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CHAPTER 5 SERVICE AVAILABILITY

Key Findings

The mapping exercise and survey of services shows sporadic service provision for all groups across Scotland. The majority of services in based in the central belt of Scotland or in highly populated regions. Services are particularly scarce in rural areas.

Local authorities offer varying levels and types of support to sensory impaired adults. Some local authorities provide no statutory community care services for the sensory impaired; instead, they contract out all services to voluntary/charitable organisations within their area. Others provide generic social work and community care services and buy in BSL interpreters or guide/communicators as and when needed. Availability of communication support was variable across different regions with some stating that they found it difficult to access any communication support at all. A number of local authorities do provide dedicated Sensory Impairment Teams.

It proved difficult to make contact with NHS representatives to discuss specialist services in place for sensory impaired adults with regard to mental health and more generally. What is clear, however, is that there is a particular dearth of specialist mental health services in Scotland. Models of good practice from England may provide a template for future developments in this regard but more consultation is needed with NHS service providers and planners before this can be achieved.

Joint working seems to be apparent between voluntary sector sensory impairment workers and mental health workers but there is perhaps less sharing of expertise cross-sector.

Survey responses and interviews with local authority staff shows that most community care and mental health services for sensory impaired adults are monitored and evaluated using a combination of formal and informal methods. Such assessment does not, however, appear to be routine and is often carried out on an ad hoc basis or only in response to more centralised calls for service assessments.

Introduction

5.1 Having outlined in the previous chapter the main areas of need identified from the literature review, this chapter explores the current availability of community care and mental health services for sensory impaired people across Scotland.

5.2 This chapter draws primarily on the findings of the survey of services and mapping exercise carried out during the period February-June 2005. It also draws on information provided by service providers from the statutory, voluntary and private sector regarding service availability and practice.

Research Caveats

5.3 It is important to note that strict criteria were applied to the inclusion of services on the service database. The database included only those services that provided specialist support for sensory impaired adults, including local and national offices of charitable organisations. Disability services which did not advertise services for sensory impaired adults were not included. Similarly, services which were branded or advertised as offering services for specific community groups such as the elderly were not included, unless it was apparent that they offered specialist support for hearing, visual and dual sensory impaired adults. For the most part, generic mental health services were included in the database.

5.4 The snowballing methodology was used until all new services had been exhausted. However, the researchers acknowledge that there will be inevitable gaps in the service database due to difficulties in locating some services in public domain media. The database is also subject to change over time as individual support projects discontinue or emerge and the database does, therefore, offer only a snapshot insight into service provision, rather than providing a long-term, comprehensive resource.

5.5 It is also important to note that statutory sector representatives who provided responses on behalf of their respective local authority or NHS Board in most cases caveated their own response as being limited to their own awareness and that of colleagues who were present at the time that the review was carried out. In many cases, consultees offered what they described as a 'best guess' in light of lack of available written policies, guidelines or standard practice for working with sensory impaired adults. Many service providers offering mainstream community care and mental health services explained that occurrence of referral from sensory impaired adults were few and far between and, therefore, often dealt with on an ad hoc basis.

5.6 The research findings presented in this chapter should, therefore, be treated with caution. The researchers recognise that the responses provided by those who were contacted may not reflect those held by other employees of the same service providing organisations, nor represent those of the organisation as a whole.

Service Mapping

5.7 For the mapping exercise, services were classified according to their target user group - visually impaired, hearing impaired or generic sensory impairments, offering services for both hearing and visually impaired people.

5.8 Figure 5.1 shows the availability of services throughout Scotland, with local authority boundaries marked. Table 5.1 shows the corresponding estimated numbers of sensory impaired adults in each local authority. More detailed maps for Glasgow City and City of Edinburgh local authorities are also shown in Figures 5.2 and 5.3.

Figure 5.1 Availability of services throughout Scotland

Table 5.1 Estimated Number of Sensory Impaired Persons by Local Authority

Notes to table
*Information not available.
¹Source: Scottish Executive Statistics Release: Registered Blind and Partially Sighted Persons, Scotland 2005.
²The number of hearing impaired persons was sourced from the Social Work Services Inspectorate ( SWSI) Annual Report 2003, Community Care Services for People with a Sensory Impairment: An Action Plan.
³Source: Deafblind Scotland Membership, Deafblind Scotland, (2005), About Deafblindness… Scotland 1995-2005, A Decade of Delay.

Figure 5.2 Services in Glasgow City Council Area

Glasgow City Council

Figure 5.3 Services in Edinburgh City Council Area

Edinburgh City Council

5.9 A total of 409 services were identified throughout Scotland. Table 5.2 shows the breakdown of services by service sector.

Table 5.2 Distribution of Services by Sector across Scotland

5.10 The maps and the above table show that, unsurprisingly, services are concentrated in central Scotland in the areas of the highest population. Rural areas, particularly Highland and island areas have very few services.

Survey Responses

5.11 All services identified in the mapping exercise received a postal/e-mail questionnaire asking for details about the service. Appendix A contains a copy of the survey questionnaire, which was adapted into different formats for completion by respondents. E-mail copies of the survey were issued on request and were automatically issued to services for which a valid e-mail address was available.

5.12 The survey was posted directly to the service providing agencies with a reply paid envelope. A response deadline was set two weeks after the issue of questionnaires. All those not responding within the specified timescale were issued with a reminder letter/e-mail along with a second copy of the questionnaire. These respondents were given an additional two week period in which to respond.

5.13 Following the reminder exercise, and a two month period in which some late responses were also received, a total of 131 questionnaires were returned. The findings presented in this section are from the responses to this survey.

5.14 The breakdown of respondents by service sector was Statutory (29), Voluntary (95) and Private/Other (7).

5.15 Services are categorised by client group below, and restrictions to types of clients accepted are noted.

Table 5.3 Service Provision by Client Group

5.16 In addition to the restrictions noted above, many services were for adults only. Also, some services for visual impairment had set criteria for accepting clients who had permanent and severe visual impairments.

Types of Service

5.17 A wide range of types of service were covered by the survey, including:

• Information and advice;
• Personal care;
• Domestic help;
• Provision of meals;
• Provision of equipment/adaptations;
• Citizen advocacy;
• Transport;
• Communication (interpreters, translation), and guides;
• Counselling and support;
• Complementary therapies and stress management;
• Leisure and social groups;
• Employment training/help in gaining or retaining employment;
• Educational guidance;
• Signposting to other organisations; and
• Campaigning and awareness raising.

5.18 Virtually all services operated more or less within office hours, with the exception of a few outreach and telephone-based services. However, 59 (45%) of services said that they also offered an out of hours service.

Funding

5.19 Of the 95 voluntary sector services, 69 gave a breakdown of their funding sources. Most of those who gave funding sources received at least partial funding from the statutory sector - 51 (74%) voluntary sector services received funding from local authorities, NHS boards and/or the Scottish Executive. Table 5.4 shows the main sources of funding specified by survey respondents.

Table 2.4 Funding Sources of Main Service Providers

Notes to table
A number of voluntary sector services received funding from more than one statutory source - nine received funding from both local authorities and NHS boards; five received funding from both local authorities and the Scottish Executive; two received funding from all three statutory sector sources.

5.20 Other funding sources for voluntary sector services included charitable donations/fundraising, trusts, Big Lottery, members fees/subscriptions and consultancy and other services (eg commercial interpreting).

5.21 Of those in the private/other sector, five gave a breakdown of their income sources and three of these included statutory sector funding (two received NHS funding and one received Scottish Executive funding).

Monitoring and Evaluation

5.22 Sixty three (48%) of the services who responded to the survey said that they employed methods of monitoring and evaluation and the outcomes were available to others. A further 30 (23%) also conducted some kind of monitoring but the results were not available to others. Thirty eight services (29%) did not conduct monitoring and evaluation (or did not detail them).

5.24 Of the 63 services who provided monitoring and evaluation information to others, 42 (66%) made these available in alternative formats. These included large print, Braille, moon, video and pictorial formats, and audio tape/ CD.

Service Staff

5.25 Half of the services (66, 50%) said that they had at least one member of paid or volunteer staff who had been specifically trained or had special skills for working with sensory impaired people. Most services which had a specific sensory impaired client group had appropriately skilled staff. However, just four generic mental health services and five generic community care services had staff with specific skills for working with sensory impaired people. Just under half (n=63) of services employed paid or volunteer staff who had a sensory impairment. Table 5.5 below shows the number of services with trained/skilled staff and with sensory impaired staff by client group type.

Table 5.5 Services with trained/skilled staff and services with staff with a sensory impairment (by service client group)

5.26 Just over half (53%) of all services said they had specific arrangements in place for BSL service users and 58% had arrangements for other deaf/hard of hearing users. Under half (44%) had arrangements for blind users and 48% had arrangements for other visually impaired users. Just 38% of all services said that they had arrangements for deafblind users. Table 5.6 below shows the breakdown by service client group.

Table 5.6 Whether Special Arrangements in Place for Specific Sensory Impairment by Client Group

Local Authority Community Care Services

5.27 The survey of services and consultation with local authorities confirmed that there is currently notable variation in the availability of services from local authority providers across the country.

5.28 Some local authorities provide no statutory community care services for the sensory impaired; instead, they contract out all services to voluntary/charitable organisations within their Council area. Others provide generic social work and community care services and buy in BSL interpreters or guide/communicators as and when needed. Availability of communication support was variable across different regions with some stating that they found it difficult to access any communication support at all.

5.29 A number of local authorities do provide dedicated Sensory Impairment Teams. There is variation across Scotland as to the types of services these Sensory Impairment Teams provide. Some offer no more than rehabilitation training, independent living aids, and advice related directly to clients' sensory impairment. In these regions, if the sensory impaired client's primary need is not directly related to their sensory impairment, or if their impairment allows, individuals are referred to/retained within the mainstream Social Work system. These Sensory Impairment Teams often provide the communication aids or interpreters necessary for sensory impaired clients to be accommodated by the generic social work departments. In other regions, the Sensory Impairment Teams offer the same services as above, but they also provide specialised social workers. They are, therefore, able to provide a wider range of services and assistance to sensory impaired clients.

5.30 All local authorities reported that they provide Community Care staff with Sensory Awareness Training. In some cases, this is bought-in from voluntary/charitable organisations, whilst other local authorities, which provide more specialised services, provide Sensory Awareness Training to other departments and organisations.

5.31 The most significant problem facing local authorities in relation to service provision for the sensory impaired appears to be a nationwide lack of trained staff. A number of local authorities also mentioned that they encounter problems due to the geography of their regions; vast, sparsely populated regions compound the staffing problems, resulting in unequal access to services within and between local authority areas.

5.32 Again, as some local authorities did not contribute to the consultation exercise, this overview of local authority services cannot be considered as comprehensive.

Non-Statutory Community Care

5.33 Voluntary organisations and societies across Scotland play a massive role in delivering community care and other services for sensory impaired adults.

5.34 As part of the survey of services, respondents were asked to identify any other organisations with whom they worked to meet the needs of clients. Table 5.7 shows the most frequently mentioned charitable organisations and societies for each of the sensory loss groups.

Table 5.7 Frequently Cited Organisations

5.35 For adults with a dual sensory impairment, Deafblind Scotland was the main recognised service provider in Scotland and was one of only two services identified working solely with deafblind or dual sensory impaired people by survey respondents.

Mental Health Services

5.36 In order to establish a picture of mental health provision or adults with a sensory impairment across Scotland, representatives from NHS Boards were contacted. In most cases, contact was made with the local area mental health teams.

5.37 The current research identified few dedicated mental health services for adults with a sensory impairment.

5.38 For Deaf and deafblind adults, the only statutory NHS service offering access to psychiatrists with BSL skills is the John Denmark Unit - the National Centre for Mental Health and Deafness - which operates from Manchester in England.

5.39 The centre, which is recognised as a national and international centre of excellence, provides services to deaf people of all ages. This includes working with those who have/may experience:

• Mental health crisis;
• Continuing mental health challenges;
• Emotional/behavioural issues;
• Personality difficulties;
• Drug and alcohol abuse;
• Communication and language disorders;
• Forensic issues;
• Learning difficulties; and
• Autism and Aspergers syndrome.

5.40 The unit currently operates satellite clinics in Glasgow and Edinburgh attended by a Clinical Psychiatrist who is hearing but can sign. The range of assessments offered includes:

• Mental state assessment and treatment;
• Psychological assessment and treatment;
• Language and communication assessment and treatment;
• Educational assessment and programmes;
• Psychotherapy assessment and provision;
• Vocational skills assessment and programmes;
• Independent living skills assessment and development programmes;
• Occupational therapy;
• Creative art; and
• Nursing care packages.

5.41 The unit appears to offer the only statutory dedicated metal heath service for Deaf adults in Scotland. However, its coverage is limited geographically and it would seem that there is a need for wider roll-out of the service or the adaptation of a similar model in Scotland.

5.42 Within the scope of this review, and accepting that contact was made with only one representative from each of the NHS Boards, there was no awareness of the NHS Management Executive Letter MEL (1998) recommendation that services should have appropriate arrangements in place to ensure that deafblind people are afforded the services of a guide communicator when they attend hospital or GP surgeries.

5.43 On a general note, some voluntary service providers consulted as part of the review commented that the recommendations and guidance issued by statutory agencies often were not taken on board by those working within the statutory sector as they were not enforced. This included concern about the extent to which recent the Scottish Executive guidance on "Access to mainstream and specialist services for people with a sensory loss and a mental health problem" would be taken on board.

5.44 Mental Health Social Work Teams/representatives were also identified in all local authorities and formal contributions were received from 14 authorities.

5.45 It would seem that local authorities do not generally have dedicated mental health services for the sensory impaired; they provide generic services and deal with each client on an individual needs basis. They source resources and help as and when it is needed. Local authorities who have a Sensory Impairment Team rely on them to assist the mental health team and a lot of joint working was reported. In addition, a number of local authority teams reported referring hearing impaired individuals onto the John Denmark visiting satellite units in Glasgow and Edinburgh.

5.46 Many local authorities reported that the numbers of sensory impaired people accessing mental health services are not high enough to necessitate dedicated services at the local authority level. However, it was suggested by a number of local authority mental health service providers that it would be appropriate to have dedicated services at a more general level, ie a number of dedicated mental health service organisations/departments for sensory impaired people could be spread throughout Scotland that could be accessed by a number of local authorities.

5.47 There were reports of individuals being misdiagnosed, not being provided with the most appropriate treatments, being referred to unsuitable organisations, having to travel to the John Denmark Unit in England, and being placed in residential care over one hundred of miles from their home. Reports of local authorities and Social Service departments trying to keep people in the mainstream, generic services as much as possible were also prevalent.

5.48 In the voluntary sector, the Hayfield Centre for Mental Health and Deafness also offers a dedicated services for Deaf adults with mental health difficulties. Deaf Connections in Glasgow are currently campaigning for a signing GP Service.

5.49 A number of other generic mental health providers were contacted as part of the review. For the most part, returns from these services again showed that support for sensory impaired adults was ad hoc.

5.50 There appear to be no specific policies for working with sensory impaired adults and, for the most part, voluntary mental health providers work alongside social work teams and/or nationally recognised charities for sensory impaired adults when clients presented with sensory loss.

5.51 The majority of voluntary mental health service providers said that they would like to develop specialist services for sensory impaired adults but this simply was not affordable within current budgets.

5.52 Importantly, the difficulties experienced in identifying and contacting specialist staff working in local authorities and NHS Boards meant that the mapping exercise was not as comprehensive as it might have been. However, the challenge of identifying nominated persons within some local authorities and NHS Boards, who were au fait with policies, practices and specialist services available to support sensory impaired adults, may indicate that there is a need for more accessible information about referral pathways and access to statutory support. Examples of good practice were found in some local authorities and these may act as a template for change in this regard.

Statutory Service Monitoring and Evaluation

5.53 All statutory service providers who took part in the survey or the subsequent telephone consultation, were asked to provide information about the methods used to monitor and evaluate the services that they offered to sensory impaired adults.

5.54 No responses were received from NHS respondents in this regard, but local authority representatives from community care and mental health teams offered a range of responses including:

• customer satisfaction surveys;
• client consultation via group interview/focus groups sessions and telephone calls;
• informal ad hoc feedback from individual clients;
• external audits of social work services pr se;
• regular reviews of local joint planning service level plans (in consultation with specialist sensory impairment charity representatives);
• complaints department;
• case review;
• development and review of annual service plans; and
• seeking advice from national voluntary organisations.

5.55 An example of a series of focus groups held in Fife between January and March 2005 can perhaps be cited as an example of best practice with regards to monitoring and evaluation. Staff there explained that consultation with blind, partially sighted, Deaf and hard of hearing, as well as those with dual sensory loss had been carried out. Specifically, these sessions were designed to look at the way in which the local Sensory Impairment Centres was being used and how it could be improved. This local authority also reported that funding had been sought from a consortium made up of local authority social work staff, and members of the sensory impaired community to consult effectively and meaningfully with people with sensory impairments.

5.56 Many of the local authorities that carried our satisfaction surveys said that these were not carried out routinely and were, in fact, quite sporadic. In some cases, surveys had not been conducted for more than 3 years. In many cases, such surveys were also carried out in response to special initiatives or audits such as the Best Value Report on Sensory Awareness and the Best Value Review on Independent Living, and were not, therefore, proactively offered. Similarly, many monitoring and evaluation strategies were only drawn up in the context of wider policy developments/requirements including the Joint Future Planning Process. Those who did offer ad hoc surveys, and some of those who did not, recognised the need for regular surveying of clients. However, there was also some suggestion that survey fatigue affected results and there were real concerns that such surveys were time consuming for staff and that this was the main reason that they were not carried out.

5.57 Although some local authorities said that hey had, in the past, carried out consultation with service users using interview/focus group sessions, examples of this were again limited. Where attempts had been made by some local authorities to arrange such events, they had proven logistically difficult, especially since many of the potential participants were elderly and/or had mobility issues (meaning that they could not attend the meeting without support). There was also some suggestion from one local authority that older people were not willing to express their needs or be seen to complain and this limited the feedback received from such sessions.

5.58 As many councils buy in services from external agencies, responses to this question often elicited examples of the way in which these external organisations were assessed, rather than the local authorities themselves.

5.59 Most respondents said that information regarding monitoring and evaluation was available on request but not routinely published.

5.60 There was limited evidence that information was routinely available in alternative formats, with alternative format information usually only provided on request. Large print documents appeared to be the most widely available adapted versions of information and these were available automatically in a small number of local authorities on an ad hoc basis.

5.61 In summary, most local authority representative consulted were in agreement that monitoring and evaluation was essential and most would like to see current practices improved. Finances, staff resources and logistical barriers were, however, cited by many as being too significant an issue for respondents to anticipate immediate change.

Service Development

5.62 The main information sources used by local authorities to inform development of service provision for sensory impaired people included:

• information, guidelines and advice from the Scottish Executive, including the Community Care Plan;
• advice from both local and national voluntary organisations such as the RNIB and RNID; and
• advice from other statutory organisations; and

5.63 In addition, some local authorities reported employing user consultation to identify areas for development. A handful of Councils said that they had developed their own process of reviewing their services and/or created a "Task Force", a "Strategy Implementation Group", or a "Sensory Impairment Steering Group" to implement review recommendations and guide future development. These groups consisted mainly of statutory and voluntary sector representatives, with some regions including user and carer representatives.

5.64 Again, no data was collected from NHS representatives in regards to service planning.

Summary

5.65 There appears to be wide geographical variation in service availability with those living in rural areas perhaps being least likely to be able to access the support that they need.

5.66 Regional variation in service provision is also reflected in the statutory services that are provided by local authorities across the country - some have no dedicated sensory impairment services or teams, others use a combination of in-house and externally purchased expertise/trained communicators whilst some provide dedicated Sensory Impairment Teams and resources.

5.67 Although it proved difficult to make contact with NHS representatives, it seems clear that there is lack of dedicated mental health support available for sensory impaired adults experiencing mental ill-health. More consultation is needed with NHS service providers and planners in order to achieve a more comprehensive overview of current statutory mental health service provision and gaps.

5.68 Monitoring and evaluation of services appears to be somewhat ad hoc although all those consulted recognised the importance of such undertakings.

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