6 Stage 3 : Implications - lessons from the test sites
Introduction
6.1 In this final chapter, we outline some lessons from the experience of the 3 local authority SDS test sites, drawing across the evaluation findings. This evaluation faced several challenges, not least of which was that it was undertaken at a time when national and local SDS policy and practice were in a state of flux. Local authorities were undergoing local restructuring or modernisation of services, and public services generally were under pressure due to a change in the UK Government and the economic downturn. This evaluation report must therefore, be read in this context.
6.2 Also, while the SDS test sites were originally conceived of as addressing the same 3 themes - leadership and training, cutting red tape and bridging finance - how the Scottish Government's brief was interpreted was left to the local authorities, resulting in 3 variations on the themes and one of the local authorities stated from the start that they were not following the 3 themes but rather, implementing personalisation in a broad way. The 3 sites did not adopt specific models of implementation which we could compare and contrast, and therefore the scope for systematic assessment of differential impact across the sites was limited. The definition of SDS changed during the course of the evaluation in response to the growing evidence that choice should be broadened, with a new national SDS Strategy published in 2010. The evaluation is thus mainly descriptive and process orientated.
6.3 Despite such challenges, the evaluation is able to offer some insights about how local authority processes need to change to enable SDS to become mainstreamed. This will add to the growing body of knowledge about SDS/personalisation. In this sense it is worth bearing in mind that the overarching policy aim of SDS is to progress systems towards greater flexibility, choice and control. The evaluation is thus concerned with a process on a continuum, rather than an 'all or nothing' assessment of whether the particular local authorities were able to achieve increased SDS or not. With these caveats, we now consider some general and specific lessons from the research overall.
General Lessons
Pace of Change
6.4 One general lesson relates to the rationale for the pace of change in implementing a major shift in service delivery. There was considerable Scottish Government investment in SDS test sites (over £3.5 million), and this evaluation found that over a 2-year period, this resulted in fewer than 150 new SDS packages being set up across 3 local authorities. While these numbers seem small overall, it should be acknowledged that development of policy and/or practice of this magnitude will of necessity take time, and investment in infrastructure for implementation may not translate into outcomes for individuals in the first year or so. As stated in Chapter 4, the test sites were not up and running until well into their first year, which meant that the impact of the work of specialist teams was not fully realised within the timeframe (2 years and 3 months). This experience demonstrates that progress will very much depend on local areas getting agreement at senior level on the scope of activity and having dedicated resources in place to take this forward. The slow pace of democratic decision making within local authorities, coupled with time-consuming recruitment procedures for hiring to newly created posts, were significant barriers to the development of the test sites. This needs to be borne in mind by those considering implementing systems to increase SDS, especially given that the pace of change ultimately affects what outcomes can be achieved within the timeframe set.
Recommendation 1 - Local areas need to gain agreement at senior level about the scope and extent of activity and what is reasonable to expect in a particular timeframe.
Recommendation 2 - Local authorities will need to allocate resources for taking SDS developments forward to ensure they have the capacity to design new systems or re-design existing systems, for example, for assessment and decision making around IBs.
DP and SDS
6.5 At baseline, several flaws were highlighted by national and local stakeholders with existing DP systems and SDS was perceived as a new way for local authorities to increase choice, control and flexibility in support arrangements. DPs were perceived as restrictive and inflexible and focused on specified outputs. In all 3 test sites there was a paradox at the heart of the SDS process. Consistently we found a (mis)perception by staff, service users and carers of SDS as an alternative to, not only managed or direct services but also, DPs. Rather than the test site local authorities perceiving DPs as an option along the SDS continuum, new and parallel SDS systems to those delivering DPs were created, with subsequent attempts at integration occurring late on in the test sites.
Recommendation 3 - A useful starting point for local authorities wanting to develop SDS would be a review of current DP systems, seeking to identify barriers to offering flexibility.
Recommendation 4 - To avoid duplication and confusion and to operationalise the broader ideal of SDS, more work needs to be put into integrating systems.
Measuring SDS
6.6 Collecting information for the evaluation about how SDS was being implemented in the test sites provided an opportunity to compare information gathered through basic monitoring (cohort form) with qualitative information from interviews with service users, carers and care managers/assessors. The latter provided richer information that yielded a more complex picture about SDS implementation and access than that provided by the cohort data. This confirms that gathering crude statistical indicators of SDS will only paint a partial picture and there is a need to capture data using different methods. Further, while there was an expectation that the test sites would increase uptake of DPs, which they did as the majority of SDS packages involved DPs (one-off or regular payments), such payments were not included in the local authorities' DP statistics. The need to develop more meaningful and accurate ways of capturing the SDS practice across Scotland is reflected in the national Strategy recommendations.
Recommendation 5 - When collecting information on SDS, local authorities may need to integrate different systems for recording DPs.
Recommendation 6 - A range of types of information (quantitative and qualitative) needs to be collected to capture how local authorities are implementing the full spectrum of SDS.
Impact of Increasing Knowledge
6.7 From the start, test sites argued for adopting a broad definition of SDS, apart from Highland who directly linked increasing uptake of SDS with uptake of DPs. Even so, the vast majority of SDS packages set up by the test sites involved some form of DP. This goes some way to dispelling claims that there is a lack of interest or low demand for DPs. Indeed, poor awareness and knowledge of DPs was identified as a barrier to uptake at baseline, and also by research studies examined in the literature review. Active promotion of SDS, including DPs, resulted in increased numbers of people opting for payments instead of direct services to pay for more flexible, individualised packages. However, the fact that some also opted for mixed packages, which included ISFs, also demonstrates that adopting a broader definition of SDS (beyond DPs), enables more people to achieve greater flexibility, choice and control in their support arrangements.
6.8 Lack of information and understanding of DPs and SDS had, in the past, led to misconceptions about what payments can be used for, and to variations in practice across Scottish local authorities. We found some differences between the test site local authorities and practitioners within them regarding interpretation of the law, for example, on the employment of relatives, and on understandings of what payments can be spent on. Such discrepancies had an impact on the flexibility of the SDS package and service user and carer satisfaction with SDS.
Recommendation 7 - Continued investment in increasing service users', carers' and staff knowledge and awareness about the range of SDS options available.
Recommendation 8 - Consistency of message and/or clarity about how decisions are made is needed and about how payments can be used.
Satisfaction with SDS Packages
6.9 The test sites increased the uptake of SDS for a relatively small number of people - that is, 132 SDS packages in total over the 2 years. Those that accessed SDS packages during this time were extremely positive about their support and very satisfied with the flexibility and choice that SDS had offered them. This indicates that where sufficient time and resources are put into developing SDS, service users (or their carers) are able to achieve a greater level of choice, control and flexibility. When the focus was on meeting defined outcomes, SDS was perceived positively, and this was frequently contrasted with what had been available before through DPs. While it is too early to tell whether this will ultimately result in better outcomes for these individuals, other research on IBs and personalisation suggests that this is likely to be the case.
6.10 We need, however, to be cautious in drawing conclusions about this because it was also apparent that some people had accessed new or additional resources through the test sites. Some positive comments about SDS therefore may have related more to receiving new or greater levels of support (in terms of professional support and/or actual funding) during the test site period than would otherwise have been possible. Test sites and other pilots may temporarily inflate the positive effects of SDS when promotion involves making new resources available.
Recommendation 9 - A review of eligibility and funding criteria may be needed in order to ensure equitability of access.
Recommendation 10 - Continued funding of packages may be required at the level enabled during the pilot if local authorities are to see positive outcomes.
SDS and Adult Protection
6.11 Whilst disappointing that cross referencing between SDS and adult protection ( AP) remained in its infancy during the test sites, it is perhaps understandable in the broader context in which these policies were being rolled out. As SDS is being mainstreamed, and now that AP implementation has bedded down in Scotland, the challenge is to respond to suggestions that disproportionate focus on fraud prevention in SDS may dilute the focus on both positive risk-taking and identifying risk (Carr, 2010).
6.12 A related issue is the question of the registration of the social care workforce (Protecting Vulnerable Adults (Scotland) Act (2007). Those interviewed expressed some concerns that Personal Assistants ( PAs) were not subject to registration in the same way as those working in managed services. The national Strategy does not identify the registration of the PA workforce as an ambition, and indeed there are many who believe this interferes with the individual's right to determine who they wish to employ. Nonetheless, this workforce needs to have access to training and skills development, and those taking on the role of employer must take responsibility for accessing the information available to them to ensure they do not employ a person barred under the PVG Scheme. Striking a balance between enabling and empowering individuals, whilst at the same time protecting those at risk, remains with the lead assessor. Positive leadership from middle and senior management is crucial in supporting staff to transfer power to individuals.
Recommendation 11 - There is a need to consider joint training on SDS and Adult Protection, as well as integrated practice initiatives programmes.
Addressing Scottish Government Themes
Leadership and Training
6.13 At baseline, leadership was identified by national and local stakeholders, as well as in the national Strategy, as a vital component. Scottish local authorities had already implemented various strategies with different results, but there was no consensus about the most effective form of leadership for the test sites to adopt. In the event, all 3 test sites invested in specialist SDS teams and project managers. The specialist SDS or personalisation teams were felt necessary to support the development of new SDS systems and tools, as well as to grow a body of practice expertise.
6.14 However, some service users, carers and care managers perceived SDS to be a new and separate service to Social Work or DPs, rather than being part of a major shift in service delivery overall. The local authorities may have placed disproportionate responsibility for change on local SDS Project Managers and teams which, in some cases, could have been mitigated by stronger project boards and leadership from senior managers. The Scottish Government recently (April 2011) allocated funding to all local authorities to build on the work and expertise of existing teams to support the development of SDS and delivery of DPs, to focus more specifically on implementation of the Strategy.
6.15 Despite extensive training activities reported by all 3 test sites delivered by the SDS teams and external consultants, we found that not all those who needed to receive training had done so. In addition, few staff had received what they considered sufficiently in-depth training. This underlines the importance of developing a strategic training and communications strategy both at local and national level, and also of considering training and support as on-going needs. By way of reinforcing this point, the National Implementation Group agreed an action plan that identifies communications and workforce development strategies as early priorities.
Recommendation 12 - Where a separate project team is set up to kick start developments it is important to ensure this is driven by a high level Project Board, and there is strategic consideration of this impact of the approach taken on wider implementation.
Recommendation 13 - Communication is needed from the start with all those involved including frontline staff carrying out SDS assessments with service users, especially about the 'nuts and bolts' of new systems.
Recommendation 14 - A multi-pronged training strategy is essential and needs to inform action by practitioners in parallel with driving culture change and knowledge and skills development on a wider basis.
Cutting Red Tape
6.16 At baseline, DPs were perceived by those interviewed and in the literature review as overly bureaucratic and, in some cases, processes were felt to be heavy handed and lacking flexibility. While 'cutting red tape' was a theme of the test sites, none were able to specifically reduce the paperwork involved. Instead, by concentrating more on designing effective systems to support SDS implementation, there tended to be an increase in paperwork and bureaucracy, at least in the short term. This was perhaps unavoidable given the approach the test sites took in that they were trialling new parallel systems and setting up new SDS teams. In many cases, SDS assessment tools were perceived as an improvement, which resulted in more comprehensive and inclusive assessment. It was uncertain, however, whether or not these would be adopted instead of established systems such as single shared assessment. This may change if new SDS systems are mainstreamed. There is still a danger that the social care system may become more, rather than less, bureaucratic and complex and perceptions of unnecessary red tape and bureaucracy increase if the In Control approach is left to run side by side with older assessment and care management systems.
6.17 One issue of note is that despite self-assessment being a key feature of SDS, many assessments were driven by carers and coordinated by professionals. Despite social workers being told to write self-assessments in the first person, several service users had very limited input due to complex disabilities and problems with cognition. This highlights the importance of being clear about what 'self-assessment' really means, and that different models might be needed to ensure that such assessments are recorded openly and honestly. Additional investment may be needed in independent advocacy and other supported decision-making mechanisms to ensure that people with complex needs are as fully involved in assessment as possible.
6.18 We are limited in what we can say about changes to monitoring and review processes and, therefore, about the impact of implementing 'light touch' monitoring systems. This is because of the early stage of development of the test sites when we collected information. Some of those interviewed concluded that the local authorities still had to work out how to manage both the 'light touch' exhortation from Scottish Government and the CIPFA guidance on financial accountability, good governance and probity. While test sites had explored initiatives such as the Edinburgh Card, an electronic purchase card, as a way of reducing red tape for service users and carers, this was only at the end of the test sites.
Recommendation 15 - In developing SDS assessment processes, local authorities need to take stock of existing systems and how these can be integrated with SDS.
Recommendation 16 - Developing a range of assessment approaches including supported self-assessment may be necessary, as well as ensuring access to independent advocacy to ensure people with complex needs have sufficient input into their care.
Recommendation 17 - Consideration is needed as to whether the SDS 'self-assessment' can address complex issues and inputs required from a variety of social care and health services to ensure a comprehensive and integrated response.
Bridging Finance
6.19 Despite an anticipation that bridging finance (defined by Scottish Government as double funding existing services while developing and providing new, more personalised, packages) would be a main focus of the test sites, in practice, test site activity was least focused on implementing this theme. Certainly only in Glasgow was there any evidence of strategic consideration of bridging finance, and there was learning in this test site about using bridging finance to remodel services. Where this test site was most successful was in reshaping its respite/short breaks service using bridging finance monies. The main conclusion from activities on this theme was that the critical issue is the timing of availability of funds to act as bridging finance or a change fund.
6.20 Investing to save is not a new issue - local authorities have been reviewing their investment in buildings based services for some years, partly through policy drivers such as institutional reprovisioning programmes, The same as you?, and partly through best value reviews. Other Scottish local authorities, such as one of those we consulted for the evaluation (not a test site), disinvested in the buildings-based model some time ago, when resources were more readily available. Those with largest investment in directly managed services will have the biggest challenge in releasing resources. One test site had some success with using bridging finance to reshape respite/short breaks services.
Recommendation 18 - Local authorities need to be able to identify when and how much bridging resource will be needed to plan future service development.
Other Themes
6.21 In addition to the 3 main themes, the test sites were asked to consider, among other things, equal access to SDS by all client groups, mixed funding packages including incorporating health monies, and the role of advocacy and support services.
Equal Access
6.22 Previous research has identified major inequalities in access to DPs, especially for people with learning disabilities, people with mental health problems and older people. The learning from the test sites about how to promote SDS to all groups is limited. While access to people with learning disabilities (generally severe) improved as a result of the test sites, given this was the group most often targeted for inclusion, there was limited inclusion of, for example, people with mental health problems. An obvious gap in promotion, and a missed opportunity for the test sites, was ensuring people from BME groups gain access SDS packages.
Recommendation 19 - A deliberate focus is needed to ensure SDS becomes an option for a wide range of individuals with varying needs, including those from BME communities.
Recommendation 20 - It will be important to apply equal opportunities monitoring to SDS uptake.
Mixed Funding Packages
6.23 This theme was not really addressed by the test sites and, given that the cohorts included some people with complex and multiple needs, it is unclear why this was the case. There was no evidence of any pooling of NHS and social care budgets, which may have not been possible legally or, indeed, little evidence of specific use of other budgets in addition to social care. While, in theory, SDS presents an opportunity to address needs holistically, the extent to which support can be integrated across funding streams could not be assessed.
Recommendation 21 -SDS monitoring systems need to find ways of recording access by [and outcomes for] people with multiple and complex needs.
Recommendation 22 - Understand and overcome the barriers to utilising additional funding from other sources such as health.
Advocacy and Support
6.24 Inadequate or non-existent support infrastructures for service users and carers wanting to consider DPs was identified as a key obstacle to increasing the uptake of SDS at baseline. Test site monies were not, however, used by any of the 3 sites to invest in either capacity building of disabled people's organisations (such as independent living centres) that could offer user-led support on SDS/ DPs, or independent advocacy to support individuals through the process. A recent study (Johnston et al, 2009) found that a pro-active approach to service user engagement is critical. Interviews with representatives of both service user and carer organisations at Stages 1 and 2 of the evaluation (where these could be identified) indicated only peripheral, if any, involvement of service users and carers in developing test site action plans. Given that citizen leadership and co-production, at both individual and strategic level, are central to the values and principles of SDS, this would seem an important omission.
Recommendation 23 - Commitment to promoting collective and strategic user involvement would seem essential if the perception that SDS is a professionally-led concept is to shift.
Recommendation 24 - Developing the capacity of local disability organisations should be recognised as a key aspect of SDS policy and practice implementation.
Conclusions
6.25 Given that some similar concerns emerged across all 3 test sites, it seems likely that these are not specific to the test sites but are more general challenges facing all local authorities attempting to make changes in the direction of SDS.
6.26 Specific conclusions in relation to the test sites can be drawn, especially about the longer term sustainability of the small but important changes that the sites were able to make. The implementation of SDS using a managerial rather than a strategic model, that is as a project or initiative with a designated team leading developments within local authorities, had limitations: a specialist SDS or personalisation team offered expertise and management of the ' SDS project' but also created the impression that SDS was separate from, and operated differently to, the local authority and other systems, such as DPs. There was a risk of these systems appearing to be working in parallel, which can mean unhelpful duplication and confusion. Unless senior managers take a lead role, there is always the danger that initiatives will be marginalised, regardless of how committed those managing and involved in it are. Certainly by the end of the test site period, the 3 local authorities had resolved to move towards mainstreaming SDS with support from their senior management. An ambitious programme of SDS development in Glasgow involving external providers, for example, has far reaching consequences for future practice that we are unable to assess in this evaluation.
6.27 The new SDS processes created by the test sites worked extremely well overall for the selected individuals who benefited from SDS during the test site period offering increased choice, flexibility and control. The uptake of SDS and of DPs had increased as a result, and through the work of dedicated teams the local authorities found they could be more creative and innovative in the ways they worked with people. The key issue now is maintaining such innovation and flexibility for greater numbers of individuals. Clearly, involvement of service user and carer organisations and investment in the necessary support infrastructures are essential, as well as continued availability of funding for the care packages themselves. In the foreword to the national Strategy, political leaders state that "more of the same will not work". It will be essential, therefore, for all local authorities to grapple with the challenges faced by these test sites, and to find a way to implement this shift from service provision to greater involvement and co-production of care and support. The outcomes of this Strategy are worthy of continuing assessment.