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

4 ACCESSING SDS

Introduction

4.1 Data from the cohort forms, in addition to information from stakeholder interviews and the survey of care managers, have been used to consider issues of accessibility and uptake of SDS, including the extent to which the sites had addressed gaps and inequalities in access that were identified in the original evaluation. This chapter looks at the evidence about the scale and scope of implementation in the past year, the reach of the local authorities roll out programmes to implement SDS, and differences in the type of SDS options that had occurred in the follow-up period.

Access Post Test Site

4.2 As the paragraphs that follow will evidence, access to SDS had increased in terms of numbers and for different groups of service users in all 3 local authorities over the follow-up period. That said, reservations about extending access to SDS to mental health service users were expressed even among stakeholders interviewed in Glasgow, where the current phase of development (since March 2012) involves their incorporation into the programme.

4.3 The sheer scale of the increase in Glasgow was in marked contrast to the steady growth of SDS in the other 2 sites. Care managers in Glasgow commented that SDS was not so much an option but was fast becoming enforced as the only way to access support. As a result most of their service users were now accessing SDS, compared with less than 10% of care managers' caseloads in the other 2 sites. Despite achieving a positive result in terms of increasing uptake therefore, care managers and third sector stakeholders in Glasgow commented that from their perspective implementation had been "rushed" and the focus had been on "quantity rather than quality". There was concern that this had a negative effect on their ability to carry out quality assessments and move towards genuine co-production. Consequently, care managers reported feeling pressurised, deskilled and overwhelmed.

4.4 While a steady increase in the number of personalisation packages was evidenced in Dumfries & Galloway, the perception of key stakeholders was that people with learning disabilities were accessing personalisation/SDS more than any other groups because there were fewer traditional services for people with learning disabilities, and also because staff working with this group were more open to adopting a personalisation approach. Third sector interviewees commented on an increased uptake amongst young physically disabled people and their enthusiasm for personalisation. The pace of uptake was reportedly slow partly because of the time it took to implement a personalisation package compared to arranging traditional services, which was confirmed by care managers', third sector providers' and advocacy organisations' experience. Senior managers emphasised the approach as being "outcomes not numbers focused". It was noted that uptake from the geographical area - Wigtownshire - involved in the Dumfries & Galloway test site had slowed since the end of the pilot whilst care managers in other areas were promoting personalisation more enthusiastically. What had increased was the number of older people now interested in having a DP.

4.5 The relatively slow "incremental" pace of SDS implementation in Highland was reported by key stakeholders to be both deliberate, and the result of needing to develop new systems and train the wider workforce. Systems that had been developed during the test site were not felt to be suited to general implementation across all client groups. Uptake generally was perceived to have "plateaued" as they had learnt the process takes longer than was anticipated, and longer than arranging traditional service provision. The aspiration expressed by senior managers was that SDS would eventually become the norm. However, frontline workers reported an average of just 8% of their caseloads consisting of people who had opted for SDS, which suggests that it had not reached as far into practice as hoped. Nonetheless as the SDS team pointed out there was a sense that this would build up as more social workers become experienced and confident in the approach. The experience of advocacy organisations (including carers' advocacy), as well as providers, confirmed this slow and steady pace of implementation.

SDS Packages

4.6 Information was sought via a modified cohort form as used during the original evaluation to capture basic demographics of those opting for SDS, the types of SDS options selected, and the funding mix of packages during the follow-up period. Information was received from the 3 local authorities but Glasgow was unable to supply details of the funding mix of SDS packages for technical reasons. The numbers refer to those who started the SDS process and/or had an SDS package agreed during the period 1^st April 2011 to 31^st March 2012.

Number of SDS packages

4.7 There had been an increase in the number of people accessing SDS in the year immediately following the end of the test sites in all 3 areas. As Table 1 clearly shows in the intervening year the number of SDS packages when counted across the test sites had increased dramatically. While all sites had increased access to some degree this was not evenly spread, with Glasgow having more than 10 times the number in both the other areas. The table below, which presents the number of packages both during the test sites and the follow-up period, needs to be read cautiously as some of the test site packages have not continued and/or were one off payments.

Table 4.1: Summary of SDS packages during the test site and follow-up periods

	Test site (2009-2011)	Follow-up (2011-2012)	Total (2009-2012)
Dumfries & Galloway	35	67	102
Glasgow	57	892	949
Highland	40	52	92
All	132	1011	1143

4.8 By the end of the test site, Dumfries & Galloway had set up personalisation packages with 35 individuals and had another 51 people at earlier stages in the process, the majority (33) of which had continued. In the follow-up period, an additional 133 individuals were now at some stage in the personalisation process, that is, 67 new personalisation packages plus 66 individuals who were at either initial stages of assessment, had completed a self-assessment or support plan and were awaiting a Panel meeting to agree the budget and outcomes.

4.9 During the test site, Glasgow had set up 57 SDS packages and over 50 other individuals were reported to be at some stage in the process although packages had not been agreed. Information was not forthcoming from Glasgow about whether these SDS packages had continued after the test site so it is not possible to comment on the sustainability of test site packages from this test site. In the year following, Glasgow had begun the SDS process with 2,296 individuals, 69% of whom had a support plan agreed although not all of these had an agreed package. Of the 2,296 individuals, 39% (892 individuals) had progressed through the whole process and had an agreed SDS package.

4.10 A total of 40 SDS packages had been created in Highland and a further 101 individuals had expressed an interest in SDS during the test site. In the year following the test site, an additional 52 SDS packages had been set up and a further 7 individuals had been assessed and were awaiting a decision about the package. Only 6 of the original 40 SDS packages continued post test site - 4 were existing DPs that were involved with the test site; 21 were one-off payments; one was in or leaving hospital care and 8 had chosen not to continue.

4.11 The following analysis of demographic information and about the SDS packages set up in the year following the test site is in relation to those with SDS packages. It does not include all those in the process as this information was not consistently available. Therefore, it includes 67 individuals in Dumfries & Galloway, 892 in Glasgow and 52 in Highland.

Service user categories

4.12 People with learning disabilities were the main group to access SDS during the test sites, although this was less the case in Dumfries & Galloway. The following table shows a similar pattern one year on from the test sites even though larger numbers of other types of service user group were also in evidence, and the local authorities had aimed to promote SDS to all service user groups. The number of people with mental health problems accessing SDS across the sites remained low at just 2% of all packages. However, people with mental health problems accessing SDS had increased from just one to 18 people in Glasgow. While 2 local authorities had allocated cases a main service user category, Glasgow also provided details from its client index system of secondary needs; however, the information collected overall does not reflect probable levels of multiple and complex needs.

Table 4.2: Comparison of main service user category

Client Group	Local Authority
	Dumfries & Galloway	Glasgow	Highland	Total
				Number	Percent
Learning disabilities	27	547	20	594	59%
Physical disabilities	20	152	17	189	19%
Older people	8	7	14	29	3%
Parent (disabled child)	9	56	-	65	6%
Mental health problems	3	18	1	22	2%
Not known	-	23	-	23	2%
Other*	-	89	-	89	9%
Total	67	892	52	1011	100

*includes vulnerable people, special educational needs, homeless, head injury, criminal justice, financial/material abuse, addictions.

Gender of SDS recipients

4.13 As during the test sites, men were in the majority (57%) of those accessing SDS overall. However, the gender distribution between the sites varied as the following table illustrates, with women being in the majority of those with personalisation packages in Dumfries & Galloway.

Table 4.3: Ratios of men and women accessing SDS in follow-up period

Sex	Dumfries & Galloway	Glasgow*	Highland
Female	(39) 58%	(371) 42%	(25) 48%
Male	(28) 42%	(520) 58%	(27) 52%

Age of SDS recipients

4.14 As during the test sites, the age profile of those accessing SDS varied between sites with a broader age distribution evident in Dumfries & Galloway. Table 4.4 below summarises the data we have on the age of SDS recipients. The proportion of recipients who were recorded as being younger than 25 years was greater in Dumfries & Galloway than during the test site - 45% of clients were under 25 years, which included some children where the SDS package was set up with the parent(s). Less than 10% of clients in Glasgow were under 25 years. Whereas nearly three quarters of the test site cohort in Highland had been under 25 years, in the follow-up period this was 27%, which reflects the increase in SDS packages including DPs with older people. Indeed, 27% of SDS packages were set up with people aged 65 or over, some of whom were 75 years or more. In a departure from the test site when 42% of clients were under 25 years, the majority (75%) of SDS recipients during the follow-up period in Glasgow were adults aged 25-64 years.

Table 4.4: Age of SDS recipients as percentage

Age	Dumfries & Galloway	Glasgow	Highland
Under 16yrs	9%	-	10%
16-17yrs	3%	0.1%	4%
18-24 yrs	33%	9%	13%
25-64 yrs	43%	75%	46%
65 and over	12%	16%	27%
Total	100	100*	100

*does not sum 100% due to rounding up

Ethnicity of SDS recipients

4.15 Apart from in Glasgow, SDS recipients were recorded as either white British or white Scottish. During the test site Glasgow did not record ethnicity, which precludes any comparison although it was noted in the original evaluation report that none of the 10 case study individuals were from BME groups. Post test site figures for Glasgow show the majority of those with SDS packages were of white ethnicity (853 or 95.7%) while 18 or around 2% were of Asian ethnicity (Indian, Pakistani, Chinese, other Asian), one person (0.1%) was Black (African/Caribbean), 3 were of mixed ethnicity (0.3%), 6 (0.7%) were of 'other ethnicity' and the ethnicity of 10 people (1.1%) was unrecorded. While indicating an increase in access for BME clients due to the rollout from zero to around 4%, this is lower than might be expected from current estimates of approximately 8% of the Glasgow population from BME groups^[13] and is in contrast to Dumfries & Galloway for example, where just 0.64% of the population were from BME groups according to the last census.

Range of options in SDS packages

4.16 Taken overall, a range of SDS options were offered across the test sites in the follow-up period including DPs and individual service funds (ISF) with either external providers or the local authority reflecting the broad definition of SDS advocated by Scottish Government (2010). The pattern of SDS options differs from that during the test sites with only Glasgow recording any mixed packages (e.g. a combination of DP, ISF) whereas only Dumfries & Galloway recorded mixed packages previously.

Table 4.5: Type of SDS options

Local Authority
	DP Self	DP 3rd Party	ISF LA	ISF Provider	Mixed Package
Dumfries & Galloway	59	-	-	8	-
Glasgow	73	368	37	821	380
Highland	27	25			-
TOTAL	159	393	37	821	380

4.17 In a departure from the test site period due to an alternative pattern emerging in Glasgow, using IBs to arrange support with external providers had become far more common than choosing DPs. No ISFs (either local authority or with external providers) were recorded as selected by service users in Highland, and it will be remembered that an initiative with Leonard Cheshire at the end of the test site had been unsuccessful. Plans by Highland to develop an ISF pilot with 2-3 providers working with people with learning disability were underway later in 2012. The SDS option most commonly taken up by service users in Glasgow was an ISF to arrange support from a commissioned provider, reflecting the nature of its SDS implementation programme, which started with what was termed a 'provider pathway' whereby providers undertook SDS assessments with numbers of people with learning disabilities. ISF was an option chosen by just 8 of the service users in Dumfries & Galloway, all involving using IBs to arrange support from a commissioned external provider.

4.18 The pattern of DPs - self or third party payments - had changed in the post test site period. While third party payments had been the norm in Highland during the test site on account of working with young people in transition, this was no longer the case and there were almost equal numbers of DPs allocated to individuals and to third parties. As during the test site, DPs in Dumfries & Galloway were received by the individual rather than a third party. Five times as many third party payments had been set up in Glasgow than DPs managed by individuals themselves.

Funding mix of SDS packages

4.19 As before, social work funding and client contributions were the main sources of funding of SDS packages in the follow-up period. We have limited information from Glasgow regarding the funding mix of SDS packages except about client contribution. It is clear from the table below that client contributions are a key feature of SDS packages in Glasgow while this is far less common in the other sites, particularly Highland. In the previous report we suggested that this might be accounted for by Glasgow's income maximisation and funding policy, and the young age group of the cohort in Highland, though the latter was not relevant in the follow-up period. Glasgow City Council's financial procedures for service users remain explicit that as part of SDS process, the financial assessment will determine the appropriateness and level of personal financial contributions^[14]. Independent Living Fund (ILF) did not feature in any of the SDS packages and there was no evidence of any development towards mixed funding streams with for example, Health or Housing.

Table 4.6: Funding mix of SDS packages in each test site

Local Authority	Type of Funding Stream
	SW	Housing	ILF	Health	Client contribution	Other
Dumfries & Galloway	67	-	-	-	15	-
Glasgow	892*				792
Highland	52	-	-	-	6

*Although only information on number of client contributions was given by Glasgow, it has been assumed that all had Social Work funding.

Summary/Key Points

• Access and uptake of SDS had increased after the test sites, most dramatically in Glasgow.
• The sheer scale of the increase of SDS packages in Glasgow was in marked contrast to the steady growth in the other 2 sites.
• In the follow-up period over 1,000 new SDS packages had been set up, the majority (892) of which were set up by Glasgow.
• Most SDS packages in the follow-up period in Glasgow consisted of ISFs with external providers, and there were no ISFs in Highland.
• People with learning disabilities were still the main client group accessing SDS across the sites (59% of all packages), although gaps in access were clearly being addressed.
• Direct Payments to third parties were much more common in Glasgow than they had been during the test site, while a DP managed by the individual was the most frequent SDS option in Dumfries & Galloway and Highland.
• We sought information regarding whether SDS packages that were set up during the test site continued as a marker of sustainability. However, this information was not forthcoming from Glasgow, and Highland appeared not to have developed sustainable packages (but rather focused on one-off payments during the test site).
• In contrast, Dumfries & Galloway did appear to show some sustainability in terms of continuing to fund SDS packages set up during the test site. This is important given the anxiety expressed by service users and carers who had benefited from SDS in the test site period about the likely persistence of support arrangements (Ridley et al, 2011).