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

7 DISCUSSION AND ISSUES

Introduction

7.1 In this chapter we discuss some of the main findings in the report, focussing particularly on the implications for policy and practice as the move towards SDS in Scottish social care policy takes shape.

SDS in the policy and practice context

7.2 As both our own, and previous, research indicates, SDS has the potential to deliver significant potential benefits in terms of improved choice and control by service users, better co-ordination of services across different sectors (public, private, voluntary and family carers), and improved cost effectiveness and efficiency of services. However, these potential benefits need to be weighed against a cautious approach about the risks to service providers, front-line staff, service users and family carers, particularly concerning the potential destabilisation of services, exploitation of vulnerable users, exploitation of workers, the risks to family carers and users, and the inequity across different user groups caused by different criteria and uptake.

7.3 Local policy and practice contexts are, and will continue to be, important. The range of providers available locally, and how prepared they are to work with individual users rather than Local Authorities as commissioners of services, will have an impact on whether the potential benefits of SDS can be realised for users and their families. Similarly, the availability of impartial, local, advice and support will continue to be crucial in helping users make well-informed and appropriate choices about SDS.

7.4 At the time the fieldwork for this project was taking place, cuts to social care expenditure were making headlines both nationally and locally. In the light of this, the participants in this study voiced concerns that SDS will be associated in the minds of providers, advisor organisations and users with cuts in resources and services. This association may make it difficult for the positive messages about the potential for SDS to be empowering and give users greater choice and control to inform practice.

Issues for commissioners of services

7.5 The evidence from our study suggests that a number of potential trends could emerge with increased levels of SDS. The costs of services are as yet not fully understood: however we predict that they will become more transparent if Local Authorities can learn effectively from the costing systems that have been developed for DPs.

7.6 Whilst our data indicates that the increased flexibility and choice potentially offered by SDS is broadly welcomed, the evidence also suggests that there are significant variation in costs, and the way they are calculated, across different local contexts and for different groups of social care users. Tackling these variations appear to be important to ensure the fair and equitable use of scarce resources. More transparency around service costs could make things fairer: on the other hand, they may well expose inequities that are difficult to address.

7.7 Local Authority informants were very concerned that SDS could destabilise existing service providers. They also felt that support agencies will need 'fair notice' of changes in contractual arrangements. Our data indicates that there is clearly some variation as to how prepared providers are to adjust to the flexibility in provision that will be needed for SDS. The ability of commissioners to influence the quality of SDS services will continue to be important: even though SDS users could, theoretically change providers more quickly if they were unhappy with the quality of services.

7.8 Although initially the resources needed for SDS assessments may increase, our data indicates that these should decrease over time as SDS becomes more mainstream and assessment systems develop. There is no evidence to suggest that the resources and costs associated with managing SDS will be greater than for managing social care resources generally.

7.9 Spending on social care services will increase, but this is due to an anticipated increase in demand, and not to SDS per se.

Issues for service providers

7.10 Providers were broadly in favour of the increased empowerment, choice and control offered to users through SDS. However, there were concerns about the costs and workforce implications of the predicted flexibility arising from SDS: investment in staff training and infrastructure may prove difficult to sustain for those providers who would be destabilised if SDS user changed contracts at short notice.

7.11 Variations in pricing and demand for services may make it more difficult for some providers to effectively plan and deliver services. Some provider organisations also felt they may be vulnerable to staff leaving to work as PAs to SDS users.

7.12 At present PAs do not have to register with the Scottish Social Services Council, unlike care workers working for Local Authorities or care agencies. The evidence from this project suggests there are concerns about a 'two tier' workforce emerging in social care, which has implications for vulnerable service users and for PAs working with less employment protection and training than their colleagues in the more regulated sector - these concerns are echoed in other studies (Ungerson and Yeandle, 2007; Rummery, 2011).

7.13 Changes in the structure of contracts may increase risks for providers who cannot easily pass these on when faced with large Local Authorities as their main commissioner. New opportunities for providers (for example in providing training, advocacy and advice/brokerage services) may arise.

Issues for SDS users and family carers

7.14 Although it is difficult to judge precisely what these will be, it is likely that some of the costs of increased flexibility in SDS will fall on users and family carers. Users and family carers will be particularly vulnerable to increased costs and risks if Local Authorities do not continue to invest in independent support and advocacy services for SDS.

7.15 However, in line with other research, the DP users in our study were largely positive about the benefits of using DPs, and we judge that these benefits would translate to other SDS users. These benefits included increased flexibility, choice and control over services and support, and the benefits were felt by family carers as well as users.

7.16 Most DP users had chosen DPs because previous service options had not adequately met their needs. However, they did highlight that there was sometimes significant additional work associated for themselves and for family carers in administering DPs, and we predict this burden will continue to fall on users and carers under SDS. Again, this highlights the need for continued investment in support, advice and advocacy organisations.

7.17 It may prove difficult for individual SDS users to use their purchasing power to improve the quality of services in the way that Local Authorities can. It is possible that there may not be sufficient volume of SDS users willing to change contracts and exercise 'choice, voice and exit' to push down prices whilst ensuring that providers who offer high quality services thrive.

Future trends

7.18 Our research indicates that the relationship between user needs and the costs of packages of care is not clear: higher needs do not necessarily mean larger, or costlier care packages.

7.19 DP users are most likely to employ a PA, and least likely to purchase services from a Local Authority: we predict that SDS users will follow similar patterns and chose options like directly employing PAs which offer users the most control and flexibility.

7.20 Our research also indicates that there is no significant difference in hours of care between DP users and the matched sample of users receiving 'standard' service packages. This suggests that SDS, if it follows the same pattern as DPs, will not mean a reduction in services, and costs will not differ significantly between DPs, other forms of SDS and 'standard' services. We conclude that fears about reduced services and increased costs associated with SDS are therefore unfounded: personalisation and SDS do not, per se, lead to reduced services and support.

7.21 However, consideration of scenarios in which SDS becomes more mainstream raises questions about what will happen in the market for care if unit costs are driven up by new contractual forms, or if more SDS users opt to employ PAs. The role of, and costs to, Local Authorities are also likely to change, particularly the costs associated with stimulating local markets to deliver sufficient capacity, putting in place additional support for SDS users (particularly with administration, and training for PAs).

7.22 We predict that opportunities for new providers are likely to increase under SDS, particularly for those offering additional administrative services and those well placed to offer flexible, responsive care services.

7.23 Our modelling indicates that the costs of care will increase. However, these rising costs are mainly the result of the changing demographics and the rising levels of need in the population. They are not specific to SDS. However, projected expenditure on SDS is sensitive to the rate of expansion of this provision and to the costs of (for example) PAs as compared to 'in-house' carers: PAs have associated costs which are not well understood (such as administrative and training costs).

Conclusions

7.24 The expansion of SDS in Scotland is not uncontentious: it remains an area of significant debate. The aspirations towards improved choice and control for users, which drive current policy, are widely supported by all the stakeholders involved in this research.

7.25 However, it is not yet clear that SDS policy and practice can deliver them fully for all users, nor what the impact on the costs of care will be. In the context of the significant variations between Local Authorities in terms of care provision and the uncertainties regarding equity of provision, whether users' needs are being met, where the various costs associated with SDS will fall, and what the impact of SDS will be on service provision in different sectors, the policy drive towards choice becoming the 'default' position in social care policy in Scotland appears to require, to a certain extent, a 'leap of faith' for all concerned.

7.26 Nevertheless, there is no evidence to suggest that SDS is more costly than other options for delivering social care services. Given the potential for increased empowerment, choice and control for users and family carers, that 'leap of faith' will, hopefully, prove justified.