Self-directed Support Implementation Study 2018: report 3

8. Reflections

Introduction

The case studies within this third report, alongside Report 1 (the SDS Change Map) and Report 2 (the Evidence Assessment) provide insight and some understanding about self-directed support as a policy and the implementation of the legislation. Together, they will support the Scottish Government to make better-informed decisions about the ongoing national monitoring and future evaluation of social care.

This research did not set out to gather case studies that were representative of the degree to which self-directed support has become the mainstream approach, across the country for enabling individuals to have their social care support needs and outcomes met. The case studies were not intended to be fully evaluative, looking in-depth at social care outcomes for an area and how they were being delivered.  Instead, they were exploratory studies to capture some of the many ways self-directed approaches are being implemented and to consider the potential for scaling up and replicating documented approaches.

Case study approach as an evaluation activity

The aim was to undertake 13 case studies exemplifying social care, accessed under the four options across a diverse population; this ambition was tempered slightly by the time it eventually required to identify and secure participation (of individuals using social care and families, and social care staff). The people accessing social care within the case studies are predominantly older or middle-aged people with degenerative diseases, neurological conditions, people who experienced a life changing critical incident and some individuals with a genetic disorder.

Undertaking the case studies was resource intensive and took several months to complete, which is important to be aware of when considering a case study approach as part of future research and evaluation. Each case study involved; gaining initial co-operation of the local authority; working with Council officials to identify individuals and gaining informed consent; then liaison with the individuals, their families/carers, their social worker and providers to arrange the fieldwork, which was in the form of face-to-face and telephone interviews. The discussions were followed up with further email exchanges or telephone calls to clarify facts and details and for participants to check and confirm that they were happy with the written case study account. The involvement of all these contributors provided detailed insight, through multiple first-hand perspectives, into self-directed support. The case studies also throw light on the extent to which self-directed support is meeting its policy outcomes in this small number of cases, although conclusions about policy implementation would require fuller evaluation.

This project shows how a case study approach (perhaps with a wider set of research questions and participants) could be a valuable component of any future, larger evaluation of self-directed support implementation.

Emerging themes

The timescale and size of this project meant that it could not reflect all of the diverse approaches to implementing self-directed support across Scotland. There are, however, clear, recurrent themes across the local authorities that were part of this case study research.

The case studies were intended to capture diverse instances of how individuals and their families, communities, and providers have been negotiating the self-directed principles and options. They were also designed to document a range of fairly typical examples of individuals using social care. It is also clear from the case studies that the local authorities started from different baselines in terms of their existing approaches to social care and the extent that personalisation, choice and control featured in social work practice prior to the 2010 strategy and subsequent legislation. They echo other evidence about the pace and means of implementation varying across the country.

Local authority resource and cost implications of implementing self-directed support

Understanding the difference in Council resource use and costs associated with implementing self-directed support requires an understanding of the current difference in resource use compared to previous social care practices. The case studies highlighted that additional administrative and social work resources associated with delivering choice and control lies predominantly in the assessment process and in resource allocation panels. Ascertaining resource use either in panels or in the assessment process proved difficult to gather, with only one site (North Lanarkshire) providing information that allows the costs of both the assessment and allocation process to be estimated.  The Western Isles provided partial costings as well.

A full evaluation of the economic and resource implications of self-directed support would ideally include a comparison of current estimates of local authority resource use on assessment and allocation activities compared to previous practice. In the absence of any established system for recording relevant data, such a comparison would require research into time spent on assessment and allocation processes before 2014 and an understanding on a case-by-case basis of how much the Council was already engaging in practices to support choice and control and personalisation. It is likely to be challenging to involve councils in such work and they may not be in a position to provide the necessary data.

Researching resource use and costs in the past would be extremely challenging.

Furthermore, any attempt to evaluate whether the shift to self-directed support has led to health and social care system-wide costs and benefits will inevitably run into potentially intractable difficulties, not least those arising from the range of services and support that contribute to an individual’s personalised outcomes and well-being.  In addition, compared, for example, to many medical interventions or narrower service interventions with less diverse target populations, it is extremely difficult to monetise social care and social care outcomes or estimate returns on investment – and this has become even more so the case with the move to self-directed support.

The scope of any economic evaluation of self-directed support implementation and policy outcomes will necessarily be limited. This is further discussed in “Report 2: Evidence assessment for self-directed support”.

Resource allocation panels

Resource allocation panels were not in use by all authorities but where they were, they were seen as a crucial part of the approach to enable supported people to direct their social care and support. In the case study areas with panels, these involved both social workers and budget holders and meet at least fortnightly. There were two main reasons for their use. First, to ensure that overall budgets for social care were not being exceeded at a council level. Second, the panels were seen - particularly in North Lanarkshire - as a means to test and develop creative solutions to people’s needs and provide social workers with the confidence to move from a ‘good conversation’ to a care plan that was truly bespoke to meeting an individual’s outcomes.

The constraint with such panels is time. They require considerable investment in social worker and management time to attend. Currently, resource allocation panels identified in the case studies predominantly consider social care support under Option 1, 2 or 4. It is unclear whether there would be sufficient capacity to hold such meetings for every social care assessment which identifies the need and eligibility for support. An example of this is in North Lanarkshire home care for the elderly where a significant proportion of all social care is provided under Option 3 and so does not currently go to the resource allocation panel.  There are indications that the lack of local authority capacity for such panels may be limiting how self-directed support is implemented for all groups of supported people in an authority.

The need for review and changing circumstances

Several of the case studies highlighted how changing circumstances altered the support needed for individuals to achieve their outcomes, which outcomes they wanted to achieve, the priority of those outcomes, and/or how much responsibility they wanted for managing support (partly translated into the Options they choose). This is highlighted in Case Study 8 when Gerry moved to Dundee to study and changed contractor and the option under which his care package was provided. Social workers are required to be proactive in both maintaining ongoing relationships with supported people and addressing changing circumstances as they arise. Equally important is for individuals to be able to request reviews where they can speak freely about how support needs and personal outcomes have changed. In Case Study 2, Alastair’s needs have been met by the same care provider for almost ten years and the opportunities to discuss alternative provision have been limited.

Sufficient supply and ensuring quality of supply

Challenges in the social care market in terms of the conditions and supply of care workers are well documented and reported^[16]. The complex provision and changes in delivery of services, the challenges within rural and urban areas, the financial environment and resource constraints, and the impacts of social and technological change are placing demands on the social care workforce skills requirements and supply.

The case studies provided further evidence of the impact of supply issues on the outcomes individuals are trying to achieve. Some of the outcomes required traditional caring but with a high degree of flexibility, others called for support that was not routinely offered by existing care providers. Even where a budget (and sometimes other practical help) was provided for individuals to recruit support workers or Personal Assistants, it was not always possible to find suitable people who could deliver that support, as seen in Case Study 10 with Joanne struggling to recruit additional support. In addition, the Option 1 case studies highlighted that there may well not be any training and support for their role (for example those within the local community providing support to James in Case Study 13). It is vital to introduce training and support to ensure the quality of support they can offer is at a minimum maintained and ideally improves over time.

Does the use of the four self-directed support options to access social care reflect the intended policy outcomes?

The case studies highlighted the different ways that local authorities interpret, deliver and record the four self-directed support options. Some local authorities only record as having self-directed support those individuals who went through an assessment (including the good conversation), a resource allocation calculation and then a decision process on the care package from a range of provider options. In other areas, essentially anyone accessing social care or support is assumed to have made an ‘informed choice’ and is recorded as accessing self-directed support. This has significant implications for the collection and comparison of high-level statistics on self-directed support across local authorities in Scotland. This has been a significant issue routinely commented on by authorities in relation to published statistics on self-directed support. There is an inconsistency in what is recorded and why, from area to area, and this has been recognised at Government-level.

Although the four options are explained within the legislation, translating them into practice has varied across local authorities and within the case studies there are examples where Option 1 does not offer a similar extent of choice and control in different places. This contrast can be seen between Case Study 3 where Linda and William need to use the pre-paid (All Pay) payment card that not all providers accept and Case Study 13 where Moira can use the personal budget for a range of support and care activities for James. The case studies also exemplify where Option 1, as seen for Joanne in Case Study 10, reflects a restriction of choice for individuals who do not want to manage their own care but for whom this option maximises their personal budget.

The boundaries between the options were not always clear across the different authorities. Option 2 in one area, like Case Study 2 of Linda and William in Edinburgh accessing homecare, appeared to be similar to the personalisation, choice and control under Option 3 for Jane in Case Study 3 in Dumfries and Galloway, where she ‘banks’ unused hours and so this creative contracting provides the flexibility needed.

Ultimately, the four options are a means to ensure the realisation of the values and principles of self-directed support.  The case studies highlight that the options are a real focus for change in areas but that there can be an over-emphasis on a local authority demonstrating an increase in the use of a particular option.  Similarly, there was a focus in the case studies for staff and supported people to talk about the hours or nature of support received rather than outcomes they were being supported to achieve, suggesting that there is still a cultural shift required to fully embrace and embed self-directed support as Scotland’s approach to social care delivery.