Social care - self-directed support: national framework - learning review

Approach of SDS Project Team

• 19. From the outset, the Project Team set out clear stages for this activity: research; engagement and focused work; production of the framework; testing and evaluation; and adoption. This paper reflects progress on the activity undertaken to date from November 2019 – March 2021 and is discussed in three phases:

Phase 1 (November 2019-March 2020)
Gathering intelligence and assessing the current picture

Phase 2 (April 2020-January 2021)
Developing a national framework and building the evidence base

Phase 3 (January-March 2021)
Publish final national framework and plan for implementation

Phase 1: Gathering intelligence and assessing the current picture

20. During this research gathering stage, there were six key aspects to the activity of the Team:

• Gathering research and practice evidence
• Approaches to frame and support implementation
• Identifying and engaging stakeholders and contributors
• Messages from phase 1: the current picture
• Planning phase 2
• Governance and accountability

Gathering research and practice evidence

21. The Team gathered extensive intelligence about implementation of self-directed support across Scotland, what was working and information on the barriers and challenges. This was gathered through reviews of research evidence, reports and practice evaluations, the Team's own mapping of activity across Scotland and consulting with key national and local stakeholders including local authorities, national partner organisations and supported people.

Approaches to support implementation

22. There have been many excellent examples of pockets of SDS practice across Scotland, but consistently high quality practice has not been achieved across the country. In acknowledging this, Social Work Scotland sought a structured and evidence-based approach to determining and contextualising recommendations for further development. Implementation science was identified as it provided a set of interconnected frameworks that can support successful implementation of complex social policy. Key to this was the overarching question which framed the activity of the SDS Project Team What will it take to do what needs to be done? (Fixen, Blase and Van Dyke 2019 ^[1]) with a proactive approach to making it happen through identified and structured step change.

23. A body of evidence (Active Implementation Research Network^[2]) has shown that implementation of complex change cannot rely on laws and regulation, stand-alone training or moving people's roles without amending structures. Without a national implementation strategy for SDS, each local area has interpreted the legislation and guidance differently and few areas had successfully reconfigured their systems and processes to facilitate effective SDS. Supported people also reported inconsistencies in local responses.

24. In order to address this, the Team with Social Work Scotland considered what was necessary to implement change complex change from available evidence. The more complex the ask, the more the organisational and system structures and supports would have be to adjusted. Some evidence (Blase, Fixen and Van Dyke 2018^[3]) identified that it was necessary to have a clearly defined practice to implement so that people understand what effective SDS looks like. It was also essential to have the right implementation supports in place, such as a team to support the SDS practitioners and to drive forward the organisational and system changes required. In recent years, CELCIS had been developing its approach to implementation science in Scotland and Social Work Scotland engaged CELCIS to help support and inform its implementation approach to the development of a national framework.

Identifying stakeholders and contributors

25. In early 2020, the Team mapped out the key stakeholders and contributors across Scotland, identified the proposed level of engagement for each, purpose of engagement and method of engagement. This mapping identified 76 distinct individuals, teams, groups or organisations across health and social care.

26. This ranged from Scottish Government, Scottish Parliament, local government including legal and finance representatives, NHS Scotland, Public Health, Health and Social Care Partnerships including finance, Providers such as Self Directed Support Scotland (SDS Scotland) and the Alliance, Other Agencies such as ILF Scotland, Professional Bodies such as SSSC, Regulatory Bodies including Health Improvement Scotland and Care Inspectorate, Third Sector organisations and alliances, Policy and Advocacy such as People-Led Policy Group, Research Community, Media, Workforce and Public (see Appendix 1 for list of contributors). All would be kept engaged through joint working, regular meetings, briefing sessions, parliamentary submissions, presentations and workshops, regular targeted written updates, general verbal and written updates, websites, social media updates and press releases.

27. The Team met with individuals and groups and also issued a questionnaire to National Partners in January 2020 asking for information on what was working, key messages for HSCPs and how best to engage moving forward. Seven partners responded. A Practice Based Return to HSCPs and local authorities had been planned for March 2020 asking each to identify what was working well, what was challenging, what should a national framework provide, where are there gaps and to provide examples of their assessment models and resource release models. This was not issued, however, as the timing coincided with the huge pressures on HSCPs and local authorities to respond to the demands of the COVID-19 pandemic.

Messages from phase 1: The current picture

28. The full impact of the Social Care (Self-directed Support) (Scotland) Act 2013 has yet to be realised (Audit Commission 2017^[4]; Care Inspectorate 2019^[5]; Critchley and Gillies 2018^[6]; Smith and Brown 2018^[7]). The scale and complexity of change that the SDS agenda demands of services is clear, especially at a time of pressured budgets, organisational change and high levels of demand impacted more recently by Covid-19. Service users also reported challenges in implementing the SDS legislation into all relevant areas of practice. Making high level strategic changes in line with the Act whilst training frontline and operational staff in skilled outcomes based practice had yet to be realised across most of Scotland (Critchley and Gillies 2018).

29. Critchley and Gillies (2018) also identified that significant investment had been committed in training of staff in understanding outcomes in good conversations and in co-production, in community capacity building initiatives, public awareness raising and information sharing. There was good evidence of the crucial role of third sector partners in broadening access to social care and supporting individuals and families to gain more choice and control over their support. The Care Inspectorate's (2019) thematic review of self-directed support found good-quality services providing care and support to people in most areas, however, this was not always happening in a way that allowed for personalised approaches or that reflected a shift in choice and control from services to people.

30. The Care Inspectorate (2019) also identified some key challenges: good conversations were not happening consistently across Scotland; there was a lack of consistent data recording; tension between the principles of self-directed support and eligibility criteria frameworks used to determine allocation of resources; a lack of transparency in recording decisions; limited options in the market for people to make a choice, particularly in rural areas; and variable knowledge of SDS across partnerships. Option 1 was generally well established across partnerships, but the availability of services for Option 2 was more limited. Option 3 was the most commonly used support for people, particularly older people and providing a combination of services through Option 4 was limited by the lack of progress on Option 2.

31. Key to successful implementation was strong and visible leadership for SDS with senior managers on board and progressing this agenda with involvement of service users, carers and wider communities. More training and support for staff in undertaking good conversations, assessment and planning, and managing risk. Supported people and unpaid carers need accessible and up-to-date information and greater focus was needed on increasing the transparency around how resources were allocated to supported people. Many care providers want to work flexibly and as partners in realising the SDS agenda, but traditional commissioning does not have the flexibility in delivery required for SDS (Audit Commission 2017; Care Inspectorate 2019; Critchley and Gillies 2018).

32. The consultation undertaken by the SDS Team identified similar issues. In particular, that leaders were key to supporting the workforce by valuing their work, trusting their professional opinions and giving them permission to work autonomously and within a supported risk enabled approach. Workers are key in supporting people to have choice and control throughout the process, and to talk through what matters to the person. The consultation also found that low uptake of personalised options (Options 1 and 2) was disproportionate in older age groups, people with mental health issues and people without carers, inflexible commissioning​ often focused on commissioning services before conversations were completed with people and poor monitoring of outcomes.

33. In summary, the main factors affecting the way self-directed support has been implemented as Scotland's mainstream approach to social care were:

• Different thresholds in dealing with risk between people, their workers and organisations (in terms of their reputations);
• Different levels of budget available for different groups of people and who decides what can and cannot be spent with public money and the type and impact of scrutiny of resource release models, some operating Resource Allocation Systems, some operating Equivalency Models and some a hybrid of both;
• Applications for flexible funding (i.e. alternative types of care and support) being put forward by social workers/assessors that are subsequently rejected by senior management, mostly due to the two previous factors; and where block-funded commissioning practice leaves very little flexibility in the system to provide real choice and control;
• The often negative impact that local legal, finance, systems, policies and processes have had on the ability to deliver SDS;
• The differences that exist between urban and rural settings, mainly where the social care support market is underdeveloped or non-existent;
• Worker autonomy for accessing budgets was beginning to be rolled out across several Local Authorities, although monetary limits varied considerably. Some areas however did not allow for worker autonomy thought to be due to anxiety about managing resources and fear of the potential reputational risks; and
• Eligibility Criteria used in some local authorities to determine if they meet requirements for support.

Planning for phase 2

Revising project deliverables

34. Following this intelligence gathering, initial consultation, and in light of the demands made on Scottish social work services during the pandemic, the Project Team in collaboration with Social Work Scotland, Scottish Government and COSLA changed the project's anticipated deliverables. The project remained focused on developing a national framework to deliver more consistent approach to SDS, but now a set of professional standards would be developed for social care and social work staff around assessment, resource release and increasing worker autonomy. Stakeholders agreed the development of standards was a more consistent approach with attention given to the right conditions needed to make self-directed support a reality for all people eligible for social care support funding.

35. The national framework should support local authorities and Health and Social Care Partnerships (HSCPs) in fulfilling their legislative duties, regulatory and social care requirements, and support practitioners in developing their professional practice. The Standards would also benefit supported people (adults and children) and carers to exercise their rights; and community organisations, providers and voluntary sector partners to play an equal role in helping deliver social care and support in Scotland. The standards would be designed to sit alongside the SSSC codes of practice and Advanced Practice statements.

Governance and accountability

36. The Team also established clear structures for governance and accountability. The project was managed and overseen by Social Work Scotland with clear reporting mechanisms throughout. Day to day management was overseen by a Project Lead. Fortnightly internal team meetings helped drive the project and maintain focus on its key priorities. There were also regular meetings with the Self-directed Support Policy Lead within the Health and Social Care Directorate, Scottish Government.

37. A Steering Group (Consistency and SDS Steering Group) hosted by Social Work Scotland was established to oversee the deliverables of the SDS project and to maintain links with work related to the Consistency workstream of the Adult Social Care Reform Programme. The Steering Group provided advice and guidance, contributed to the development of all deliverables; provided mechanisms to cascade information back to the organisations they represent, and gave feedback on the findings of the Team and advised on legal, financial and delivery responsibilities.

38. The Steering Group was chaired by the chair of Social Work Scotland's Adult Social Care Standing Committee and during phase two and three met on 11 occasions every 6-8 weeks. Its 48 members were from organisations presenting a wide range of perspectives (see Appendix 2).

Phase 2 Proposed national framework and building the evidence base

39. The approach to phase two of project from May 2020 to January 2021 is discussed under the following headings:

• Developing the proposed national framework for self-directed support
• Engaging contributors
• Undertaking formal consultation
• Message from phase 2: building the evidence base
• Planning for phase 3

Developing proposed national framework for Self-directed Support

40. The proposed framework built on the three emerging key assumptions which were considered to underpin the SDS Change Map developed in 2019:

Assumption 1 Assessment and the identification of resources is all part of the same process and should not start with the budget, but with a 'good conversation'.

Assumption 2 Community-led models offer early help and support to people who are not eligible for directly-funded social care supports

Assumption 3 All social care systems and processes need to be designed to meet the values and principles of SDS

41. In line with Active Implementation 11 standards were developed and proposed to be supported by detailed statements outlining the actions and behaviours required by leaders, practitioners, supported people, community organisations and providers to ensure consistency of outcomes and approaches across Scotland, and links to tools and resources developed since the inception of the 2013 Act by key SDS partners. The action statements were co-produced with relevant stakeholders and took account of system-wide drivers for change:

• setting the right culture
• ensuring that the vision, values and principles are evident through systems, organisation, leadership and practice.
• designing data and financial systems around SDS
• aligning key processes, policies and procedures to deliver best practice
• recruiting, training and coaching the workforce so that they can deliver SDS best practice as intended by legislation and guidance.

42. The aim was to design standards which were helpful, measurable, provide more accountability to people who want more choice and control over their social care, provide local authorities with an understanding of the drivers and road blocks for implementation of SDS and provide the basis for a self-evaluation framework for local authorities. A self-assessment evaluation tool was proposed to support future inspection methodology.

43. The standards and actions were designed to align with the Children's Charter and the Health and Social Care Standards, both of which expressed what people could expect from their care and supports in terms of personalisation and the level of expected involvement from assessment through to the delivery of care and support.

Engaging with contributors

44. The Project Team engaged with contributors in four ways: conversations, discussions and meetings with individuals, groups, collaboratives and organisations from across the UK; ongoing and regular links with links with existing meetings or networks; groups or workstreams brought together by the Project Team to undertake specific tasks; and formal written consultations.

Conversations, discussions and meetings

45. Throughout phases two and three, the Team has meet with, spoken and consulted extensively with individuals, groups, collaboratives and organisations from across the UK.

Ongoing and regular links with existing networks

46. The Project Team linked with Social Work Scotland's Practice Network whose members included HSCPs, local authorities and Scottish Government to consult on developments and provide updates. The Team met with the Practice Network on eight occasions. Local authority SDS leads represented on Social Work Scotland's SDS Subgroup also supported and advised the Project Team throughout the project.

Groups brought together by the Project Team to undertake specific tasks

47. During phase two, the Project Team established a Short Life Local Authority Reference Group to provide critical comments as the framework developed, including the practicalities of implementation. It met on two occasions and its 36 members represented 15 organisations (see Appendix 3 for membership). Representatives from ARC Scotland, COSLA and Scottish Government also joined the meeting as observers. The group scrutinised the SDS standards in development providing feedback from their own perspectives and areas of expertise.

48. Feedback throughout informed the development of nine workstreams:

• Assessment, Care Planning and Review, Transparency, and Meaningful and Measurable recording practice
• Access to independent support and advocacy
• Early help and community support
• Early planning for transitions
• Accountability
• Worker autonomy
• Consistency of care
• Flexible and outcome focussed commissioning
• Resource release

49. For each workstream, relevant stakeholders were invited to participate to provide detailed comment on the development of the standards and action statements, provided guidance and support, and ensure mechanisms were in place to cascade information back to the organisations they represented. All contributed skills, knowledge and expertise in order to refine the proposed draft framework and standards. A total of 44 members from across all stakeholders were represented across the nine workshops which each met on two occasions.

Formal consultations

50. There were distinct periods of formal consultation throughout the project where the Team asked for written responses:

• Short Life Working Reference Group questionnaire: a brief questionnaire was developed for the Reference Group members in advance to explore what it would take to make SDS a success. 17 responses were received.
• Steering Group Questionnaire: a brief questionnaire was developed for the Steering Group members in advance to explore what it would take to make SDS a success.
• Pre-workstream survey
• Consultation (November 2019 – January 2020): HSCPs and local authorities were asked to comment to comment on the practicality of further implementation taking the assumptions into account. 25 responses from 23 organisationswere submitted which included wider discussions locally by some.
• Call for comment (November 2019 – January 2020): an open call on the Social Work Scotland Website asked for ideas from individuals - people, workers and leaders - for taking forward the standards. 31 responses were submitted which also included wider discussions locally within some organisations.

Message from phase 2: Building the evidence base

51. The evidence base developed in relation to the draft national framework adopted an Active Implementation approach. All contributors were asked about what was working and what was getting in the way of making self-directed support a reality for people and what changes would be required to apply SDS more consistently.

52. The process of building the evidence base was iterative and some messages and feedback related to the draft national framework in its entirety and others focussed on particular aspects or issues. The broad messages are discussed in this report, but more detailed comments on each standard and assumptions from the consultation and call for comment have been written up separately^[8].

Responses to draft national framework

53. The importance and broad acceptance of the vision and principles of the Social Care (Self-directed Support) (Scotland) Act 2013 was recognised, particularly that the duties placed on a local authority were positive, aspirational principles such as involvement, collaboration and informed choices. The general consensus throughout the project was that SDS remained a good model which embodied the general principles of social work. It was asked that the final national framework should be checked to ensure the standards enhance rather than diminish the existing articulation of these principles in describing people's experience in directing their own support. The national framework was considered timely, aspirational and a blueprint for practice and improvement. There was minimal disagreement on the principles and assumptions underpinning the national framework and the 11 standards.

54. There was recognition of excellent and effective practice in local areas in many responses. Good conversations were thought fundamental to the relationship between individuals, family and practitioner, and need underpinned by a strong awareness of the SDS legislation, local implementation and available community assets and resources that can be accessed. HSCPs and local authorities commented they were better prepared or making good progress in having good conversations and identifying resources to support individuals and that much development work and training had taken place in more recent years. Extensive work had been undertaken in many areas, which contributed to their preparedness for the standards and assumptions. Almost all had undertaken extensive engagement with staff from all levels within the organisation, partner agencies and people living in communities to increase breadth and depth of knowledge amongst the workforce about local services and resources.

55. Another message identified in the responses was growth in the levels of community support available. There was a sense that many local authorities had been developing or building on strong community links through Community Hubs, Connected Communities and Resilience Partnerships. Those engaged in the Community Led Support programme highlighted different approaches through widespread engagement with the community, community councils and a range of services, building early access to information, advice and sign-posting to local, informal, community-based activities and supports or nurturing working across a range of partners in the third, private and statutory sectors. The impact to Covid-19 and local responses to the pandemic had identified new ways of doing things. It was thought important to retain this learning to consider what this would mean for development, continuation and support for all organisations as it was not yet known if this increased response and support would continue once there was some return to community life post-Covid.

56. The concerns and scepticism expressed were in relation to implementing the national framework into practice. Many felt openness and honesty was needed about the scale of the power shift and cultural change, and re-design of services required to implement the framework as well as the considerable financial implications of building a social care system that would address need. It was thought important that the national framework should encourage good practice rather than highlight poor practice, and that quality indicators should be developed to support local areas to self-evaluate implementation of the standards. A further tension was highlighted regarding how to uphold the choices of the supported person of what times they want to be supported, and capacity of the supported person or employer to resolve these issues. Current zero hours contracts were not thought sustainable or ethical, and principles of Fair Work needed to be supported within the SDS framework.

57. One key voice was that of rural and particularly island communities. Colleagues felt there need to be a better understanding of remote work and island geographical realities going forward. There is not the variety of services as are perhaps available in more urban areas. Funding disbursed on a pro rata basis means posts affordable in less populated geographies are often part-time leading to a lack of coherence and cover. There was also reflection that the standards should be more comprehensive in relation to Support Plans. Without robust support plans anchored in the assessment there is a real risk that outcomes can be 'lost'. Standards need to be balanced across assessment, resource allocation and support plans.

58. Informed by implementation science, key ingredients for implementing the national framework and developing a more consistent approach to assessment, planning and review were identified throughout the project work and formal consultations:

• National commitment and leadership
• Culture shift
• Rights-based approach to practice
• Increase partnership working
• Re-thinking funding of rural communities
• Re-thinking eligibility criteria
• Re-thinking resource release
• Increase resources and services
• Community development and Community-led Support
• Skilled and confident workforce
• Workforce training and development
• More work to embed SDS within Children's Services
• Reduce bureaucracy
• Better engagement with the public
• Inequity of access to social care budgets across different groups of people. (e.g. less money can be accessed per head of the older people's population, compared to all other adults).

59. Several contributors identified the need for a clear process and strategy to progress implementation of the national framework in local areas. Some discussed establishing or re-establishing a local SDS Programme Board to oversee the delivery of self-directed support across children's and adult's social work services, and to promote the facilitation of the National implementation Plan and local Improvement Plans with attention given to:

• clarity about what is being implemented including clear descriptions on who the practice is for, the underpinning values, principles and philosophy, the essential components of the practice;
• identify what supports will be needed to help the implementation recognising that implementation takes time and should build on the wealth of local practice that has been developed;
• enable the local context to be ready for change with local leadership supporting the changes necessary for implementing the practices that support SDS; and
• acknowledging that when implementing complex change it is important to start small, finding teams and local areas who can test out the practice.

60. Once implemented and as organisations deliver better and improved outcomes for service users, contributors identified the need for ongoing self-assessment and review of practice across all roles and services to measure improvement, evidence better improvement and to measure outcomes for supported people. Supported people and carer contributions were thought vital to reviewing local SDS processes and procedures. More consideration was needed about how best to involve local community groups representing service users and carers in more regular dialogue about SDS implementation and review.

Responses to individual elements

61. From all consultation, comments on the assumptions reflected that the term assumption could be stronger and if these assumptions underpinned the vision of practice then perhaps the terms Principles or Mission Statement would describe this better and suggestions on terminology and language. There was little discussion on the Action Statements as those had not been the focus of the consultations and were still in development.

62. From all consultation, there was strong support for all eleven standards with broader reflections on what would be needed to implement each standard into practice and the practical implications for doing so. Detailed comments were also submitted in relation to terminology, language and tone of each standard. One key recommendation was that local authority systems should encourage trust, and support timely decisions about change of use of a budget when this is required. In considering these aspects, one response concluded there should be a separate standard to cover these points under the heading Budget allocation.

Planning for phase 3

63. Three areas of activity were identified for phase 3:

a. Extensive revisions to the current draft assumptions and 11 standards taking account of all feedback from phases 1 and 2;

b. Development of a new twelfth standard for budget allocation and continued development of the action statements for the detail of what is required of leaders, manager and the workforce to implement each standard; and

c. Planning the next stage (or route map) for implementation of the national framework informed by phases one and two.