Follow-Up Evaluation of Self-Directed Support Test Sites in Scotland - Research Findings

Main Findings

• Overall, the evidence concerning uptake, activities and systems showed continued progress towards the implementation of SDS and system wide change in the three test site local authorities - Glasgow, Highland and Dumfries & Galloway.
• Access and uptake of SDS increased after the test sites, most dramatically in Glasgow where there had been a fast pace of change. In the follow-up period over 1,000 new SDS packages had been set up, the majority (892) by Glasgow.
• Most SDS packages in the follow-up period in Glasgow comprised Individual Service Funds (ISFs); by contrast there were no ISFs in Highland and a small number in Dumfries & Galloway.
• People with learning disabilities were still the main client group accessing SDS across all the sites (59% of all packages), although access was widening and gaps were beginning to be addressed.
• Ensuring wider access to SDS presented a number of ongoing challenges for the training and support of front-line workers and providers.
• Increased awareness about SDS was coupled with uncertainties and anxieties for users, carers, staff and external providers in the current context. Some stakeholders expressed concern about a perceived discrepancy between the aspirational promotion of SDS and what could be funded in reality.
• Ongoing change in assessment and resource allocation systems persisted in the follow-up period in all areas, and systems of equitable and transparent resource allocation continued to be one of the most challenging aspects of SDS implementation.
• Strategic choices about implementation, such as the scale and pace of change, and wider constraints, particularly the financial context, were felt to compromise the ethos of Independent Living and the degree of choice and control afforded through SDS.
• A top-down process of fast-paced implementation in a context of resource constraints, resulted in front-line social work staff feeling under pressure, which had a knock-on effect on the quality of SDS assessments, levels of involvement, choice and control and staff morale.

Policy Context

In 2009, Scottish Government selected three local authorities to act as test sites - Dumfries & Galloway, City of Glasgow and Highland - to trial targeted activities addressing three key issues identified by past research, as part of its investment in promoting SDS. A 2-year evaluation of the test sites was commissioned by Scottish Government to inform national strategy and the development of SDS legislation, and this found SDS to be an 'evolving concept' and one that was clearly interpreted variably in practice (Ridley et al, 2011).

The 10-year national plan for SDS (Scottish Government, 2010) aims to bring SDS into the mainstream of social care and increase the number of people directing their own support, including the number doing so via Direct Payments (DPs). If enacted in 2013, the Social Care (Self-Directed Support) (Scotland) Bill will make offering SDS the duty of local authorities.

Evaluation of the SDS test sites set up 2009-2011 demonstrated that local authorities face a number of challenges in implementing SDS and achieving transformational change (Ridley et al, 2011). Another study (Rummery et al, 2012) of the macro level financial and economic evidence on costs, benefits and impacts of increasing SDS in Scotland, concluded that while implementation remains an area of contention, the cost of further uptake does not differ significantly between SDS and more traditional services.

A number of commentators, including ADSW (2009), argue that the change needed will be transformational for the work of those at the front line of providing support and services, as well as for the structures and systems of service delivery in local authorities and other sectors. Directors of Social Work from the three test site local authorities giving evidence to Scottish Parliament in May 2009 identified what they called the 'seismic change' required, and referred to the inevitable slow progress in terms of numbers opting for SDS initially (Scottish Parliament, 2012).

Follow-Up Evaluation

The overall aim of the follow-up work was to assess the continuing and longer-term impacts of the interventions employed in the SDS test sites in the original project. The objectives were to:

• Assess the continued uptake and impact of the interventions used to improve uptake of SDS in each test site.
• Identify the activities to further promote and increase awareness and knowledge of SDS, particularly amongst care users, carers and the workforce.
• Identify system-wide change within the test sites and what can be learnt from such change.

In addition, the study sought to further examine issues identified in the earlier evaluation: for example, the extent of wider implementation of SDS since the test sites; whether creative and innovative ways of working had continued; the degree of shift towards greater involvement and co-production in social care; how local authorities had addressed inequality of access to SDS; and the involvement and role of independent advocacy organisations in SDS.

Given the wider financial context of resourcing social care, the study also set out to understand how this might be impacting upon SDS implementation. For example, how SDS was being presented in this context to potential service users and carers; what information was being given to service users about SDS; how care managers perceived the impact on support arrangements; and assessing whether packages were agreed and/or sustainable post
test site.

Organising to Implement SDS

All three local authorities had retained a specialist team to continue to be a source of expertise and support for operational staff developing new systems, and provided a link between strategic management and operations. These teams continued to be highly valued by front-line workers, but concerns were expressed about their capacity to cope with greater demand and widening access. Specialist teams differed in the extent to which they were developmental and strategic and/or directly involved in implementing SDS.

Only Highland had integrated SDS and DPs. However, during the follow-up period, DP Teams in both Dumfries & Galloway and Glasgow local authorities were working more closely with the Personalisation/SDS teams and frameworks.

Promotion and Awareness

Whilst there were continuous efforts to provide information, raise awareness and provide training about SDS in all three sites, a number of challenges remained. In Glasgow, providers and social workers consulted expressed concerns about the discrepancy between the aspirational promotion of SDS to service users and carers and the reality of implementation. This was still a concern in the other sites which had implemented SDS more slowly, resulting in caution about how much to promote SDS and how to manage any subsequent demand.

The more SDS is 'mainstreamed' beyond the test site target groups the more pressure there appears to be on front-line and specialist services (especially SDS teams) which are inevitably spread more thinly. This exposes a lack of capacity and expertise elsewhere in the system. Whilst the majority of care managers said they had received training, their overall view was that it was still not sufficient to enable them to implement SDS effectively in the current context. Where bespoke support was offered by specialist teams to front-line workers in situ this was highly valued. However, this was not always available as capacity was quickly stretched.

Accessing SDS

In the year following the test sites, access and uptake of SDS increased in all sites and especially in Glasgow where the pace of change was much greater than the other two areas, reflecting extensive promotional activity in all three areas. During the follow-up period the number of packages in each area was: 67 in Dumfries & Galloway; 892 in Glasgow and 52 in Highland.

Unlike during the test site period when DPs were the most common SDS option, the vast majority of these new SDS packages were Individual Service Funds (ISF) with external providers. There was still no evidence of mixed funding streams being used, and fewer people appeared to be accessing Independent Living Fund monies.

Although the local authorities had promoted SDS more widely, people with learning disabilities were still the main client group accessing SDS (59% of all packages), though this appeared to be in process of changing.

Systems and Processes

Change and developments in assessment and, in particular, resource allocation systems had continued as a main preoccupation. In all three areas, more resource allocation panels had been created to enable greater numbers of support plans to be considered and to enable decisions to be taken at the local level. However, some key stakeholders, notably those in Dumfries & Galloway, emphasised the cultural shift needed to implement real choice and control rather than focusing on systems being 'right'.

A key criticism of the assessment processes developed during the test sites was that they tended to be too orientated to people with learning disabilities and required further development. There was an indication of increased involvement of independent advocacy in all areas, though this was notably inconsistent.

Just as during the test site, the bureaucracy resulting from implementing SDS had increased. In some cases, SDS support planning continued in parallel to single shared assessment.

Perceptions of the Impact of the Financial Context

There was disparity in stakeholders' perceptions about the relationship between SDS and the harsh financial context facing local authorities. Senior managers stressed that SDS was being pursued on principle and to achieve better outcomes for people, and not as a response to the serious and persistent financial constraints on local authorities.

Providers and care managers’ responses illustrated differing opinions. Care managers were asked if they thought SDS was being used to make budget cuts. In Highland it was difficult to get a clear picture of views because the overall response rate was low – nearly a quarter of respondents did not answer the question and of those who did the largest proportion of respondents (39%) felt that they didn’t know or were unable to comment. Although in Dumfries & Galloway, a similar proportion felt that they didn’t know/couldn’t answer (34%), of those that gave a view there was a much stronger sense (54%) that SDS was not being used as a mechanism for making cuts. In stark contrast, we had a far higher response rate in Glasgow overall, with the majority of those respondents expressing the view that SDS was being used a mechanism to make cost savings (81%). The vast majority of care managers across all three sites were in favour of SDS as an ideal. However, they often struggled with how to implement this effectively in the current context. In some cases this led to tensions, pressure and demoralisation.

Short-term sustainability of SDS was uneven and varied across areas. This was measured by the continuation of support packages that had been set up during the test site. While the majority of personalisation packages set up by Dumfries & Galloway under the test site had continued, only a minority of those in Highland had, and we were unable to obtain evidence of the picture for Glasgow. Given these support packages had been highly valued by service users and families during the test site, this raised some concern.

Longer-term sustainability appears even more challenging and uncertain, especially given the harsh financial context. The key challenge is ensuring implementation stays true to the ethos of Independent Living and maximising choice and control. This has implications for how SDS is promoted to the public and service users in relation to the rhetoric of SDS and its reality in practice.

Implications

Scottish Government investment in the test sites had clearly enabled new processes and infrastructure to be established and knowledge of, and expertise in, SDS to be developed. This all contributed to increased take-up of SDS during the follow-up period. However, all three sites faced continuing and significant challenges in ensuring communications about SDS were transparent and up to date, as well as managing the impact of financial and capacity constraints which might compromise choice and control.

Pace of implementation was found to be a significant factor influencing perceptions of the success of implementation, and high numbers of SDS packages per se were not considered to be positive when this compromised quality of involvement and co-production in assessment and support planning. More generally, this suggests the need for greater transparency about eligibility criteria for social care; a wider debate about the future funding of social care; and how to ensure that implementation of SDS does not compromise the broader philosophy of Independent Living (Morris 2011).

In summary, the following lessons emerged:

• The need to develop greater capacity and skills to enable co-production and involve service users and carers more fully in assessments and setting up care packages.
• Evaluation and monitoring of SDS needs to find ways of capturing the level of choice and control exercised by service users.
• Local authorities need to carefully consider how they manage the pace of SDS implementation and especially its impact on front-line workers.
• Increased clarity about funding and eligibility criteria operating for social care is necessary to ensure transparency.
• Local authorities may need to re-consider how SDS is promoted to service users and the public, and to continually revisit the support and training needs of staff.
• SDS information and forms need to be constantly updated, and to be sufficiently flexible and adaptable.
• Careful planning is required to enable SDS skills, expertise and capacity to be developed and shared.
• The pressure to make budget savings will impact on the way personalisation is perceived and can compromise the ethos of Independent Living.
• In order to ensure SDS is developed in line with the ethos of Independent Living local authorities need to consider the position of Independent Living Centres and other service user-led organisations as they have a critical role.

Note on Evaluation Design and Methods

Building upon the design and data from the original evaluation of the test sites, the study collected information about developments and progress over the time period of 1 April 2011 to 31 March 2012. Four main methods were used:

• Interviews with local stakeholders in each area (including staff and managers from the local authority, Third Sector organisations, advocacy and service user organisations).
• Cohort information collating data about access to SDS and types of SDS packages.
• Information from local documents including Social Work Committee reports, leaflets and promotional materials, including a 'mystery browser' exercise of local authority SDS websites.
• Questionnaire survey of care managers and other social work staff involved in community care assessments.