Self-directed Support Implementation Study 2018: report 3

3. Edinburgh

Local context

Just over half a million people (513,210) live in the City of Edinburgh.

Before the implementation of the self-directed support legislation, the transition team in Edinburgh used In Control Scotland (a third sector organisation) to allocate individual budgets to young people and to make an Individual Service Fund for short breaks for adults with learning disabilities. When the legislation was implemented, there was a concerted effort by the Council to set up and implement self-directed support options. However, this was at the time of the financial crisis when managing a limited budget became a priority and, like other areas, integration affected and continues to have an impact with its associated significant changes to systems and processes and movement of key personnel. All this has affected the extent to which self-directed support is embedded in Edinburgh.

A dedicated funding and independence expert team, with social workers who previously provided support and advice to supported people, workers and assessors, was disbanded as part of restructuring and organisational review in 2017.

Implementation of social care and support in Edinburgh

Across the city, social workers are said to base their assessments and reviews around ‘good conversations’ but this is not consistent. The Council has recently reinvigorated their approach, delivering training on having ‘good conversations’. This is helping to progress and build greater personalisation, choice and control for individuals accessing social care and support in Edinburgh.

After a social worker has completed the assessment of someone’s care and support needs, an indicative social care budget is calculated using a financial allocation system, which considers hours of care ‘needed’ and creates an equivalence in money terms. Like other areas that use this approach, it means the budget is calculated on a fixed number of hours of support related to ‘need’ at a particular cost rather than the more holistic assets-based and outcome-focused approach at the heart of self-directed support.

Once the budget has been calculated, a self-directed support option can be chosen. Authorising the support plan and personal budget, regardless of the self-directed support option, requires different levels of sign off, depending on the amount and the type of support. This approach to approving personal budgets is largely consistent across the City, but there are some differences, depending on the senior manager who has sign-off responsibility.

Data for 2016-17 shows that Option 3 is the most common approach in Edinburgh, with 51% of adults under 65 and 76% of those 65 and over taking it up. However, Option 1 is also commonly used, particularly among people aged under 65. A third of those under 18 and 40% of those aged between 18 and 64 choose this.

Option 1 is administered via a payment card system (or a designated bank account for long established supported people) and social workers should check whether there is a sufficient amount of money on the card. There are restrictions as to which providers can be paid using the card. At present, the local authority is considering their duty of care and responsibility where the system allows people to use providers that are currently suspended from council contracts or that the authority would not use. Individuals taking up Option 1 can also access financial management services depending on their level of need. Those who access the mid-level service receive some support like completing tax returns and paying national insurance contributions for PAs. Individuals that access the enhanced financial management service receive more support, for example with payroll (delivered by Fife Business Services) or other practical help like recruiting a PA (delivered by Lothian Centre for Inclusive Living). 

When an individual chooses Option 2, this is through an Individual Service Fund with a nominee, often the provider, managing the allocated budget on a supported person’s behalf. Whilst the contract is between a person and a provider, the provider has to be on the local authority’s framework having gone through the appropriate contract and commissioning checks. There are a limited number of providers on the framework, but there is more flexibility in what can be provided; and it is consistently the option that is quicker to put in place. The social worker draws up the support plan together with the supported person, a provider is found and the business support team arrange the funding.

The process for Option 3 can take many months. The support plan goes to the service matching unit, a finance and contract team, who complete a questionnaire about the support needed. This is sent to the providers on the framework and the matching service waits for a response. Social workers are aware of the potential for long delays and so actively encourage individuals to consider Option 2 instead. If the supported person prefers to opt for Option 3, they will use local knowledge to establish which provider has availability so they can make a specific request.

The local authority recognises that they need to continue to work with providers to develop the range of services needed to meet people’s social care needs. They are increasingly engaging with providers about what they do and what they need, holding marketplace events to help foster working relationships between the different types of provider. The Council appreciates that more can be done to develop the partnership with providers and to involve communities and supported people in ways that enable them to influence commissioning.

Three case studies were undertaken in Edinburgh:

• Case study 2: Alastair uses self-directed support Option 3 to arrange his care;
• Case study 3: discusses the experience of a couple, Linda and William, who use self-directed support Options 1 and 2 to meet different aspects of their support needs; and,
• Case study 4: focuses on Janet’s experience of using self-directed support Option 1 to receive support to help her care for her mother.

Case Study 2: Alastair and Eleanor, Edinburgh

Alastair was a teacher and a Director of a business. In 2008 when he was in his late 50s, Alastair experienced a major stroke which left him with physical and mental impairments. He receives a lot of support from his ex-wife, Eleanor, and she has helped Alastair to ensure that the most appropriate package of care is in place.

Alastair was in hospital for almost 12 months and when considering the support that would need to be in place it was agreed that they should choose supported accommodation provided by Leonard Cheshire (a large UK-wide charity) to continue his rehabilitation.

Alastair stayed in this development in the south side of Edinburgh for a year, but he was very keen to return to the familiar surroundings of his own house and local community in the north of the city. However, because he would be living alone, it took several months to discuss and establish what package of care could support independent living at home. An independent advocate who participated in all the meetings that were held with Alastair, Eleanor and the social workers supported this process.

Eleanor continues to advocate on Alastair’s behalf. When establishing the package of care, they were offered Option 1 (this was before self-directed support legislation came into force) but opted for a package arranged by the social work team.

The care at home package was provided by the same provider, Leonard Cheshire, and Alastair and Eleanor agreed the support and home adaptations required to ensure Alastair’s safety. Alastair was able to move home in 2010 and a support worker provides daily support within the home and by accompanying Alastair to various activities which enables him to be involved in his local community.

The Leonard Cheshire contact explained that the working relationship with Alastair and Eleanor was effective and they had shaped the package to suit his needs and the personal outcomes he had identified.

Whilst the care at home package that Alastair receives is via a spot purchase contract^[9], they are also on the provider framework with the City of Edinburgh Council for Option 2 of self-directed support and can offer supported accommodation and respite care.

The social worker who had the most recent involvement with Alastair explained that, because of service capacity issues, his case had not been reviewed annually. The last review with Alastair and the provider (in February 2016), had shown that everything was working well and everyone seemed happy. The case review in 2014 also showed a positive arrangement. The social worker explained that Alastair and Eleanor had a lot of control over the service they received and an established relationship with Leonard Cheshire, so there has not been any discussion about other self-directed options. The social worker also commented that the backlog of cases and the time to complete the assessment and support plan and process contributed to there not being a recent review.

Alastair and Eleanor are reasonably happy with the care provided by Leonard Cheshire and, whilst they do not anticipate the need to make any change to the current arrangements, they would like to understand what self-directed options they have, should they want to consider alternatives in the future.

Alastair has received support for his care from the same provider for more than eight years under Option 3 and whilst this has been provided in line with his needs, he would like the opportunity to explore other options through more regular reviews and discussion of his needs.

Case Study 3: Linda and William, Edinburgh

Linda and William are a retired couple. Their experience shows that self-directed approaches to care can be used flexibly to allow people to make different arrangements for the various elements of their care. It also illustrates the importance of local authorities ensuring that their systems are appropriate and enable the varied choices that people make for different aspects of their care.

Linda was diagnosed with Parkinson’s in 2003 and has very little mobility. A hoist is required for Linda to move around the home that she has shared with William for over 40 years.

William does all of the cooking and cleaning in the house but, since an assessment with the City of Edinburgh Council in 2012, home care workers have supported Linda with personal care.

Initially, Linda received four one-hour long visits per day from one care worker under Option 3 but an assessment in 2013 identified the need for two workers to attend each visit in order to move Linda safely.

In 2014, the Council informed Linda that it could not provide two carers per visit but suggested she should source another provider herself under Option 2. However, it was difficult for their daughter Jillian to find a supplier with the capacity to deliver this service. She contacted 35 different agencies before finding one who could meet their needs. The family selected this agency.

The decision to select Option 2 in 2014 was taken because the local authority could not provide the service they needed, rather than because the couple proactively wanted to switch to this option. However, Linda and William appreciate having control over the choice of the home care company and the frequency and timing of visits from care workers, while the Council deals with the arrangements and the payments.

As well as home care, the couple receives support with respite care. Later in 2014, William had some difficulties coping with his caring role so Jillian contacted the local authority to discuss if any other support could be provided. This prompted a review, which led to Linda and William identifying a need for respite care. The couple’s savings fund most of this, but the authority contributes (£2,500 per year, around 20% of the annual cost). This is managed via a direct payment, which was paid directly to William (Option 1). This means they can arrange the respite care themselves with the provider of their choice, which accepts the Council’s payment cards, and at the times when they need it.

Linda and William are satisfied with their package of care and they are very happy with the home and respite care services they receive, however the administration of their budget has led to some confusion.

Up until 2017, the couple’s main point of contact with the local authority was their Occupational Therapist (OT). They discussed their needs with the OT who then sourced the equipment and care services they required, without any discussion of budgets, and the Council made the payments for home care on the couple’s behalf. As William said, “everything was so simple”.

In 2017, their OT advised the couple that she could no longer be the key contact for arranging the care and William needed to liaise with the Finance team in the City of Edinburgh Council. William was nervous about the new system for discussing their needs, and his son accompanied him to the meeting because he was asked for some information (such as an email address) that he would not have been able to provide on his own.

The assessment meant that the Council agreed to maintain the same level of funding for respite care, and the first instalment of the respite care budget (£1,400) was provided on a pre-paid (All Pay) payment card, instead of a direct payment into William’s bank account, so that they could continue to manage the finances for this aspect of Linda’s care.

However, confusion arose when William noticed there was a much larger amount of money (£24,000) on the payment card. The local authority has made excess payments on to the card, and the home care provider has not been receiving the payments it was due from the authority.

This has caused some concern for the couple: the provider cannot accept the payment card, and Linda and William want the Council to make the payments direct to the home care provider. The situation is not yet resolved, but the home care provider is currently liaising with the Council to revert to the original payment method so that they receive the funding directly from the local authority.

Figure 3: Summary infographic - Case Study 3, Edinburgh

Case Study 4: Liz and Janet, Edinburgh

Liz, who is in her 90s, has dementia and lives at home with her daughter, Janet. Their experience shows that Option 1 can provide the best choice and control for some people’s care and support, especially in situations where there is more choice of providers.

Liz was first diagnosed with dementia in 2010. By 2014, the condition had progressed and, after an assessment, Liz was found to be eligible for social care. Janet is the main carer for Liz and they chose Option 1 to design a flexible package of home care that provides appropriate support and enables Liz to continue with everyday activities and hobbies. Janet set up a dedicated bank account to manage the budget.

This approach allowed Janet and Liz to appoint a carer of their choice, identified through personal contacts, to support them at the days and times that suited them. Janet was able to access the enhanced financial management services offered by the local authority and she received support from Lothian Centre for Inclusive Living (LCIL) to manage the administrative aspects of paying the carer.

This arrangement worked well until the carer left her post. Janet felt the potential replacements identified by LCIL could not deliver Liz’s desired outcomes. With support and help from their social worker, Janet recruited a new team of carers (again identified through personal contacts) which was “quite complicated to get started”. Without the social worker’s help, Janet felt she would have been unable to arrange care.

Janet now undertakes all the employment responsibilities for the carers. The local authority continues to pay the budget directly into the bank account which gives Janet more flexibility than the All Pay card. To keep a track of the payments, Janet created her own receipt template that the carers complete each time she makes a payment. This, she feels, helps to “keep it right”.

Janet likes using Option 1 because, although the local authority reduced the budget available after a re-assessment in 2017, she has been able to design a flexible care package delivered by carers she knows and trusts, at times that suit her. Liz’s dementia has become more advanced over the past few months. There have been instances of wandering behaviour and Liz often requires care during the night. As well as daytime care, the budget includes funds for six sleepovers per month to provide night time support.

The flexible provision does mean that some weeks Janet uses more care than in other weeks, depending on what she has planned, and when this happens and the costs exceed the personal budget, Janet uses her own money to meet the shortfall.

A social worker involved with the case noted that the flexibility of Option 1 ensures that there is appropriate “support for the daughter which has helped Liz to remain at home”. She also observed that this means Janet is able to identify a group of carers, people she has established relationships with, to support her Mum’s care.