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

7 SUMMARY AND CONCLUSION

Introduction

7.1 The overall aim of this follow-up evaluation was to assess the continuing and longer term impacts of the interventions employed in the SDS test sites funded by Scottish Government between 2009-2011. Some of the same methods from the original evaluation were used in addition to a survey of care managers and documentary evidence to gather information about what progress had been made in the year following the end of the test sites, that is, from 1^st April 2011 to 31^st March 2012. Our findings support the claim of the 3 test sites that an evaluation over 2 years was insufficient to do justice to what they had achieved in implementing SDS. This is a dynamic and evolving situation. It is also likely that perceptions of developments will change over time, which underlines the need for on-going research particularly into impact and outcomes. There were more recent and significant developments highlighted by participants in the study, such as promotion of SDS to new groups, which would be of wider interest but have not been included because they fell outwith the end of March 2012 timeframe. Nevertheless, the findings provide supplementary evidence of the progress made by the local authorities in 3 years. In this chapter, we consider the findings in relation to the research objectives, and what can be learnt to inform future implementation of SDS.

Overview

7.2 Taken as a whole, the evidence concerning uptake, activities and systems evidences substantial progress towards the implementation of SDS and system wide change in the 3 local authorities. Scottish Government investment in test sites had encouraged development of a firm foundation of processes and systems to implement SDS and more importantly, the investment had facilitated change in practice and approach to delivering social care. However, both strategic choices about implementation, such as the scale and pace of change, and wider constraints, particularly the financial context, were compromising the ethos of independent living and the degree of choice and control afforded through SDS.

7.3 Reviewing activities and implementation one year on revealed continuous building of infrastructure, trialling and reviewing of systems and approaches in all 3 areas. A high level of political and strategic support and integration of SDS/personalisation as a policy priority was in evidence. However, there was less emphasis on addressing wider implementation issues, that is, ensuring SDS/personalisation becomes more than Social Work's responsibility. For instance involvement of Health was lacking apart from in Highland, where integrating health and social care services was at an early stage. Different streams of funding were not being brought together - the SDS packages set up were all funded by Social Work and client contributions. There is clearly potential to further explore such links and inputs to SDS.

7.4 As well as building positive foundations and infrastructures for SDS, the commitment and expertise developed in the SDS/personalisation teams, as well as among social work staff and across providers, was clearly evident. The commitment and vision of the specialist teams had enabled the momentum and vision to continue at a time of "hiatus" and other policy changes, which were both enabling, and a barrier to, SDS implementation. There was no doubt about the value of the SDS/personalisation teams, which care managers, senior managers and external agencies all identified as an essential resource to support implementation. It was notable in all 3 areas however, that such teams remained extremely small (4-8 staff) and are limited in their capacity to offer support and guidance to the numbers of staff, service users, carers and external providers who might potentially need support in accessing and using SDS. How best to share such expertise and how to cascade skills and knowledge about SDS throughout the organisation so that the approach becomes more widespread, remains a key challenge.

Successful Implementation?

7.5 A key contrast between Glasgow and the other 2 sites was the rapid pace of implementation achieved in the past year: Glasgow increased its number of SDS packages from 57 to 892, while the other 2 test sites showed more steady increases. Though full scale implementation was what Scottish Government had originally asked of the test sites, our findings show high levels of uncertainty and dissatisfaction with the SDS programme in Glasgow, and indications that this had caused major stress for service users, carers, staff and providers alike. The Council was aware of, and had responded to such criticism about the pace of the implementation programme by adjusting the timeframe, while emphasising that implementation will stretch into 2016. Despite these contrasts in the pace of implementation, all 3 sites struggled with the development of wider systems which were user friendly, flexible, and accessible, and all had concerns about longer term capacity and sustainability.

7.6 The starkness of the contrast between the test sites in terms of scale of implementation needs to be examined further. If we were to measure success by numbers of SDS packages alone, then only in Glasgow could it be said that implementation had shifted from a pilot to mainstream. However, other evidence, such as negative feedback from care managers, service users, carers and providers, suggests this would be to lose sight of the importance of involving service users and carers as fully as possible in the assessment process and the co-production of their support. Key stakeholders in Dumfries & Galloway frequently referred to the importance of focusing on the quality of the conversation with service users and spending time assessing personal and community capacity in order to build packages of support. The key challenge is how to ensure that the movement to increase the scale of SDS/ personalisation programmes will enable the 'quality of conversation' about SDS to be sustained and that good outcomes in terms of control and choice are achieved.

7.7 Full implementation thus needs to be measured by something other than quantifying the uptake of SDS. Further, a balance needs to be struck between encouragement and enforcement, which can exhaust capacity in the system to change, which has potential to ruin any progress made. A next stage could be to investigate the outcomes, gains and losses that have accrued throughout the SDS implementation process.

Innovation & Co-Production

7.8 Although unable to assess outcomes of SDS for individuals from service user and carer perspectives, there were positive reports of involvement and innovation in support packages from independent advocates working alongside individuals and care managers, and also from those involved in assessments. Countering this were indications of uncertainty amongst advocates about how to engage with SDS. Additionally there were reports of rushed assessments, of care managers not having time to do the process properly, of variation in approach between different care assessors, and IBs not being enough to meet people's needs, all of which were more common in Glasgow.

7.9 With fewer resources for social care, it is unclear how the limited, but nonetheless, important innovations demonstrated during the test sites can be sustained. Only in Dumfries & Galloway did we find that personalisation packages set up during the test site had been sustained. Whilst this situation may require more detailed investigation, it does raise questions about whether, and the extent to which, the kinds of support packages that were highly valued by service users and carers during the test site period can be sustained and replicated. In other words, whether the level of support to enable these packages to be set up, as well as the level of packages themselves, will be available to a wider section of the social care population once the spotlight of the test sites has disappeared.

Addressing Inequalities of Access

7.10 The test sites had begun to address the inequalities of access to SDS that were highlighted in the original evaluation report. The follow-up work showed an increase in access by older people in some areas, and the inclusion of those from BME communities in Glasgow. Stakeholder interviews revealed that staff time had been spent consulting different service user groups including BME groups, and systems created during the test sites had been reviewed and modified to take account of different needs. Nonetheless, access by people with mental health problems was still an issue, although a recent programme of implementation in Glasgow was attempting to address this gap. There remains wariness amongst key stakeholders about how far SDS will be able to meet the needs of people with fluctuating conditions including mental health problems. People with learning disabilities were still the main service user group to benefit from SDS in all areas, and one criticism levelled at new SDS processes was that they were too learning disability orientated, and thus created a barrier for other groups wanting to access SDS. This would suggest that there is still work to do on the approach and systems to open up access to SDS.

Independent Advocacy

7.11 In a departure from the test sites when we found little or no involvement of independent advocates in assessments and support planning, advocacy organisations including carers' advocacy were becoming more involved in individual cases. Advocates were extremely positive about some of the support planning they had been part of and were full of praise for care managers, while others were critical and felt that care managers did not understand the value of independent advocacy, and the process of SDS was still baffling for their advocacy partner. It appeared that learning disability advocacy organisations were the most involved and there were still gaps for some groups, such as mental health advocacy, to become involved in the implementation of SDS.

7.12 There was an indication that advocates and advice agencies needed access to more training on SDS. Scottish Government resources had been used to support advocacy organisations to develop their role. However, it was not the experience of the advocacy organisations that we consulted that financial support for independent advocacy from the local authority had changed as a result of SDS implementation. Furthermore, the existing role and/or capacity of Independent Living Centres in Scotland needs further consideration if SDS is to develop in accordance with the Independent Living philosophy which is supposed to underpin it.

Impact of Financial Context

7.13 While some have argued that limited budgets can encourage innovation, this study suggests that innovative practice may be impacted upon by financial challenges faced by local authorities in terms of expenditure. This was evident in a number of ways, including in regard to resourcing for implementation and resource allocation to individual budgets. The 3 local authorities, like all others, had received Scottish Government funding (note: they were given some start-up funding previously) and were committed to continue the role of specialist teams and to on-going development of infra-structure, such as information resources. However, only in Highland had the team expanded with the scale of the programme. Across the areas, budget levels currently and in the future were of concern to managers and teams, personal contributions appeared to be increasing, and there were indications that experience of the SDS process could be very uncertain and sometimes fraught for service users, carers and professionals.

7.14 A strong message from the research was that a top-down process of fast paced implementation in a context of resource constraints, results in front-line social work staff feeling under pressure, which has a knock on effect on the quality of SDS assessments and support packages. Some providers are concerned about future viability of services and a number have lost staff or services due to re-commissioning.

7.15 There was a perceived and growing discrepancy between how SDS is promoted as aspirational with accompanying 'success stories' versus the increasing reality of the kinds of packages that might be supported in the current context. This has a number of implications for the future integrity of SDS and its underlying value base and for the way that SDS is promoted to service users, carers and the public. These perceptions seem to be in tension with aims to increase the exercise of choice and control, and the Independent Living philosophy which is supposed to underpin SDS (Morris, 2011).

7.16 It is worth bearing in mind that the findings from this study in relation to the different sites need to be considered in the context of the differential financial pressures experienced by local authorities. For example, local authorities in large urban areas with the most concentrated social care needs (such as Glasgow) may feel they are hardest hit by UK Central Government austerity measures. This study has not had the capacity to evaluate this context.

7.17 Given that there are no indications that the financial context will improve in the immediate future (revenue funding for local government for the next 3 years is being maintained in the form of a flat cash settlement, although this represents a cut in real terms), this could be argued presents a bleak picture for SDS and for social care generally. However, it also strengthens the case for finding creative ways to maximise choice, control and innovation in this context, as well as the need for a commitment to increase resource capacity in areas that will facilitate this.

7.18 Monitoring will also be a challenge as it will be important to ensure clarity about SDS outcomes for individuals and their support packages and how these have changed. In particular, transparency about each local authority's eligibility criteria for the range of social care services would help address this situation.

Lessons

7.19 The findings from this follow-up study of the test sites suggest there are a number of lessons that can be learned by other local authorities implementing SDS. In summary, we believe these are:

• In order to successfully implement SDS, local authorities need to develop greater capacity and skills to enable co-production and involve service users and carers more fully in assessments and setting up support packages.
• In auditing and monitoring implementation of SDS, local authorities need to capture how service users have exercised choice and control especially when the option of not making changes to existing support has been chosen.
• Implementing SDS requires transforming the culture and delivery of social care, embracing new roles and approaches to working with individual and community assets and resources.
• Local authorities need to carefully consider how they manage the pace of SDS implementation in the context of constraints on local government funding and local decisions made around expenditure as this will impact on perceptions of SDS, and its long term sustainability.
• Increased clarity by central government and local authorities about funding and eligibility criteria operating for social care is necessary in order to ensure transparency, and to enable assessment of SDS and the impact of the financial context on implementation.
• 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 as this situation continually evolves.
• SDS information and forms need to be constantly updated, and to be flexible and adaptable to different client group needs to ensure equity. A system of alerts may be helpful to prevent confusion over what is the most up to date version.
• Careful planning is required to enable SDS skills, expertise and capacity to be developed and shared throughout the organisation and to ensure that the expertise of specialist SDS teams are maximised but not overstretched.
• When making strategic implementation decisions, local authorities need to be aware that the pressure to make budget savings will impact on the way personalisation is perceived and can compromise the ethos of independent living and the degree of choice and control afforded by SDS.
• Local authorities need to consider the position of Independent Living centres and other service user-led organisations as they have a critical role in supporting a more service user-driven development of SDS.

Conclusion

7.20 In the year following the end of the test sites, the 3 local authorities had managed to shift perceptions of SDS further towards it being seen as a mainstream approach to service delivery. Scottish Government investment in the test sites 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 3 sites faced remaining and significant challenges. For example, ensuring communications about SDS were transparent and up-to date; managing the impact of financial and capacity constraints which might compromise choice and control; and, whilst specialist SDS teams were highly valued, they were all described as stretched. The 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 a wider debate and greater transparency about eligibility, the future funding of social care and how to ensure that SDS develops in line with the broader philosophy of Independent Living.