disabilities and those with mental health needs, the provision of direct payments became mandatory, and available to families with disabled children, through the Community Care and Health (Scotland) Act 2002. The intention was:
"To increase the independence of people who use community care or children's services, promoting a more person centred approach to service provision by giving people more control and choice over the way the services they need are delivered." (Scottish Executive, 2004a)
In 2005, direct payments were extended to other community care groups. To encourage take up among people with learning disabilities, Direct Payments Scotland ran two pilot projects, in Stirling and South Lanarkshire. However, take-up has been slow (Pearson, 2004) with 1,438 people in Scotland receiving a direct payment in 2004/5 (Direct Payments Scotland, 2005b). Guidance on Direct Payments has recently been distributed for consultation.
Developments in health policy
The same as you? suggested that " LACs may be best placed in Local Health Care Co-operatives" ( LHCCs) (Scottish Executive, 2000a:19). However, the White Paper Partnership for Care (Scottish Executive, 2003c) stated that LHCCs should evolve into Community Health Partnerships ( CHPs), which would become one element in a more local, integrated health and social care system. The mandate on Health Boards to set up CHPs appears in the NHS Reform (Scotland) Act 2004. They are described as:
"Key building blocks in the modernisation of the NHS and joint services, with a vital role in partnership, integration and service design." (Scottish Executive, 2004b, 9).
In practice, very few LACs are based in health settings. However, the role and remit of the new CHPs has some resonance with those of LACs. For example, part of the CHPs' remit is to reduce local health inequalities, including those affecting disabled children and adults. They are expected to have a lead role in co-ordinating a range of services, including home based support for children with complex needs, joint learning disability services, short break services and support to community based services provided by voluntary organisations. They also have a major role in integrated children's services, another policy initiative discussed below, and in supporting wider public involvement in planning and decision making through the development of local public partnership forums.
In May 2005, NHS Scotland issued a report outlining a National Framework for Service Change in Scotland (the Kerr report) ( NHS Scotland, 2005). The thrust of this document was that the public should take greater responsibility for its own health and for the effectiveness of the health care system generally. The document focused on: ensuring sustainable and safe local services; delivering the bulk of health care services in local communities rather than hospitals; preventative care as opposed to 'reactive management', and promoting participation in planning change to:
"develop options for change WITH people not FOR them, starting from the patient experience and engaging the public early on to develop solutions rather than have them respond to pre-determined plans conceived by professionals." (ibid: 2).
The policy document Delivering for Health (Scottish Executive, 2005b) builds on the national framework, setting out a programme of action for the NHS which includes preventive medicine, support for self-care, easier access to services and support for informal carers - all themes which could, potentially, dovetail with LAC.
Integrated children's services
Scottish ministers have repeatedly declared their commitment to placing children and young people at the forefront of policy making and legislative change. In 2001, an Action Team produced the report For Scotland's Children: Better Integrated Children's Services (Scottish Executive, 2001). Although this identified many pockets of good practice, overall support to children was described as fragmented and poorly co-ordinated, with the most vulnerable and disadvantaged young people at risk of missing out on vital services and opportunities. Education, child health and children's services were urged to better align their planning and delivery systems and in 2003, the Executive published a vision statement of 'high-level aims' for all children and young people (Scottish Executive, 2003a); for example, that they should be safe, fulfilled, healthy, active and included. Success in meeting these aims depends on many factors, but integrated planning and joint delivery systems are likely to be key. Local area co-ordination could be seen as having an important contribution to make here, given its remit to work with all age groups.
Community planning, learning and development
The remaining pieces of the policy jigsaw relating to LAC concern community planning, and community development and learning initiatives. The Local Government in Scotland Act 2003 placed a duty on local authorities to set up community planning processes, bringing together statutory, voluntary and community groups. This was designed to provide a framework for making public services more responsive to, and organised around, community needs (Scottish Executive, 2003c). Community planning has two main aims: first, to involve local people in making decisions about public services and secondly, to encourage organisations to work together to provide better services. Community planning is intended to be the 'over-arching framework' for other partnerships and initiatives at regional, local and neighbourhood levels. Its relevance to LAC is highlighted in its focus on building social capital, defined here as
"The motivation, networks, knowledge, confidence and skills within communities [which] should be an integral part of achieving more effective community engagement." (ibid: 9).
Community learning and development are identified as having a central role to play in engaging people within community planning processes. In the latest guidance, they are, again, described as central to social capital and a means to 'help individuals and communities tackle real issues in their lives through community action and community based learning' (Scottish Executive, 2004c: p8). Three national priorities for community learning and development are identified: achievement through learning for adults; for young people; and through building community capacity. The latter involves enabling individuals to develop the confidence, understanding and skills to have a say in decision making and service delivery.
Many of these issues are reinforced in Transforming Public Services: The Next Phase of Reform (Scottish Executive, 2006g). This report gives considerable attention to the importance of 'user focused and personalised' public services "organised around users' and citizens' needs and aspirations, not the convenience of the service provider" (ibid, 7, 14.1). Emphasis is given to the importance of 'choice' and innovation in the delivery of public services, juxtaposed with the need for 'efficiency and productivity'.
It is clear from this review that little research has been carried out about LAC to date with some existing studies tending towards uncritical acceptance of LAC as 'a good thing'. The main benefits identified for individuals and families, from LAC and other individualised support and funding schemes, include empowerment, trusting relationships with LACs or other key workers, accessibility, choice, flexibility, reliability and the provision of emotional and practical support. Communities are said to become more inclusive and accepting, with people enabled to stay in their own areas rather than moving many miles away for support. Concerns raised in the literature include the market-driven nature of individual funding schemes which may increase privatisation and a low wage sector; insecure and inconsistent support; inappropriate expansion of the role, resulting in high workloads, dilution of the values and role conflict; a blurring of professional/personal boundaries, raising questions about the sustainability of the relationships involved, and a need for more robust support mechanisms. Like LAC, community capacity building has a strong value base and a range of positive benefits are claimed for it. Social capital is an important element of capacity building.
The policy context in which LAC has been introduced to Scotland is a complex one, with an array of legislation and guidance from social work, education, children's services, health and community planning and development potentially impacting on, and in turn being influenced by, local area co-ordination. Common themes emerging from these various policy arenas include many recurring issues such as partnership and joint working, service user, carer and community participation and empowerment, easier access to services and support, social inclusion, choice and control, and early intervention and preventive work. Also important is the emphasis given to challenging discriminatory attitudes. There are also some more recent additions such as 'personalisation' and 'co-production of wellbeing'. Overall, these initiatives appear to have much in common and resonate closely with various aspects of LAC. National standards for community engagement herald a development that is compatible with LAC. However, some potential areas of conflict have been noted. These include the promotion of carers' rights which may at times be at odds with the wishes or rights of individuals. It has also been suggested that historically, too optimistic a view has been taken about the capacity of communities to 'care' and include, and that personalisation may lead to a reduction in formal support to those who need it.
Nevertheless, the introduction of LAC in Scotland has been innovative, at the forefront of broader UK developments. Within the existing array of policy developments and practice guidelines, LAC is cited as an example of the more flexible services that should be developed. Indeed, much of the vision outlined for social work in the future, or more specifically for para-professionals around social work, resonates with the LAC role and ethos. LAC would appear to fit well with current policy agendas and offers some insights into potential directions for implementation of policy initiatives. These themes will be explored in the following detailed examination of LAC in Scotland.