1 Introduction and Background
1.1 Increasing individuals' choice and control over their community care support arrangements has been a key element of Scottish Executive/Government policy since the late 1990s and the introduction of Direct Payments ( DPs). Self-directed support ( SDS) is an approach to delivering care and support that is embedded within wider policy frameworks including that of 'personalisation', social inclusion, participation, empowerment, and most recently, 'co-production' (Scottish Executive, 2006; Pestoff, 2006; Hunter & Ritchie, 2007; Scottish Government, 2007; Leadbeater & Gallagher, 2008).
1.2 As an umbrella term, SDS encompasses many concepts and practices in social care including DPs as well as Individual Budgets ( IBs) (Manthorpe et al, 2011). IBs enable individuals to either purchase their own support packages to meet their assessed personal, social, and, to a lesser extent, healthcare needs, or at least to determine how this budget will be spent on their support. Although IBs can be sourced from more than one funding stream, research in England has found that NHS resources have been rarely included and combinations of funding streams have been unusual with the exception of social care and Supporting People (housing support) monies (Glendinning et al, 2008).
1.3 Since the Community Care and Health (Scotland) Act 2002, implemented in April 2003, it has been mandatory for everyone entitled to publicly funded community care services, with a few exclusions, to be offered the option of a DP by the local authority. DPs are payments in lieu of services provided directly to individuals assessed as being in need of community care services. While the early evidence base shows that those in receipt of DPs generally considered the benefits far outweigh the challenges (Homer & Gilder, 2008; Witcher et al, 2000), implementation has been slow in Scotland. A study for the Scottish Parliament Health Committee (Riddell et al, 2006) identified several problems that slowed implementation, including:
- A lack of shift in funds from traditional services into DPs and concerns about the impact on existing provision
- Inadequate skills development and information about SDS for local authority staff
- Anxieties about financial accountability issues and cumbersome bureaucracy
- Concerns about the employment of unregulated personal assistants ( PAs)
- The influence of micro-cultures or organisational practice and beliefs that inhibit or support the development of DPs.
1.4 More recently, recommendations from another Scottish study (Homer & Gilder, 2008), which explored innovative work in areas with a good track record of delivering DPs, included the need for an effective support service for DP recipients; local authority leadership; a dedicated team; 'light touch' financial systems; and better training for social workers.
1.5 Research has continued to highlight differences in uptake of DPs (and now IBs) across community care groups: people with physical disabilities who are under 65 years are more likely than people with learning disabilities, mental health service users or older people to be in receipt of DPs (Witcher et al, 2000; Ridley & Jones, 2003; Spandler & Vick, 2004; Riddell et al, 2006; Davey et al, 2007; Scottish Government Statistics, 2010).
1.6 At the start of this evaluation, the 3 local authorities who became SDS test sites showed wide variation in uptake of DPs: Glasgow had the lowest rate of 3.6 per 10,000 population compared to Highland with 8 per 10,000 population, and Dumfries & Galloway with 11 per 10,000 population (Scottish Government Statistics, 2009).
1.7 Since DPs have been introduced, policy and practice surrounding adult support and protection have also evolved, particularly in relation to decision making and mental capacity with the advent of the Adult Support and Protection (Scotland) Act 2007. Questions around risk, vulnerability and adult safeguarding or protection continue to emerge, and from the English experience, it would appear that policy and practice have travelled along 'parallel tracks' with developments in SDS generally occurring separately from developments in adult safeguarding (Manthorpe et al, 2009). The implication of this is that practitioners concentrating on SDS alone may miss the risks of exploitation and abuse/neglect, while those concentrating on safeguarding alone may try to over-control and so not take risks.
SDS - An Evolving Concept
1.8 A fundamental issue at the start of this evaluation was that what was meant by 'self-directed support' in Scotland was evolving, as was policy and legislation to ensure that SDS becomes the mainstream approach to care and support. At the start of the evaluation, SDS and DPs were referred to almost synonymously:
"Self-directed support ( SDS) policy ( encompassing direct payments) provides individual budgets for people to buy their own support packages to meet their assessed personal, social and healthcare needs...The person is in control of their support arrangements using an individual budget that is usually sourced from more than one funding stream. Most people use the money to buy support from a service provider and/or to employ a personal assistant." (Evaluation brief, 2009)
1.9 There was much debate around the definition of SDS, as well about which model should be used, including whether or not the 7-steps model (or aspects of this) developed by the organisation In Control should be implemented by all the test sites. The consensus of opinion from early stakeholder interviews was that SDS refers to a spectrum of options ranging from the 'sharpness' or 'purity' of a DP at one end, to more individually tailored local authority provided services at the other. In other words, an individual might choose to directly control his/her social care allocation and employ his/her own staff via a DP, or instead choose to:
"...co-design the service, to talk about what kind of outcomes they want to achieve from the service, what they want their lives to be like - and they have a pretty good say, then, in how the resources for that service are directed." (National provider organisation)
1.10 The key requirement, regardless of the mechanism used to deliver the support, was that the individual could exercise more choice and control over his/her social care than had previously been possible. During the lifetime of the research, the Scottish Government and COSLA published a 10-year strategy for SDS in Scotland (Scottish Government, 2010), which aimed to set out and drive a cultural shift around the delivery of support with SDS becoming the mainstream approach. This Strategy adopted a far broader definition of SDS than DPs, which had an impact on how SDS was operationalised by the test sites. The National SDS Strategy defined SDS as support that:
"Individuals and families have after making an informed choice on how their Individual Budget is used to meet the outcomes they have agreed. SDS means giving people choice and control.
The process for deciding on support through SDS is through co-production . . .
The mechanisms for getting support through SDS can be through a Direct Payment ( DP) or through the person deciding how their individual budget is allocated by the council to arrange support from a provider. . . Some people may choose to leave the decision on how their support is provided to the council." (Scottish Government, 2010, p7)
1.11 Unlike DPs - which are easier to record as an individual (or a 3rd party on their behalf) either receives or does not receive it - measuring SDS is a more nebulous activity. At the start of the evaluation, the only aspect of SDS that was measured by official statistics was the uptake of DPs. As a result, reporting on and measuring the impact of SDS presented a number of challenges for the evaluation, and also for the Scottish Government in its collection of annual statistics on SDS. These challenges included:
- How to measure the exercise of choice over how individual outcomes will be met;
- Gaining agreement with local authorities about the criteria to be used for monitoring implementation;
- Integrating monitoring with other systems such as single outcome agreements;
- Assessing the broad spectrum because choice and control are never 'all or nothing';
- Measuring choice and control when service provision stays the same and there is no cash transaction at end user level;
- How to consider longer-term outcomes.
1.12 The complexity of assessing the shift towards greater choice and control was exemplified by the challenge that care and support may be newly described as being more personalised, while, in practice, any difference can be hard to gauge. Given that the extent of choice and control will itself be experienced at the individual level, more nuanced ways will be needed to meaningfully capture the SDS process and its outcomes for individuals. In particular, any evaluation of SDS has to move beyond simply counting take-up of DPs. Therefore, towards the end of the evaluation, the Scottish Government started discussions with local authorities to consider better ways to capture SDS in its broadest sense as it was acknowledged that what has been recorded thus far did not reflect innovative practice and the real extent of SDS policy implementation.
Creation of SDS Test Sites
1.13 The Scottish Government selected 3 local authorities to become SDS test sites: Dumfries & Galloway, Glasgow, and Highland. The decision about the selection of local authorities was agreed between Scottish Government, COSLA and ADSW, and was based on a range of factors, including geography (covering urban, rural, and remote rural sites) and an assessment of the broad performance of the local authority according to the conclusions from inspections by the Social Work Inspection Agency ( SWIA).
1.14 While there was support amongst most policy makers and senior managers interviewed at Stage 1 for the general rationale by which local authorities had been chosen, there was some suggestion that generalisation of findings across the rest of Scotland may be limited given that only 3 of the 32 Scottish local authorities were involved, and because there is known to be a high degree of diversity among Scotland's authorities. It was also highlighted that there had been some disquiet about the decision among some of the other 29 local authorities, although on the whole, it was accepted there had been sufficient prior consultation.
1.15 Each site was funded over 2 years and 3 months (January 2009 to 31 March 2011) to put in place mechanisms to facilitate a shift towards SDS. At the outset it was agreed that each site needed to find ways to address 3 particular subjects that were seen as necessary to enable this change: bridging finance, cutting red tape, and leadership and training (refer to appendices for further detail). These were identified as important themes by the Scottish Government from the research evidence on DPs and SDS.
1.16 The selected local authorities were to trial specific activities relating to these 3 themes in order to implement SDS. While the themes were pre-determined, according to one Local Government Organisation representative there was broad agreement amongst members of the national SDS Reference Group that these were the 'hot topics':
"Those were 3 elements that were constantly being discussed. So yes, I would say that the areas that are being looked at in the test sites very much come from the discussions around the country, people expressing their views on what the issues were."
(Local Government Organisation representative)
1.17 The 3 local authorities were invited to produce test site action plans specifying how they would implement the Scottish Government's agenda over a 2 year period. In practice, agreement between Scottish Government and local authorities on the test sites was not reached in some cases until March 2009, and so the original deadline was extended to March 2011. The Scottish Government's objectives for the test sites were that local authorities should consider how focusing on the 3 specific themes could contribute to increasing the 'uptake of SDS', and also to consider:
- How SDS can be used by all client groups and how it relates to carers and respite
- How SDS can be used for preventative care
- How SDS relates to other funding streams
- The role of advocacy and support services
- SDS packages that incorporate health monies, including support for palliative care
- "leap-frog" learning throughout the 2 years of the project and participation in an independent evaluation.
(Letter from Scottish Government to test sites local authorities; Evaluation brief)
1.18 Rather than direct how these themes should be addressed, Scottish Government invited the 3 local authorities to interpret the overall brief set by them in the context of local circumstances and to develop local action plans. Nevertheless, there was an expectation that the test sites would meet certain national commitments, for instance:
"...the very baseline is Manifesto commitments, each of the test sites must demonstrate increase in take up of direct payments as an absolute given so it's the Manifesto commitments. They must all have trialled something that looks like an IB one way or another...'" (Scottish Government SDS Team)
1.19 Support to the test sites from the Scottish Government took 3 main forms: policy level support; financial support; and professional support. Throughout the life of the test sites, Scottish Government continued to promote SDS as policy through development of a national strategy for SDS with COSLA (Scottish Government, 2010), and latterly, through an SDS Bill, upon which it consulted widely during 2010/2011. Planned financial investment in 3 test sites totalled just over £3.5 million allocated to each test site as follows:
Table 1.1: Annual breakdown of financial support to each test site
|Financial Year||Estimated budget (,000s) per test site|
1.20 Professional support to the test sites came from a designated appointee within the Scottish Government SDS Team in the Adult Care & Support Division. Three part-time secondees contributed different knowledge and skills including experience of DP implementation, as well as of working in senior management positions in the voluntary and private sectors. Their key role was about sharing information and expertise, and keeping the Scottish Government informed of the implications of test site activity for policy development. Initially each test site was allocated a designated appointee, but later on this support was extended so that more than one secondee worked with each site.
1.21 Scottish Government expected sites to be in regular contact with the secondees and to receive updates on progress. This led to some uncertainty within the test sites and a perception that this was a form of scrutiny of their work, adding another tier of reporting to Scottish Government alongside the evaluation. Because these secondees were also employed by other organisations in other capacities, there were local sensitivities about some of the advice given and references made to 'how things are done elsewhere'. Similarly, it was considered unhelpful if experience in another capacity was seen to drive their contribution. Their input overall was generally perceived as constructive and helpful, although there were differences of opinion. We now briefly summarise the 3 test sites below.
Dumfries & Galloway Test Site
1.22 Becoming a test site served to progress and develop the local authority's existing plans for the transformation of social care service delivery. As a test site, the local authority aimed to test the applicability of the In Control method in a rural setting and across client groups, even though early plans focused on developing personalisation approaches in learning disability services. Initially, activities also centred around one geographical area. Expressly not wanting to implement personalisation as a top down policy, the test site took what they described as an organic or community development approach to promoting personalisation and building staff confidence in working in this new way. The work of the test site initially distanced itself from DPs in the Council, and its action plan was described as informed by, but not driven by, Scottish Government's 3 themes for the SDS test sites.
Glasgow Test Site
1.23 The test site initially was developed in the East of the City with people with learning disabilities. It built directly upon an earlier Individual Budgets ( IBs) pilot in Glasgow which aimed to achieve more personalised support for people with learning disabilities. The test site action plan was framed around the 3 test site themes, and stated that it would increase the number of IBs, wherever possible as DPs. To begin with, SDS was developed separately from the existing DP system. The local authority tested and refined information resources and operational systems (including a Resource Allocation System ( RAS), and self-assessment) building on the In Control approach. It also increasingly used Individual Service Funds ( ISFs). Partnership working has been a key element of the test site, as reflected in joint work with the Glasgow Social Care Providers Forum ( GSCPF), which also received separate Scottish Government funding to promote SDS.
Highland Test Site
1.24 This test site aimed to promote SDS through directly increasing the number of people accessing DPs, although towards the end of the 2 years, this primary focus shifted to include ISFs. Test site activities concentrated on adapting self-assessment and other systems from an English local authority that had developed the In Control model. The test site aimed to recruit SDS champions within users/carers and staff members who would become exemplars. An existing local resource allocation system (known as the equivalency model) was tested for establishing IBs. At first the SDS test site was run as a separate initiative to DPs, with links explored later on. SDS was promoted mainly to young people in transition into adult services, commonly those with learning disabilities and/or autism, though one-off payments were made to a wider range of client groups. Plans to extend SDS to older people leaving hospital were tried and abandoned.