In November 2017, the Scottish Government commissioned a consortium of Blake Stevenson Ltd, Rocket Science and the York Health Economics Consortium (YHEC) to conduct a study of the implementation of self-directed support which will contribute to and help to shape ongoing national monitoring and evaluation.
The original brief was for a commission which covered three interconnected elements:
- A: an Evaluability Assessment of self-directed support;
- B: research on the economics/resource implications of self-directed support; and
- C: research on Option 2 in practice.
It was proposed that case studies were a good approach to address research questions related to elements B and C. Through discussion at the Research Advisory Group (RAG) for this project, it was agreed that a small number of detailed case studies would explore the various ways self-directed approaches are being implemented across user groups.
Four reports, including an overview of findings across the other three, have been produced to detail the methodology and findings of this study:
- Report 1: the SDS Change Map;
- Report 2: Evidence Assessment for Self-directed Support (this report);
- Report 3: Self-directed Support Case Studies; and
- Report 4: Summary of Study Findings and Implications
The Scottish Government launched Self-directed Support: A National Strategy for Scotland (SDS Strategy) in 2010. The strategy set out the Scottish Government’s aim to mainstream a self-directed approach to the delivery of care and support. This formed part of a wider shift towards personalisation, co-production and assets-based thinking in social care, in contrast to the case management approach brought in by the NHS and Community Care Act 1990.
Self-directed support, and the core principles underpinning it, represented a change in the relationship between supported people, commissioners and providers, with more choice and control given to supported people and more flexibility required of providers and commissioners. It encourages more creative solutions to meet people’s support needs. This has entailed a significant cultural shift for some services, from making decisions for supported people to making decisions with supported people.
Self-directed support was given a statutory footing with the Social Care (Self-directed Support) (Scotland) Act 2013 which was implemented from 2014. The legislation requires local authorities to offer individuals a range of options when they are thinking about how to meet their social care outcomes and health and social care services. These options are:
- Option 1: The individual or carer chooses and arranges the support and manages the budget as a direct payment;
- Option 2: The individual chooses the support and the authority or other organisation arranges the chosen support and manages the budget;
- Option 3: The authority chooses and arranges the support; and
- Option 4: A mixture of options 1, 2 and 3.
The Self-directed Support Strategy Implementation Plan 2016-2018 states the current priority is to “consolidate the learning from innovative practice and the application of guidance; and to embed self-directed support as Scotland’s mainstream approach to social care.”
Audit Scotland’s progress report on the implementation of SDS notes that not everyone who asks for social care or support is eligible to receive it. Each local authority is responsible for setting local eligibility criteria for access to social care services, based on national guidance produced by the Scottish Government and COSLA. Local authorities assess people’s needs in partnership between the assessor, the person with social care needs and, if appropriate, a family member or carer. Anyone assessed as being eligible for social care can expect to have a discussion with their social worker about the personal outcomes they want to achieve, what support they need to reach these, and how much control they would like over arranging and managing their support.
Self-directed social care applies to all user groups and age groups. This includes children and adults as well as older people, people with disabilities and people with mental health problems. The main exception is people receiving re-ablement services (short-term support to help people regain some or all of their independence). Where the person lacks the capacity to provide consent themselves, a carer or guardian can apply for power of attorney or guardianship so they can make decisions on the person’s behalf.
The Audit Scotland progress report acknowledged that these changes to provision came at a time when public sector budgets were under significant pressure due to the ongoing financial constraints, while there is increasing expectations and rising demand for health and social care support, and when there are social care workforce shortages. All of these have contributed to a slower than expected speed of implementation of person-led and person-centred support and, in some cases, resulted in limited choices for supported people.
Audit Scotland also identified that the integration of health and social care has likely further slowed the pace of self-directed approaches being mainstreamed.
One of the main aims of the study was to produce a refreshed set of key research questions for the ongoing monitoring and potential evaluation of the move to self-directed support and the changes following from this. This assessment began with a review and refinement of existing draft logic models through a theory of change exercise. This process led to the creation of the SDS Change Map for effective policy delivery, which captures specific outcomes identified by a range of stakeholders. Report 1 details this process and the elements of the change map.
After creating the SDS Change Map, an assessment of existing evidence helped to create a revised set of research questions for future monitoring and evaluation, as well as looking at the economics/resource implications of self-directed approaches. The assessment of existing evidence included:
- a literature review of other evaluations of similar programmes;
- a review of current data collections in Scotland that potentially relate to self-directed support; and
- the production of case studies to explore the various ways self-directed approaches are being implemented across user groups and the potential for scaling up and replicating (Report 3).
Structure of this report
This report sets out the findings from the assessment of evidence sources and the implications for monitoring and evaluation of self-directed support; and proposes ways forward to monitor and evaluate the policy over the next five years.
Chaper 1 reviews the available literature, Chapter 2 presents a literature review, in Chapter 3 we assess the current data collections and evidence of self-directed approaches to care and support, and in Chapter 4 we present the evidence from the case studies.