Adapting for Change: evaluation

Chapter 5: Personalisation and a single point of access

AWG recommendation: Arrangements enabling people to have control and choice through personalisation and self-directed support.

AWG recommendation: A single point of access with a lead agency - 'one-stop-shop' - with clear communication and a single point of contact for service users throughout the process.

The AWG was clear that the person and their carer(s) should be placed at the centre of service provision and be in control. This was connected with supporting the right to independent living, listening to and respecting people's views and responding quickly, while managing risk.

More specifically, the AWG felt that a single point of access for those seeking information, advice or assistance with adapting their home, had potential as the front-end entry to assessment, and to a wider range of information on options and services.

Two themes are covered within this chapter. The importance of personalisation was a theme running through the AWG's work and, by extension, has been a major theme underpinning the work of the test sites. In some areas, this has included looking at options for a one-stop-shop style, single point of access. These two issues emerged as very clearly connected, particularly for service users, and hence are considered together.

Please note that part of the AWG's personalisation recommendation (above) focused on personalisation and Self-directed Support. None of the five test sites was looking at a Self-directed Support specific test of change, but the ihub has been working with another local authority area, in parallel to the main AfC initiative, to examine issues relating specifically to Self-directed Support and adaptations. That work does not fall under the remit of this evaluation and will be reported separately by the ihub.

Key research evidence

As outlined in the previous chapter, the views of current and former service users very much reflected those of the AWG. Personalisation was a theme people raised not only in relation to decisions about whether they wished to remain in their current home and/or receive advice on an adaptation, but as important to them through all stages of subsequent contact with services.

Service users' views on personalisation

The overall message which service users wished to send to those developing and delivering services was that they wanted to be treated as an individual and not as an 'old person' or a 'disabled person'. A small number of service users reported feeling increasingly 'invisible' to society more widely and to certain services.

However, in terms of the adaptations-related service they had received within the test sites, some very positive messages emerged. In general, service users reported that:

• They had felt fully involved in making the key decisions about any adaptations to be made to their home. This included having the reasons for any recommendations explained, having any choices set out and being given the time and necessary support to make those choices. People varied in terms of how much they wanted to be involved, but overall felt that the system had given them the opportunities they wanted.
• They were particularly pleased to have been given choices around making an adaptation 'fit in well' with the rest of their home. This included being given the choice to pay to 'upgrade' certain elements or pay for additional work, such as the tiling of areas which were not covered by grant funding. However, people did also recognise that the primary focus needed to be on addressing their needs.

Although the design stage generally appeared to have been well handled, some issues were highlighted about the assessment, grant application and installation stages. It should be noted, however, that these were generally about a set of arrangements that would not as yet have undergone any AfC-driven change. In that respect, they speak more to the issues the changes need to address than to the efficacy of any changes underway. Issues raised included:

• Frustration at waiting, in some cases for a significant period, for the assessment process to begin. Service users sometimes noted that they were aware services were under pressure but also noted that they were looking for the type of help that could avoid them needing to draw on other resources.
• Not being kept informed of the progress of their case; service users often understood that there would be stages in the process which would take time, including the wait for the first assessment or the grant processing phase. However, there were also worries that their case could have been 'lost' within the system. When people had received regular updates on progress these were very much appreciated; when they had not, this had sometimes caused anxiety.
• When people did wish to make contact with someone dealing with their case, for whatever reason, they were not always clear who to go to and there were occasional reports of having been 'passed from pillar to post'. Conversely, having a named and known contact who responded to their queries was much appreciated.

In terms of the later stages of the process, there was some evidence of a lack of consultation with service users about the arrangements for the works themselves. Again, people generally understood that a range of factors - including the availability of those carrying out the work and the ordering of equipment - could affect the timings. However, especially if arrangements needed to be made for themselves or family members to be elsewhere when work was being carried out, a small number of people felt that the short notice they had been given was unreasonable or unhelpful. On a connected point, people occasionally highlighted that, although the adaptation may have been for them, in many respects they were not the most vulnerable member of their household. Examples included children, partners or parents with breathing difficulties which meant they could not be in the home when larger works were being carried out.

This latter issue points very much to a common theme to emerge across the conversations with service users that they not only wanted the system to treat them with respect and as an individual, but also wanted services to recognise that making changes to their home could affect all members of the household. The varied experiences of service users suggest that some people have received just such a service, but that in other cases services have fallen short.

Although yet to emerge through research evidence to inform this evaluation, changes that have already been made or are being planned across all of the test sites may well help address some of these issues. These changes are discussed below and within Chapter 6.

Opportunities for positive change

Creating more person-centred services has been a clear priority across the test sites. The research evidence (including both the considerable majority of key stakeholder interviews and the document review), points to a considerable emphasis being placed on how any changes made can contribute towards creating a package of person-centred services. Examples of the type of work being taken forward include:

• Developing a cross-sector, service user survey which will gather views on the adaptations process. The information gathered is expected to inform the development of the area's adaptations policy and otherwise ensure that client feedback informs future action.
• Plans to introduce a peer mentoring system, with support being offered by volunteers. The aim of this service will be to allow service users to talk through options at their own pace and to help them feel more in control of the situation.
• Handyperson Services expanding the range of services offered to include small jobs which help people to maintain their independence and prevent trips and falls.
• Organisations working in partnership with owner-occupiers to create individually designed solutions and then offer practical and on-going assistance with the tendering process and the management of the work.

Otherwise, much of the work within the test sites has focused on developing options around self-assessment and single points of access. These are considered in turn below.

Self-assessment and smaller works

One area which many key stakeholders saw as offering real potential to give the individual greater control and influence was self-assessment. However, this was an issue about which views were mixed; for a small number of key stakeholders, and particularly for a small number of OT professionals, the self-assessment approach created a tension between supporting client choice and ensuring that the system delivers on its duty of care and uses public resources to their best effect. It was also reported that a small number of elected members had expressed concerns about the approach. These concerns were primarily about self-assessment leading to a less than optimal solution.

For others within the test sites, however, self-assessment was seen as an enabling approach which, if implemented well, could reduce the overall pressure on OT services and, by extension, reduce overall waiting times for assessments. The self-assessment approach, supported by clear mechanisms for self-referring for smaller adaptation work, was seen by many key stakeholders across all sectors as a common-sense approach which could allow specialist resources to be focused on more complex cases and those in greatest need. However, ensuring that the self-assessment process did trigger a referral for a full OT assessment if required was seen as key, and as a core consideration when developing service pathways (discussed further in the next chapter, Chapter 6).

One of the test sites has been piloting a self-assessment tool. Very much reflecting some of the concerns outlined above, a small number of key stakeholders from this test site area felt that not everyone was on board with the idea and that some frontline staff remain of the view that face-to-face contact with a professional leading on the assessment is always required. Others were confident that, including as a result of pathways-related work, the approach would allow for a professional assessment to be triggered and prioritised should it be required.

Other test sites have been considering, or testing, ways to reduce waiting times for assessment by using staff other than OTs to assess and progress minor works. This work has included staff trained to OT Assistant level being able to assess the need for smaller works, such as the fitting of grab rails and handrails. Those most closely involved with taking this approach forward, along with housing association and local authority housing strategy stakeholders, were very confident that it was offering a quick, efficient and customer-friendly approach. They also suggested a full OT assessment could be triggered if needed. A small number of examples was given of a request for a handrail or bannister resulting in a full OT assessment and a more comprehensive package of adaptation work.

These debates highlight some of the fundamental challenges that test sites have encountered and which may well be experienced in other areas. There will be different perspectives and, in certain cases, people may feel that their professional boundaries are being encroached upon. A whole range of factors may contribute to staff feeling this way, and some of these may be more about the pace and scale of change rather than the nature of the changes themselves. However, when those concerns are about the system delivering on its duty of care they do need to be given careful consideration.

On a connected point, there were also occasional reports of service users who had gone through a professional assessment then exiting the process because the solutions being offered were not to their liking, or because they felt they would not meet their needs. This highlights a potential tension between a professional assessment of need and the view and wishes of the individual and their family. Those commenting on this issue were clear that, while every effort should be made to keep the client at the centre, this could not be at the expense of putting safe and effective solutions in place.

A single access point

When looking at a single access point, the focus has tended to fall on developing services for people living in the private sector and who do not have routes into advice and information services through their social landlord. However, it was clear that, irrespective of whether they lived in an owner-occupied, privately rented or social rented sector home, all service users valued being treated with respect and receiving a responsive service from an organisation which they trusted.

Encouragingly, in test sites yet to establish a one-stop-shop type approach, many social rented sector service users did feel they had received this level of service from their local authority or housing association landlord. The early, information-provision stages had generally worked well. Once the relevant OT assessment had been made, landlords were perceived to be good at progressing the work and keeping tenants informed. The problems which were reported tended to be connected to delays in, or lack of information about, OT assessments. The landlords themselves sometimes reported similar problems and frustrations and some staff said that they had become involved in trying to move cases forward.

In terms of specific work being taken forward under AfC, the overwhelming view of key stakeholders was that a tenure neutral, single point of access offers the most client-friendly approach. Critically, service users who had direct experience of having the whole process managed by, or through, a single organisation tended to be extremely appreciative of this approach.

Many key stakeholders within the test sites, and particularly those within housing and the third sector, felt the single access point model is one with significant potential which could and should be taken further. However, these key stakeholders were clear that the approach needs to reflect local circumstances; there will not be a 'one size fits all' model. Particular issues identified for consideration were:

• There may be a strong case for a physical presence, in other words a one-stop-shop, in particular areas. If this approach is to be taken, it may work best and be easier to establish if attached to, or located within, the existing premises of a well-known organisation (such as the local Care and Repair Service) or within local authority or housing association premises. In one of the test sites, a single access point service is already being delivered out of the premises of a housing association-based Care and Repair service.
• However, in larger local authority areas and/or where there is a very dispersed rural population, the equivalent of the high-street presence may not be viable or bring particular value. The focus then becomes on delivering an accessible package of services in a viable way.
• Ensuring that the OT assessment process is fully integrated into the single access point delivery model will be key. The AfC evidence to date suggests that a model in which specialist housing OT services are central can support a positive client experience and help foster constructive working relationships across a range of key services.
• Irrespective of where located or how otherwise structured, the key component should be a person-centred, case-management type approach, with everyone having a named contact who also has oversight of their 'journey' through the system. As noted earlier, where this is already happening, and particularly when this type of service is being delivered through a Care and Repair service, the feedback from service users was extremely positive.
• The local Care and Repair service tended to be cited as the most obvious 'host organisation' for such a service by key stakeholders. The early intervention, person-centred type of approach required was seen as very much in line with the ethos behind Care and Repair services and with the skills and experience likely to be present in those services. Housing and third sector stakeholders were most likely to take this view but it was also expressed by a minority of social care and health stakeholders.
• However, others, including housing, social care and health stakeholders, were of the view that local authority or health-based services should be the service user's main point of contact and that they should be responsible for the assessment and on-going management of adaptations cases. Reasons given were varied but included that local authority or health-based OT staff are best placed to lead on this work, including because of their existing qualifications and experience. However, this approach would be less likely to result in the service user having a single, named point of contact.

Irrespective of the organisation leading on a single access point approach, or hosting a one-stop-shop approach, moving to a model of assessment and management of work through a single access point is a potentially significant change. The evidence to date from the test sites suggests that the approach can certainly deliver the type of personalised, high quality service which clients want. However, its longer-term success is likely to depend on a wide group of key stakeholders, including health and social care stakeholders, being committed to the approach.

Summary findings

There is evidence throughout all the test sites of a real commitment to developing and delivering client-focused services which work for and with service users. The feedback from service users very much emphasises the importance of taking such an approach.

Many of the specific approaches being considered - including single access points and self-assessment - are seen by many key stakeholders as offering considerable potential to provide a prevention-focused, personalised and cost-effective service.

However, not all key stakeholders agree that these approaches offer the best ways forward. There are some concerns, albeit a minority position, that the self-assessment approach could result in service users who should have a full OT assessment not receiving one. Also, there are varying views as to whether a single access point, and especially when delivered through a third sector organisation, is necessarily the best way forward. Again, this was a minority view but was occasionally a very strongly-held one. There was a broad consensus that the approach taken needs to reflect local circumstances and that there is not be a 'one size fits all' model.

As the work in the test sites continues, and particularly once a body of outcome-based evidence is developed, a clear picture should emerge. In the meantime, the evidence to date suggests that both the self-assessment and single access point approaches do warrant further testing.