Evaluation of Self-Directed Support Test Sites in Scotland
This evaluative study was commissioned to assess the impact of interventions implemented within 3 local authority test sites to improve uptake of self-directed support ( SDS). The study, which lasted 2 years, used a mix of methods to involve and consult service users, carers, social care professionals and representatives of various national organisations. While care should be taken in generalising the findings to other areas, our literature review clarified that many of the issues and challenges that emerged were similar to, and reflect challenges other local authorities may encounter.
Main Findings
Those who accessed SDS packages during the test sites, were positive about their support and satisfied with the flexibility and choice that SDS had provided.
The test sites improved access to SDS especially for people with learning disabilities, but did little to promote SDS to other groups, for example, those with mental health problems, from Black or Minority Ethnic groups, older people, those who have addictions or homeless people.
In spite of considerable Scottish Government investment in SDS test sites, fewer than 150 new individual SDS arrangements were set up. This suggests that significant time and investment in infrastructure are needed to implement major policy initiatives.
None of the test sites had directly addressed issues around mixed funding packages, so the potential to integrate or join up funding streams e.g. with the NHS, could not be assessed.
The paradox at the heart of SDS was a (mis)perception by staff, service users, and carers of SDS as an alternative to, direct services and even, Direct Payments ( DPs). New and parallel SDS systems to those delivering DPs were created by the test sites.
Active promotion of SDS, including DPs, increased the numbers of people opting for payments instead of direct services to pay for more flexible, individualised care and support.
All test sites invested in specialist SDS teams and project managers to support development of new systems and administrative processes, as well as generating a body of practice expertise. Consequently, some service users, carers and professionals perceived SDS as separate to both Social Work support and DPs.
None of the test sites was able to cut 'red tape' or reduce bureaucratic or administrative requirements. Instead, by designing new support systems for SDS, they experienced a (possibly temporary) increase in bureaucracy associated with assessment and resource allocation.
Only one of the test sites used test site monies to invest in strategic service development.
By the end of the test site period the 3 local authorities had resolved to move towards mainstreaming SDS with support from their senior management and Councillors.
Introduction
This evaluation investigated how 3 local authority test sites implemented key Scottish Government themes to improve uptake of self-directed support ( SDS), starting with a baseline assessment, and examining how and what they implemented. The study also explored the issues that arose for the test sites, and how their activities impacted upon service users' and carers' experience, as well as the work of frontline social work staff.
The evaluation brief was to:
Describe current SDS policy, activity and practice;
Develop the evaluation tools with test site managers
Examine the extent to which each test site addressed 3 key areas
Assess the impact of the 3 interventions in each test site in progressing SDS
Identify implications for policy and practice within the wider context
Disseminate to relevant stakeholders.
Policy Context
Promoting self-directed support ( SDS) is part of the Scottish Government's wider programme to increase individuals' choice and control over their community care and support arrangements.
SDS is an approach to delivering care and support that is embedded within wider policy frameworks including those of social inclusion, participation and more recently, 'co-production'. As an umbrella term, SDS encompasses many concepts and practices in social care including Direct Payments ( DPs), as well as Individual Budgets ( IBs). DPs are payments in lieu of services provided directly to individuals assessed as being in need of community care services. IBs enable individuals to either purchase their own support packages to meet their assessed personal, social, and to a lesser extent, healthcare needs, or at least to determine how this budget will be spent on their support.
Since the Community Care and Health (Scotland) Act 2002, it has been mandatory for everyone entitled to publicly funded community care services, with a few exclusions, to be offered the option of a DP by the local authority. While the early evidence base shows that those in receipt of DPs generally consider the benefits far outweigh the challenges (Homer & Gilder, 2008; Witcher et al, 2000), implementation has been slow in Scotland. Research has continued to highlight differences in uptake across community care groups: people with physical disabilities who are under 65 years are still more likely to be in receipt of DPs than any other group (Scottish Government Statistics, 2010).
As part of its activities to promote SDS, the Scottish Government selected 3 local authorities - Dumfries & Galloway, City of Glasgow and Highland - to act as test sites to trial targeted activities to address 3 themes in order to increase the uptake of SDS. The 3 target themes - leadership and training; cutting 'red tape'; and bridging finance - were based on past research. The test sites were funded between January 2009 and March 2011).
SDS: An Evolving Concept
A fundamental issue from the start of the test sites and the evaluation was that SDS was an evolving concept, and there were different ideas about what it was. Initially, SDS and DPs were referred to almost synonymously. There was much debate between the test sites and Scottish Government about SDS and what this should mean in the test sites.
The consensus of opinion from early stakeholder interviews at national and local levels, was that SDS refers to a spectrum of options ranging from the 'sharpness' or 'purity' of DPs at one end to more individually tailored local authority provided services at the other. The key requirement, regardless of the mechanism chosen to deliver the support, was that the individual could exercise more choice and control over his/her social care than had previously been possible.
During the lifetime of the research, Scottish Government and COSLA published a 10-year strategy for SDS in Scotland, which aimed to set out and drive a cultural shift towards SDS becoming the mainstream approach in social care. The national Strategy defines SDS as:
"The process for deciding on support through SDS is through co-production…The mechanisms for getting support through SDS can be through a Direct Payment ( DP) or through the person deciding how their individual budget is allocated by the council to arrange support from a provider…." (Scottish Government, 2010, p7).
Given such a broad definition the evaluation needed to move from simply counting numbers of DPs to looking at individual experiences, as well as the processes set up to implement an SDS approach.
Stage 1: Baseline
A key finding at this stage was that at local test site level, and to an extent at the national level, DPs were perceived as failing to deliver choice, flexibility and control and to be overly prescriptive, bureaucratic, and using 'old style' care management processes.
Across Scotland, implementation of SDS, and DPs in particular, was inconsistent. Local leadership to promote SDS via DPs was perceived to vary greatly, and, other than some notable exceptions, local authorities had not taken a strategic or holistic approach to implementing SDS.
Inadequate, or even non-existent, support infrastructures for service users and carers were a major barrier to implementing SDS across Scotland. Linked to this, was the view that at local level in particular, the development of SDS policy had not enlisted sufficient input from service user and carer organisations and was in danger of being professional-led. Some service user and carer groups were thus sceptical that implementing SDS was a cost-cutting exercise.
Stage 2: Evaluating Process & Impact
While operational definitions of SDS were broader than DPs, in practice, the majority of SDS packages in all 3 test sites involved a cash transfer, either direct to the service user or a third party, usually a family member. However, there was a misperception by service users, carers and staff that SDS was an alternative to DPs, and test sites ran parallel SDS and DP systems throughout the period.
All 3 test sites created a project lead/manager role and this post was critical to taking developments forward. They also all created SDS teams and had project boards, although Glasgow initially planned for the project manager to work with existing teams. While this strategy worked well for the test sites in relation to supporting the small numbers of service users and staff involved with new systems, it may have limited the extent of systemic change.
In relation to cutting red tape, the local SDS teams' efforts went into designing or re-designing systems for assessment and resource allocation that were more 'fit for purpose', which in all cases created a parallel, and therefore, additional bureaucracy. In the short term, this was felt to be necessary until new systems were accepted and assimilated into the local authority but it did create an additional burden for service users and staff.
On the whole, test site activities were short on specifics regarding addressing the theme of bridging finance. The impact of this theme was therefore, difficult to ascertain.
Individual Experiences of SDS
While the experience of the quality of assessment processes varied, overall, carers and service users interviewed felt the assessment had been comprehensive and inclusive, with outcomes based upon what the individual wanted. There were, however, differences between the test sites in the degree of flexibility experienced in terms of, for example, employing relatives and the appropriateness of funding particular activities.
SDS had expanded choice and control for the vast majority of those we interviewed. More flexible support was being offered and there were positive outcomes for individuals. From the individual accounts however, it was not always clear whether positive comments related solely to the model of SDS or because the test sites had enabled access to some who had not been eligible for services previously, or to higher levels of social work support.
Stage 3: Implications and lessons
Given that some similar concerns emerged across all 3 test sites, it seems likely that these are not specific to the test sites but are more general challenges facing all local authorities attempting to make changes in the direction of SDS.
The implementation of SDS using a managerial and project based model rather than a strategic approach had limitations: a specialist SDS or personalisation team offered expertise and management of the ' SDS project' but also created the impression that SDS was separate from, and operated differently to, the local authority and other systems, such as DPs. There was a risk of unhelpful duplication and confusion. Unless senior managers take a lead role, there is always the danger that initiatives will be marginalised, regardless of the commitment of those managing and involved in it.
The new SDS processes created by the test sites worked extremely well overall for the selected individuals who benefited from SDS during the test site period, offering increased choice, flexibility and control. The uptake of SDS and of DPs had increased as a result, and through the work of dedicated teams, the local authorities found they could be more creative and innovative in the ways they worked with people. The key issue now is maintaining such innovation and flexibility for greater numbers of individuals.
Clearly involvement of service user and carer organisations and investment in the necessary support infrastructures are essential as well as continued availability of funding for the care packages themselves. In the foreword to the national Strategy, political leaders state that "more of the same will not work". It will be essential therefore for all local authorities to grapple with the challenges faced by these test sites, and to find a way to implement this shift from existing service provision to greater involvement and co-production of care and support. The outcomes of this Strategy are worthy of continuing assessment.
Research Design & Methods
The evaluation had 3 main stages: Stage 1) establishing the baseline; Stage 2) evaluating process and impact; and Stage 3) reflecting on findings for wider policy and practice. Various methods were used to gather data including:
Literature review (Manthorpe et al 2011)
Collation and analysis of secondary information about SDS and community care services
Interviews with test site local stakeholders
Interviews with national stakeholders
Learning Sets in each test site
Monitoring framework - quarterly monitoring of test site action plans and collection of test site information about recipients of SDS packages
Case studies - 30 individuals, their carers and assessors/care managers were interviewed
Evaluation stakeholder event -March 2011
Analysis of all findings from the test sites.
Although a cost-analysis of the test sites was not possible for various reasons, interviews were conducted with finance officers in the 3 sites at Stages 1 and 2, to discuss their perspectives, especially about how national ( CIPFA) guidelines on introducing 'light touch' monitoring were being implemented by the test sites. Also, although not a key requirement of the evaluation brief, the relationship between Adult Protection ( AP) and SDS was explored in very general terms and this revealed that greater links needed to be made between these areas of work.
References
Homer, T. & Gilder, P. (2008), A Review of Self Directed Support in Scotland, Social Research Report, Edinburgh: Scottish Government.
Manthorpe, J., Hindes, J., Martineau, S., Cornes, M., Ridley, J., Rosengard, A., Hunter, S., Little, S. & Gray, B. (2011) Self Directed Support: A Review of the Barriers and Facilitators, Edinburgh, Scottish Government Social Research.
Scottish Government (2010), Self-directed Support (Direct Payments), Scotland, 2010, A National Statistics Publication for Scotland, Edinburgh: Scottish Government.
Scottish Government (2010), Self Directed Support: A National Strategy for Scotland, Edinburgh: The Scottish Government.
Witcher, S., Stalker, K., Roadburg, M., & Jones, C. (2000), Direct payments: The Impact on Choice and Control for Disabled People, Edinburgh: Scottish Executive Central Research Unit.
Research Findings No.109/2011
This document, along with full research report of the project, and further information about social and policy research commissioned and published on behalf of the Scottish Government, can be viewed on the Internet at:
http://www.scotland.gov.uk/socialresearch. If you have any further queries about social research, or would like further copies of this research findings summary document, please contact us at
socialresearch@scotland.gsi.gov.uk or on 0131-244 7560.
http://www.scotland.gov.uk/Publications/2011/09/20090707/1
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