Section Five: The Shift
5.1. Providers and the social care market
Services and support are provided by local authorities or contracted out to private and voluntary organisations, with a significant proportion contracted out. The current provider market is substantial, significant, skilled and ensures essential and valuable services are delivered. This includes the combined membership of Community Care Providers Scotland, which supports approximately 220,000 people and their families, and managed a total annual income in 2008-2009 of nearly £1.1 billion, of which an average of 70% per member organisation relates to public funding. It employs approximately 36,700 staff and works in all 32 of Scotland's council areas.
The Social Care Market Place has been a focus of substantial change in recent times. This arguably has been driven by a number of factors and drivers such as:
- Procurement practices
- Delivering efficiencies and cost savings
- Delivering to high volume
- Delivering to high expectations
- Increasing complex support needs
- Person centred, empowerment and personalisation approaches
- Regulation, scrutiny and monitoring
The management of the social care market is crucial to ensuring that services develop and maintain the capacity to meet and respond to identified needs within local communities.
5.2. Strategic commissioning
Among the known barriers that need to be overcome are resources tied up in buildings and block contracts, which limit the resources available to individuals. Block purchasing of respite care, for example cuts against the GIRFEC approach particularly in regard to children's disability. This approach limits flexibility, pushing respite as a catch-all solution, rather than tailoring individual solutions, as it appears more efficient to deploy already purchased time.
The shift to self-directed support requires strategic commissioning that focuses on outcomes for individuals, and that ensures a good supply at an affordable cost. Some tools have been developed in Scotland to support this.
Commissioning for Personalisation' looks specifically at the commissioning process and the implications of developing a personalised services approach and 'A Personalised Commissioning Approach To Support and Care Services' which seeks to explore the issues identified by 'Commissioning for Personalisation' in more detail and from a wider public sector approach through outcome-based commissioning and improvements to public and provider partnership working.
The SWIA Strategic Commissioning Guide26 is designed to help councils working with key strategic partners to evaluate their performance of strategic commissioning of care and wider support for adults, children and young people. It advocates the adoption of a long term view which considers the needs of the whole community.
Commissioning should be seen as a cross-cutting activity with councils linking strategic and financial planning with assessment and care management and making decisions about how to use resources most effectively to achieve desired outcomes for people. Commissioners should be planning at least 10 - 15 years ahead and considering what mix of services and support will best meet predicted needs and self-directed support choices, whilst delivering the best value.
The success of a care package depends on service providers and individuals having responsibility for agreeing the approach to meeting quality of life outcomes. This can only be achieved by commissioning for outcomes. Current practice has boxed both assessor and provider into inflexible time and cost based activity with more emphasis on the process inputs and outputs.
Re-ablement, recovery, and rehabilitation services are demonstrating how this co- production of outcomes can, and is, developing improved and valued services. A shared outcomes focus should be through changing the relationships between provider and commissioning staff, and to better include and facilitate the lead voice of the individual service user. Better tri-partite co-production partnership relationships are required. A culture change has to happen with key emphasis on trust enablement, sustainability, reward and incentive built in for all partners. This will be the key to achieving innovation and ensuring consistency.
Traditionally the means to securing stability and certainty of service provision has been through the procurement of block contracts of services. Undoubtedly this has helped grow an experienced, diverse and able provider sector. However, the positioning of the individual within large block contracts can impact on the development of personalised and individualised service response solutions. The development of individual budgets, and processes that include individual service funds, and self managed service funds offer alternative means of achieving co-produced service and support plans, and the potential for different organisational structures and support models and relationships. Equally there is the potential for individuals to be more involved in the commissioning of services in order to design the outcomes that are wanted on a local community level.
A challenge exists over how to best manage and ensure the provision of responsive support services whilst moving to more person led solutions. The move away from block contracting arrangements to "spot" arrangements can enhance the positioning of the person within the service. In doing so, there needs to be care taken to avoid unintentionally destabilising services. The loss of valuable services can have dramatic distressing impact on service users. Price awareness and price sensitivity are key issues that service users need to be supported on so that expectations are not lowered and remain realistic in terms of achieving quality of outcomes.
Local authorities need to plan for and commission services in an effective way and have robust systems in place to monitor and review the effectiveness of procurement, mindful of both the needs and choices of individuals and the ability of providers to deliver good quality care. They need to put systems in place that identify and respond to regulatory bodies' assessments of the performance of regulated services. Procurement practice will need to take account of the principles of self-directed support in that it will need to consider:
- The extent and measurement of quality of life outcomes and service level satisfaction;
- The provision of information about procurement to citizens;
- Involving service users and carers in the development of commissioning strategies, procurement policies and individual procurement plans;
- Development of the social and health care market;
- New forms of financial planning and financial management;
- Balancing risks and responsibilities;
- Systems to deliver direct services or purchase other services in line with personally determined support plans;
- Aggregating data from support plans to inform procurement exercises;
- Means to support service purchase by service users if this option is chosen;
- Maintaining quality standards and ensuring cost-effectiveness;
- Flexibility in service specifications and contracts;
- Contract monitoring and review.
Recently developed Social Care Procurement Scotland Guidance 27 outlines useful ways to structure and conduct social care procurement activity. The guidance is based on a set of guiding principles which, taken together, are intended to govern all social care procurement activity. The guidance considers the ways in which the developing National Strategy, and existing National Guidance 28 for self-directed Support will influence social care procurement. It highlights the need for each council to consider the development of their social care procurement policy and their commissioning strategy in the context of advancements in self-directed support.
In applying Scottish Government guidance on procurement, local authorities should implement the values and principles of self-directed support, and in turn promote independent living
There is clearly a need for councils to work closely with providers in developing responsive models of support. This is being achieved in some areas, with provider networks at local level, in addition to the national focus that CCPS has.
Glasgow Social Care Providers Forum ( GSCPF) established the Self Directed Support ( SDS) Capacity Building Project within Glasgow in 2009, called the 'Festival of Ideas- Crafting Innovative Responses to Self Directed Support', with over 35 partnership workshops and 5 collaborative mini projects involving around 1000 people ( social care providers and associates, public sector social work and health, service users and carers) in networking, peer learning exchanges and action progression on key SDS themes.
Perspectives and information gathered from key stakeholders involved in the Festival was captured in an SDS newspaper called 'On the Record' and a dedicated SDS resource website, www.selfdirectedsupportideasfactory.co.uk
In 2010 the Self Directed Support Ideas Factory was launched to take the issues and learning needs identified during the Festival of Ideas and focus on creating 7 specific SDS themed projects.
1. Working Together - models for collaboration, user led organisations, peer provider and service user models, people leadership, brokerage & provider pathway models.
2. SDSbudgets for Children, Young People & Families s- an exploration of the issues and the practice of involving children, young people and their families in self directed support
3. SDS- a changing marketplace - practical supports on marketing, branding, e-marketplaces and getting your message across to the new 'customer', in print and online. How to construct an effective marketing strategy, ways in which personalisation affects the way provider organisations market their services, developing brand, new, innovative techniques to market services to whole communities, utilising the strengths of new media to create social networks and reviewing the effectiveness of your marketing
4. Personalised Technology - Assistive technology, Telecare & personalised technologies that encompass all high/low tech devices to increase real outcomes for people. Focusing on case studies, ethics, individual rights, policy initiatives and practice.
5. Practitioner Skills- outcomes based support planning, input into supports with assessments, how to spend your budget, risk and safeguarding
6. SDSIdeas Factory website- The unique website providing SDS resources to practitioners, managers and those keen to build Provider capacity (collectively and organisationally) to deliver effective, quality responses to meet the expansion of Self Directed Support ( SDS) and Individual bud
The aim of these projects will be to move beyond information intake to action, with practice that impacts significantly on the progression of the SDS agenda for all stakeholders. Through this project we aim to build on the innovative and active network of self selected Glasgow Social Care Providers who are eager to progress their understanding, knowledge and practice of SDS models and systems in Glasgow. With onsite and open events to inform, create learning exchanges and aid practical planning with peers in a safe, supportive environment.
During 2011, local authorities should work in partnership with providers to develop provider networks in each area. These networks should look at ways of supporting citizens to individually or collectively commission services and examine the impact of self directed support within services.
5.3. SDS for specific groups
For self-directed support to develop as a mainstream choice, the needs of some client groups will have to be better understood so that support plans adequately address the specific impact of some conditions on interaction and communication. Some disabled and older people still face stigma and discrimination in society and have concerns about access to high quality care services. Awareness raising campaigns to increase public understanding are beginning to change attitudes and current and developing national policy and guidance address some of these. A key issue relates to people who are considered to lack capacity and individuals need to be aware of the various laws and safeguards that exist to both protect them and to allow them to manage as many aspects of their own lives as possible. Consideration of Guardianship under the Adults with Incapacity Act, consent to treatment and financial measures require careful attention, as do legal requirements through the Human Rights Act and Disability Discrimination Act.
This list is not exhaustive and does not attempt to prioritise any group over others -decisions on self-directed support should not be based on a particular diagnosis or label.
The learning disability review The same as you? was instrumental in bringing about a focus on individuals having more control over the care and support that they receive, and highlighted the role of direct payments in achieving this. People with learning disabilities have been well represented in pilots to trial individual budgets, both in Scotland and elsewhere. The development of self-directed support must ensure that people with learning disabilities have access to the same opportunities as other people to have choice and take control of their lives.
Scottish Government guidance on commissioning services for people with autism spectrum conditions ( ASD) describes the need for better identification of people with ASD and suggests models of support that may deliver better outcomes. Self-directed support clearly contributes to support being tailored to the individual's needs. Knowledge and understanding of ASD in Scotland is growing, with a range of training now available for professionals. The Scottish Autism Service Network provides practitioners with much needed information and on the specific features of ASD.
National guidance on community care services for people with sensory impairment in 2007 sets out the key outcomes for people who have a visual or hearing impairment, or dual sensory impairment. The guidance describes the need for a specific response to sensory needs at the point of assessment, and particular attention to the impact of sensory loss on other groups. Outcomes focused assessment and support planning should enable individuals to tailor support to their particular needs.
The Ministerial Strategic Group on Health and Community Care, chaired by the Minister for Public Health and Sport, is sponsoring a major review of care of older people. The main aim is to foster a philosophy of co-production to support a mutual care approach as mainstream practice, with broad community support. Health and social care will be organised in integrated teams to provide personalised support based on outcomes/goals which focus on recovery, rehabilitation and re-ablement.
In 2009, the Government brought together a working group to consider how the needs of people who require Alternative and Augmentative Communication ( AAC) support could be better addressed. The group identified a number of common problems with the provision of AAC equipment and support, including: long waits for equipment; poorly maintained equipment and difficulty replacing old equipment; lack of clarity about funding responsibilities, and lack of training in using equipment -for users, families and staff in mainstream services. Communication is a fundamental human right, and poor service provision means that some people are denied that right. Self-directed support may be particularly relevant to young people who require AAC support at the point of transition from child to adult services.
It will be important to ensure people with complex needs do not fall through the net in being able to access self-directed support due to the challenges faced in meeting their needs, not least of which is the potential cost attached to individual packages of support.
The self-directed support (Direct Payments) survey indicates that 471 of the 3017 direct payment recipients in 2009 were children and young people aged 0-17. The current Scottish Government national guidance on self-directed support describes the flexibility direct payments can already provide for families. In developing a broader approach to self-directed support, there will be opportunities to consider the contribution of education and employment agencies to individual budgets. Such a broader approach would also need to actively address barriers to uptake for families with disabled children, in order to rectify historical anomalies and inconsistencies in service provision.
People with dementia and their carers should also be able to access the right support to enable them to continue to live their normal lives in the community for as long as possible . People with dementia and their carers (family members and friends) have the same human and other legal rights, to enjoy the same freedom, choice, dignity and control, as every other citizen. However, it is widely recognised that, in addition to the impact of the illness, they face cultural, social and economic barriers to fulfilling these.
Throughout much of the illness people with dementia continue to be able to indicate their preferences and wishes about decisions which affect them. Nevertheless, over time dementia affects the capacity of individuals to make some or all decisions about their everyday lives, including decisions about their money, health and welfare. The illness gradually affects their ability to communicate, reason and act in their own interests; severely compromising their ability to protect their own rights; because of this people with dementia are often at greater risk of violence, injury or mental abuse, neglect or negligent treatment, maltreatment or financial exploitation.
Caring for someone with dementia can be stressful because of the complex, unpredictable and progressive nature of the illness and may have a profound social, emotional, physical and financial impact on carers, including increased risk of stress related illness such as depression. Many carers feel that their views and needs are overlooked by health and social care professionals and that their right to support as partners in the provision of care is not well recognised.
Figures show that direct payments have not previously been accessible to people with mental illness less than 3% of direct payment packages in 2009 were for people with a mental illness. This may reflect the complex and fluctuating nature of some mental health problems, which mean that people's needs may vary substantially over time. Increasing the availability of self-directed support to people with mental health problems will therefore need to be based on an awareness of the specific issues involved.
Local authorities will need information and reassurance about safeguarding systems if they are to offer self-directed support to people with mental health problems more widely. Education, information and choice will be vital for people with mental health problems: in consultation, many people said they were worried about becoming an employer and needed more information about self-directed support.
The shift towards commissioning for individuals rather than groups needs to recognise that traditional commissioning methods cannot be simply imported. These are often based on the number of hours of support provided to a group or individual, allowing for little flexibility to take into account the varying needs of the individual. This is particularly relevant in mental health, where people may need very little support one week but a great deal the next. Commissioning for self-directed support should focus on the needs of the individual: this will also need to take into account the fact that many people will have both physical and mental health problems.
People with mental illness are more likely to be socially isolated than others. While a shift to increased self-directed support will be positive for many people, allowing them to expand their social circle, for others they may prefer to receive services in a group setting. It will be particularly important for people with mental health problems to be given accurate information about their choices in self-directed support and traditional service commissioning, and supported to make whatever choice they prefer.
5.4. Unpaid Carers
There are an estimated 660,000 unpaid carers in Scotland, providing support and care to family members, friends and neighbours affected by illness, disability, frailty or substance misuse.
Unpaid carers make a significant contribution in supporting individuals to live safely and independently in their own homes, to enjoy a quality of life and to maintain links with their families, friends and local communities. However, unpaid caring can impact on the natural relationship between the person receiving and the person giving the care. It can also affect the carer's own quality of life, their health, employment and financial situation, and relationships, ambition and opportunity.
Appreciating the importance of unpaid caring and also the extent to which it relieves health and social care services of significant demands, the Scottish Government recognises carers as "partners in care" - partners who require to be acknowledged, supported and equipped to continue to provide unpaid care. SDS provides an effective means of delivering more flexible support to individuals and also to their unpaid carers. Involving unpaid carers in the assessment process and assessing them in their own right can help identify and deliver support that is personalised, preventative, responsive and sustainable. This involvement can also lead to greater satisfaction with the process and can contribute to improved outcomes for the service user, as well as for any unpaid carer. The earlier discussion on co-production and a holistic approach to identifying outcomes addresses the need for partners to agree rights, roles and responsibilities. In doing so, it is important to identify, and respond to, the support a carer may need to enable them to continue in that role. The action plan for this strategy should set out specific links with the delivery of Caring Together, the national strategy for carers.
There are many situations where a traditional, arranged support service meets the service user's assessed needs. This, in turn, can benefit the unpaid carer, by supporting them to care, or by providing a break from caring. However, these services can lack flexibility and there can be limited opportunity to influence when the service is delivered, by whom and how. This in turn limits the benefit to the service user and their carer, who have to manage their lives around the service, rather than vice versa.
SDS can improve outcomes for service users by giving them greater control, flexibility and choice in their support. Unpaid carers report that they too can derive benefits from the service user having SDS, for example; where this allows them more flexibility about the care they provide; where it provides fewer support staff with greater continuity, communication and consistency; where it enables them to achieve a better balance in their life outwith caring, sustaining the carer in employment, or; where they see the service user enjoying greater opportunity and an enhanced quality of life, as a result of the SDS.
However, recognising the significance of unpaid carers' contribution, understanding that their needs can be distinct from the service users' and that their views on the effects of caring can be different, carers are also entitled to receive an assessment in their own right.
Carer assessments consider the contribution made by the unpaid carer to the individual's care and support. They also take into account the demands that this places on the unpaid carer. Agencies responsible for agreeing and delivering on support plans should take account of voluntary contribution unpaid carers wish to make to support individuals. In doing so, they should ensure the carer's support plan considers the outcomes that allow him or her to continue in that role.
Direct payments that enable flexible use of resources - perhaps more for respite care - can be an effective means of supporting carers. Legislation in Scotland at present does not provide for direct payments to carers in their own right, although carers can clearly benefit from SDS for the person they support where it takes account of their needs too.
Unpaid carers also benefit from having their own health needs considered and from being able to have interests and opportunities that enable them to have a good quality of life outwith caring.
Unpaid carers often highlight that their priority need is for a break from caring or "respite". Reflecting this priority, the Scottish Government and COSLA jointly produced "Guidance on Short Breaks (Respite)" 29 in 2008. This guidance seeks to shift the balance towards more preventative support, that is more personalised and which delivers improved outcomes for both the service user and the carer.
Unpaid carers' needs can be met in a variety of ways and by a range of service providers. Social Work and Health services have an important role to play. Additionally many carers receive vital support from dedicated carer services, particularly from the network of Carers Centres across Scotland.
Direct payments for individuals have been used for
- a short break away, where the service user is supported and the carer enjoys a break
- driving lessons and test to enable the carer to transport or visit the service user
- taxi fares to visit or go out with the service user
- swimming lessons to be able to then accompany the service user in the pool
- the purchase of a mobile phone to facilitate emergency contact
- a gardening, laundry or cleaning service to allow the carer to focus on personal care
- club membership to access leisure and recreational facilities, to improve fitness
- complementary therapies, relaxation classes, therapeutic massage
- a sitter service to provide flexible short breaks when required
- the purchase of a washing machine to reduce trips to the laundrette
- a personal assistant to accompany the carer and service user on holiday
Supporting unpaid carers provides benefits to the service user as well as to the carers themselves. Timely intervention can also help to reduce the demands that local authorities and their health partners would otherwise have to respond to. As such, supporting and sustaining unpaid carers, particularly through SDS, can contribute significantly to preventative strategies and assist community partnerships in their efforts to develop more personalised and effective interventions that prevent individuals from developing more acute needs. However, local authorities and their health care partners already recognise that some carers reach a point when, even with respite, they no longer feel able to continue to provide the level of care needed.
The Scottish Government proposals for a Self-directed Support Bill include a proposal to introduce a power to allow councils to make a direct payment where it would help the carer to continue in the caring role. These proposals will depend on the outcome of the Parliamentary process.
Employing Family Carers as Personal Assistants
Current direct payment legislation only allows DPs to be used to employ a close family member in exceptional circumstances, "…where securing the service from such a person it is necessary to satisfactorily meet the service user's assessed needs." Family carers highlight that this provision is used less in some local authorities than others, despite there being particular circumstances when applying it could bring significant benefit to the service user.
Whilst there is no drive to remove this legislative limitation on employing family members as personal assistants, it is important that this facility at councils' disposal is used where this could provide best outcomes.
The following are examples of local authorities using this power to deliver the best outcomes for all concerned.
- a person requires end-of-life care
- there are limitations in the availability of suitable service providers in a rural or remote areas
- it is considered to be the most appropriate way of meeting an individual's cultural needs
- a feature of the person's disability is challenging behaviour towards strangers
The list is purely illustrative and there will be many examples of using the power in to enable individuals and carers to achieve the best outcomes.