Self-directed Support Implementation Study 2018: report 3

4. Highland

Local context

The population of the Highland Council area is 235,180.

The Highland approach to self-directed support has developed to reflect features based upon geography and history, underpinned by a strong emphasis on enhancing performance and service quality across social care through a forensic focus on weekly performance data and understanding trends and patterns.

Implementation of social care and support in Highland

For Option 1, the approach is to focus on a three-way assessment:

• What can the family offer?
• What can the community offer?
• What needs to be offered through Option 1 to fill any gaps?

Option 1 is the main choice for people aged under 18, with 92% choosing Option 1 compared to 2% of people aged 65 or over in 2016/17.

The roll out of Option 2 in Highland is based on the ‘Boleskine Community Care model’, named after an area on Loch Ness-side.^[10] This features the delivery of support by community-based organisations, which ensures strong local ownership and connections, and close working relationships with District Nurses and GPs. Uptake of Option 2 is relatively low, with 3% of adults aged under 65 and 2% over 65 taking Option 2.

A strategy of reducing direct NHS provision of Care at Home and expanding the provision of outsourced Care at Home through self-directed support Option 3 contracts with a range of trusted providers has been adopted.  This is seen as a way of offering better value, more flexibility and responsiveness, and greater choice for supported people.

Option 3 contracts in Inverness have now been awarded on a neighbourhood basis. This means that staff become familiar with local residents and build effective working relationships with other local services in each area and minimises travel time between home visits.

For adults, Option 3 is the choice made by the majority, with 78% of adults aged under 65 and 93% aged 65 or over taking this option. The distinctive feature of Option 3 is that NHS Highland, rather than the local authority, retains control over funding and variations through its contract terms. This contrasts with Option 2 where local teams, which are managed by community-based organisations, can vary services offered to meet personal outcomes without formal sign-off by NHS Highland.

There are three case studies from Highland:

• Case study 5: focuses on an example of local communities working with statutory agencies to develop services under Option 2; and,
• Case studies 6 and 7: outline examples of two supported people’s use of Option 2.

Case Study 5: Boleskine, Highland

This case study, based in Boleskine in the Highlands, highlights how local communities in combination with statutory agencies can work together to develop services under Option 2, and how learning from a relatively small area, with a dispersed population, can be disseminated across the wider local authority.

The approach to supporting people at home in Boleskine arose from a recognition that there was a growing local need. The ageing community and lack of local service provision meant moving to homes outside the area for some people.  However, there was potential capacity to boost the supply of care, as there were local residents who felt keen and able to provide support.

Following discussions involving community leaders, NHS Highland and Highland Home Carers, a community-based organisation called Boleskine Community Care (BCC) was created and registered as a charity. Highland Home Carers (HHC) employs all the carers managed through BCC as well as the 3-day a week service manager. (HHC is an employee owned company with charitable status). HHC and BCC have a Memorandum of Understanding that sets out their respective roles, how they will work together and mutual expectations.

HHC funds provision of administrative support, employment and training by a levy on each Option 2 payment (of 15-20%). Their costs covered by this levy include 2 days of the manager’s time:  the third day is paid by Boleskine Community Trust from income from local energy production.

BCC now has 10 part time carers and a part time service manager, and 14 supported people. All BCC support is funded through Option 2. Boleskine carers are locally recruited – adverts are placed in the BCC newsletter and the local post office.  Currently all 10 care staff live locally. They are all part time and work flexibly to suit their availability on zero-hour contracts but with the terms and conditions of permanent posts (e.g. in terms of paid holidays and other employment rights).

Referrals for assessment are made by GPs, District Nurses or through BCC (who may identify additional support needs when people attend their range of other activities). A social worker (sometimes accompanied by the BCC manager) makes assessments.

Each care plan is the subject of a tripartite agreement between the supported person, HHC and NHS Highland. This agreement is designed to be easily understood by supported people and their relatives. Care plans may be subsequently adjusted by BCC staff (any increase in provision needs to be agreed by a social worker) and are often adjusted downwards in the short term – with any savings in funding being ‘banked’ for later use on other forms of appropriate support for that person.

The key features of the Boleskine model are therefore local ownership through a community based organisation, and a strong working relationship with a support organisation (HHC) and other local professional services.

The relationships between BCC and other local services – notably with local GPs and District Nurses – has strengthened considerably.  BCC now has a physical base in Lower Foyers (The Hub) and District Nurses have the access code and are able to leave equipment there.  District Nurses have trained BCC staff in skincare so they can apply ointments and related care to their own supported people or others if convenient.  BCC staff are also willing to deliver mobility aids and commodes in response to local requests.

Much of this activity is designed to ensure that BCC and its services are seen as highly approachable – so that in the future, there will be less resistance to seeking and accepting support and so a reduced risk of unplanned hospital admissions related to a lack of support.  This approachable local service should be valued as part of an approach of investing in prevention.

The role of BCC is evolving and it is extending its local services into a range of other activities for elderly people in the area. It is doubling the size of its base and this will allow it to deliver additional services such as day respite care.

Elements of the Boleskine approach have now been adopted by the Community Health Project of the Strathdearn Community Developments Company (which includes Tomatin and Moy) and by Black Isle Cares. Both these charities drew on the experience and support of HHC and BCC in developing their local model – but in both the areas, elements of the model and the agreements that underpin it have been adjusted to respond to the nature of the community and the concerns of local trustees in each area.

It is possible to identify some of the features for successful transfer.

There needs to be a strong local group of potential Trustees ready to take on responsibility for the approach and drive its implementation. In all three areas to date, there has been a pre-existing community trust, which has provided a base of local commitment to build on.  An organisation, which is able to act as employer, trainer and source of technical HR support, is needed as well as a close and trusting relationship with this organisation.

It is paramount that local people are able and willing to provide support and keen to be trained to do this. The role of the service manager is also critical – they are central to the ethos and values of the approach and are important in terms of building local trust and strong working relationships with other sources of local support such as GPs and District Nurses.

The existence of independent local income is important but not vital – the managers in two of the three areas which have adopted the approach are at least part funded from community interest from wind and/or hydro schemes.  Particularly in smaller communities, the scope for adopting the approach may be limited by a lack of alternative sources of income.

Case Study 6: Violet, Highland

Violet started drawing on BCC support when she needed skincare on her legs.  Over time, this has developed to become 3 day a week support – 1 hour in the morning just after getting up. Violet clearly has a strong relationship with all her carers and looks forward to their visits – they provide what she needs and provide an opportunity to share local news.

Option 2 means that she can get the support she needs from a trusted local provider staffed by local people without the difficulties of organising the service herself.

Case Study 7: Douglas, Highland

Douglas suffered a bad accident at home; he broke his neck and was advised that he may never walk again. Following surgery outside the area he returned home to his daughter’s house (which was suitable for a wheelchair) with 1 hour of care every day of the week, provided under Option 2 by BCC. His condition improved significantly over time and he was able to walk with the aid of sticks and move back to his own home nearby with his wife.

He now gets 1 hour of support 3 times a week. Under Option 2, he is able to get support from a local, trusted organisation and it is clearly an arrangement with which he is happy.