Self-directed Support Implementation Study 2018: report 4

4. Research findings: Case studies

The case studies aimed to explore some of the various ways that self-directed approaches are being implemented and the potential for scaling up and replicating good practice. In addition to providing evidence for Option 2 in practice (which had been under-explored), these case studies can also help inform the assessment of the economics/resource implications of self-directed support.

Case study areas 

Six local authorities took part, selected to provide a range across areas of deprivation and urban and rural geography: Dumfries & Galloway; Edinburgh; Highland; Midlothian; North Lanarkshire; and Eilean Siar (Western Isles). Case study examples were requested from each area. It was easier for some areas than others to work with their social workers to identify cases and then secure informed consent from individuals and providers. At least one case study in each of the six local authority areas was completed.

Case study contributors

Figure 2 details the range of contributors, involved in or supporting the delivery of social care, who participated in the research for the case studies.

Figure 2: Range of contributors

In most cases, we carried out face-to-face interviews with participants along with follow-up telephone and email correspondence to confirm details.

Discussions with case study participants

The discussions with people in receipt of a personal budget, carers, frontline staff, and provider organisations focused on their experience of accessing or supporting the delivery of social care.

With local authority officials in each area, the focus of the discussion was on the local context and the processes and structures that underpinned the local approach.

In order to understand the resources needed and to assist in understanding the economic implications of self-directed support, the local authority officials in each area were sent follow-up questions about the resource allocation system and time spent on key activities. Two areas provided all this information, which is included in their case study and discussed in more detail in Report 2: Evidence assessment for self-directed support. 

Appendix 1 includes one of the infographics that summarises an individual case study and “Report 3: Self-directed Support Case Studies” includes full details of the case studies.^[17]

Case Study Reflections 

The case studies were not designed to be representative of the degree to which self-directed support has become the mainstream. Rather they were intended to capture diverse instances of how individuals and their families, communities, and providers have been negotiating the self-directed principles and formal options, to enable individuals to meet their personal outcomes.

It is also clear from the case studies that the local authorities started from different baselines in terms of their existing approaches to social care and the extent that personalisation, choice and control featured in social work practice before the legislation was implemented. They echo other evidence of the pace and means of implementation varying across the country.

Local authority resource and cost implications 

Understanding the difference in local authority resource use and costs associated with implementing self-directed support requires an understanding of the difference between current resource use and 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.

The scope of any economic evaluation of self-directed support will necessarily be limited.

Resource allocation panels

Local authorities with resource allocation panels saw them as a crucial part of their approach to enable supported people to direct their social care and support. These panels involved both social workers and budget holders and met at least fortnightly. There were two main reasons for their use: to ensure that overall budgets for social care were not being exceeded at a local authority level; and as a means to test and develop creative solutions to people’s needs and provide social workers with the confidence to move from a ‘good conversation’ to a care plan that was truly bespoke for the supported person.

Panels require considerable investment in social worker and management time to attend. Resource allocation panels identified in the case studies predominantly considered social care support under Option 1, 2 or 4. It is unclear whether there would be sufficient capacity to hold such meetings for every assessment that identifies the need for support. The lack of local authority capacity for such panels may influence how self-directed support is implemented across all groups of supported people in that area.

The need for review and changing circumstances

Several of the case studies highlighted how changing circumstances altered the support needed for individuals to achieve their outcomes, which outcomes they wanted to achieve, the priority of those outcomes, and/or how much responsibility they wanted for managing support (partly translated into Options they choose). Social workers are required to be proactive in maintaining ongoing relationships with supported people and addressing changing circumstances as they arise. Equally important is for individuals to be able to request reviews where they can speak freely about how personal outcomes and support needs have changed.

Sufficient supply and ensuring quality of supply

Challenges in the social care market are well documented ^[18].The complex provision and changes in delivery of services, the challenges within rural and urban areas, the financial environment and resource constraints, and the impacts of social and technological change all impact on the social care workforce skill requirements and supply.

The case studies provided further evidence of the impact of supply issues - e.g. some people’s outcomes required traditional caring, but with a high degree of flexibility, and others needed support that existing care providers did not routinely offer. Even where individuals had a budget to recruit support workers or Personal Assistants, it was not always possible to find suitable people who could deliver that support. In addition, the Option 1 case studies highlighted that there may well not be any training and support for their role. It is important to introduce training and support to ensure the quality of support they can offer is at a minimum maintained and ideally improves over time.

Does the use of the four self-directed support options reflect intended policy outcomes? 

The case studies highlighted the different ways that local authorities interpret, deliver and record the four self-directed support options. As noted elsewhere, there is an inconsistency in what is recorded and why, from area to area, and this has been recognised at Government-level. Some local authorities only record as using self-directed support individuals who have been through an assessment, a resource allocation calculation and then a decision process on the care package from a range of provider options. In other areas, essentially anyone accessing social care or support is assumed to have made an informed choice and recorded accordingly. This has significant implications for the collection and comparison of high-level statistics on self-directed support implementation from local authorities in Scotland. This has been a significant issue routinely commented on by authorities in relation to published statistics 

Although the four options are explained within the legislation, translating them into practice has varied. Within the case studies, there are examples where: Option 1 does not offer a similar extent of choice and control in different places; or Option 1 reflects a restriction of choice for individuals who do not want to manage their own care but for whom this option maximises their personal budget.

The boundaries between the options were not always clear across the different authorities. Option 2 in one area appeared to be similar to the personalisation, choice and control under Option 3 in another area, where creative contracting provided more flexibility.

Ultimately, the options for self-directed approaches to care should be understood as a means to deliver the values and principles of self-directed support. The options should not be treated as if synonymous with self-directed support itself. The case studies highlight that the options can be a real focus for genuine change in some areas, but it also appears that there can be an over-emphasis on a local authority demonstrating an increase in the use of a particular option. Similarly, in the case studies, staff and supported people tended to talk about the hours or nature of support received rather than the outcomes being pursued, suggesting that there is still a cultural shift required to fully embrace self-directed support as mainstream social care.