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 that 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 and the potential for scaling up and replicating good practice.
Four reports, including an overview of findings across the other three, have been produced to detail the methodology and findings of the Self-directed Support Implementation Study 2018:
- Report 1: the SDS Change Map;
- Report 2: Evidence Assessment for Self-directed Support;
- Report 3: Self-directed Support Case Studies (this report); 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 individuals 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 support services, from making decisions for supported people to making decisions with 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, 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.
Audit Scotland’s report also found that the pace of mainstreaming self-directed support in social care has varied across the country and for different groups of people, which made it difficult to draw conclusions about implementation ‘progress’ at a national level. The report did find that many people are being supported in new ways; although more information and guidance is needed to help individuals make informed decisions.
The 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 is likely to have further slowed the pace of self-directed approaches being mainstreamed.
Case study areas and contributors
The case studies highlight that the local authorities started their journey towards self-directed support from different places. Some councils had already introduced more creative and flexible approaches to social care or demonstrated social work practice that already featured personalisation, choice and control. They also show how their populations and geographical locations present different challenges and needs.
Six local authorities took part, selected to provide the range of difference across areas of deprivation and urban and rural geography:
- Dumfries & Galloway;
- North Lanarkshire; and
- Eilean Siar (Western Isles).
Initially the Scottish Government liaised with Social Work Scotland under an agreed research access protocol between the two organisations. In each area, the Chief Social Work Officer was then contacted by the Deputy Director for Care, Support and Rights in the Scottish Government. Following this contact, the study team liaised with local nominees to make the case study arrangements.
We requested case study examples from each area. It was easier for some councils than others to work with their social workers to identify cases and then secure informed consent from individuals and providers. We were able to complete at least one case study in each of the six areas. For each case study, we identified a range of contributors who were involved in or supporting the delivery of social care. This is detailed in Figure 1.
Figure 1: Range of contributors
Again, the modes and degree of engagement across this range of contributors varied by area. In most cases, we carried out face-to-face interviews with participants along with follow-up telephone and email correspondence to confirm details. Each full case study has been signed off by a local authority contact. The research team have shared the case studies with the individuals involved when they had their contact details. In this situation, these case studies have been signed off by them or their family member/carer.
The discussions with people in receipt of a personal budget, carers, frontline staff, and provider organisations focused on their experience of accessing or supporting the delivery of social care.
With local authority officials in each area, the focus of the discussion was on the local context and the processes and structures that underpinned the approach to social care delivery that provided personalisation, choice and control. In order to understand the economic implications of self-directed support, the researchers asked the officials in each area to answer follow up questions about the resource allocation system, the time spent on key activities like the review and assessment, and the staff time and frequency for meetings like decision making panels. This exercise sought to capture information to allow greater understanding of the resources needed to implement self-directed support.
Two areas provided information about the economic resources associated with delivery, which is included in their case study and discussed in more detail in “Report 2: Evidence assessment for self-directed support”. The reasons why the other areas did not respond is not known. It was possibly because calculating time and resources for some of the activities was challenging or that they were too busy to respond within the timeframe.
Structure of this report
For the remainder of the report, each chapter is dedicated to a case study area, providing local context and the structures and processes that underpin self-directed approaches.
The chapters document case studies of individuals, and a few social care providers, that capture a variety of experiences of self-directed approaches to care and support. In order to prevent the potential identification of individuals, some details were changed.
In the final chapter, we reflect on the experiences described in the case studies, and consider some of the emerging themes about self-directed support implementation for those who receive care and support and those involved in delivering it.