Section Three: SDS - The Processes
3.1. Information and advice - supporting individual choice and control - the role of support organisations
Support organisations are able to offer first class accessible advice and support to people to make genuine individual choices, and to effectively promote self-directed support and independent living.
The Local Government (Scotland) Act 2003 provides that local authorities have a duty to involve service users in the services they provide. This can take the form of local support organisations, either as a user led organisation or directly through a local authority.
The current provision of local support organisations varies across Scotland. These can be broadly divided into local authority support, user led support and other representative voluntary organisations. Local authority support provision tends to be focused on direct payment recipients and is pan-client group. These services do not offer independent advocacy or a campaigning voice for people and user involvement may be limited.
The Centre For Independent Living ( CIL) is a successful user led model which offers direct payment support, advocacy and a campaigning voice for improving services and for the principles of Independent Living. However despite recent efforts, they are perceived by some client groups as being primarily focussed on people with physical disabilities. Other voluntary organisations may or may not include staff or Board members who are services users, and some have a stronger focus on campaigning than on providing specialist direct payment advice.
When I was offered direct payments, I panicked. I had been told that they were difficult to manage. My family were worried about their responsibilities. They were already doing a lot. They did not want to have to take on more. Having only used traditional services, I had no way of knowing how things could be better with direct payments.
When I met my advisor, she had used direct payments before and still used them now. She told me how she did it. She also told me how all the hard bits, like payroll and knowing the law, could be taken care of. Hearing her story and getting her help, gave me the confidence to take a direct payment.
Research suggests that each model of support organisation is workable and acceptable in its local context. Each is highly valued and provides effective support to SDS clients, resulting in them being considered by all parties as representing a valued model 16. However, consultation responses from this strategy indicated a strong desire from individuals that support provision is best provided and more trusted, when done so by a user led organisation.
A review of self-directed support in Scotland highlighted the need to ensure that local support services are sustainable to achieve further development of self-directed support. These services are valued by their clients in particular for the support they can provide to the individual in their role as an employer.
At a national level, user led support mirrors provision at a local level, in that some organisations are client specific where others such as SDSS specialise in direct payments for all groups. This focus tends to be provided on a client group basis despite efforts by some to be more inclusive of others. These national organisations often share the same principles as the local organisations, and the development of SDS should provide opportunities for working together to improve effectiveness.
SDSS represents user led organisations and provides a network to share experiences and good practice. Local Authority provided support for direct payments practice also offers a similar network through ADSW, but there is currently no shared learning between the two networks.
Time to think
The first year of this project aimed to capacity build the member organisations by offering training opportunities to all member organisation staff including boards and committee members.
Three main areas were explored. The first was Ethos which gave member organisations a deeper understanding of the Independent Living Movement, Models of Disability and practical aspects of operating within the social model, including the implications of not using a shared core language.
The second workshop explored Shared work practice which enabled member organisations to identify key components vital to their role, share examples of good practices and identify area of common working they would like to take forward. The final workshop, Strategic Thinking explored the current climate member organisations are working in and barriers to survival.
Three sets of workshops were run in 4 locations with the exception of Strategic thinking which was run in 3 locations due to the target audience of managers and team leaders etc, reducing the overall numbers.
All the sessions were well received, made a positive impact on thinking as well as being well attended. The information and material gathered has informed the second year programme 'Preparing for Change.
In the Know
The project has two main targets, Advocacy Organisations and Local Authorities ( LAs)/Health Boards ( HBs). It's aim is to promote and provide training on SDS to so that all parties have a full understanding of SDS, not just as a community care service but also as the key tool to Independent Living. In order to maximise the impact on LAs and HBs a partnership approach with SPAEN was designed so that SDSS could raise awareness whilst SPAEN could explored issues of compliance.
Topics covered within the project include the basics of Personalisation, the rise of ILM, the role of Disabled Peoples Support Organisations, Implications of implementation for LAs and health boards.
Advocacy organisations have responded very positively. The geographical area covered by the project has been expanded and ranges from Glasgow and the Lothians area, to the Highlands.
Feedback from advocacy organisations clearly indicates that they value the opportunities which SDS can provide for the individuals they assist. They are keen to increase their knowledge and awareness of this area in order to signpost individuals more effectively to sources of help and advice.
By summer 2010, the Scottish Government should begin work with national and local organisations to review their capacity to deliver support - that includes peer support - for other forms of self-directed support and independent living whilst maintaining their focus on direct payments.
Beginning in 2010, the National Implementation Group should evaluate existing models of support provision to inform a more efficient, sustainable and joined up approach, at both local and national level, suitable for all client groups.
3.2. National outcomes and minimum information standards
People will feel confident in identifying and agreeing the outcomes they want. Assessment and review processes will focus on these outcomes and will take a holistic, human rights based approach to individuals and family carers.
Social care is at its best when it helps people to be independent and to feel safe. This works most effectively when people control for themselves the support they may need. Local Authorities have a duty to assess, and must therefore ensure that people are assessed, under section 47 of the NHSand Community Care Act 1990; and that the assessment complies with binding policy and guidance; that qualifying carers are offered a carers assessment; that relevant local eligibility criteria are operated, and that all needs that are considered eligible are met by service provision or direct payments; that financial resources are not used as a reason for not meeting an eligible need; financial contributions are assessed; and that services and support meet minimum human rights standards - most importantly, the dignity standard.
Local authorities and their health partners work within a framework where National Information standards define the nature of information used, and collected for national and local information purposes. Current assessment processes, shared or otherwise, have led to needs being responded to in time units ("Task and go"). This, in turn, has limited individuals, carers and assessing staff, compromising the provision of services focussed on outcomes, in particular those elements of soft but necessary support (contact, relationships) which mean so much to individuals.
Recent reports have consistently indicated the need to change the way in which services are provided. In particular, the Changing Lives report indicated the need to significantly change the relationship between assessor and user and carer; to enable the provision of more personalised services; and to co-production 17 of services with disabled people, their families and wider communities. There needs to be further development of alternative assessment models, including supported self assessment styles, models of co-production and e-solutions;, giving more choice and control at this point, as well as when deciding on what support should be provided.
The Association of Directors of Adult Social Services ( ADASS) in England have published a paper 18 confirming that self-assessment is not legal, and local authorities cannot legally contract out eligibility, resource allocation and support planning decisions. There is however a clear role for supported assessment and pre-assessment in taking forward the principles of self-directed support.
3.3. Agreeing outcomes
The National Performance Framework and the Concordat between national and local government moved away from measuring outputs to a focus on outcomes. The Talking Points Framework developed from research into user and carer outcomes provides a means of looking at the desired personal outcomes for individuals and for family carers within the context of the Community Care National Outcomes, while ensuring best value in the use of resources:
- Improved health
- Improved wellbeing
- Improved social inclusion
- Improved independence
The Talking Points framework is now being used, albeit in different ways across all Scottish local authorities, in some at assessment and in others in review processes.
The change outcomes, identified by individuals as being central to their needs, together with process and quality of life outcomes provide a template whereby people's needs and aspirations can be met more fully. This process effectively engages individuals in setting their agenda based on their perception of the situation.
The shift to an outcomes focus is central to the vision of SDS and will be one of the main elements of the training strategy in the action plan.
Carers' assessment should similarly move to support planning and co-production models, having greater attention to the outcomes that carers require, including partnership, training, information, skill level, but especially the limits to the role they are able to fulfil and the support available. There is a danger that self assessment models and the right of carers to a separate assessment may be bypassed if the relationships and limits in support are not approached through a model of co-production. A co-production approach should assist the normal or natural relationships between the carer and the person for whom they care.
3.4. Resource allocation
At present, legislation provides for assessment of need and provision of services, and not to assessment of financial payments. Direct payments legislation does not specify the amount of payment, other than a payment that secures a service that meets assessed needs.
There are a number of approaches to setting direct payment rates, some through a fixed rate system for DP's and others through meeting the agency rate for the direct service provided. This in effect means that rates are often determined by agency market forces and available resources.
To move towards the personalisation of services in a measured way, local authorities will need to consider the use of a mechanism such as a Resource Allocation System ( RAS) to determine the resources available to the individual that is transparent and sustainable. IBSEN describes how in pilot sites in England there were mixed views on the RAS approach and devising new processes for allocating resources was particularly challenging, with no consensus on the best method. In Scotland the experience of developing and using the Indicator of Relative Need, albeit a tool designed to meet a different set of purposes, might offer one avenue for improving the design of systems for the allocation of resources based on a more objectively rigorous approach. A fusion of the current approaches, if this could be achieved through detailed research and development, might be capable of delivering a method that has both technical rigour and a personalised, transparent and outcomes focus.
The Government does not recommend any particular resource allocation system and believes more evidence is needed of the most effective means for delivering outcomes.
Whatever system or tools are used, local authorities are expected to develop up-front and transparent methods for the allocation of resources to eligible people. To do so, they will need to understand patterns of spend and costs for services; manage resources to deliver good quality outcomes; and be able to meet predicted demands.
The Joint Improvement Team ( JIT) developed a capacity planning toolkit which allows agencies to draw together this type of information. Along with data gathering at individual level, such as the E-say learning disability database, local authorities can more readily predict future demand and agree strategic frameworks for the development of future service commissioning, redesign or decommissioning.
A system for allocating resources should be used as a means of giving an approximate indication of what it may reasonably cost to meet a person's particular needs according to his/her individual circumstances. It is important for councils to ensure that their resource allocation process is sufficiently flexible to allow individual circumstances to be taken into account when determining the amount of resources they are allocated in their individual budgets.
In estimating the reasonable cost of securing the support required, councils should consider associated costs that are necessarily incurred in securing provision, without which the support could not be provided or could not lawfully be provided. The particular costs involved will vary depending on the way in which the support is secured.
Fairness and equity have to be built into Local Authority SDS arrangements to ensure that rates for SDS packages of support are fair and fit for purpose, taking into account key quality factors such as training and the outcomes desired from the SDS, by the individual. Concerns over short changing time allocations need to be managed and monitored.
Some councils have found it helpful to include a one-off start-up fund within the current direct payments to meet these costs as well as other forms of support that might be required, such as brokerage, payroll services and Disclosure Scotland checks on employees and prospective employees.
Beginning in 2010 the SDS Implementation Group should gather and interpret information on resource allocation models and systems to see which approaches best deliver the outcomes for all groups and levels of need. The group should consider whether research and development is required to recommend a method that has both technical rigour and a personalised, transparent and outcomes focus.
Building on recommendation above, the Scottish Government, in conjunction with COSLA, should commission a Scotland-wide cost analysis of the rates offered for individual budgets and existing direct payments and the costs for provider equivalents in local authorities and the independent sector with a view to assessing how funding levels for individuals meet the outcomes.
Choice and Control.
Following on from an outcomes based assessment - or review- choice in how to reach the desired outcomes is more transparent. The respective roles and responsibilities of individual and carer, and responses from the assessing and provider agencies are clearer as part of a negotiated agreement. It is at this point that individuals and their carers can exercise choice about the way their support needs are to be met and how support will be provided to them.
Here, there is a clear opportunity to consider the implementation of alternative forms of provision, taking as much control as the individual chooses. Maximum control would be through an individual budget taken as a direct payment. For those who prefer not to manage the money, the IB can be through an individual service fund lodged with a provider. For others, the choice might be to select a commissioned service, albeit with greater involvement from the service provider in designing how the support will be delivered in the context of the agreed support plan.
The shift to genuine informed choice for the individual will be significantly influenced by the power and knowledge of the assessor to deliver that choice. Implementation of the strategy will therefore need to include some activity to review assessment and support planning systems and processes.
JM had lived at home with his family before his admission to hospital where he was diagnosed with Korsakoff's Syndrome. As a result of a change in family circumstances, it was decided that JM should move back in to the community in to his own home with a package of support paid for with an individual budget. JM was assessed as not having capacity to manage his own affairs and his family felt unable to do this on his behalf.
The Council asked C-Change for Inclusion to work with JM and his family and manage his Individual Budget using an Individual Service Fund ( ISF). The expressed aim was for JM to have access all the benefits of a direct payment without the responsibility for directly managing the budget.
C-Change and the Local Authority worked closely with JM and his family discussing ways in which he could use his ISF. JM is a gentleman who enjoys his own company and was well known within his local community. Living in hospital for a prolonged period he had lost many of his contacts and connections. The initial outcomes identified in JM's plan were to support him to move back home and to re-establish his old networks and relationships.
JM moved back home at the beginning of 2010. Initially he received a high level of paid support, managed through his Individual Service Fund. C-Change has worked with JM and his family and with the Council to develop his support arrangements. The plans are that with the introduction of assistive technology and the re-establishment of his connections and relationships in his community JM's reliance upon paid support will decrease and he will use his money differently to achieve other goals.