Adapting for Change: evaluation

Chapter 2: Context for the Adapting for Change Initiative

Scottish Government policy places a clear emphasis on supporting independent living and enabling people to stay in their own homes for as long as they want and are able to do so. People having a safe and secure home which meets their needs is at the heart of this policy. Crucially, this home must be able to meet any mobility or other needs, including those arising from age or disability.

Scotland's older population is increasing and with that increase the number of people needing support is likely to rise; this corresponds with a time when public services are under increasing financial pressure. An increased focus on prevention, particularly in light of the recommendations of the Christie Commission, is seen as key to addressing the inevitable challenges which will result. In particular, investment in preventative measures could reduce the need for more intensive and costly service interventions at a later date.

The role of housing adaptations in supporting independent living is well recognised. However, the delivery of those adaptations is seen to be complex and driven by tenure as much as the needs of the individual. Resource pressures, and especially the need to make best use of public funds, also comes into play. The Scottish Government has therefore been amongst those developing and supporting programmes of work focused on the housing adaptations process and maximising its capacity to improve individual outcomes.

The Adaptations Working Group

In 2011, an independent Adaptations Working Group was established by the Scottish Government and was tasked with reviewing housing adaptations practice and providing recommendations for change. It was asked to:

• Consider systems for the delivery of adaptations to people of all ages;
• Explore ways in which the current delivery systems could be streamlined to improve outcomes; and
• Consider whether there was a need for fundamental change to adaptations services to support equality across all housing tenures.

The AWG's 'Adapting for Change' report was published in November 2012 ^[6] and the Scottish Government's response ^[7] followed in March 2013. The Adapting for Change report recommended that fundamental changes were needed to the delivery and funding arrangements for housing adaptations. The AWG identified a number of issues which supported the case for change:

• Assistance with housing adaptations can be driven by tenure rather than individual need, leading to locality and financial inequalities.
• Current systems that base support for adaptations on tenure rather than individual need are unlikely to support fairness and equity.
• The range of different approaches is both complex and confusing and does not support the delivery of a consistent, co-produced or cost-effective service.
• Most current adaptations services focus on existing problems rather than planning for the longer term. Equally, assessments tend to be geared toward current rather than anticipated need.
• There is some evidence that the provision of adaptations is becoming increasingly budget-driven, and at odds with a person-centred and preventative approach.
• Retaining the status quo may lead to longer waiting times and increased costs to other parts of the health and care systems, as well as reducing the quality of life and independence of those in need of support.

The AWG outlined a set of core principles when developing adaptations services for the future:

• The person and their carer(s) should be placed at the centre of service provision and be in control.
• Support for adaptations should have a prevention focus.
• Adaptations should promote enablement.
• Access to assessment and provision should take account of need and be fair, consistent, reliable and reasonable, with a focus on prevention, and take a holistic view of a person's life.
• Assessment and access to financial and other non-financial supports for adaptations should be equitable, fair, anti-poverty and complement systems for Self-Directed Support.

A number of key strategic recommendations was also identified, providing a framework for change. They focused on: a clear local strategy; better information and advice; clarity in assessment; involving people more in-service delivery; self-assessment and self-help; Self-Directed Support; prevention and planning ahead; more attractive, sustainable design; planning for maintenance; links to repairs; more effective use of existing investment; procurement efficiencies; and partnership, leadership and management .

The AWG considered that addressing any of these elements had the potential to deliver important improvements but that addressed together, they offered the potential for achieving fundamental change.

The AWG concluded with a number of overall recommendations for consideration in future service design, and to mitigate some of the current challenges. In summary, these were:

• Strategic leadership with the local housing authority. Housing adaptations is, and should remain, a partnership service. Strategic leadership should unambiguously rest with the local housing authority.
• Centred around the individual. This would ensure that the needs, circumstances and choices of the individual and their family and/or carer(s) are central to the way in which services and supports are designed, including: a single point of access; assessments of people's circumstances and discussion of choices and preferences; and arrangements which enable the person to have control over the process.
• A broader, outcomes-focused service. Services and support must become wider than simply providing grant funding or directly undertaking an adaptation. A successful outcome must be more clearly defined as helping someone to retain or recover their independence.
• Partnership governance. Governance and management of housing adaptations should be undertaken as a partnership between commissioners, providers and those using the services.

The AWG proposed that the recommendations be tested as pilots, within several sites, prior to large-scale roll-out.

The Scottish Government's response to the AWG report endorsed the vital contribution adaptations play in supporting people to live safely, comfortably and independently at home. The Scottish Government committed to work in partnership with housing associations, service users, local authorities and others around: streamlining measures within the current delivery systems; fundamental change to current delivery systems; and measures enabling people to plan ahead and pro-actively adapt their homes.

The Health & Social Care Integration context

The Public Bodies (Joint Working) (Scotland) Act 2014 (the Act), which establishes the legal framework for integrating health and social care in Scotland, came into force in April 2016. The Act requires each Health Board and Local Authority to delegate some of their statutory functions, and associated budgets, to their Integration Authority which is responsible for the planning and delivery of all delegated services using the delegated budget at the disposal of the Integration Joint Board ( IJB). Please note that the arrangements in Highland, and hence which apply to the Lochaber test site, are different. Highland is the only area to have adopted the Lead Agency Model and the NHS is the lead agency for adult health and social care services. The Highland Strategic Commissioning Group is the forum for joint decision-making on adult social care services and, in this respect, is similar to an IJB.

The Scottish Government's expectation that the housing sector has a key role to play is set out clearly in statutory guidance in the form of a Housing Advice Note ^[8] . The Housing Advice Note states: "The Scottish Ministers consider it essential that housing services are coordinated with health and social care in order to achieve joined-up, person-centred approaches."

Further, the Act's Regulations establish that services involving equipment and adaptations must be delegated ^[9] . This means that Integration Authorities are now responsible for housing adaptations as part of the wider strategic planning and delivery of integrated health and social care services. This responsibility extends across all housing tenures.

Central to Health and Social Care Integration is the principle of personalisation of services, with increasing involvement of service users in selecting and shaping the services they receive. This principle has been steadily embedded in policy, particularly following Changing lives - the report of the 21st Century review of social work (2006) ^[10] . Changing lives placed the person firmly at the centre, as a participant in shaping the services they get and allowing them to work with professionals and their carers to manage risk and resources.

As noted within the AWG report, Self-directed Support is one aspect of the personalisation of services and provides a number of options enabling people to choose and control their support services, and identify the right solutions for them. The Social Care (Self-directed Support) (Scotland) Act came into force in 2014 and requires local authority social work departments to work in partnership with service users to identify what their support looks like and how it is delivered.

This is the legislative and policy framework within which the AfC test sites have been taking their work forward.

The Adapting for Change pilot

As noted above, the AWG recommended piloting its advised approach in order to develop and test key aspects and models of delivery. The Scottish Government accepted this recommendation and, with support from the ihub, and following consultation with key stakeholders, moved forward with the AfC initiative.

The overall aim of the pilots was to develop and test key aspects of the approach recommended by the AWG to inform a revision of the national policy framework for housing adaptations, and to provide learning to improve practice. The accompanying objectives were:

• To test approaches in relation to key issues around current services and supports.
• To identify approaches, consistent with recommended principles, which deliver better outcomes.
• To capture the learning on a continuing basis over the test period and share this across Scotland.
• To inform the review and revision of the national policy and funding framework for housing adaptations.

A range of specific changes to be tested ^[11] was also developed. Tests focused on areas for improvement, new opportunities and issues of interest to emerge from the piloting process:

• Partnership governance - which includes people using services - and integrates with health and social care.
• Greater focus on prevention and early intervention.
• Adaptations as one response in an integrated menu of options to secure suitable/fit-for-purpose housing.
• Helping people to help themselves, offering services over and above those associated with funding.
• A single funding pot for adaptations, with tenure-neutral access and eligibility.
• Adaptations for people with dementia.
• Design aspects - making adaptations more attractive at the same cost.
• Improved data collection on impact and effectiveness, including added value.
• The use of the Self-directed Support in housing adaptations.

Applications to be a test site were judged based on: strategic fit; outcomes, impact and equity; collaboration; feasibility; and transferability and flexibility. It was always recognised that some of the features set out would be challenging to achieve, particularly if any test site was looking to address a number of the tests of change. In the call for applications from potential test sites, it was acknowledged that it would not be possible for all sites to test the viability of every recommendation put forward by the AWG.

Five areas became test sites, with the pilot phase running from Autumn 2014 until the end of the 2016/17 financial year. Each of the five test sites has been receiving advice and support through the ihub; however, they have received no additional funding from the Scottish Government. A very brief summary of the original plans in each test site is set out below.

Aberdeen aimed to improve partnership working and promote a person-centred approach. Local practice would be reviewed across all tenure types, providing a baseline on which to develop a more equitable, preventative and holistic approach to adaptations. The aim was for this delivery model to be easy to navigate and well understood, empowering both service users and carers. A focus would also be placed on early planning and improved input to new build housing in the area.

Falkirk aimed to develop a new service model for adaptations, which was outcome focused, and provided a common approach across all tenures. The aspiration was to improve resource use, reduce duplication, improve information on housing options and develop an efficient provision across the partnership. The new model would be supported by a clear governance framework, robust performance management, and a clearly set out funding framework.

Fife aimed to test approaches to address key issues around service and support and consider new ways to better deliver outcomes across the partnership. The intention would be to capture learning and share it across Scotland, and thus inform the review and revision of a national policy and funding framework for housing adaptations.

Lochaber planned specifically to redesign the existing Care and Repair service to deliver a local, tenure-neutral route to aids, adaptations and equipment. Care and Repair would therefore provide local leadership on behalf of statutory stakeholders. This development would hope to simplify and improve the customer journey and improve the ability to monitor outcomes and achieve best value across the partnership. A multi-agency review of data would be undertaken to prioritise areas for improvement. Commercial service opportunities would in addition be explored for clients not eligible under the Scheme of Assistance or participating in Self-Directed Support.

Scottish Borders aimed to further develop the Care and Repair service to establish a one-stop-shop approach for adaptations, to which individuals could directly self-refer. The assessment responsibility for adaptations would be transferred from the social work locality team Occupational Therapists ( OTs) to the Care and Repair OTs, and further development opportunities would be taken with Registered Social Landlords ( RSLs) locally to improve services for people with disabilities.

Further information on the work undertaken by each test site is available from Scotland's Housing Network website at: http://www.scotlandshousingnetwork.org/health-social-care/adapting-for-change/.

Information on the website focuses on capturing practice and learning and has been developed entirely independently of this evaluation.

Package of test site-related support

As noted earlier, there was no financial support associated with becoming a test site. However, the test sites have been receiving a package of consultancy-type support through the ihub ^[12] . The original remit for this support was that it would include:

• Supporting the lead partner to identify relevant stakeholders, put in place governance, practical project support, communication arrangements, and detailed delivery plans.
• Providing constructive challenge to local partners throughout the demonstration period to draw on good practice and achieve more from their resources.
• Supporting local teams to identify solutions to problems that arise, such as through connecting to others, providing practice examples, or brokering between partners.
• Designing and facilitating progress reviews at key points in the project delivery.
• Channelling and referring experience which has wider learning to the Adaptations Network.
• Ensuring that local teams provide progress reports to the National Project Team. This took the form of the test sites providing regular updates on progress to be shared with the ihub team and with colleagues from the other test sites at regular learning events.

Around two days of support per month was made available. In addition, representatives from each test site have been part of a learning network which has focused on practice improvement.

'Starting point' in the test sites

To set all subsequent evidence and analysis in context, it is worth noting that there was almost universal agreement amongst the test site professional interviewees taking part in the evaluation that:

• A well-functioning, person-centred approach to adaptations will be a key component of a fit-for-purpose, prevention-focused package of services which promotes wellbeing and supports people to live independently for as long as possible.
• There was, and probably remains, (considerable) potential to 'do things better' within their local area and/or within their own services.
• These improvements will be key to providing a sustainable package of services into the future, especially in the context of an ageing population and a financial climate in which already challenging resource constraints may increase.
• No service or organisation will be able to make truly effective and systemically-significant changes in isolation, particularly in the context of the integration of health and social care services.

Along with the broad consensus that change is required and desirable, there also tended to be a view that the need to improve adaptations services is a long-standing one, but also an area in which truly transformative change has been very difficult to deliver. The need for sustained partnership working between a range of key services was generally seen as being the single greatest challenge.