Counting the Cost of Choice and Control: Evidence for the costs of self-directed support in Scotland

4 FINDINGS 2: PROVIDER AND ADVISOR PERSPECTIVES

Introduction

4.1 In this chapter we discuss a range of issues and concerns associated with the costs of SDS that were raised by provider organisations. The findings discussed in this chapter, alongside those discussed in chapters three and five, informed the analysis and modelling of SDS costs in the chapter six, and our discussion of the issues raised for various stakeholders in chapter seven. They are based on the interviews with individual provider organisations (both Local Authority specific and crossing Local Authorities), interviews with workers in advisor and advocacy organisations, the focus group with representatives from a user-specific provider organisation, and views expressed in the workshop discussion.

SDS: Empowerment or cost cutting?

4.2 At the time the fieldwork for this project was taking place, cuts to social care spending in Scotland and the wider UK were making headlines both nationally and locally. Several Scottish Local Authorities had moved large numbers of users onto DPs whilst re-assessing their needs and reducing service packages, and there was a general feeling amongst all the participants in this study that the 'new austerity' in welfare following the financial crisis was having, and going to continue to have, a significant impact resulting in the reduced availability of social care services. The timing of the move towards SDS and cuts to social care happening at the same time had the effect of linking DPs and SDS in the minds of provider and advocacy organisations with cuts and reductions to services, rather than with the broader goals of user empowerment and control. One provider discussed how a public disquiet engendered by the withdrawal of some services affected perceptions of SDS:

When this is being discussed, it is consistently stated that self directed support is not about saving money, it is about transforming the way things are done, however, the issue about having to use resources wisely and the eligibility criteria and so on - it is all there anyway. It would be clear to everybody who is in the social care sector that the council is not going down this route because it is going to save them money, that is not the case....[However] I think the experience in [Local Authority A] showed that if you do not do commissioning and retendering in the way that is carefully thought out...people can take the wrong message from that in terms of feeling that they are being put for sale...we have the experience... of people reacting very strongly to the way that self directed support was being approached. (Interview, voluntary sector provider, Local Authority B)

4.3 Providers cited many case examples where, despite reassurances that SDS was not 'about saving money', support packages were being reduced due to resource constraints as SDS packages were being negotiated with users. They were alarmed about the implications of this for users:

The council had identified a budget for some individuals, but we had identified catastrophic risks associated with just changing and agreeing that because what it meant, essentially, is that individuals who have always had 24 hour support had someone with them all of the time. With the new budgets that were identified, it would not be possible to give them 24 hour support, so there may well be periods in the day and in the week where they have no support and, ultimately, that comes with a lot of risks. (Focus group, client-specific cross LA providers)

4.4 However, there was a sense that different Local Authorities were managing this budgetary pressure in different ways, with a differential impact on DP users and the transition to greater uptake of SDS. One provider stated that he was 'very uncomfortable' with the overt use of SDS as a vehicle to save money, which ran in direct opposition to the stated aims of the policy. This had the effect of damaging relationships between providers, users and Local Authorities:

The difficulty which providers have in this process is that a Local Authority have gone into this with a determination of what is going to come out, so it has been predetermined in some ways. That is something we have been incredibly uncomfortable about because it does not seem to be a personalised approach. Our perception is that in getting to the place we have with some individuals now, that has only been at significant compromise to those individuals in terms of the quality of their life and life experiences just now. That, in our view, has not been the intention of personalisation. (Interview, voluntary sector service provider, cross Local Authority)

4.5 A related concern was that users with good past experiences of DPs offering choice and empowerment would find moving to a service that had been reduced due to resource constraints difficult, and that this would cause significant anxiety. One interviewee spoke of a conversation with a client with a learning disability who had recently switched to SDS:

[S/he] was saying that it is brilliant, I have got a life, I can do the things I want to do. I used to go to a day centre and I was bored but now it is great and I am really really happy but I am worried what if someone takes that away from me in the future, what if somebody changes that, and that was a really understandable concern. (Interview, voluntary sector provider, Local Authority B).

4.6 It is difficult to estimate what the costs associated with these concerns might be. On the one hand, managing changing needs and resources is what the present system of social care allocation in Scotland is explicitly designed to do. As one provider pointed out:

We have experienced a number of people we support whose care packages have been reviewed downwards in a way that really the priority, I suspect, was to save money for the council, but that has not been anything to do with self-directed support, that has been to do with the financial constraints within the council. (Interview 2, voluntary sector provider, Local Authority B).

4.7 On the other hand, if, as some of the Local Authority commissioners asserted, the costs associated with monitoring and review of SDS are not very different from those associated with standard care management (and indeed may well reduce as users take on more responsibility for managing their own care packages), then the implications are that the risks - and therefore the costs - of managing changes will be borne by users.

Cost and quality

4.8 The second range of concerns expressed by providers with regards to costs related to their view that there will be strong pressure for SDS users to commission services for themselves based on price rather than quality - although we do not know, of course, whether this will really be the case, and both our own research and that conducted by Leadbetter et al (2008) and Wood (2010) indicate that factors such as the quality and continuity of care are of greater importance that price alone.

That [perceived pressure] can be quite difficult for families who are thrust with this responsibility that they have never ever had, where the authorities dealt with that, where the authorities assessed a provider, where there is quality assurances procedures in place between the Local Authority and the provider. Parents of individuals that have got significant disabilities are going to have the responsibility to decide and they will probably be driven by cost initially without really having the understanding about the quality, about the quality assurance models that are behind all that and essentially what they may or may not provide. (Focus group, client-specific cross Local Authority providers).

4.9 Some of the costs associated with providing a high quality service are to do with the recruitment and training of the workforce. There were concerns expressed that currently investment in training is supported by providers and by Local Authorities who have quality standards, including workforce qualifications, in mind when they commission services. PAs who are directly employed by individuals using SDS do not have to attain social care qualifications, which caused some concern amongst providers:

We invest a lot in the recruitment process to taking up references, to supervising workers, to training them and protection issues, to having an organisational stance on disclosures. It worries me when you are buying personal assistance as to the power imbalance and the relationship issues that may well transpire as a consequence of that. (Focus group, client-specific cross Local Authority providers)

4.10 Some providers were concerned that SDS users may be able to undercut agency providers by compromising on the quality of care:

There would be a financial attraction in employing a personal assistant because they buy a service from us and we charge them, say, £15 an hour. They will say, I can hire a personal assistant, a good one, and I will pay her £8 an hour - there's a wee bit on costs, I can do the whole thing for £10 an hour - so I can buy more hours, or I can do something else. But the £15 we are charging includes the costs of training, the costs of managing staff, staff supervision. Potentially you could get a whole lot of unregulated, unsupervised, untrained people providing support to vulnerable people. (Interview 2, voluntary sector provider, Local Authority B).

4.11 However, in some cases SDS users will be effectively providing the 'training, managing and supervision' of staff themselves, so it makes sense that this investment frees up resources to be used elsewhere. If they chose to commission a service from an agency at a higher fee, then it could be argued that they will be making a rational choice to pay for the 'training, managing and supervision' element rather than provide it themselves. It is difficult to predict how much SDS users would make these decisions based on cost rather than other criteria (Leadbetter et al, 2008; Wood 2010), but the aims of the SDS legislation would indicate that policy makers intend these choices to be made by SDS users themselves.

Variation, flexibility and costs

4.12 Some of the larger providers contracted for services across different Local Authorities, and were used to the different ways of setting prices and service level agreements (as one informant put it: '32 different Local Authorities means more than 32 different contracting arrangements'). They were confident that this ability to respond to variation would translate into good practice in contracting with individual SDS users.

Our basic financial system could cope with 95 invoices instead of one invoice. We are big enough to be able to have that infrastructure probably in place. (Interview 2, voluntary sector provider, Local Authority B).

4.13 However, this might mitigate against smaller providers who only had experience of contracting with one Local Authority. Representatives from smaller providers voiced concerns that if provider organisations were not able to develop systems that could cope with varying and flexible demands from SDS users, they might not be able to continue operating if a large amount of business came that way. This would mean that fewer, larger providers could dominate the market, potentially reducing choice, increasing costs and increasing prices for SDS users.

4.14 However, it is difficult to assess the real impact this would have on the costs of SDS. Experience with DPs shows that most (but not all) users preferred to directly employ PAs rather than to contract with agencies, partly because of the flexibility, control and working relationships that this makes possible. Although not yet extensive, there was anecdotal evidence of PAs leaving agencies to work privately for DP users and concern that this would become more common if more users directly employed their own carers: some users in our survey had done this and several examples were cited by provider agencies. Whilst this has cost implications for the agency, it also indicates that good quality workers would have a potentially wider range of employers under SDS. Provider agencies and SDS users may well compete to offer better working conditions: the scope of SDS users will be limited to do this if the wages they can offer PAs are not competitive. The increased choice and flexibility offered to good quality care workers might have the effect of forcing both agencies and SDS users to be very careful about the conditions and pay they offered workers.

4.15 There was a concern expressed that providers would be left to take on the costs associated with SDS users terminating contracts with short notice, or having changing needs and experiences:

In terms of DPs, people are shopping around so there is very much that bit in our service agreement we have to look at cancellation periods or ending periods as well. In terms of recruiting staff, if you recruit a full time member of staff because a family come to you looking for that but six weeks later it is not there, you are then left with staff, and there are practical issues about contracts. (Interview with voluntary sector service provider, cross Local Authority).

4.16 Other informants pointed out that some of the costs associated with wanting flexibility and the ability to change providers quickly would fall on users:

It affects the cost of the service to the person. There is an issue there about how much money people will have available to them to purchase support and obviously individuals would not want to be in a position where they are signing up to something and they are having to pay for that when they no longer want it or whatever....In terms of expecting people to take that on and pay for it, I think would be unrealistic - and would they have the money to be able to fund that, because in effect, that individual would have to double fund probably if they decided they had the need and they had to get it from somewhere else, they are funding the new services while they are funding the old services. (Interview 1, voluntary sector provider, Local Authority B).

4.17 In effect, this is a micro-version of the argument that providers and Local Authorities will need bridging finance to enable them to invest in new services and systems before resources are released from the closure of old services. However, the 'bridging finance' in this case is likely to come from the resources available to SDS users themselves, rather than through Local Authorities. There is therefore a tension between the needs of providers (to be able to recruit and retain trained staff, to be able to keep their organisations in business) and those of SDS users (the need for flexibility in support options). What kinds of systems are developed will have an impact on the costs for users and providers, and where those costs fall.

4.18 Some providers were positive about the possibilities opened up to new providers entering the market who might be in tune with the needs of SDS users. It was felt that this was likely to increase choice and quality for SDS users whilst keeping costs down.

The role of care managers, carers and advocates

4.19 Like the commissioners, many providers envisaged a reduced role for care management as SDS users and their carers took on more responsibility for arranging and managing their own care packages:

During your usual commissioning meeting, we had mum, care manager, and us. Throughout the whole meeting the care manager did not have anything to say because it was mum who was doing it all. She was effectively put in control of that because she held the budget. She knew exactly what they wanted to do and it was more a case of her getting into discussion or constructively challenging us about how we could actually achieve those key outcomes with that amount of money, but all through the meeting I was getting more and more conscious that the care manager was just kind of there and had nothing much to say. (Interview, voluntary sector provider, cross Local Authority).

4.20 Clearly articulate and well-informed SDS users (or those with powerful supporters and advocates) are going to be in a fairly strong position to negotiate services at a higher quality and reduced cost. However, as a higher volume of users without these attributes enter into SDS, it is clear that care managers and advocacy and support organisation will have to play a significant role in enabling more vulnerable users to receive care services that meet their needs and are within their allocated budgets. It is therefore likely that any anticipated cost savings in care management for more experienced SDS users (or those with strong informal support) will be offset by the need to retain (and possibly invest in) care management and advocacy and support organisations for newer and more vulnerable users.

Summary

4.21 The analysis of our findings indicates that:

• SDS is being implemented at the same time as resource constraints are leading to cutbacks in service provision;
• SDS users have more responsibility in managing their care than users of standard services. In the view of service providers they may also be more likely to bear more of the risks and costs associated with reductions in service packages;
• Some providers were concerned they would find it more difficult to recoup investments made in staff training and quality assurance under SDS;
• The complexity and variation of SDS systems means that larger providers may be better placed to absorb the costs of the changes to managerial practices and structures needed. Fewer variations, and clearer pricing structures, would make it easier for smaller providers to compete fairly; and
• As more vulnerable users take up SDS options they may be disadvantaged in terms of negotiating quality and cost effective services unless there is investment in care management and support/advocacy organisations.