Devolved disability benefits: decision making – commissioned research report - annex A

Executive summary

Introduction

The Scotland Act 2016 grants the Scottish Government authority over certain benefits, including those related to disability. The government is committed to evaluating the implementation and impact of these devolved benefits.

This research focuses on how the delivery of devolved disability benefits affects client experiences in decision-making processes. The benefits covered include Adult Disability Payment (ADP), Child Disability Payment (CDP), and Pension Age Disability Payment (PADP). The study investigates both clients' and Social Security Scotland staff's understanding of policy principles guiding decisions, consultations, review periods, and reviews, along with their practical application experiences. Decision-making themes were explored with staff through policy principles and guidance elements, while clients were engaged through intended outcomes. Detailed intended outcomes and principles are provided in the Annex.

Methodology

Qualitative research was conducted, through discussions and observations with clients and Social Security Scotland staff. This comprised:

• 16 focus groups and 7 interviews with clients across ADP, CDP, and PADP applications, reviews and consultations – including a mix of clients with successful and unsuccessful outcomes.
• 12 in-depth interviews with Case Managers, and 8 discussions with Quality Support Staff, Decision Support Staff, Decision Team Managers, and Health and Social Care Practitioners (called ‘Practitioners’ for short).
• 17 observations of Case Managers ‘thinking aloud’ while working through previous decisions they had made, including applications, reviews and consultations.

In the discussions, clients and staff were shown ‘typical’ client journeys for an ADP, CDP or PADP application, scheduled review, unscheduled review or consultation (as relevant to the client or staff member). They were also shown the relevant intended outcomes (in the case of clients) or policy principles (in the case of staff). This was used as stimulus to help clients and staff discuss the extent to which their experiences aligned with these outcomes / principles.

The observations were designed differently; we did not prompt Case Managers with the client journeys or principles, rather we asked each Case Manager to ‘think aloud’, talking us through their approach to making a real decision on ADP, CDP or PADP (a decision that they previously made ‘for real’.) What they said about the decision-making process was then linked to the principles at the analysis stage.

Summary of key findings

Whether experience of decision-making process was person-centred and trust-based:

Client perceptions of whether their experience of decision-making was person-centred and trust-based generally correlated with the outcome of their decision. A positive outcome generally left clients feeling understood and believed. However, the extent to which they had been able to explain their situation through dialogue with Social Security Scotland or someone supporting them, and had positive interactions with Social Security Scotland, also affected this.

Case Managers were confident they considered each case on its own merits, with a trust-based approach. They felt the use of supporting information and internal resources such as case discussions strengthened their understanding of clients’ situations, without burdening the client. The use of these could lead to a focus on conditions more than the impacts on the client as an individual, however, and sometimes they were used to query the client’s account.

Experiences of reviews, review periods, and consultations to some extent contributed to the process feeling person-centred and trust-based. Staff and client perceptions of reviews were mixed: some agreed they were ‘light touch’ (i.e. using information already held where still relevant and fully employing decision-making tools to ensure requests for further information, including supporting information, are necessary and proportionate), but some clients felt they were not given enough opportunity to explain their current situation.

Where staff felt they had too-limited information for a review, they sought to collect additional supporting information to ensure a robust decision. Staff were confident they used a range of information to set appropriate review periods, but client perceptions varied, based on how well the review period set was explained.

Clients who had experienced a consultation felt they were person-centred and the staff doing them were described as understanding, medically-informed and caring. These felt like a dialogue, resulting in clients feeling treated with dignity, fairness and respect. Negative feedback from clients on consultations was about not having a consultation, rather than about the experience of having one, with clients feeling there was an unmet appetite for being able to explain their situation via dialogue with Social Security Scotland. Staff views were more mixed, with some feeling consultations were used appropriately and others feeling they happened too rarely and via too formal a process.

Whether experience of decision-making process was justifiable and free from bias:

Client perceptions of whether decision-making was justifiable and free from bias generally correlated with the outcome of their decision. Clients with a positive outcome tended to feel that the decision was evidence-based, with the decision letter reassuring clients about what information was used. However, clients with unsuccessful outcomes felt that the letter sometimes revealed that staff had not considered all the supporting information that had been provided or had not contacted all the professionals or support network contacts in their application, which left them wondering if the decision-making was affected by bias. These clients also felt the forms made it hard to express their situation fully.

Some clients also felt justifications about review periods could have been clearer to show assumptions had not been made about their health. Case Managers generally thought they succeeded in considering each case on its own merits and avoiding burdening the client when making decisions; however, some staff acknowledged that unconscious bias is difficult to eliminate entirely. We also observed decision-making tools or resources, which could challenge bias, not always being used by staff.

Review clients who had experienced a no change or increased award were more likely to think the review process was clear and less burdensome than those who experienced a decrease in their award. Staff confirmed using information from previous decisions to reduce the burden on clients, where appropriate.

Some clients for whom it was more clear that they had had a consultation appreciated having the opportunity to share how their condition was impacting them. For those where it was less clear whether they had had a consultation and more likely that they had had an informal phone call, some would have liked more time to prepare for this. Staff felt that consultations were helpful to make sure that decisions were based on the client’s account and not staff’s personal bias or preconceptions.

Whether experience of decision-making process was transparent, clear and accurate:

Clients were mixed in their perceptions of whether decisions were transparent, clear and accurate. Client perceptions of whether the decision was clearly explained was influenced by whether they thought the decision letter gave a clear account of what information had been used and how, and whether or not it was clear what further information the client could have included. Staff were generally confident they included in decision letters, for each element, a clear justification and details of what information was used and said that they used a clear templated structure balanced with tailored content. They also noted that, for transparency, they recorded the steps taken in decision-making in a ‘case canvas’.^[1]

Clients were similarly mixed in their perceptions of whether decisions were accurate. They were more positive when they thought the decision letter explained the decision and information used in a manner that left them feeling understood; but more negative when they felt the letter implied the case manager did not take account of all the information provided, did not consider how conditions can impact people differently, or did not contact some of the suggested individuals for supporting information. This left some feeling like the impacts of their condition were not understood. Despite some caveats, staff were again generally confident that they used various information sources and internal tools and resources to reach an accurate decision.

Clients were generally negative about the transparency of the process; although some received confirmation that their application had been received, there was often a lack of updates from Social Security Scotland and it was sometimes difficult to contact Social Security Scotland. Though not directly related to the policy underpinning decision-making, clients felt that updates on application progress could have been improved.

Whether experience of decision-making process alleviated financial pressures:

Client perceptions of whether decision-making alleviated financial pressures correlated with the decision outcome. Those who had a successful outcome generally felt this gave them some financial stability and peace of mind, to be able to afford additional support (which sometimes led to positive mental health benefits). However, regardless of the outcome, hearing the outcome more promptly was positively viewed as it provided some certainty, allowing clients to plan ahead financially.

Whether experience of decision-making process encouraged a positive relationship with Social Security Scotland:

Clients were mixed in their perceptions of whether the decision-making approach encouraged a positive relationship with Social Security Scotland. They were generally more positive when their outcome was successful, as this signalled that they were believed. Perceptions were also influenced by whether there had been any positive contact with Social Security Scotland during the process; whether there had been any dialogue with Social Security Scotland that gave the client the opportunity to explain their situation; and whether the decision was clearly explained in the decision letter.

Conclusions:

Clients had mixed perceptions of their experiences of decision-making outcomes, with this often depending on whether or not their outcome was successful. While some aspects of decision-making delivered on the intended outcomes, clients emphasised the importance of clear explanations in decision letters, for them to feel understood and confident in the process. Staff believed they use diverse information sources and tools to make unbiased decisions without overburdening clients, though sometimes these resources could lead to a focus on conditions more than the impacts on the client as an individual, or were used to challenge the client’s account. Clients expressed a desire to provide more information and engage in dialogue with Social Security Scotland. Although reviews aim to minimise unnecessary information requests, clients often find the process unclear and the information generated by the process is sometimes not comprehensive enough for Case Managers. Trust in fair decision-making is sometimes weakened by the perception that supporting information that clients provided had not been used or that professionals or support network contacts had not been contacted, and the relationship with Social Security Scotland is sometimes strained by insufficient progress updates and long decision timescales, causing stress and uncertainty for clients.

Recommendations:

The findings point towards several recommendations to enhance the decision-making process and client experience with Social Security Scotland:

1. Ensure decision letters consistently describe what information was used and how, for each decision element.

2. Consider how to ensure Case Managers are using decision-making tools to make an accurate decision but not to query the impact of the client’s account of their condition. Furthermore, Case Managers should maintain that the tools can be used for understanding conditions in more depth as well as for understanding and drawing on the impacts of those conditions based on the information the client has shared with them. This might include the use of ‘drop-in sessions’ for Case Managers to engage with colleagues (e.g. Decision Support Staff), consistency calls or feedback sessions. This was suggested by staff as a possible refinement.

3. Explore whether there is an opportunity to enable more informal dialogue between the client and Social Security Scotland (including Practitioners, where appropriate) as a way for clients to explain their situation more fully. This may particularly apply to those with complex, fluctuating or non-physical conditions. This was suggested by clients and staff as a possible refinement.

4. Revisit the guidance provided to clients about the types of information to provide in a review, to improve clarity for clients and generate more of the information required by Case Managers. This should include clarification of what information to provide about circumstances where the client believes there is ‘no change’, which particularly caused confusion for some clients.

5. In addition, given that clients did not always realise that Social Security Scotland were using information from previous decisions when conducting reviews, consideration should be given to including in the review pack for clients, wording stating that Social Security Scotland will be using existing information held on the case where still relevant to inform their review decision. This was suggested by clients and staff as a possible refinement.

6. Greater clarity should be given to clients that Social Security Scotland only gathers as much supporting information as is needed to reach a robust decision.

7. Consider staff ideas for supporting decision-making through closer working between Case Managers and Practitioners – for instance, a process for Case Managers to ask ‘quick questions’; or more Case Manager guidance on requesting case discussions and consultations.

8. Consider raising awareness for clients that they can request a consultation as part of the decision-making process when they apply or undergo a review.