Self-directed Support Implementation Study 2018: report 2

4. Evidence from the case studies

As part of the wider research conducted around self-directed support, thirteen case studies were produced to highlight how self-directed approaches were working in practice across a sample of six local authorities in Scotland.

The case studies were not evaluative. Neither was their primary focus to inform the national monitoring.  In their design and delivery, they instead provide useful context and information that have implications for future national evaluation and research on social care in Scotland.

Case study approach as an evaluation activity

The aim was to undertake case studies exemplifying social care, accessed under the four options across a diverse population. This ambition was tempered slightly by the ability to identify and secure the participation of individuals. The individuals within the case studies are predominantly older or middle-aged people with degenerative diseases, neurological conditions, people who experienced a life changing critical incident and some individuals with a genetic disorder.

Undertaking the case studies was resource intensive and took several months to complete, which is important to be aware of when considering a case study approach as part of future research and evaluation of social care. Each case study involved working with local authority officials to identify individuals and gaining informed consent and then liaison with the individuals, their families/carers, their social worker and providers to arrange face-to-face and telephone interviews. The discussions were followed up with further email exchanges or telephone calls to clarify facts and details and for participants to check the written case study account. The involvement of all these contributors provided the detailed insight into the experience of self-directed support and, if this had been an evaluation, this would help us to understand the extent to which self-directed support is meeting its policy outcome in this small number of cases.  However, only individuals who wanted to be involved with the research were the subject of case studies which potentially increases significant bias to those who have had positive or negative experiences they wish to share – neither of which may be representative of the experiences of most people.

Given the depth of information provided, case studies could be a valuable option for evaluation of specific aspects of social care but the resource intensity required for case studies means they would be difficult to include as part of ongoing evaluation and monitoring.

Local authority engagement 

Whilst some local authorities were keen to engage with the case study research, in other areas it was challenging to get full engagement and considerable effort was required by researchers to gather sufficient information to construct a case study. The case studies were voluntary, not designed to be evaluative and did not require the level of challenge and evidence as evaluation would. It was, however, difficult to obtain sufficient information for some of them, largely because it was not easily accessible or in some cases not available at all. This is exacerbated by the time pressures on local authority staff, and an inevitable disadvantage of case studies is that they rely on individuals’ recall of events and some details might therefore be missing. This highlights how difficult evidence gathering and engagement for evaluation may prove to be.

Variation of delivery between and within local authorities

Choice and control were not uniformly embedded in statutory care services across the case study areas. This would be expected and would be explored in an evaluation, especially if the approach used a robust change map.

What is potentially more challenging for an evaluation, is the varying implementation of choice and control within local authorities.

In some case study areas, this variation was because choice and control and personalisation were more readily available to some groups, such as younger adults with disabilities or parents of children with disabilities. In such local authority areas, evaluation would need to ensure that the focus is not only on where the authority is doing well, but also on understanding why choice and control is not being offered to all.

In other case study areas, the variation in the degree of choice and control available is not only between client groups but there is variation at individual social work team or worker level. The individualisation, choice and control a supported person experiences is shaped by their social worker and how that professional can operate within the system.

An evaluation needs to have sufficient depth to be able to unpick issues of variance in the offer of choice and control that may both explain but also be masked by aggregate statistics currently collected or potentially collected in the future.

Resource allocation panels

Resource allocation panels were not in use by all authorities but where they were they were seen as a crucial part of people being able to direct their social care support. In the case study areas with panels, these involved social workers and budget holders and meetings at least fortnightly. There were two main reasons for their use. Firstly, to ensure that overall budgets for social care were not being exceeded at a local authority level. Secondly, the panels were seen as a means to test and develop creative solutions to people’s needs and provide social workers with the confidence to move from a quality conversation to a care plan that was truly bespoke to meeting an individual’s outcomes.

The constraint with such panels is time. They require considerable investment in social worker and management time to attend. Currently, resource allocation panels identified in the case studies predominantly consider social care support under Options 1, 2 or 4. It is unclear whether there would be sufficient capacity to hold such meetings for every social care assessment which identifies the need for support (for example, in North Lanarkshire home care for the elderly, a significant proportion of all social care is provided under Option 3 and does not currently go to the resource allocation panel) and there are indications that the lack of local authority capacity for such panels may be limiting how self-directed support is implemented for all groups of service users in an authority.

An evaluation needs to consider how panels are used in the process of individual decision-making, if they are not being used for decision-making related to individual funding requests. For an economic evaluation, the resources dedicated to these processes needs to be considered.

The need for review and changing circumstances

Several of the case studies highlighted how changing circumstances altered not only the support needed for individuals to achieve their outcomes, but also which outcomes they wanted to achieve, the priority of those outcomes and/or how much responsibility they wanted in terms of managing their support. Whilst social workers need to be pro-active to address changing circumstances as they arise and maintain ongoing relationships with supported people, the need for reviews to be conducted in such a manner that individuals can speak freely about how their support needs and desired outcomes change should not be overlooked. Several case studies also highlighted how circumstances in terms of funding available and priorities for funding can also change rapidly within an authority. The rapid changes that can take place for individuals and authorities highlight the importance of regular monitoring, not only of a random sample of individuals in an authority to provide a snapshot, but also of the need for longitudinal studies with regular monitoring points with a cohort of individuals followed over time.

Sufficient supply and ensuring quality of supply

Challenges in the social care market in terms of the supply of care workers are well documented and reported. The case studies provided further evidence of the impact of supply of the care workforce on the outcomes individuals are trying to achieve. Even where a budget was provided for individuals to recruit people to provide support, it was not always possible to find suitable people. It is also potentially concerning that non-traditional methods of recruitment are being used and it is unclear how appropriate checks and balances on the quality of care a person can provide (as opposed to basic safety through criminal records checks and registration with the Scottish Social Services Council) are being undertaken.  In addition, it is not clear how people employed through Option 1, or in some cases Option 2, receive ongoing training and support in their role to ensure the quality of support they can offer is - at a minimum - maintained and ideally improves over time. Whilst aspects of this were picked up in the SDS Change Map, the case studies reinforced the importance of an evaluation to gather information on how local care markets are being managed and developing and how quality and stability of provision is assured.

Does the use of the four options to access social care reflect full implementation of self-directed support? 

The case studies highlighted the different ways that local authorities interpret, deliver and record the four self-directed support options. Some authorities only record as having ‘self-directed support’ those individuals who went through their full process (an assessment including the good conversation, a resource allocation calculation and then a decision process on the care package from a range of provider options). In other authorities essentially anyone accessing social care or support is assumed to have made an informed choice and recorded as having ‘self-directed support’. This has significant implications for the collection and comparison of high-level statistics on self-directed support from across local authorities in Scotland.

Although the four options are explained within the legislation, translating them into practice has varied across local authorities. For instance, within the case studies, there are examples where Option 1 does not offer the same degree of choice and control in different places. The case studies also exemplify where Option 1 can reflect a removal of choice for individuals who would rather not have to manage their own budget but for whom this option maximises their personal budget. The boundaries between the options were not always clear across the different authorities.

Evaluating the economics of self-directed support

Understanding the difference in local authority resource use and costs associated with implementing self-directed support requires an understanding of the current difference in resource use compared to previous social care practices. The case studies highlighted that the additional administrative and social work resource needed for choice and control is predominantly in the assessment process and in resource allocation panels. Ascertaining resource use in either panels or in the assessment process proved difficult to gather, with only one site (North Lanarkshire) providing information that allows the costs of both the assessment and allocation process to be estimated.

A full evaluation of the economic and resource implications of self-directed support would ideally include a comparison of current estimates of local authority resource use on assessment and allocation activities compared to previous practice. In the absence of any established system for recording relevant data, such a comparison would require research into time spent on assessment and allocation processes before 2014 and an understanding on a case-by-case basis of how much the local authority was already engaging in practices to support choice and control and personalisation. It is likely to be challenging to involve local authorities in such work and they may not be in a position to provide the necessary data.

Furthermore, any attempt to evaluate whether the shift to self-directed support has led to health and social care system-wide costs and benefits will inevitably run into potentially intractable difficulties, not least those arising from the range of services and support that contribute to an individual’s personalised outcomes and well-being. In addition, compared, for example, to many medical interventions or narrower service interventions with less diverse target populations, it is extremely difficult to monetise social care and social care outcomes or estimate returns on investment – and this has become even more so the case with the move to self-directed support.

The case studies therefore reinforced how challenging it will be to undertake an economic evaluation of self-directed approaches to social care.