Self-directed Support Implementation Study 2018: report 3

6. North Lanarkshire

Local context

The population of North Lanarkshire is 339,960.

North Lanarkshire was developing self-directed approaches for some time before the legislation. In 2006, the local authority started working with In Control Scotland to help understand how individualised support could be delivered, building on work that was already happening for people leaving long term care.  A key component of this work was understanding the costs of care for individual supported people.

In 2007, work started on developing a resource allocation system that developed into a guided self-assessment tool that has now been in place for 11 years. Where a social worker and their senior practitioner determine that an individual meets the criteria for funding, the person’s case is referred to the Local Enablement Group (LEG). If the LEG agrees, the social worker then completes the guided self-assessment tool together with the supported person at their home. It contains a series of eight questions about the individual’s care needs, and asks for the views of both the supported person and the social worker. The results of this are used to calculate an indicative budget, and for most people this has proved to be an accurate estimate of the resources that are actually required.

Implementation of social care and support in North Lanarkshire

At the heart of the approach to social care in North Lanarkshire is a high-quality conversation with a social worker to help people understand the different self-directed support options and develop a care plan. As well as guiding people through a process of identifying the outcomes that are important to them and helping people to think creatively about how these can be met, social workers also explain the different organisations offering services under Option 2 and how Option 1 can be managed.

North Lanarkshire estimate that their social workers spend between 4 and 8 hours completing each social care assessment, resulting in a cost of social worker time of between £172 and £344.^[11]

North Lanarkshire operates a preferred provider framework for Option 2. It does not guarantee work for providers on the framework, as the emphasis is on choice and flexibility for supported people. This creates an atmosphere where social workers themselves keep in close contact with local provider organisations. This keeps the social worker informed, as they understand what services providers offer; their current levels of capacity and locations they cover; and allows them to keep supported people informed. Quarterly provider development days help to build the relationships with the providers and social workers.

Each new proposed budget and support plan or review of funding is first approved by the social worker, before being discussed at one of six LEGs.  The groups meet fortnightly and involve two social work managers, at least three senior social work managers for each area, service managers and administration support.  The meetings last between 1.5 and 3 hours at an estimated cost of social worker time of between £405 and £810^[12].

At each meeting, up to 80 cases are discussed. As social workers have already approved plans, the meetings necessarily focus on those cases that are most challenging in terms of whether the proposed package will meet a person’s outcomes or where the support package may have risks, e.g. for the individuals or reputational implications for the local authority.

Decisions are approved at the LEG before being passed to the Council-wide Social Work Enablement Group (SWEG) for final sign-off.  The SWEG meets fortnightly, meetings last three hours, and are attended by a locality social work manager and senior social worker and a local authority service manager, senior officer and finance representative.  The cost of the social worker involvement at LEG meetings is estimated to be £453.^[13]

North Lanarkshire is clear that, whilst choice and control are central to delivery of all support they provide, they have not managed to roll out self-directed approaches to everyone.  They are actively working towards the full process for people over 65 receiving homecare who currently are not offered a choice over their social care. Planning around this includes building in capacity for the LEG/SWEG systems to manage increased demand. The Council remains committed to maintaining people in their own homes for as long as possible.

Three case studies were undertaken in North Lanarkshire:

• Case study 10: describes the experience of Joanne, who used Option 1 to meet her care needs
• Case study 11: is an example of a supported person (Graham) using Option 2 to design a package of care
• Case study 12: explores the case of Joyce, who takes up Option 1 to fund her support package.

Case Study 10: Joanne, North Lanarkshire

Joanne is in her early forties and a mother of a 6-year old boy called Joshua.  Her story illustrates the flexibility available to meet very specific outcomes, but also highlights the need for continued review of changing situations and the challenges of finding appropriate care.

In 2015, Joanne was diagnosed with a rare degenerative disorder that results in declining physical and cognitive capacity, similar to dementia.  She has been unable to work for several years due to her condition and her husband, David, needs to work full-time to financially support the family.

The condition means Joanne has substantial personal and social care needs that increased over time. Initially these needs could be met by support from the local early onset dementia team, but this support had to increase when it became clear that Joanne needed some support throughout the day, even after they had moved into a bungalow that was a more suitable residence as her motor skills declined.

The personal care was provided through the locality team for about six months at which point she was re-assessed and self-directed support options were discussed.  Whilst David is able to partly meet Joanne’s needs, the self-assessment made it clear his work commitments mean that personal assistants are required to ensure she has the level of assistance she requires.

During the guided self-assessment process, beyond meeting her personal care outcomes, it was clear that the outcomes that mattered to Joanne were around being able to continue to do some of the activities she enjoyed – such as going to the cinema – but mostly related to her son and family. Joanne wanted to be able to still spend quality time with her son.

Discussing the four options with their social worker, Joanne and David wanted control over their support and so initially chose Option 2 with the Council’s resource allocation system estimating a budget of around £19,760 per year.

Whilst local providers were happy to help, it proved a struggle to find providers who could offer the support required because the provider and direct staff had to be registered to look after both adults and children (Joshua being at home when David was at work). In the end support was found but, due to the complexities of the situation, for only 22 hours a week.  This would have meant that David could no longer work full-time which would have placed significant financial strain on the family, so was not an option.

Whilst reluctant to take on the responsibilities of employment that come with Option 1, Joanne and David realised that Option 1 was the best way that they could achieve the outcomes Joanne had identified in her self-assessment.

With the budget available, they managed to employ two personal assistants through advertising on Gumtree (after no success advertising at Job Centre Plus) for 34 hours a week over weekdays with a schedule that suited them and left Joanne and David with enough of the budget to fund two weeks a year of 24/7 support so the family could go on holiday.  Whilst David found becoming an employer challenging, he used some of his budget to pay for the Scottish Personal Assistants Support Network’s (SPAEN) fully managed service to help with the administration and payment of their personal assistants.

As a degenerative condition, Joanne’s personal care needs have increased over time, in some areas quite rapidly.  At the same time, Joshua has grown older and his needs have changed. David missed being able to spontaneously do activities with his son (like take him to the park or out on his bike) as it was proving increasingly difficult to prepare Joanne to leave the house and she could no longer be safely left home alone.

On reviewing the level of support provided, North Lanarkshire agreed that the personal budget should be increased by £6,240 for ad hoc care or support over the weekend. However, whilst he has been trying for some time, David has not been able to find anyone to employ in this capacity, so the extra hours have not been filled.

The current personal assistants cannot take on any more hours due to the impact it would have on their own financial circumstances and their benefit entitlement and, whilst they do on occasion work more hours for no payment to help David and Joshua have time together, this is not a situation that is sustainable or allows any sort of routine to develop.

As Joanne needs consistency in the people supporting her, a third-party provider cannot offer the flexibility required without sending different people at different times and so is not an option. This is putting additional strain on David who is increasingly worried about not being able to spend quality time with his son.

Until recently, Joanne’s outcomes have been met through Option 1. Whilst the system has been flexible enough to adapt – in terms of funding – to the family’s changing requirements, the local care market has been found wanting in terms of its ability to supply the services that are now required.

Joanne’s situation highlights that supply in the market is not only constrained by the physical ability of potential providers to offer the care required, but also by the financial constraint imposed by a ‘benefits trap' (benefit entitlement can depend on how many hours of paid work you do per week) that is likely to exist for many low paid workers such as personal assistants, artificially lowering the potential supply of services available.

Figure 5: Summary infographic - Case Study 10, North Lanarkshire

Case Study 11: Graham, North Lanarkshire

Graham is in his 40s and has recently left long term care in a hospital for a brain injury. His story illustrates how a local authority can work together with the individual, their family and the local care market to develop a package of support to meet complex needs whilst maintaining an individual’s independence in their own home.

After an accident four years ago, Graham was left with neurological impairment.  Following a substantial time in an acute hospital, Graham had been resident for 2.5 years in the Robert Ferguson Unit, the national specialist NHS brain injury unit in Edinburgh.

The medical team at the Robert Ferguson Unit advised that a care home would be the best residential environment given his support needs and without self-directed support it can be assumed that he would have been ultimately discharged into residential care. Social workers did not think that residential care would produce the best outcomes for Graham and suggested to his cousin and niece – who act as his advocates and have power of attorney – that it would be better for Graham if he could be supported in a home of his own. However, his family had concerns about this because of both advice from the medical staff and Graham’s lifestyle and choices before the injury.

Whilst respecting the family’s concerns, social workers agreed to scope out the options available to Graham should he be discharged to his own home. They then explored how to reassure the family. The local authority found suitable accommodation and asked three trusted providers from the 24 on the North Lanarkshire framework to meet the family and tender for the support required for Graham to live as independently as possible. The family appointed Turning Point.

Six months before he was discharged from hospital, the staff from Turning Point started to visit Graham three times a week. This was to help Graham to get to know the staff, to allow the staff to work in partnership with the health professionals to understand his needs and to work with him to redevelop basic life skills and define his own personal outcomes.

Turning Point offer a range of services to people in receipt of a social care budget, from intensive at home care to limited daily support to help with personal care, taking medications, or support to help participate in social activities. They provide support through a keyworker system that ensures consistency and predictability.  These are important elements for the support Graham needs as he has a tendency to wander and to engage in activities that could potentially expose him to harm. It is important that he is carefully monitored and supported by people he knows and trusts and who also know Graham well.

Having seen the support Turning Point can offer, Graham’s advocates/relatives with power of attorney agreed that he could be discharged into the accommodation found by the Council.  At the moment, his family still make all the decisions about the support provided but they and Turning Point are hoping in the future that he will be able to become increasingly involved in the decision making process.

Turning Point are currently providing 24-hour support to Graham to maintain his independence but keep him safe. In planning the support for Graham and keeping in mind his support needs and the concerns of the family, they have introduced door alarms and a GPS watch. By exploring what activities he likes, they are using music-based activities to reintegrate him in the community and going on daily walks to build up his stamina. The work they did whilst he was in the hospital is continuing and increasingly he is able to do more around the home.

Graham’s needs and abilities will change over time so his support needs are reviewed every 6-8 weeks through discussions with the family, provider and social worker. The worker and senior social work practitioners who will attend Local Enablement Group meetings to establish how Graham’s support requirements are changing and how the support provided needs to change.

The North Lanarkshire approach has created flexibility in the support that Graham has received. Without this flexibility, Graham would undoubtedly have been discharged into residential care.

As a result of the introduction of self-directed support, the Council has played an active role in developing the local care market encouraging greater flexibility in the way it joins up support offered by providers and enabled providers to develop innovative and bespoke support solutions.  This has been through the LEG meetings and the close contact the local authority keeps with all its providers.  A quality assurance team works with new providers to meet the standards required to achieve a place on the Council provider framework and ensure that existing providers continue to fulfil requirements to remain on the framework.

The way social care operates in North Lanarkshire has also shaped the way Turning Point as an organisation works, working closely with the Council to look at where services are required, and consider how their service could address these needs.

There are still challenges in the market, notably around recruitment especially now the Scottish Living Wage has levelled the playing field with care providers and alternative employment such as in retail or catering.  There is also competition from people using Option 1. This is because they can often pay more for support workers than providers can, with organisations such as Turning Point trying to distinguish themselves from other potential employers through their conditions of service and training opportunities. 

Case Study 12: Joyce, North Lanarkshire

Joyce is 66 years old and married to Barry. Her story illustrates the continuity in care that self-directed support is able to provide that can be important when an individual requires substantial assistance in their own home.

In 2010, Joyce – who had recently taken early retirement - had a major stroke which left her with significant mobility problems. At the time, she was assessed by the Council as eligible for homecare, but the support offered did not match what Joyce and Barry needed in terms of the flexibility of times. In addition, it was especially important for both of them to know and trust the person coming into their home.  This carer would be there for many hours each day and would be responsible for key aspects of Joyce’s personal care.

Joyce and Barry heard about Option 1 from a friend who suggested that this may be a route for them. The Council assessed the level of payment that would be available, but initially Joyce and Barry felt that this was significantly below what should have been expected, given the level of support Joyce needed. Working with the Council and through reassessment and evaluation, Joyce and Barry were able to access a budget more suitable to her situation.

Under Option 1, they employed a local care worker, Claire, who has now been working with Joyce for eight years and is involved in all aspects of her care. Option 1 allowed Joyce and Barry to employ a care worker they felt comfortable with.  It has also allowed them to maintain continuity of staff over eight years. There has been no change in care workers nor any requirement for multiple care workers as would have been the case with an agency or local authority provided services.