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

2. Experience and implementation of the principles

2.1 Person-centred and trust-based

2.1.1 Key findings

Clients discussed the principles of the decision-making process being person-centred and trust based. Client feelings of being understood and believed was often (but not always) correlated with successful decision outcomes, although meaningful dialogue and positive interactions with Social Security Scotland also contributed. Case Managers believed they approach each case individually and from a trust-based position, using supporting information and resources to enhance understanding without burdening clients. However, this can sometimes lead to a focus on conditions more than the impacts on the client as an individual or questioning of the client's account.

Reviews and consultations contributed to the perception of a person-centred process, though opinions varied. Some clients and staff saw reviews as 'light touch,' using existing information and decision-making tools effectively, while other clients who did not agree with their outcome felt they lacked opportunities to explain their situation. Client perceptions of review periods depended on how well they were explained to them in the decision letter.

Clients who experienced consultations found them person-centred, with staff described as understanding and caring, creating a dialogue that left clients feeling treated with dignity, fairness and respect. Negative feedback often stemmed from not having a consultation, indicating a desire for more dialogue. Staff opinions on consultations varied, with some seeing them as appropriately used and others as too rare and too formal.

2.1.2 ‘Top of mind’ perceptions

Staff: Before being shown the principles, staff awareness of them varied from being ‘very aware’ to ‘background awareness’. Most commonly, awareness of the principles was from training, especially induction training, and also from using the guidance day-to-day, as the principles are embedded in it. Staff commonly mentioned a person-centred approach which involves being holistic and focusing on impacts of health conditions on the individual client, rather than the condition itself. Staff also commonly noted how these principles show that the Social Security Scotland approach is not ‘investigative’, ‘evidence first’ or ‘looking for proof’.

In terms of ‘top of mind’ experiences of the decision-making process in practice (before being prompted with any of the decision-making principles), some staff mentioned feeling confident that they were able to take a holistic approach to decision-making, taking into account all supporting information on its merits and trusting the individual’s account. Some mentioned being able to source supporting information when needed. Some staff mentioned being confident they had sufficient understanding of the impacts of some health conditions. On the other hand, there were also some health conditions where staff were less confident of the impacts, including complex or multiple conditions; and some noted that they sometimes struggled to secure supporting information from the suggested sources. Some staff also mentioned being less confident setting review periods for children with lifelong conditions or children approaching age 16.

Clients: Some clients had heard of ‘dignity, fairness and respect’ – often from Social Security Scotland letters, particularly the decision letter. Clients viewed this intended outcome positively, as they felt it was good to respect everyone is different. They also assumed that Social Security Scotland would want it to be easy to apply or to complete the form or review, and for this to be a supportive experience.

In terms of ‘top of mind’ experiences of the decision-making process in practice (before being prompted with any intended outcomes), some clients found the application process simple and accessible, with clear step-by-step instructions. The same was true for the review process if the client’s conditions had not changed. Some clients appreciated how they received text or email updates on their case’s progress, as this reassured them and reduced stress. Clients who had interactions with Social Security Scotland staff (including through consultations) got the impression staff were engaged, kind and keen to help, which made them feel supported. On the other hand, some clients found filling in the forms emotionally difficult because this involved acknowledging their struggles with their own or their child’s health conditions; or found the questions in the forms repetitious, as if Social Security Scotland were trying to ‘catch them out’. Some clients who wanted help from, or to put a query to, Social Security Scotland found it difficult to reach them by phone; and some were worried by not understanding the purpose of the review process or what was involved in it.

2.1.3 Person-centred decision-making processes

For clients, there was a mix of more and less aligned experiences which, to some extent, correlated with outcome. Generally, when clients were discussing the intended outcomes, the more ‘aligned’ experiences regarding the decision-making process being person-centred and trust-based, tended to be those with successful outcomes and the less ‘aligned’ experiences tended to be those with unsuccessful outcomes (but not exclusively so).

Some successful ADP, CDP and PADP applicants or review clients (i.e. no change or increased award) felt their experience was person-centred: they felt the form was easy which helped to avoid stress; and that the supporting information they had supplied as part of their application was considered. They also felt that the decision accurately reflected the impact(s) of their health condition, as the information in the decision letter about how the decision had been reached, suggested to them that this was the case. They felt listened to and trusted as a result.

Some received help with their application from Social Security Scotland or another organisation, which helped them feel their experience was person-centred, because this interaction helped them feel listened to and understood.

Positive interactions with Social Security Scotland by phone – where staff were empathetic, listened, took time to explain things and to understand the client's situation, and without giving the impression that clients are viewed with suspicion – made some clients feel supported, reassured, and treated as a human being.

“You felt that you weren't just one of 20 that was about to be dealt with that afternoon. You know, she was very happy to listen... she had patience... and I didn't feel that I'd annoyed her by taking a wee bit of time to remind myself where I put [the information].”

(PADP application, successful)

Some unsuccessful applicants and review clients who experienced a decrease in their award, however, felt the experience was not person-centred: they felt Social Security Scotland did not understand their situation or the impacts of their condition which led to an award they did not feel reflected their situation (or no award at all). They felt not heard, trusted or believed. For example, some ADP clients felt the ‘points-based system’ did not allow Social Security Scotland to fully understand the impact of their condition.

Some ADP applicants felt the style of the form was ‘yes / no’ questions without space for elaboration. They felt this did not allow them to share the full impact of complex or fluctuating health conditions (e.g. mental health conditions, autoimmune diseases), which they felt was not person-centred.

"It's just it can't be person-centred if they're using like a one size fits all, a lump tool to make the assessments a point scoring system."

(ADP application unsuccessful)

For some clients, a ‘difficult process’ with Social Security Scotland, such as finding it difficult to get through to Social Security Scotland on the phone and not being able to email them, led to stress and a feeling that the process was not person-centred. Appointees were frustrated at having to validate themselves as an approved contact every time they contacted Social Security Scotland, which left them feeling they were not trusted.

Mostly staff approaches and experiences tended towards being ‘more aligned’, in terms of being person-centred. Some staff (Case Managers, a Decision Team Manager), felt they treat each application on its own merits and focus on how the condition affects the client (rather than focussing on the condition, or on previous experiences of decisions involving that health condition), so that decision-making is person-centred.

“It’s not about the condition or disability [per se], it’s how it impacts on that person.”

(Decision Team Manager, PADP)

Practitioners and Decision Support Staff thought the collection of supporting information and the use of case discussions supports person-centred decision-making, as Case Managers use these to better understand how conditions can affect clients. ADP Case Managers also thought that consultations, when used, supported a person-centred approach by enabling the client to share how their condition impacts them.

Pre-approved online medical guidance such as NHS portals^[2] were used by Case Managers to expand their knowledge on certain health conditions, clarify information provided by clients, and prevent assumptions being made about a client’s application.

CDP Case Managers considered a child’s full circumstances, particularly age and whether that indicated a transition point. Case Managers also reported using phone calls to clients only when needed to collect additional information, to avoid stress and burden on the individual.

However, some staff experiences were less aligned with the process being person-centred and trust-based. We observed some Case Managers reporting ‘knowing’ a condition and using past experiences of the condition to feed into decision-making.

Some aspects of decision-making could align more or less with the policy principles depending on the balance of how they are used. For example, some Case Managers felt that case discussions do not show you the impact on an individual client because they are generalised to the condition, rather than based on an understanding of the individual. Some Case Managers weighed up information from a case discussion with client information, suggesting a more person-centred approach. Similarly, staff felt that decision-making tools can be drawn on to try to better understand the impact of a condition on an individual client, but staff also felt that this could risk resulting in a discussion that focusses on conditions more than the impacts on the client as an individual.

Those staff with experience of decision-making across all types of disability payments felt the decision-making process for CDP and PADP was more person-centred than ADP, because the questions were more open, allowing the client to fully express the impact of their health condition, giving the Case Manager a holistic picture. However, because the questions are more open, Case Managers reflected that CDP and PADP applicants did not always include the right amount of information for them to make an informed decision, which led to ‘call traffic’ to clarify information with applicants.

2.1.4 Trust-based decision-making process

In terms of being trust-based, staff suggested the client’s account was trusted, but not considered on its own. Staff tended to agree that decision-making is trust-based overall. Practitioners, Decision Support Staff and some Case Managers reported trusting the client’s account and using the balance of probabilities.

However, the client’s account was not considered on its own. Some Case Managers and a Decision Team Manager noted collecting supporting information was important to achieve a more holistic picture, in case the client was under-reporting their needs in their application or had not included some information. Some Case Managers reported that the use of supporting information, pre-approved online medical guidance such as NHS portals^[2], or decision-making tools (e.g. case discussion) was sometimes to query the impacts of conditions, stated by clients in their application, especially if the application included conflicting information. There was also some concern about clients over or underreporting the impact of their health condition.

“We trust the client that they are giving us information that is correct as for how those conditions affect their life, except when we find inconsistencies in the application.”

(Case Manager, PADP)

Case Managers also reported that the collection of supporting information from professionals and the support network is more likely to occur with PADP and CDP, compared to ADP. For example, case managers reported collecting supporting information from carers and family members when making decisions about PADP. When making decisions about CDP, case managers reported collecting supporting information from schools, health visitors, social workers, parents and carers. Case Managers used these examples to demonstrate that a wider range of supporting information is used to aid in decision-making for these types of payments.

Some Case Managers and Practitioners felt all supporting information was treated equally or that, in some instances, the client’s account would be trusted above other supporting information, even if it conflicted. Within ADP, some Case Managers were more likely to trust supporting information from professionals (e.g. doctors, social workers, schoolteachers) as they were perceived as more ‘objective’; whereas supporting information from family / friends was considered less robust. Some Case Managers were therefore not considering supporting information on an equal basis.

2.1.5 Experience of reviews

Review experiences were a mix of more and less aligned, for clients and staff.

Some clients felt the review process was person-centred in that Social Security Scotland were considering previous information for reviews so the client did not have to explain everything again, which avoided stress / burden. Clients are provided a copy of their most recent determination at scheduled review so that they can make informed decisions when considering if their circumstances have changed. The ’declaration of no change in circumstances’ was well-received, especially if applicants had experienced an arduous first application.

“I thought it [the review process] was really good. Like it was tick a box and you're done."

(ADP, scheduled review, unsuccessful)

Staff (Case Managers, Decision Support Staff) tended to agree that, where possible, they use information from all previous decisions to support the review decision. Some Case Managers reported collecting further supporting information during reviews only if the client reported a new condition.

According to Case Managers and Practitioners, scheduled reviews tended to require more supporting information if the client reports a change relating to a new or worsening condition or if there was limited supporting information from the first decision, as the ‘open-ended’ form can lead to clients giving too little information. Similarly, Case Manager observations suggested that, if the client reports ‘no change’, the Case Manager uses information from previous decisions to check whether ‘no change’ is viable, and, if not, they will seek more information including, where appropriate, supporting information. For example, supporting information from a doctor might indicate whether symptoms are likely to improve. It is important to note that the policy sets out that staff should seek more supporting information if a new condition is reported which leads to an increased level of award, symptoms worsen to an extent that is not expected, or the level of needs is reported to be the same where this is not expected.

However, clients who did not agree with the review outcome felt reviews could be ‘too light touch’ and so did not allow for them to provide context to changes of circumstances. For example, one ADP client felt they lost their mobility payment because they were exercising more on instruction from their doctor. However, they felt the decision was unfair because their condition still caused them chronic pain. They would have wanted more opportunity to explain their condition in a discussion with staff as they felt they would be better able to describe the impact of their condition through a discussion rather than in a review form. Overall, the perception of not being able to provide context left these clients not feeling fully heard or understood. This could then increase burden on the client, e.g. if they challenged the decision.

“So it [the review] is this light touch ... but on the flip side, it's provided a real burden to me because I'm now having to go through this challenging process to be heard.”

(ADP scheduled review, successful)

2.1.6 Experience of review periods

For review periods, clients’ perceptions were a mix of more and less aligned.

Clients had positive perceptions of review periods when they understood why the review period was set and felt it considered their circumstances. They understood there needed to be a review at some point but appreciated the stability of longer review periods, where this was appropriate. CDP clients understood shorter review periods are set because a child’s needs are likely to change in a shorter period.

“He’s four just now and hopefully by the time he's six, you know he will maybe be a bit more independent and need less help with things and so hopefully things will be different for him.”

(CDP application, successful)

Some clients, however, were unsure of why their review period was set and felt it was not explained to them. Within ADP, review periods sometimes felt too short if clients thought their health condition was not going to improve in that time, as they felt it would create a burden of repeating the same information, and implied that Social Security Scotland had not considered their situation properly. This was more common amongst ADP clients who had not yet experienced a review. Some ADP clients, most of whom had deteriorating conditions, felt there should be no review periods, as they thought that dealing with a health condition is traumatic enough; and felt they needed stability.

The staff consensus was that the approach to review periods was well aligned with the principles. When deciding on a review period for all payments, staff would consider a variety of factors to make an informed decision based on the individual client’s circumstances. These included the type, severity and stability of health condition; and whether treatments indicated things might improve. They also considered the age of the client to account for transition periods that could affect health conditions, e.g. school transitions (for CDP), or being near end of life (for PADP).

Some CDP Case Managers felt setting review periods is straightforward because there are key transition points and ‘age and stage’ resources as a guide. Some ADP and PADP Case Managers felt setting review periods can be challenging and depends on how clients react to treatments, the type of health condition and whether the condition fluctuates. PADP Case Managers found it easier to award indefinitely whereas ADP Case Managers found this more difficult. For PADP Case Managers, this was felt to be because clients were older and more likely to have a health condition that was unlikely to improve. Though not explicitly stated by staff, it may also be because an indefinite award can only be considered for ADP if the client has been awarded the higher rate for both daily living and mobility. Case Managers were guided on when to award indefinitely, by training and through the input of practitioners.

“Why would we review them [individuals receiving PADP]? It's just putting further stress on them. It's not going to get better.”

(Case Manager, PADP)

2.1.7 Experience of consultations

Feedback on consultations was mixed for staff. Amongst clients, feedback from those who had experienced a consultation was generally positive; with the more negative feedback coming from clients who had not had a consultation but would have liked some form of dialogue with Social Security Scotland, as an opportunity to explain their situation and needs.

Some clients had experienced consultations and felt they were person-centred. The Practitioner had been understanding, medically-informed, and caring; it felt like a dialogue and they felt their situation was fully understood, as a result. They were left feeling they had been treated with dignity, fairness and respect.

On the other hand, some clients with complex or fluctuating conditions, all of whom were unsuccessful ADP and CDP applicants, would have welcomed a consultation or a similar opportunity for dialogue with Social Security Scotland, as an opportunity to explain their needs. These ADP clients were not aware they could request one (consultations are not used for CDP); and were left feeling that they had not been heard or understood.

Case Managers and Practitioners felt consultations were used appropriately, as a last resort (e.g. when Case Managers are experiencing difficulties accessing supporting information) or when it could benefit the client (e.g. if the client is potentially underreporting the impacts of their health condition). They were rare because of this. These staff felt that consultations were used only to collect the information needed to make a robust determination that could not be gathered by using other decision-making tools, not to scrutinise information that had already been provided. ADP Case Managers thought that consultations, when used, enable the individual to share how their condition impacts them, thus supporting a person-centred approach. Case Managers and Practitioners also reported clients can specify preferences for the consultation time and format, ensuring it is suited to their needs. A couple of Case Managers reported cases where they felt they would benefit from a consultation, but Practitioners felt there was enough information provided by the client for a decision and so encouraged the Case Manager to trust the client’s account. On these occasions, Case Managers reported they would feel more confident in their decision if it was informed by a conversation with someone with health or social care training.

“Sometimes [Practitioners] will just say there isn't a need for a consultation. You've got enough information there. It's meant to be trust based. Just make a decision.”

(Case Manager, ADP)

Some staff described consultations as ‘too formal’ as they were communicated like an official appointment which the client may interpret as a ‘test’. They reported that clients had to wait a long time for a consultation which caused stress.

2.2 Justifiable and bias-free

2.2.1 Key findings

Clients reflected on the fairness and impartiality of decision-making. Their perceptions of this often aligned with the decision outcome. Clients with successful outcomes often felt that decisions were evidence-based, with decision letters providing reassurance about the information used. However, clients (with a mixture of successful and unsuccessful outcomes) sometimes felt that the decision letter showed that staff had not considered all the supporting information that had been provided or had not contacted all the professionals or support network contacts they had provided in their application, leading them to question if there was potential bias in the decision-making process. They also found it challenging to fully express their situation through the forms; and wanted clearer justifications for review periods to reassure them that no assumptions about their health were made in setting these.

Case Managers believed they assess each case individually on its own merits, and aim to avoid burdening clients. However, some staff acknowledge the difficulty of completely eliminating unconscious bias due to perceptions that social security staff were generally from similar backgrounds. Additionally, decision-making tools and resources designed to mitigate bias are not always utilised 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 consultation clients appreciated having the opportunity to share how their condition was impacting them. Others (for whom it was less clear whether they had had a consultation) would have liked more time to prepare for their interaction with Social Security Scotland staff. 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.

2.2.2 ‘Top of mind’ perceptions

Staff: Before being shown the principles, staff commonly mentioned dignity, fairness and respect, as core values that sum up the decision-making approach and Social Security Scotland culture. In addition, staff mentioned trust-based decision-making and using the balance of probabilities, including using case discussions or Practitioner input to establish likely impacts of a health condition.

In terms of ‘top of mind’ experiences of the decision-making process in practice (before being prompted with any of the decision-making principles), staff noted that, through their collaborative approach with colleagues, they were able to mitigate biases and resolve uncertainty when making decisions. On the other hand, some staff felt it was harder to apply the balance of probabilities for cases not fully covered by guidance or where there was limited evidence available to them.

Clients: Again, before being shown the intended outcomes, some clients had heard of ‘dignity, fairness and respect’ – often from Social Security Scotland letters, and particularly the decision letter. Clients viewed this intended outcome positively, as they felt it was not ‘trying to trip you up’. Clients assumed Social Security Scotland aimed to make benefits accessible to those who need them.

2.2.3 Decision-making process is justifiable and bias-free

Both clients and staff gave mixed feedback when prompted with the principles and intended outcomes for this theme. Amongst clients, the more ‘aligned’ experiences, tended to be amongst those with successful outcomes.

Generally, clients felt the evidence-based approach to decision-making enabled the process to be non-judgemental and free from bias, as it was based on the information (and supporting information) provided in the application form or review form. Some commented on the decision letter clearly explaining the information that had been considered.

On the other hand, some clients, with successful and unsuccessful outcomes, felt 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, because some information had not been referenced in their decision letter. This led them to question whether there was bias involved in the decision-making process: they questioned whether, without having considered all the suggested supporting information, Social Security Scotland could have fully understood their situation. This led them to wonder if other factors, such as biases or preconceptions, had been involved in making the decision.

“My understanding is that [Social Security Scotland] is trying to move away from the more…judgmental things done in the past, and that's why the evidence-based way they're going about it is actually …quite fair. That's a good way of doing it, but it only works if the right questions are asked first time around…I think that's where they need to really up their game."

(ADP application, unsuccessful)

Some individuals felt the application forms could be improved, with more guidance on what sort of information to include, so as to collect more accurate and detailed information on how health conditions impact individuals’ lives (particularly those with fluctuating or non-physical conditions).

Some clients also felt that justifications provided in the decision letter could have been clearer relating to review periods, as they did not understand why their review period had been decided upon or felt like assumptions had been made about their health conditions improving, when determining these.

Some Case Managers were observed to proactively consider each application individually to understand the applicant’s situation, without allowing previous decisions to influence their thought processes, and they used decision-making tools to guard against bias. Case Managers and Practitioners felt the balance of probabilities was used effectively to infer additional likely impacts on a client, to achieve a more holistic picture of their situation, without burdening them with direct contact to get more information.

"Making informed judgements while acknowledging and addressing biases... I'd normally do that by getting another set of eyes on it just to make sure that I'm not narrow minded for lack of a better term and considering the individual.”

(Case Manager, PADP)

On the other hand, some Case Managers felt that decision-making tools were not always used. We observed some Case Managers reporting ‘knowing’ a condition and using past experiences of the condition to feed into decision-making. In addition, some Case Managers acknowledged the decision-making process was not completely unbiased. One Case Manager felt that there is the potential that decisions could be influenced by bias because most of the staff they worked with come from a similar group, and highlighted the importance of processes that allow staff to mitigate unconscious bias. However, a team leader felt that consistency was improving with additional training.

"From my personal experience in dealing with the organisation, bias is a big problem... like bias and then taking the client’s full circumstances and information provided by their support network, those will be the two where I think the organisation falls short...everyone here comes from a similar group [in terms of background]. You have the odd outlier, that sort of thing, but there's quite a narrow viewpoint of how society functions. My thing was maybe we need to communicate what can impact our colleagues more. Think of it as this whole… how would you treat your neighbour thing… runs through so many different veins of life or treat your neighbour how you would want to be treated."

(Case Manager, PADP)

2.2.4 Experience of reviews

Review experiences were mixed. For clients, this tended to correlate with outcome. For example, those who experienced a no change or increased award were more likely to report a positive experience.

Some clients felt the review process was clear as the decision letter or other contact with Social Security Scotland made it clear that they had to report changes of circumstances. In addition, some clients felt that Social Security Scotland had considered previous information for reviews. This meant clients did not have to explain everything again which avoided unnecessary stress and burden. On the other hand, some clients, particularly those with unsuccessful outcomes (e.g. a decrease in award), felt the review process was unclear and burdensome.

Staff reported using information from previous decisions when making review decisions to reduce burden. They would only require updated supporting information if the previous information was outdated or did not reflect the client’s current condition. However, Case Managers reported that clients did not always realise that Social Security Scotland were able to use information from previous decisions where still relevant; meaning they would submit further supporting information which staff felt was arduous and stressful for clients and in some cases not needed. In contrast, Case Managers sometimes reported individuals providing too little information at a review, making it difficult to fully understand their situation.

“When I was reading the first review form, I was thinking this man does sound really severe, but I don't think he's telling us the full picture.”

(Case Manager, ADP)

2.2.5 Experience of consultations

Consultation experiences were more aligned for staff. During interviews and focus groups with clients, it became apparent that some clients were not clear on whether they had had a consultation or not and that some of these clients had mistaken a more informal phone call from Social Security Scotland staff for a consultation. Experiences were more aligned for clients where it was more clear they had had a consultation and less aligned for those where it was less clear.

For clients for whom it was more clear that they had had a consultation, some felt consultations were useful in allowing them to ‘have a voice’ and explain how their health conditions impacted their life. This was particularly the case for those with complex or fluctuating conditions.

On the other hand, for clients for whom it was less clear that they had a consultation, some felt that they would have liked more communication in advance of interacting with Social Security Scotland staff, so as to fully understand the purpose and to allow time to prepare in advance. Some of these clients would have liked more advance warning to give themselves time to prepare as they felt Social Security Scotland were trying to ‘catch them out’.

Staff felt consultations were helpful to make sure that decisions were based on the client’s account and not staff’s personal bias or preconceptions. Staff felt consultations benefitted the client and were used appropriately, in cases where there was a lack of supporting information, conflicting information, or it was suspected that the individual was under-reporting their condition. They were used as a ‘last resort’ to avoid burden on individuals.

“It's a last resort. We don't want to re-traumatise people. We don't want to have consultations that are unnecessary."

(Health and Social Care Practitioner)

2.3 Transparent, clear and accurate

2.3.1 Key findings

Clients reflected on the transparency, clarity and accuracy of decision-making processes. There were mixed perceptions about these concepts. Clients' views on the clarity of decisions at both reviews and applications often depended on whether decision letters clearly explained the information used and what additional information could have been provided. Staff were generally confident that decision letters offer clear justifications, referencing where each piece of information in the letters come from and using a structured yet tailored format. They also discussed recording decision-making steps in a 'case canvas' for transparency. Clients also had mixed perceptions about the accuracy of decisions. Positive views were linked to decision letters that clearly explained decisions and the information used, making clients feel understood. This was even the case for those who disagreed with the decision. Negative views arose when letters suggested not all information provided was used, or when people felt that case managers 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. Despite some reservations, staff believed they use various information sources and tools to make accurate decisions.

2.3.2 ‘Top of mind’ perceptions

Staff: In terms of ‘top of mind’ experiences of the decision-making process in practice (before being prompted with any of the decision-making principles), some staff reported feeling confident that they would be able to draw on all the information necessary to make an accurate decision.

Clients: Before being shown the intended outcomes, clients assumed Social Security Scotland aimed for a rigorous process, to assess your situation properly and ensure the right people got support, with evidence or an audit trail.

“So, it's something that needs to be processed correctly…but not dragged out… fair and accurate, with an audit trail.”

(PADP application, successful)

In terms of ‘top of mind’ experiences of the decision-making process in practice (before being prompted with any intended outcomes), some clients felt validated and reassured when Social Security Scotland had considered their application or review form carefully and gave detailed justifications, contacted their support network or called them to clarify information. On the other hand, some clients did not feel that Social Security Scotland had contacted the most appropriate individuals for supporting information; or had felt unsure what level and type of detail to include in the second part of their application form, feeling there was insufficient guidance on this – and these experiences led them to question the accuracy of the decision made.

2.3.3 Decision-making process is transparent, clear and accurate

Staff felt decisions were clearly explained. Clients had more mixed views, and this was the case amongst those with successful and unsuccessful outcomes, at application and review (i.e. increased, no change, or decreased award).

Some clients agreed decisions were well explained in the decision letter, as this set out clearly what they had told Social Security Scotland in their application and how that information had been used. The ADP points-based system was noted as being easy to understand. As a result, clients understood why the decision was made. This was even the case for those who felt it was the wrong decision and those who disagreed with the outcome; they said that they felt better informed if reapplying.

“I've got several pages here of the decision…they've gone back over what I told them and what things I told them that [they] had accepted, how they arrived at their decision. Which was quite interesting to read through – [re]assuring as well, that they have understood and taken notice of what was in the application, and that the detail was all very accurate.”

(PADP application, successful)

On the other hand, some clients felt the decision was not well explained in the letter so were not sure how the decision was reached. For example, saying their child’s needs did not meet the criteria, but not explaining why this was so. Additionally, some ADP applicants felt the wording in the decision letter seemed quite generic, like a ‘standard letter’, and so lacked detail about how the decision was made. Some clients also felt the lack of an explanation of what other information could have been included made the decision letter less useful in informing future applications.

Case Managers reported including a justification in the decision letter for each payment element, even if not awarded or relevant to the client. They referenced where each piece of information came from (e.g. SI, a consultation) and any other guidance or structures used (e.g. CDP ‘age and stage’ guidance, the points system for ADP). While having standardised letter templates provides a clear structure, they tailor the wordings within these to the individual client’s situation and language. They also reported collaborative working between Case Managers with them reviewing each other’s responses to make sure they’re clear, short, and succinct.

“With any of your justifications... you should have some reference to where you're getting this from [in the decision letter].”

(Case Manager, ADP)

One Practitioner reported that they felt decision letters can sometimes be a little vague as to why an award has not been given (however this was an outlying view, in terms of the staff perspective).

Clients had mixed views on decision accuracy. The less ‘aligned’ experiences were a mix of successful and unsuccessful outcomes, at application and review (i.e. increased, no change or decreased awards). Staff were positive about decision accuracy, with some caveats.

Some clients felt that the decision letter explained how the decision was made and made it clear that Social Security Scotland had taken note of, and thought about, what was said in the application and supporting information, both at the initial decision and at review. As a result, they felt heard and believed, and confident Social Security Scotland had understood their situation. For one client, their consultation experience made them feel the right decision was made first time, as they felt the consultation was a dialogue which allowed their situation to be understood.

On the other hand, some clients felt the right decision was not made first time because the decision letter gave the impression 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. ADP clients also felt the points-based system was inflexible to certain conditions e.g. autoimmune diseases.

"You don't understand what's actually taking place at that decision…Are these people qualified to comment on a medical condition they don't understand? Who are they? Why didn't they speak to my professor? Because they don't know, I can put money on it, they will not understand what this condition is."

(ADP application, unsuccessful)

Some clients also thought the decision showed that receiving treatment was seen as indicating a condition would improve or that being in work was taken as evidence a condition was not that severe. This made them feel frustrated and misunderstood.

Some clients felt the right decision was not made first time because the form did not provide enough guidance on how much information to provide; and they did not have the chance to speak to someone as a way of explaining their situation. This was particularly the case for clients who had had their award reduced at a review; who felt the decision letter made it clear that the Case Manager had misunderstood their situation.

“In my case, certainly they didn't make the right decision first time, but that's because it turned out they didn't have all the information…they needed.”

(CDP application, unsuccessful)

Case Managers reported using various sources to help them feel confident they had made the right decision first time, including information from the client, professionals, and pre-approved online medical guidance such as NHS Inform.^[3]

“Obviously people can put in redetermination if they disagree with the decision that we make. But the decisions that we are making, we’re making based on the information that we have available at that time, and the caring needs that are described.”

(Case Manager, CDP)

Case Managers also reported using internal resources, in some cases, to ensure an accurate decision is made. This included discussing cases with colleagues, to check they’re interpreting the guidance correctly; asking their Decision Team Manager to discuss these at daily stand-up meetings; putting guidance queries to Decision Support Staff; or asking for input from Practitioners. These resources were used for first decisions and reviews, particularly since review forms were felt to collect limited information.

As mentioned in section 2.1.4, case managers reported collecting supporting information and using decision-making tools to, in some cases, query the impact of conditions stated by clients in their application, especially if the application included conflicting information. There is a tension here, in that the way these various sources and tools are being used in this example, to try to ensure decisions are robust, can potentially contradict the idea the client’s account is ‘trusted’; and staff also referenced having to balance the use of tools with trust.

Decision Support staff also felt that there could be difficulties to decision-making because the information about a client picked up from forms and supporting information, and the way it is understood, can vary a lot from person to person.

"It's so subjective and you will get people that can come to different conclusions and make different decisions, and it won't be incorrect. I think the issue here if you're taking our trust-based approach…is that every decision maker will do different things.... They would all use different tools and…probably it would be inconsistent."

(Decision Support Staff)

Staff also mentioned other difficulties with regard to decision-making, but these were less commonly spoken about:

• One Case Manager felt that decision-making tools, such as case discussions, are less useful when there is a lack of clarity around the information provided by clients in forms.
• One Case Manager felt that there is operational pressure to get through a certain number of cases a week, which can make it difficult for them to use all the decision-making tools available to them.
• One Case Manager felt that there is difficulty in seeking support from Decision Support staff because they approach the decision using guidance without understanding the specifics of cases.
• One Case Manager felt that support from Decision Support staff was most useful when they interrogated the Case Manager’s thought process, helping the right decision to be made first time.

Client feedback also suggested the process was not transparent enough. While some clients felt treated well because they had received a notification text or email, when they submitted their application, stating it was being progressed, with an approximate timescale; other clients were not informed of application progress, and just received the decision letter without any updates preceding this.

Though not directly related to the policy underpinning decision-making, as a result of this clients reported feeling uncertain, unable to plan ahead, stressed, or overwhelmed. This was reported by clients with successful and unsuccessful outcomes, relating to both ADP and CDP, and mostly in relation to applications. Relatedly, some clients found it difficult to get through to Social Security Scotland by phone and found there was no way of emailing; or, if they did get through, were given conflicting information by Social Security Scotland verbally and in writing. These clients found this stressful; or felt treated as a 'non-person’.

“Actually, it's after that, where I feel as if, when the application's in, you’re kind of it's just…in limbo really.”

(CDP application, successful)

Client feedback suggested further ways in which they felt the process was not fully transparent. While not a requirement of the policy principles, some clients were not aware of which professionals were being contacted for supporting information. This also led to them not feeling empowered to potentially contact specific individuals to encourage a response. Clients also felt that applications needed the right “buzzwords”, requiring the knowledge of a professional (indeed, many received help with their applications). This suggests a possible need to increase the visibility of how applications are considered, to clients, before they apply; for instance, providing more guidance or checklists around what types of information to include.

There was also mixed client feedback on the transparency of the review process. Some clients felt the review process was clear. The decision letter or other contact with Social Security Scotland made it clear that they had to report changes of circumstances; and some had done so. On the other hand, some clients with unsuccessful review outcomes (i.e. whose award had decreased) felt the review process was unclear. For example, one client was not sure if they had to inform Social Security Scotland of what had not changed, as well as what had.

2.4 Alleviates financial pressures

2.4.1 Key findings

When considering the potential impacts of the policy, clients reflected on whether decision-making alleviated financial pressures. To some extent, the perception of this 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.

2.4.2 ‘Top of mind’ perceptions

There were no ‘top of mind’ perceptions that emerged, that were relevant to this theme.

2.4.3 Decision-making process alleviates financial pressures

Clients with successful outcomes often felt that the outcome alleviated financial pressures by providing stability and reducing stress, as they could meet their needs and plan for the future without immediate financial concerns. These payments helped cover essential additional costs like larger bills and transportation to medical appointments. In particular, PADP applicants noted the payment helped to cover heating bills. Additionally, the payments enabled clients to budget for extra support needs, such as activities for children or therapies, and allowed those working to reduce hours when necessary. Beyond financial relief, the payments positively impacted mental health, offering a ‘boost’ during tough times or enabling clients to afford additional activities that benefited mental health. Even some clients who did not receive successful outcomes appreciated knowing their financial situation, as it allowed them to plan ahead financially.

“It does kind of lift some of the stress and worry knowing that you're going to get this money coming in and that's what it's there for - I feel like it's taking a big weight off my shoulders, financially.”

(CDP application, successful)

Conversely, some successful review clients did not feel a sense of stability from receiving payments, noting that they were not intended as income replacement and could not replace lost income. The time taken to receive a decision, especially for ADP applications, hindered some clients’ financial planning and affected their mental health, as they could not plan ahead until receiving the decision. In addition, confusion arose for some applicants who received payments or changes in payment amounts before receiving official decision letters, causing them concern about potential errors.

2.5 Encourages a positive relationship

2.5.1 Key findings

Clients discussed the potential impact of decision-making processes encouraging a positive relationship with Social Security Scotland and were mixed in their perceptions of this. They were generally more positive when their outcome was successful, as they felt 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.

2.5.2 ‘Top of mind’ perceptions

There were no ‘top of mind’ perceptions that emerged, that were relevant to this theme.

2.5.3 Decision-making process encourages a positive relationship

Clients had a mix of more and less aligned experiences regarding decision-making encouraging a positive relationship with Social Security Scotland. This was, to some extent, correlated with experiences of the application process and decision outcome.

Clients with a successful outcome were more positive about their experience and relationship with Social Security Scotland, as they had received the outcome they expected; and felt listened to and valued.

“You felt you were taken seriously as an individual and your request was actually taken into account, and you were valued.”

(ADP consultation, successful)

On the other hand, clients who were unsuccessful tended to feel more negatively towards Social Security Scotland as they did not feel the correct decision had been made. This was particularly where the decision letter suggested information provided had not been taken into account, or professionals listed in the application were not consulted. For some clients with both successful and unsuccessful outcomes, across ADP and CDP, a lack of communication about the decision-making process and how decisions are made, negatively impacted the relationship. Not being given the opportunity to discuss their situation directly with someone at Social Security Scotland also negatively impacted the relationship for some of these clients. Some mentioned they would have liked more transparency in the process to understand the decision-making process and outcome. This led to feelings that the decision was incorrect as their situation was not fully understood. This was particularly true for unsuccessful reviews.

Clients who had direct contact with Social Security Scotland staff via phone were positive about the interactions and described staff as friendly, respectful, and having a ‘human touch’. Trust in Social Security Scotland decision-making was more evident where decisions were explained clearly in the decision letter, for both successful and unsuccessful applications.

On the other hand, for some clients, a lack of updates and difficulty getting through to Social Security Scotland for updates about their application, negatively impacted the relationship, as they felt treated as a 'non-person’. Though not directly related to the policy underpinning decision-making, clients felt that updates on application progress could have been improved.

In addition, not being able to discuss the situation directly with someone at Social Security Scotland negatively impacted relationships and led to feelings that the decision was incorrect as their situation was not fully understood (this was particularly the case for those who had received a decrease in their award as part of their review). For appointees, verifying their identity on each contact with Social Security Scotland was arduous and made it difficult to progress an application. As a result, they felt as if they were not trusted by Social Security Scotland.

2.6 In summary, what is working well?

The findings suggest a number of ways in which, at least some of the time, client experiences of decision-making processes are delivering on the intended outcomes, and staff experiences are in line with the decision-making principles.

For some clients:

• The application / review form is easy to use and avoids stress.
• Clients feel informed about the progress of their application or review.
• When successful, clients have peace of mind knowing their needs can be met.
• Direct contact with Social Security Scotland has ‘the human touch’ and treats clients with dignity.
• Decision letters and contact with Social Security Scotland make it feel like personal circumstances are recognised.
• Decision letters make clear the outcome, how it was reached, what info was used (although some felt they included inaccurate / lacking information).
• Those who had had consultations, felt listened to and treated with respect.

The final four aspects in this above list, led to some clients feeling trusted, heard and believed.

For some staff:

• There was evidence, from observations, of staff trusting the individual’s account and being conscious of ‘not putting words in their mouth’.
• Input from Practitioners led to more confident and informed decision-making.
• Justifications in decision letters were often detailed to allow the client to understand the rationale behind decision-making.
• Case Managers seek out and consider a range of information when making a decision.
• There was evidence, from observations, of staff challenging their own assumptions and biases by seeking support.
• Staff tailor review periods to the individual and their health condition.