Self-directed Support Implementation Study 2018: report 1

2. The SDS Change Map narrative

The SDS Change Map is intended to capture the required changes for the effective delivery of social care within the context of self-directed support. The map consists of three tiers:

• the overall vision;
• the four key outcomes (numbered 1 to 4); and
• for each of the key outcomes, a set of intermediate outcomes (numbered 5 to 17), that need to be in place for the four key outcomes and overall vision to be achieved.

This section describes the rationale for each outcome. In creating the outcomes, the participants were asked to ensure that they were clear; concise; related to the Implementation Plan 2016-18^[3], or the Social Care (Self-directed Support) (Scotland) Act or accompaying guidance; and that the outcome could feasibly be evidenced either through monitoring or evaluation.

Overall aim of self-directed support

Scotland's approach to social care and support places human rights and independent living at the heart of delivery. The aim of self-directed support is to ensure that care and support is centred around a person's own care and wellbeing outcomes, and that people exercise the level of choice and control they desire over that support.

The ToC workshops considered that aim and the changes that need to support it . In the SDS Change Map, the aim (people's social care and support outcomes are met) focuses on this mainstream approach which ensures that people have choice and control over their social care and support. This change should extend to all those receiving social care and support (i.e. including carers and family members and not just supported people) as it is consistent with the longer-term vision that the principles underpinning self-directed approaches should be central to service engagement and delivery. This more inclusive approach is reflected across the SDS Change Map.

Key outcomes

The four strategic outcomes defined in the current Implementation Plan for 2016-18 are:

• supported people have more choice and control;
• workers are confident and valued;
• commissioning is more flexible and responsive; and
• systems are more widely understood, flexible and less complex.

These were used as a starting point for the workshop discussions and formed the basis for the key outcomes (1-4) of the SDS Change Map.

There were two main refinements to the key outcomes highlighted by the ToC workshops, in relation to systems and the focus on supported people.

In terms of systems, there was a recognition that changes were required across all the intermediate outcomes, and underpinned effective commissioning, staff approaches and behaviours. The strategic outcome within the Implementation Plan that focused specifically on systems has therefore been superseded by a broader key outcome that recognises the need for senior decision makers to work alongside appropriate systems to enable choice and control.

Regarding supported people, it was felt important to make explicit both the focus on change in the scale and nature of choice and control, and the change in terms of people being empowered to make informed decisions. The map therefore splits the first strategic outcome ('supported people have more choice and control') in the Implementation Plan into two key outcomes: 'people have choice and control over their social care and support' (1), and 'people are empowered to make informed decisions about their social care and support' (2).

Intermediate outcomes

The first two key outcomes relate to supported people. The following paragraphs describe the intermediate outcomes, along with the rationale that would lead to people being empowered to make informed decisions and having choice and control over their social care and support.

Figure 2: Key outcomes 1 and 2 and associated intermediate outcomes

Outcome 5 captures the significance of the initial assessment for social care and regular reviews. These discussions are the foundation of an effective approach to social care, whether a budget is agreed as a result of assessment or signposting to community supports is undertaken. This engagement process should follow the accepted 'good conversation' model detailed in ''Talking Points: Personal outcomes approach'^[4] which identifies what should be discussed, how the conversation should be conducted, who should be involved and what should happen.

The 'Talking Points' diagram in Figure 3 provides a visual account of the 'good conversation' and shows that it is a process of engagement rather than a one-off event. It will therefore be important to understand the extent to which this change has been recognised, or, in other words, the extent to which people have experienced these as good conversations, the spirit in which they are carried out, and whether practitioners 'respect what matters to them and the support they need'.

Figure 3: Talking Points

The components of a 'good conversation' (Source: Cook and Miller (2012) 'Talking Points, Personal Outcomes Approach' (Figure 8))

Access to high quality advice, support and information (intermediate outcome 6), and advocacy where required (7), are fundamental to effective change. It is important that the assessment process, and subsequent choices, are underpinned by easy and sufficient access to the independent support that people need to navigate their choice of social care and support options.

The next intermediate outcome (8) reflects the significance of people knowing the budget that is available to them, including if they choose to use local authority in-house or commissioned services under Option 3. There are challenges to providing this information but it is central if a supported person is to be able to understand the scale of resources available to them and so exert control and make choices on how that budget can be deployed.

The third key outcome focuses on workers who are involved in any aspect that affects the delivery of self-directed social care and support.

Figure 4: Key outcome 3 and associated intermediate outcomes

To meet this outcome, it is important that workers all have the skills, knowledge and confidence to engage with and support people effectively so that workers across relevant roles are clear and consistent in their support (intermediate outcome 9). An assets-based approach that mobilises the skills and knowledge of individuals and the connections and resources within communities and organisations is also required (10).

In addition to the workforce having the appropriate attributes to deliver self-directed support, the frontline social work and social care workforce also needs to be able to confidently take decisions with autonomy, in line with their standards of professional conduct and practice, that can be realised through the support from managers, systems, processes (especially the authorisation process for signing off budgets and packages of support) and policies (11).

The final key outcome (4) has a series of intermediate outcomes that will help create the conditions in which people can exert choice and control over their social care and support.

Figure 5: Key outcome 4 and associated intermediate outcomes

It is the commitment of senior managers and leaders, through support and directions to help create these conditions, and the systems and processes in place that influence how self-directed support is experienced. Systems that need to be addressed include:

• resource allocation systems;
• charging and contributions policies including waiving of charges to carers and free personal and nursing care;
• commissioning and procurement;
• performance data/reporting;
• audit;
• risk management (including individual and organisational reputational risk);
• legal;
• quality assurance (both internal and external through the Care Inspectorate/Scottish Social Services Council/Audit Scotland); and
• IT.

To achieve these system changes, statutory authorities should plan and review social care services in ways that recognise the importance of choice and control (12). People should expect that their routes for accessing social care support and the extent to which they are able to exert control and make choices are broadly comparable across different areas of Scotland.

Communities and supported people should have influence over the planning, commissioning and procuring of social care and support (13). This needs to be alongside delivery approaches that enable creativity in responding to the assets, situation and needs of people (14).

System changes also require commissioning to be supportive (15). The three main features of a supportive commissioning and procurement approach to enable self-directed support are that it is:

• flexible - able to respond to the changing needs and situation of supported people;
• proportionate - the administrative time and effort is proportionate to the scale of cost; and
• outcomes-based - focusing on the outcomes to be achieved for the supported person as opposed to a process people or workers should follow.

Commissioning also has a role in developing the local care market, and as such involves all stakeholders, including the independent sector.

Systems change needs to happen in terms of the relationship between statutory, independent and third sector agencies (16). In order for the social care and support providers and workforce to deliver the best possible care and support, discussion and involvement in decision making across all sectors is crucial. Although there may be elements of competition involved - which may become more noticeable if funding reduces - the need was identified for the changes to be reflected in relationships which are stronger in terms of trust and collaboration.

Central to all systems change is that the systems contribute to the ability of people to make choices that are flexible, personalised and creative. It is important that the approach that was started with 'good conversations' and an effective enabling environment and approach is followed through with procurement and commissioning processes that support the choices people make (17).

Use of the SDS Change Map and narrative

The SDS Change Map provides a simple outcomes framework (in the form of a logic model) to articulate major changes that need to happen in the move towards self-directed support fully being the mainstream approach to social care delivery. It provides a conceptual and practical basis for mapping, tracking and learning from major developments in social care and self-directed approaches; for visually representing the logic or theory of change which underpins self-directed support; and for checking whether and how actions are contributing to intended changes and outcomes.

The outcomes identified in the SDS Change Map were used to shape the discussions in the area Case Studies (see report 3) and to inform the Evidence Assessment for Self-directed Support (see report 2).

The Scottish Government will use the SDS Change Map as a basis for ongoing monitoring and evaluation of implementation. There are three nested logic models which set out how outcomes will be achieved and what change should look like for: supported people, the workforce, and the wider social care system. The SDS Change Map will evolve and be populated over time with different kinds of evidence and can be used to test and refine underlying theories of change and revise or refine those where necessary. The map offers a useful conceptual framework for planning, designing and reviewing social care provision. At the time of publlication it was being used to inform discussions as part of engagement activity associated with the development of the next self-directed support implementation plan.