Transforming social care: Scotland's progress towards implementing self-directed support 2011-2018

Commissioning is more flexible and responsive

Social care services and support are planned, commissioned and procured in a way that involves people and offers them real choice and flexibility in how they meet their personal outcomes.

Progress to date
Whilst changes in social work practice are a vital step towards successful implementation of self-directed support, they are only one aspect of delivery. Commissioning and procurement practices also need to support flexible and person-centred approaches. There is some evidence of change from traditional tendering to collaborative approaches which enhance choice and control for individuals, but it is not yet widely embedded across all areas and services.

Good commissioning is co-produced and involves all partners, including supported people and providers. A human rights-based approach is now promoted across all procurement activity, and with specific reference to health and social care, under the Procurement Reform (Scotland) Act 2014. This legislation was developed with input from self-directed support partners under Scottish Government funding, and both the legislation and the accompanying statutory guidance emphasise additional flexibilities open to Authorities when contracting for health and social care. The quality or availability of these services can have a significant impact on the quality of life and health of supported people and their carers, and support increasingly requires to be personalised to better match individual needs. For these reasons, section 12 of the Act exempts contracting authorities from the requirement to advertise for contracts under €750,000.

Where commissioners take an active role in collaborating and negotiating with providers, flexibility is possible within contracts (including block contracts and Service Level Agreements), with providers contracted to tailor their services around personal outcomes. The guidance referred to above is considered to be a powerful and enabling tool in those areas that wish to explore different approaches.

Some areas within SWS’s study sought to make major changes in their approach to commissioning and relationships with providers at an early stage of implementation. In other areas, there is less evidence of changes to commissioning practice for a number of reasons, including difficulty disinvesting in existing services or increases in demand.

In areas with more traditional commissioning practices, SWS found frustration among some frontline social work staff, with a view that creative assessments could not be realised and that the cultural shifts made began to feel aspirational rather than grounded in real world delivery.

Good examples of changes in commissioning were found by SWS in South Ayrshire, East Ayrshire, and East Renfrewshire, where managers had understood the need for new approaches to social care delivery. In these areas, a strategic approach was taken and dialogue opened up between supported people, frontline staff, managers and providers of care and support in order to create new ways of working together.

SWS’s research identified that substantial work was required to change these traditional commissioning relationships and shift the balance of power and responsibility between agencies. One area described significant efforts in this direction, while acknowledging that despite all the work, a flexible Option 2 arrangement (the person directs the support, and the budget is held by a third party) was still not in place.

While Scottish Government funding has facilitated many shared discussions between providers and relevant authorities, and providers have noted a positive shift in tone, the majority of social care contracts in Scotland are still two stage competitive tenders, usually on to a framework. Guidance issued as part of the Procurement Reform (Scotland) Act 2014 endorses a different approach, building on substantial pre-contract market engagement to avoid over-specification, which then reduces flexibility.

In contrast, short break provision has been successfully personalised in many areas in order to provide supported people with a more enjoyable experience, and carers with meaningful respite.

"[Three friends with learning disabilities] went and rented a log cabin and used their budget to pay for the accommodation and pay support staff to go away with them as a trio and then do stuff … and the feedback I had from that was that it was just amazing. They felt like they’d had a holiday and their parents felt like they’d had proper respite … it also then connected all these families and they built a kind of network."
Social Work Scotland research participant

For some types of specialist support there may be a need to consider the appropriate balance of rights and risk enablement for individuals, or the statutory duty to evidence Best Value. This is summarised by Audit Scotland’s Auditing Best Value in Councils as:

"Each council is obliged to:

• work with its partners to identify a clear set of priorities that respond to the needs of the local community
• be organised to deliver those priorities
• meet and clearly demonstrate that it is meeting the community’s needs
• operate in a way that drives continuous improvement in all of its activities."

Under their revised audit approach, Audit Scotland place an increased focus on quality of services, performance and outcomes for communities.

People work better together across internal and external boundaries
Working in partnership is one of the key tenets of the Scottish Approach to public policy. Some reference has already been made to the complexity of stakeholders within Authority settings, to which must be added provider organisations (both third and independent sector); supported people themselves; related voluntary sector organisations such as independent support; national bodies supporting and scrutinising social care, and a host of others.

The work developed under Scottish Government funding enabled CCPS and HIS to model the collaborative behaviours required to effect change, working with areas to support them in thinking differently about their commissioning practices. CCPS have also run a well-received series (Coping with Cuts, Coping with Complexity) focused on a shared audience of commissioners, providers and others (Care Inspectorate, the Scottish Government, carers groups etc.). These have been effective in building trust and a shared understanding across stakeholders.

Although commissioning was once seen as almost exclusively linked to the procurement practice of competitive tendering, there has been some expansion of commissioning and procurement practices which reflect the collaboration and partnership emphasis identified throughout the Guidance on the Procurement of Care and Support Services 2016 (Best-Practice). Commissioning and procurement professionals have an increasing range of tools to promote more collaborative and person-centred practice – some are highlighted below. Work continues on supporting professionals to use the flexibilities open to them.

While there is an increasing understanding of the need to work across boundaries, many sources of evidence (including the Audit Scotland progress report) have identified other drivers that make this difficult in the short term. These include the impact of financial constraint measures on budgets and, particularly in children’s services, substantial changes in legislation which require time to understand and implement. The integration of health and social care, while expected to substantially enhance cohesion and joint working in the medium to long term, has required intensive investment from senior managers as organisational structures have changed.

There is continued improvement in some areas in the dialogue between Authorities and providers. Some Authorities are becoming more confident about challenging the “more with less” approach of the last decade of procurement. In particular, these Authorities have a focus on identifying true measures of quality of care which take into account quality and sustainability as well as price. The Living Wage has also prompted helpful discussions about hourly rate transparency and understanding the true cost of care within procurement and contracting, although work remains to be done.

Collaborative commissioning models being explored in Scotland with support from Scottish Government funding include:

Public Social Partnerships
The Public Social Partnership approach is increasingly being used across many public sector commissioning settings, with specific support available to use it effectively in health and social care settings. For example, three have been created in West Lothian within preventative support for older people, drug and alcohol recovery services and community transport. Support was provided under Scottish Government funding with a focus on supporting change to practice.

Used well, a Public Social Partnership approach can help achieve service delivery models that better meet the needs of those using them. There are important lessons across these examples of the need to have clear objectives, strong and preferably mature relationships and the genuine voice of those who will use the support.

Alliance Contracting
Through Scottish Government funding there has been identification of collaborative options such as alliancing, a form of collaborative contracting that places “best for the person” at the heart of commissioning and procurement and promotes collaborative behaviours and decision making. Scottish Government funding has supported the developing Glasgow Alliance to End Homelessness, one of only two alliances in Scotland.

Innovation Partnership Procedures
Introduced by the 2014 procurement reform legislation, the Innovation Partnership Procedure ( IPP) allows providers and commissioners to work together to develop new solutions to problems. Unlike some other collaborative processes, the IPP recognises the need to resource the co-production/design phase. This approach is being trialled within Digital Health and has possible applications for social care in the future.

Flexibilities within procurement legislation are being used to develop more innovative approaches to delivery
Substantial work at national level has gone into supporting the provider-purchaser relationship in social care commissioning and procurement. There is increasing understanding of the factors that lead to effective co-production/collaboration, and increasing knowledge of possible alternatives to current processes.

The self-directed support legislation recognises that not everyone will wish to take control over their support. Option 3 (taking in-house/commissioned services) exists for that reason and Authorities recognise the need to make it a positive choice for people. Some areas are working to ensure that their Option 3 services offer personalised support in line with an individual’s personal outcomes, understanding that for those who do not wish to direct their own support, “Option 3 is a perfectly legitimate choice for individuals and … it should continue to be so ” (Social Work Scotland research participant).

Understanding of flexibilities in procurement is increasing, however it has not always proved straightforward to make the shift to more collaborative and flexible forms of commissioning and procurement on a larger scale.

SWS found that leadership within Authorities is of key importance. Management input was important to make changes that enabled staff and supported people to work together effectively to create flexible care and support packages and to divert budget to make creative purchases or access activities in the community. Lack of flexible provision and inability to develop flexible partnerships with providers could effectively stall progress in implementation of the core principles of self-directed support.

The role of the community in social care is being strengthened

Part of the self-directed approach has been an emphasis on community building so that there are opportunities to divert from traditional social care provision. Stronger communities offer greater potential for people to access meaningful activities and supports of their choice. In some areas, seed funding was provided to kick start “bright ideas” for community activities and initiatives.

"We worked with our local volunteer organisations… and one of the high schools, and we had a couple of young girls [who] set up a drama group for our children with disabilities … it was probably one of the most humbling things ever… that whole social inclusion, getting the chance to be part of something…"
Social Work Scotland research participant

"[Self-directed support] is predicated on the notion of a supportive community with activities within it and that you can access, and that you can use a [direct payment] to do something there… we’re not always masters of our destiny in that regard and we have to work with other people and recognise that … you have to have supportive communities, communities you can do something in."
Social Work Scotland research participant

Community leadership was recognised as another important factor, and where there is a lack of community resources and assets, this can have substantial impact.

The Community Led Support programme has engaged four Authorities in working collaboratively with communities, partners and staff across the whole system (not just within social care) to design health and social care that works for everyone. Between June 2016 and November 2017, East Renfrewshire, Borders and South Ayrshire (alongside additional sites in England) invested into a programme led by National Development Team for Inclusion and including Scottish Government funded support from HIS to develop this approach using community hubs. Fife has now also joined the programme.

Evidence from the evaluation sites indicates that up to 75% of people accessing community hubs did not require any additional social care intervention. Waiting times between an initial first conversation and accessing support of some kind were reduced for those who did require support. Providing community options led to better outcomes for people at the same or lower cost as standard services and support.

Key factors for success included devolving financial decision making to community teams and frontline practitioners, leading to timely decisions; and staff and people developing holistic solutions together.

Many areas outwith this programme report that they have successfully increased or hope to build community resources locally, and understand the need for stronger, more supportive communities. Promoting active citizenship and community assets is a priority in some areas and some money has been invested into seed funding for increasing community assets. There is a growing cultural desire to change, and particularly in some more remote locations, a strong wish to invest local money into the local economy and small organisations.

Areas included in the SWS research are still at the early stages of identifying where (and when) they may be able to disinvest in existing services or underused assets to focus on alternative approaches.