Public Audit and Post-legislative Scrutiny Committee 30 November 2017
The agenda for the day:
Decision on Taking Business in Private, Self-Directed Support (Post-legislative Scrutiny).
Decision on Taking Business in Private
Decision on Taking Business in Private
Good morning and welcome to the 29th meeting in 2017 of the Public Audit and Post-legislative Scrutiny Committee. Could everybody around the table and in the public gallery switch off any mobile devices so that they do not affect the committee’s work? I welcome Kenny Gibson, who is substituting for Colin Beattie today.
The first item is on taking business in private. Do we agree to take item 3 in private?
Members indicated agreement.
Self-Directed Support (Post-legislative Scrutiny)
Self-Directed Support (Post-legislative Scrutiny)
Item 2 is post-legislative scrutiny of self-directed support. We are setting something of a parliamentary precedent by combining two pieces of work. We recently invited suggestions from stakeholders and members of the public for acts on which they would like post-legislative scrutiny undertaken, and the Social Care (Self-directed Support) (Scotland) Act 2013 was suggested by a variety of different organisations. Separately, we also took evidence from Audit Scotland on its report, “Self-directed support: 2017 progress report”. Following that meeting, we agreed to combine those pieces of work into one.
I welcome our participants and thank them for coming. Would all MSPs and participants start by briefly introducing themselves? I will start on my right, both geographically and politically.
That is an outrageous thing to say. [Laughter.] I am Liam Kerr, MSP for North East Scotland for the Scottish Conservative Party.
Iain Smith (Inclusion Scotland)
I am Iain Smith, policy and public affairs officer at Inclusion Scotland, which is the national network organisation for disabled people’s organisations in Scotland.
I am Alex Neil, MSP for Airdrie and Shotts, and I should probably declare an interest in that I was the Cabinet Secretary for Health and Wellbeing when the Social Care (Self-directed Support) (Scotland) Act 2013 was passed.
I am Monica Lennon, MSP for Central Scotland.
Jess Wade (Self Directed Support Scotland)
I am the manager at Self Directed Support Scotland. We are a national membership organisation, and our members are local disabled people’s organisations that help people through the SDS journey.
I am Bill Bowman, MSP for the North East Scotland region.
I am Willie Coffey, SNP MSP for Kilmarnock and Irvine Valley.
I am Kenneth Gibson, MSP for Cunninghame North.
Kenny, you jumped in before David Williams.
I know. I am just so excited at being here, sorry.
David Williams (Glasgow City Health and Social Care Partnership)
I am David Williams, chief officer for Glasgow city health and social care partnership.
I am still Kenneth Gibson, MSP for Cunninghame North.
I am Jackie Baillie, MSP for Dumbarton.
We indicated in advance that we would discuss three themes during this round-table session. Although it is meant to be a free-flowing discussion, we want to give it a bit of structure. The first of the three themes, which we sent out in advance, is about the provision of information to people seeking access to SDS, the second is about ensuring that care decisions are outcome-based and not simply resource-led, and the third is on removing the barriers to successful implementation. If you want to give examples of good practice during our discussion, feel free to do so but we are also quite keen to get answers to some of our questions.
I will kick off with the first theme. In its report, Audit Scotland pointed out that people need better information on self-directed support and on the choices available to them, and it is clear that not everybody is given information on all four choices, nor are they aware of access to independent advice and advocacy.
How is information currently provided? Is the picture that Audit Scotland painted reasonable? Are the four options routinely described to people? What should happen in an ideal world?
I am happy to make a start on that one. Our members work to provide information and support around self-directed support and, ideally, they provide information on the four options.
How is information currently provided? The Audit Scotland report is accurate about what our members tell us about their experiences and the experiences of people they work with. Provision is really patchy. People often come to one of our member organisations because a friend or somebody they know told them about it or mentioned it.
Some of our members have really good referral pathways from the local authorities. Social workers or others will direct people to them, but that is not consistent. Some organisations try to do the work but they do not necessarily get referrals direct from the authority, which is where it really needs to be happening. Even if they do get a referral, it is sometimes because there has been a conversation in which it has been identified that the person might be interested in option 1, for example. The person might therefore have been directed to that organisation without necessarily having had the conversation to explore all the options. When we then go back and have more of that conversation, it might be that option 1 is not for them but the social worker probably did not have the time to discuss it in a lot of detail.
The four options are not being discussed routinely in every case. The data and the development work that came out earlier in the summer said that the SDS conversations have probably only been delivered to around 27 per cent of the people who are accessing social care. That means that everybody else has not had a conversation about the four options around SDS.
Again, we hear a lot from our members that people only heard about SDS because they know somebody, or something like that. Last week, I spoke to a lady who phoned up because her friend had mentioned self-directed support to her. She was having a meeting with the social worker so she thought that she would just ask about SDS. However, her social worker told her that it was nothing to do with her. That was a person with a funded package who has a budget, and it would have been the ideal time to talk about the options because the package that was in place was not working. Instead, it got dismissed and she was told, “We cannot be bringing extra things in now”. She was told that SDS was a separate thing so she did not get the opportunity that she should have had.
Your third question was about what should happen in an ideal world. It is probably not surprising that I would say that we would like in every local authority area a user-led SDS support organisation that is independent from the local authority. We already have that in lots of local authorities in Scotland, so that is great news, but we do not have it in all of them, and the funding is not always consistent. Such organisations might be funded in some areas but only to work on option 1, so there is a limit to how much work they can do around the other options, around exploring options creatively, and around moving between options.
Where SDS exists, it seems to work pretty well, but we would like to see something that has been led by disabled people—service users—who know their stuff and can support people through that journey, and we would like everybody in Scotland to have access to independent support.
Fundamental to the successful implementation of the 2013 act is clients receiving accurate information about the options that are available to them. I am sure that Alex Neil, who was the minister responsible at the time, will agree that the principle of the act is actually about enhancing the human rights of people who receive social care by giving them choice and control over the care that they receive. That is about empowerment, but you cannot have empowerment if you do not give people the information they need to be empowered. The anecdotal information that we receive from our members at events is that, too often, social workers make assumptions about what option is right for an individual, rather than giving the individual information about the options available and allowing them to make that choice themselves. That removes the choice and control from individuals about the packages that they get.
I echo Jess Wade’s points. At 27 per cent, the implementation rate for self-directed support is woefully low, given that it is now a number of years since the act went through in 2013. That means that roughly one in four people who should be receiving SDS is receiving that option because they have been given a proper choice. Three in four have not been given the option yet, which is not acceptable, and it is partly because they do not have the information about it.
Other issues are detracting from people getting SDS, and we will come on to them in some of the later questions, but providing independent information and advice to individuals so that they can make an informed choice about what option is best for them is essential if the act is to fulfil its founding principles.
In her written evidence, Jess Wade talks about a lack of accountability in local authorities. I notice that there is an issue about consistency. For example, there is a 3 per cent uptake in West Dunbartonshire compared to 78 per cent in Perth and Kinross. Do you have concerns that people are not being given the choice of options and are being steered towards specific options because the resources available might make it easier for a local authority to deliver one package over another, and that those options might not be appropriate for the individuals concerned?
Jess Wade is probably in a better position to answer that than I am, but some of the evidence that you received in the paper from the Minority Ethnic Carers of People Project and Scottish Care, for example, suggests that there is an element of social workers saying to people, “This is not right for you. We know better. It is not an appropriate package for you”, and in many cases steering people to stay on their current packages, which are effectively option 3, rather than looking at whether or not option 2 or option 1, or even option 4—a mix of different elements for different purposes that seems to be virtually unused—would be more appropriate.
The balance of power between the professionals making the assessment and the individual receiving the service has not yet shifted in the way that SDS was meant to shift it; it is still with professionals steering individuals towards certain packages.
Yes. Our members would say that it is not necessarily one particular option that people are being steered towards or away from. For example, a lot of our members who work in rural areas have concerns that people are being directed towards option 1, a direct payment, when they do not actually want it, which is as inappropriate as directing people away from that option when they do want it. That might have come about because there are not many service providers in an area, or because there are no service providers in some areas, so the only way for somebody to get support in is for them to take responsibility and directly employ someone themselves. That is fine when the person wants that, and when there is support for them to do so, that is fantastic. However, if the person does not want that, it is not an appropriate response. We are certainly hearing about cases of people in rural areas being directed towards option 1 when they do not want it.
In other areas, we hear about people being directed away from other options and sometimes that is to do with resource. We have heard of cases in which social workers have been told to encourage people towards block-contracted services first and look at alternative options only after that has happened. We believe that that has happened in some areas. Obviously, that is about resource and freeing up money that is tied into block contracts.
As Iain Smith says, the problem is not always directly resource related. It is more about not understanding what option is appropriate for different people and making assumptions rather than exploring what somebody is interested in and what might suit them best. Probably some of that is about not having time. If workers do not have the time to have a good conversation, they might make assumptions. For example, if the person sitting in front of them is older, the worker might be more inclined to think, “They are less likely to want choice and control, so I can direct them to a more straightforward route. That is probably the route they will go down anyway”, rather than taking the time to have the full conversation. SDS conversations take a long, long time to do well, but we know that when they are done well, the outcomes are better.
There are an awful lot of issues even in just that little bit of a conversation. I want to start by suggesting that the manner in which data is collected across Scotland might be a challenge. I am not persuaded that data is being collected consistently, with the same questions being asked across all 32 local authorities. That might be one of the explanations for the diversity between West Dunbartonshire and Perth and Kinross. That needs a bit of further work, as the Audit Scotland report highlighted, but it does point in the direction of general averages of 27 per cent.
I cannot speak for how 31 other local authorities have introduced or implemented self-directed support, but I can say that, as many round the table will probably be aware, we in Glasgow introduced personalisation a couple of years before the legislation came into being. There were a number of reasons for that, not least of which was the output from the 21st century review of social work that was concluded in the 2006 document, “Changing Lives”, which very clearly outlined that, at that point, social work services across Scotland were not delivering services in a way that was anywhere near personalised enough.09:15
Prior to the drafting of the bill, the Scottish Government signalled its intention to bring in self-directed support. There was a significant volume of lobbying, particularly from the user-led organisations and disability organisations, for the implementation of something like self-directed support following on from “Changing Lives”. We in Glasgow felt that it was prudent and appropriate to move ahead with that, particularly as we had been one of the initial three test sites for the implementation of the legislation.
We took the decision to introduce personalisation to all existing and new service users in the city who were in receipt of packages. That created quite a stir initially because it meant that we were reviewing individuals who had long been in receipt of established packages of support. We did that because we did not feel that it was appropriate to have a two-tier system of assessment of need for allocation of resources. We wanted to move because we believed strongly that there was a need for equality and equitable access to assessment and allocation of resource, and we could do that only by way of a single system.
The consequence of that is that self-directed support assessments and personalisation is the only route to access to services for people who are not in need of a response to a crisis or an emergency, or who need relatively low-level support to facilitate things such as coming out of hospital. People with long-expected needs have access to self-directed support right from the word go. I have lots more to say but we will come back to that I am sure.
According to the Auditor General’s report, Glasgow has one of the lowest take-ups of direct payments. There is a graph showing the variation in the number of people with direct payments per 100,000 of population. Glasgow is well below the national average and one of the poorest performers in the graph. I ask David Williams how he reconciles that with what he is saying about personalisation.
There are a few things there. I come back to the issue of data collection and consistency of approach. We need to be very clear that direct payment does not equate to self-directed support. The four options have been alluded to and we need to have a spread across those options.
There are issues around the bureaucratic processes involved in the take-up of direct payments. There is an established issue in relation to how people who receive direct payments are expected to account for that spend, in line with the agreements about what that money should be used for, the provision of receipts and so on. One of the things that we are striving to put in place by fairly early next year is a prepayment card, which will strip all of that out and take away the pressures on individuals or their carers as a result of having to be involved in a bureaucratic process, because that is the last thing that they want or need to be involved in. Those issues are also prevalent in relation to direct payments.
What I have not said is that I believe that we have got it sorted in Glasgow. The introduction of self-directed support legislation and practice is a continuing journey and the principles behind it continue to be developed.
What percentage of people in Glasgow have self-directed support?
In relation to the four options?
Yes. How does Glasgow compare? How many folk have what would be described as self-directed support?
Pretty much all individuals who having a learning disability, a mental health issue or a physical disability in the setting—
What percentage of those eligible, under the terms of the legislation, have self-directed support?
The eligibility criteria are another issue that creates a requirement for a broad approach to the implementation of the legislation. It is not a case of presenting to social work services saying, “I need or want self-directed support.” There are statutory requirements of social workers, which is about an assessment of need. If that assessment identifies a need for care support, the social work department or local authority has a duty to provide or make provision for that, which can be done in a variety of ways.
As far as I am aware, about 21 per cent of those eligible for self-directed support get it. We do not include the provision of support for people over the age of 65 in that 21 per cent, but that does not mean that they are excluded from self-directed support.
Why are they not included in those figures?
Our information and communication technology system predated the introduction of the data collection systems that were put in place when the legislation came into effect. To include support for older people would be a significant change that would mean significant investment of resource. We are moving to a phased implementation in relation to older people. In the main, we have a single provider of older people’s home care support, through an arm’s-length organisation in the city that does most of that work for us. We expect, as part of the contract with that care provider, that older people who are identified as requiring a continuing service have access to the four options at the point of their first review with the provider. That is fully in place. We have not been able to collect that data yet, but we are working on that in line with the Audit Scotland report and we would expect our figures to be measurably improved.
When will you be in a position to answer my question about the percentage of people in Glasgow, across the eligibility categories? When will your information technology systems be up to scratch to give us an indication of what the overall percentage is?
It is not just about our IT systems; there is a data collection system across Scotland in relation to how SDS is monitored and tracked. In Glasgow—
I accept that, but if I were a senior councillor in Glasgow, I would want to know when the IT systems are going to be able to give me the information that I need. That is my second question: when are you going to be in a position to tell us that you are compliant with the 2013 act?
We believe that we are compliant with the act. What we cannot do is evidence that.
How do we know? You do not have the information.
There is on-going engagement on that with our arm’s-length provider, which will allow us to provide the information in a constructive and transparent way.
When will the IT systems be ready to give you an accurate, detailed breakdown of what kind of support your clientele—if I can put it that way—are getting? You have said yourself that the IT systems are not up to scratch, so my question, put very simply, is: when will they be up to scratch?
The blunt answer is that I do not know, because there are a number of priorities around the wider business of health and social care integration that relate to ICT and connectivity between all sorts of different systems, not just within social work departments and with arm’s-length organisations but across to ICT systems on the health side. There is not a straightforward binary response, in which we say, “We are going to deal with that and nothing else.” As you will appreciate, the business of health and social care is very complex and there are multiple demands on ensuring that we are putting things in place. We are confident that we are making available the four options to older people who are supported by Cordia. We are unable to give clear data and evidence at the moment, but we are assured by our on-going engagement with the provider that that information is being relayed to service users, that service users are clear about the choices that they are making and that the choices that they are making are as a consequence of receiving that information. We cannot evidence that, but we are working on it.
Can I ask Jess Wade a supplementary?
Before you do that, I am conscious that we have been joined by two people who were held up earlier. I am delighted to welcome Colin Young, who is the senior policy and outcomes officer from the Health and Social Care Alliance Scotland—alliance Scotland—and Erik Sutherland, who is the senior manager, planning and performance, at East Ayrshire health and social care partnership.
You may have come in and seen two people talking to each other. It is of course a round-table discussion, and I am keen to ensure that that continues.
From your perspective and that of your members, is Glasgow fulfilling the requirements of the legislation?
That is a very good question. David Williams said that an arm’s-length organisation will be carrying out the first review in which older people are offered the SDS options. I would have a real concern that that is not independent information and support, because it is coming from the organisation that is currently the service provider. It will potentially ask people whether they want to continue with what it is giving them. That might make people feel as if they are being asked, “Do you want to carry on with us or do you want to change to something else?” I am not sure how easy it is for staff of a service provider to be put in that position, in terms of conflict of interest. They would be offering somebody something that meant that the money would go elsewhere, potentially affecting their job, the jobs of colleagues and the health of their organisation. I am not sure that that is a fair position to put people in.
What I will say about Glasgow is that it funds a fantastic user-led independent information and support service, the Glasgow Centre for Inclusive Living, which would be in a really great position to provide extra information and support. GCIL would obviously need additional capacity to do that work, but I am sure that it would be happy to talk about the best way to provide that support, and whether having Cordia do those reviews is the right way or the best way, or whether there are better ways of doing it. I am sure that an organisation such as GCIL would have views on the best way to provide information and support. I hope that that is a fair response.
Let us stick with the provision of information to people seeking it, because I want to wrap up on that before we move on. Liam Kerr wants to add something.
In earlier responses from Iain Smith and Jess Wade, I certainly got the impression of people being directed, and of social workers almost as gatekeepers. We might return to that later.
Who is the onus on to provide information to users? Who should the onus be on? What information is being provided? If we start from the position that the situation is not as it should be, and you are telling me, “It should actually look like this”, who would drive that change?
Local authorities have legislative responsibility to ensure that people are offered the four options. As far as I am concerned, they can pass on that duty to someone whom they commission or contract to do that work. For example, an authority can tell the service user that they will get all the information on the different options from an independent organisation if they want to. A lot of authorities have an independent provider who specialises in option 1, and that is historic—we had direct payments in place already, which is now option 1. Previously, if the issue of direct payments came up when the authority was doing an assessment, and it looked as though the person was interested, they would go off to the independent organisation and get that support. For anything else, they would stay with the social worker who would talk them through things.09:30
A lot of our members are very keen to do the extra work at an early stage with people who are thinking about their options; ideally, they work with people pre-assessment but, again, that depends on capacity and funding. Some of our members are doing that work with Government funding through a programme called support in the right direction. Before the service user has even found out whether they are eligible, our members are sitting down with them and talking about the options around SDS. In Fife, for example, there is a service called SDS options, which is funded through the Government. People can talk about the options that are open to them and then, if they want to follow up on option 1, they go elsewhere in the organisation to get that support. The transition is quite smooth.
You asked who would drive the change. We are really concerned that with SDS, as with many things in Scotland, there is a central ideal or piece of legislation and interpretation is then up to local authorities. We would like to see something stronger coming from the Government to give a bit more direction about best practice.
We know that there is little money for local authorities. If I was working in local authority finance, I might have to decide whether to fund independent support—it is recommended in the guidance, but we might be able to do without it—or independent advocacy, which legislatively I have to ensure is provided in my area. Which one will I fund? You know that I will fund the one that I absolutely have to provide and try to get by on the other one. How else can decisions be made?
We would like greater weight to be put on the need for independent support and greater clarity on what independent support is. If the local authority is providing the support itself, that is not really independent. It might be separate from the service user’s social worker, but that does not mean that it is independent. It does not feel independent for individuals.
Did that answer all your questions?
Yes, although I have a quick follow-up question. Somewhere in our papers—I cannot put my finger on where—I read about there being no consistency in how local authorities collate data. It was suggested that some authorities may be logging option 2 when actually they have delivered option 3. Mr Williams made a point about data capture, which the committee is very concerned about.
It sounds as if there needs to be a change. If we accept that, who will drive that change? The alternative is that it would be up to the authority to say, “We are not quite getting this right”, but I cannot imagine that happening.
I plead guilty to having put that into the Inclusion Scotland evidence. Our concern is that there are two outlying authorities—Glasgow and North Lanarkshire—that seem to have a very large percentage of people on option 2 compared with other authorities. Our feeling—it is just a feeling—is that that is a bit strange. We cannot understand why that is the case. David Williams might be able to answer for Glasgow.
In essence, under option 3 the council provides the service, as is the old practice. Under option 2, someone manages the payments on the service user’s behalf for the service that they receive. However, some people are being offered the same service that they get at present but they are being told that someone else is managing their funding package for them. Technically that is option 2, because someone is managing the funding package for them, but they are only really being offered what they would have had under option 3. That is our concern.
We do not have any evidence for that, because there is no audit trail back to the individual to find out whether there is a match between what they were offered and what they are getting. That is another thing that we are concerned about. We are concerned that we need more surveys and more evidence to be gathered on how the options are being implemented in each local authority area. We need to go back to the individual packages that people are receiving to find out whether they are being recorded accurately against each of the four options.
I will come back to the Cordia issue, if that is okay. Having said that I cannot talk about any of the other 31 local authorities, I can probably make a comment around North Lanarkshire. North Lanarkshire was streets ahead of pretty much every other local authority on providing a personalised and choice-led approach to the delivery of social care, particularly for people with learning disabilities. That was around the emphasis on option 2. We learned a lot from what North Lanarkshire was doing when we implemented personalisation in the development of our programme and our scheme. It was clear that we needed to be able to look at how we could afford choice to service users if they were going down the route of direct payments; we also needed to be able to demonstrate and manage that on their behalf.
Again, the situation is not straightforward. The environment is complex, and because we put pretty much all of our service users through that process it involved a review of their existing packages of support. A service user might say to us, on the back of that review, “I have been provided with support for the past 10 years by X provider. I am very happy with that provider and I want to choose under option 2 for that provider to continue, but I do not want to manage it myself. Can you do it for me?” In our view, that is a legitimate choice. That is probably an explanation in part for the fact that we and North Lanarkshire are outliers.
Home care providers are required, through the Care Inspectorate, to review their service users twice a year, and a degree of pragmatism is involved in how much an authority can do regarding the delivery of all its business. If the home care provider is required to do that anyway and there is connectivity by way of a contract between ourselves as the social work department and the arm’s-length organisation, why would we have two separate reviews, one of which is about the home care package while the other is about self-directed support? The two have to be considered as the same.
The issue around advocacy and independence is about making sure that people can be properly represented at the point of their review. Have we got that absolutely correct in all the 11,000 referrals every year that Cordia will take? Probably not, but we work on the basis that older people who receive services have family members who will be part of their review of care and support; their family members are concerned about the older person, so they want to be involved in the decision making around the provision of support. Again, I understand what you are saying, but a degree of pragmatism is required around how we are able to deliver services at the level that we are being asked to deliver them.
You suggested that most older people have family support and other people in their lives to advocate for them. However, my concern is about the people who do not have close family members and do not have that network. We see that in casework generally, when we think, “Thank goodness that person had family to come to us.” We always worry about the people who are stuck at home and have no one. The Audit Scotland report picked up on the fact that not everyone gets the choice and not everyone has that support. You mentioned 11,000 referrals, which is a lot of people. What happens when they do not have people at home or a family member to speak up on their behalf and interrogate things a bit more?
That is a fair point. We should not make assumptions that social workers across all local authorities and our provider organisations are not seriously endeavouring to implement the legislation and the spirit of the legislation. The legislation is rights based. Social workers up and down the country have to make a professional judgment that is based on their qualifications, their learning and their statutory responsibilities to be objective and non-judgmental. That is backed and influenced by a rights-based approach in all cases. We have to be able to give credit to folk to ensure that they are able to advocate as well. It is not just independent advocates who can advocate on behalf of individuals who are service users. One of the social workers’ core functions is to be able to advocate for people in the delivery and receipt of services.
We are perhaps in danger of losing sight of one of the key points. The point of independent information and advocacy is that the people who provide them can suggest alternative ways in which services can be provided, in a way that perhaps the family or the individual service user cannot do because they are not necessarily aware that the outcome can be achieved by other means than the traditional service. We must ensure that people have access to independent information and advice, because that gives them the opportunity to explore different ways in which to have their support needs met.
Erik Sutherland (East Ayrshire Health and Social Care Partnership)
I agree there is definitely a data issue for us. If we look at my life, my plan—that is our tool for having the conversation with people—along with my life, my review, we find that of the 3,500 live case loads, 2,500 have had that. We are looking at 66 or 70 per cent of service users having actively chosen that option. At a national level, we probably need to get better at capturing how that data is recorded. More critically, we need to get better at capturing how outcomes are being realised. That feeds into our commissioning processes, but that is probably for another conversation.
For us, option 2 is seen as a very real choice for people and it has been an area of growth. I think that that is a healthy thing to see. This time last year, we had about 129 people choosing option 2. As of last Friday, we now have more than 170 people. It is an area of growth for us and I think that that is a positive around the intention and the spirit of the law. People are exercising their true choice around option 2. We have had people move from option 1 to option 2, for example. That is part of the intent.
There are organisations in Ayrshire that provide independent information and advice. Ayrshire Independent Living Network provides advice and support. We also have the Community Brokerage Network in East Ayrshire, which provides a slightly different function between the professional and the individual and their families around how an individual budget can be shaped so that the person is supported to make more creative solutions. That has been a really positive thing for us.
I return to the point that Iain Smith made about advocacy. Advocates are providing for individuals alongside the independent advice and brokerage. We have developed that service very much through a co-productive way of working. Our approach, which is called everyone together, started off with practitioners, families, the public and providers being involved in taking the SDS conversation out to communities. That has been a really positive thing for us. When we look at documentation, reviewing our processes and streamlining things, our approach will again be everyone together. Let us do it round the table. Let us all have that grown-up conversation about where we are at and where we want to be.
I am sorry—I am rambling.
No, that was very useful. It is an interesting approach, which perhaps contrasts with others. Does Colin Young want to add anything about the provision of information and advocacy support?
Colin Young (Health and Social Care Alliance Scotland)
Yes, of course. I am sorry for being late.
The point has been made about self-directed support being intrinsically linked with personalisation. When you look at the provision of information and how people feel about whether the information helps them to make the decision that is right for them, it is especially the people on options 1 and 2 who feel that they have more autonomy over their outcomes. Often, when people have the right information in the first place they are more likely to decide on those options, which provide more autonomy and flexibility to give the outcome that they desire.09:45
When we were looking at whether information had helped people to make the right choice, we surveyed around 100 people. Those who were on option 3 or option 4 were less inclined to say that the information they had received had helped them make their choice; 40 per cent of those who were on option 3 said that the information did not lead to their preferred choice. There is a real link between how the information is presented and how people use it. Often, it comes down to the individual discussion between the social worker and the individual. Our research found that 25 per cent of people who had been made aware of SDS by the social worker stated that they still did not know anything, or knew only very little, about self-directed support. That is worrying. I think that David Williams was right to say that the social workers’ duty is to promote the needs of the individual, but how the person responds is very dependent on how that information is presented.
That is very useful information, which underscores the need for early and independent advocacy.
You have raised issues of staffing, which leads neatly on to questioning from Willie Coffey.
In one of the Auditor General’s comments about outcomes, which was your second theme, she said that social work staff are positive about the principles of SDS but that a significant majority of them lack understanding of or confidence in focusing on people’s outcomes. That chimes with what Colin Young just said in relation to information gathering.
To assist our social work services staff, is there a job to be done in giving them the skills that they need to do this particular job for us of information gathering and, potentially, assessing outcomes? Is it fair that we are asking our social workers to assess these outcomes, or should it be someone else? I would value your views on those issues.
There is always a job to be done in relation to how new legislation is introduced, implemented and progressed. Assessing for outcomes is a challenge for all of us. That is not exclusive to social workers; it includes provider organisations that are substantially responsible for delivering services. There are issues around the manner in which services are procured. For instance, in Glasgow, over the past couple of years, we have been working hard to see how we could move away from the procurement of services by the hour, because that is an inhibitor for the delivery of outcomes. That is about how people are supported and enabled to have the life that they wish to have, and how they are included and able to participate in their communities and in society.
That leads on to a bigger and broader picture of the delivery of support in its broadest sense for people who have SDS access because of identified need and who are provided with support to deal with that. That provision goes way beyond local authority social work departments’ responsibilities, and it takes in what is happening in communities. Therein lies the issue. How do we engage with people and create that marketplace, in crude terms, of broad support including care support, which is the bit that is commissioned and procured by social workers? There is a big, broad task in delivering on the principles and the spirit of the legislation.
I want to be absolutely clear about how the assessment process progresses and how outcomes are identified as part of what we, in Glasgow, call an outcomes-based care plan. That plan is, as Erik Sutherland has suggested, co-produced, not something that the social worker decides for themselves. We must be able to demonstrate and evidence very clearly that the service user and their advocates, if there are advocates in place, are involved in the process.
That is the significant change that the legislation makes. It used to be very much a case of providing services on an inputs and outputs basis without looking at what we were doing or why. The world has changed, but it is a developing story that is not going to be introduced overnight. As I say, that is because we are taking an approach to how need is assessed and services are provided that is fundamentally, seismically different from what has been asked of social work services over the past 20 or 30 years. The change is measurably different, so it is not going to happen overnight.
Could we hear from other colleagues?
From our point of view, it is about where that conversation starts, what the dialogue is and what that is framed around. We have started with the talking points themes—the question “What matters to you?” rather than the question “What is the matter with you?” It is about supporting the workforce to have that dialogue, being clear and putting investment into that.
We are supporting people to work in that different way, so that they talk about feeling safe, about having things to do and about the place where they live and how suitable it is for their needs. We are having that conversation, that dialogue. In East Ayrshire, we have put a lot of effort into making sure that the workforce feels confident and capable of having those conversations, which are slightly different from the previous needs-based, single shared assessment discussions that folk might have had.
We have also established a peer mentor-type model whereby individuals with a different skill set get alongside workers and teams and support them to work in that different way. For us, it is partly a matter of recognising that there is a synergy between an anticipatory care plan, self-directed support and technology-enabled care. People are having those conversations at the first point of contact, which has parallels with conversations around realistic medicine. It is not just about what other providers will do but about community capacity and maximising people’s natural assets. We are having that conversation about what is important to them, who supports them and what statutory services need to do to support them. It is about looking at the natural assets, having the conversation with the individual and then looking at the additional support that is required around that, which is a different conversation.
The self-directed support principles are very much in line with the human rights approach in the United Nations Convention on the Rights of Persons with Disabilities, the right to independent living and an approach that is about providing support to enable people to participate in society. What concerns us—it is perhaps the elephant in the room—is that the resources are not there to back up that approach.
Perhaps one of the reasons why self-directed support has not been implemented as effectively as we would have liked in the early days is that it is being implemented at a time when the criteria for beginning to receive social care have been getting tighter and tighter. In many cases, it is now just critical care or life-and-limb support. Someone being able to get out of bed in the morning is not really an outcome; the outcome is what they do once they get out of bed. Unfortunately, for many people, the only support that they get is in getting out of bed or getting back into bed at night. The amount of social care that they get is that limited.
Until we start to address some of the fundamental issues about what we expect social care to deliver and how we fund it—perhaps using the document “Our shared ambition for the future of social care support in Scotland”, which was produced by a number of third sector organisations, disabled people’s organisations and others, and which has been endorsed in the Scottish Government’s disability delivery plan—we are not going to address the problems with self-directed support.
It would be useful, convener, if we could get hold of a copy of that document.
I am happy to support the committee, convener. Until we start to address some of those fundamental issues and start to look at the outcomes that people really want—which are to be a part of society, to have a job, to participate in education and to have a social life, the same as everybody else—we are not going to solve the problems of SDS.
There was a lot of nodding when you mentioned the lack of resource.
Yes. I am not going to disagree with you about the lack of resource, but we are where we are. It seems to me that, rather than look at the legislation on self-directed support in isolation, as I suggested earlier, we now need to look at the possibilities and opportunities of the health and social care integration agenda. There are 31 health and social care partnerships up and down the country, which are all planning and delivering the receipt and experience of health and social care in a fundamentally different way from how they were previously planned and delivered. As partnerships, we are not yet at the end of the journey—we have heard lots of narrative about that—but we have only been going for a couple of years.
The key word in the title “health and social care partnership”—which, incidentally, does not appear in the legislation—is “partnership”. Too many people see the integration of health and social care as being just that bit of a council and that bit of a health board being brought together. The partnership is so much more than that. If you look at the voting and non-voting members in the integration joint board, you will see other stakeholder groups—the voluntary sector, the independent sector, service users, carers, patients, trade unions and clinicians—all of whom now have to work in partnership within this thing called health and social care integration. We also have partnership responsibilities beyond that, through things such as community planning.
What I am saying to you is that there is a significant level of asset and resource in the wider sphere that will contribute towards people being included and involved, having a life and having their aspirations met. If we focus just on the delivery of the self-directed support, we might miss the opportunities that health and social care integration can bring.
Colin Young suggested that the provision of information could go some way to delivering a freer choice. We have since heard about an almost resource-led approach. I was concerned to read, in the submission that we have had from MECOPP:
“We cite examples of practitioners sitting across from individuals with a calculator working backwards from the indicative budget to determine what they can afford to meet their personal outcomes.”
Is that correct? Is that really what is happening? That would be a significant blocker to real choice, would it not?
I can well believe that that is happening, yes. Over the years, I have spoken to people who have had their social worker say, for example, “We are going to sit down, have a conversation and agree what your outcomes are and what we think needs to happen. It is then going to go to a panel and your support is going to be cut by 70 per cent.” That gives you an idea of how social workers are feeling. I accept that there are loads of workers out there who are committed to self-directed support and want to make it work, but the reality is that their hands are tied.10:00
I agree completely with what Iain Smith said about a lack of capacity. It is not just about the money for packages or moving money out of block contracts and into individual packages; it is also about having the capacity to train social workers and having the time for those good conversations. I have been speaking to a colleague of Erik Sutherland’s at a few meetings this week, and I have heard great stuff about what is going on. However, it has taken a long time, it has been a big process and it means giving the social workers time to have those good conversations. That is a massive investment, and, if there are 11,000 referrals coming in, it is a difficult investment to make. We need to recognise that this is a huge change.
I agree with what David Williams said about there being opportunities around integration. To me, SDS is the answer to integration; if we get the two working really well together, the one will support the other. SDS should be absolutely central to making integration work, as it really supports it. However, it is a matter of moving the money around. The fact that, at the moment, folk are getting funding at a critical level and nothing else means that people are not doing preventative work, and it means that creativity and flexibility go out the window, because people are looking at how much they can afford.
This may be going away from the subject slightly, but it is important to mention that the success of those conversations is not just in the time spent on them but in the trust that is crucial to making SDS work. It is a major barrier that, at the moment, it is fair to say that there is very little trust from service users when they are sitting across from someone. Sitting across from someone with a calculator does not make them feel confident and safe or that the conversation is going to work for them.
We hear all the time of people who are scared to come for a review or do not want a review. The local authority does not have time to conduct a review unless someone asks for one, but they are not going to ask for one. They would rather put up with something that is not really working because they know that, if they have a review, the level of their package is only going to go down. It is a barrier to people coming forward and going through the SDS process that they are scared of it.
The MECOPP example is alarming and does not chime with our experience or our approach of sitting down with a calculator.
If we look at the time that is invested in the conversation with SDS in terms of the public pound, we see that someone having such a detailed conversation about what matters to them will pay dividends in the future. As Jess Wade says, we have some really good personal stories and examples that we have consistently brought to our SDS programme board and our IJB. We have costed those cases pre and post-SDS conversation, and the post-conversation cost is markedly lower, meaning not only that people can have very good personal outcomes but that they cost the public purse less.
The challenge is for SDS to have that transformative potential, and that is what we want to focus on instead of picking some of the procedural bits off it.
That is fine. The only caveat that I would add is that, when the process is driven by the individual and happens to result in a saving, that is good; when it is driven by the local authority in a blanket way, that is bad. We have seen examples of the latter.
I have a follow-up question. I am glad that things are going well in East Ayrshire, but, as I have mentioned before, the issue is consistency across local authorities. Jess Wade made the point in her submission that
“People are overwhelmed by the process and feel intimidated”.
That may not be an issue in East Ayrshire, but it seems to be one in other areas of Scotland. Could you expand on that?
That is a direct quote from one of our member organisations, which said that that is its experience in its area, but there is not only one area where people are saying that. It comes back to the point that I was making about folk often feeling that they would rather not come forward for a review; they would rather keep things as they are even though it is not working any more. Everybody’s life changes all the time. If you think about your own life, are you doing exactly the same things in the same way as you were this time last year? Life always changes, so someone’s support needs are always going to change. That might be because their work has changed or where they live has changed. Maybe they have family where they did not before, or maybe someone has moved away and they have lost key support that they used to have. People need to be able to come forward and say, “Things have changed for me and my support needs are probably different.” I think that people are scared of doing that. There is just not the level of trust. David Williams’s point is key: social workers should be on the side of the person, but more often than not they are now seen as the gatekeepers.
We did a piece of research last year on service users’ experiences of SDS. Broadly speaking, 80-plus per cent were happy with the services that they were getting, but fewer than half of them had heard of self-directed support. They had not necessarily been offered choice. What does “happy” mean? Are people happy because they are grateful to be getting something for free, or are they happy because something is enabling them to live a fulfilling life? There are questions around that and more research needs to be done. We hope to be in a position to be able to do that. One of the things that came out of that research was that, where things worked well and people really felt that they had choice and control, they were also saying that they felt that they had a social worker on their side. That was not always the case.
I would not want to do social work in a million years because it is such a hard job, especially at the moment. I have heard stories—I was going to say that we have all heard stories—of social workers sitting down with a person and thinking, “If I agree to that for you, then next week I am going to have to make a different decision for somebody else, because I am conscious of how much money is being spent.” We are hearing of examples of good practice—I think that one is in East Ayrshire, but Erik Sutherland can correct me if I am wrong—where there are systems that allow social workers themselves to sign off on quite a high level of budget without going to a senior manager. That is being regularly reviewed to make sure that it is working successfully.
However, we also hear of systems that are very rigid, where social workers do not have much autonomy to agree to very much or they know that it is just going to be cut anyway. You are going to feel intimidated if the person across the table from you is not able to work in a supportive way but instead is very conscious of how much money they may or may not be able to agree to.
I understand that point obviously, but is there still an issue with cultural resistance whereby some social workers feel that they are the ones who know best and that the individuals perhaps do not know as much as they should, so the social workers want to be in a stronger position and to guide someone down a particular route? It is not always just about finance; it is more about social workers saying, “I have been in this job 10 or 20 years, so I think that I know what is best for you.” Is there still that cultural issue? Obviously, it must vary across the country too.
There probably is that cultural issue to an extent, but it is less than it was. When I started in my job nearly six years ago, we would go around the country running stalls and speaking to people about SDS. We would speak to social workers and either they would not know what SDS was at all or they would say, “Oh, that is that thing about letting people”—letting people!—“organise their own lives or say what they want.” We would meet a real resistance. Increasingly, we are not hearing that as much and we are speaking to more social workers who are up for this. Even back then, we spoke to social workers—it tended to be people who had been through training longer ago—who said, “This is why I got into social work; this is what I want to be able to do but the system stops me.”
There will be the attitude that you describe sometimes, but I would say that it is more about the systems that are a barrier to folk. Social workers want to do this work, but they know that the system is not going to let them and there is not enough money or time, or they do not have the confidence. Colin Young talked about discussing the options. A social worker might know what the options are, but do they really understand what is available or how it would work in practice? They might not have the confidence to talk to somebody about that, so they might guide them down a route because they know better how it works, and steer them away from a route that they do not really know about.
There is a need to make the process more simple and straightforward if there are people who are intimidated by it and there are seemingly unnecessary complexities in the system.
I think that it is about making sure that people have the right support to go through that. For the individual in lots of ways it should be straightforward. What is set up does not have to be complicated. It is how you present the information. Again, as Colin Young said, it is about how information is presented. We all just talk in jargon a lot of the time, but it should not be impossible to explain SDS to people in a straightforward way. What is difficult is the complexity with how it is delivered behind the scenes. That makes it very hard for social workers to navigate.
A lot of the barriers are probably caused more by the processes and systems that the social workers are having to operate within the strategic commissioning structures, which drive people down a particular route to receive a service or have restrictions on how they can use their self-directed support payments, some of which are not lawful. They are told, “You can only use SDS for this,” when legally they can use it for anything that meets the outcome. There is an example in the MECOPP evidence of someone being driven towards a particular council-run service rather than a private service because it was marginally cheaper, but it did not meet the person’s individual outcomes. There are examples, I think in the Highlands, of restrictions being placed on how people could use their self-directed support payment that were clearly outwith the spirit, if not the letter, of the act. Those restrictions are now having to be amended after the people who were affected talked to disabled people’s organisations in the area to try to get things sorted out. There are a number of areas that are still to be ironed out, as to how local authorities loosen up their internal systems in a way that allows people to take advantage of the options that are there.
Another important point is that people need to be allowed to make mistakes. People should be able to try an option or a way of getting their support provided and, if they find out that it does not work for them, they should be able to quickly correct it. At present, there is a fear among risk-averse people in councils and perhaps also among some individuals that, if they try something, they are going to be stuck with it for a year, or two years, or however long it is until the next review. There needs to be an opportunity to experiment to get the right service for an individual.
Many of the comments that have been conveyed by Jess Wade and Iain Smith are absolutely right, but we need to be careful and mindful that we do not get into a position where “the system” is just the local authority system. The system is broader than that, and that is around expectations of social workers and local authorities. Many of the processes are bureaucratic—we absolutely, whole-heartedly sign up to that view—and there is no question but they could be and should be leaner and more understandable, but Glasgow city health and social care partnership is spending £65 million of public money every year on personalisation and self-directed support, so we cannot have too freed-up a system without being able to account for that level of public sector spend. However, as I suggested earlier, I think that we can move from the inputs and outputs type of provision, which is the fundamental driver for the hourly based procurement of services, to something that is more outcomes oriented and is about the whole and the totality of the individual budgets that our people are allocated.
I understand absolutely the comments about risk aversion, but I do not think that social workers are innately risk averse. There probably is risk aversion in the system, but that probably comes as a societal pressure on what social workers are expected to do for our most vulnerable citizens. That drives behaviour; it drives a response that says, “I will do whatever I need to do to ensure that the people for whom I have some statutory responsibility are as safe as possible, because I do not want to be the social worker who is hitting the front pages of the newspapers or media outlets as a consequence of something terrible happening.” That is what happens to social workers who are involved in child death cases, for instance; the social worker may not be responsible, but they are held accountable and the title “social worker” sits across the piece.10:15
I agree with Jess Wade that self-directed support, if it is implemented in the way that it should be implemented, is what drives social workers to come into this business in the first place. Thirty years ago, when I was doing my training as a social worker, I understood my function to be about enabling and empowering people to take control of their own lives. Over the past 20 years, as a system—not just as a profession—we have become very much something that does to people, rather than something that does with people and allows things to happen. Self-directed support is getting us back to the place where social work should be but, as I say, it is not just about social work.
Going back to the point made, I think that we are where we are. From our research, it seems that, if people know and have a conversation about what the costs are and what the resources are, they understand that and they know the situation. It is about inflexibility and resistance to allowing people to take more control over their own choices. The issue that has been raised about agencies that seem to be flouting the legislation is worrying. People are being told, “You are not allowed to use this for X,” but the legislation is quite clear that it is allowed if it meets the outcome. That has real consequences for people.
For instance, we interviewed someone who had moved authorities. Previously, she was allowed to budget in a lump sum to take her husband away once a year, but, when she moved authorities, she was told, “No, you have to take it month on month,” and that frustrated what she was able to do. It leads to much poorer outcomes for people. We also had an instance of people having a budget agreed to pay their support assistant’s lunch; that went on for a year before the local authority came back and said, “We believe that you are not allowed to do that, so can you pay us £2,000 back, please?”
I think that it comes from senior management. People have to be given the autonomy to make sensible comments and decisions.
Can I put a general question to our guests? Has any work been done since the act was passed to demonstrate and evaluate the impact of SDS on outcomes? Have the outcomes improved since the introduction of SDS? Is there evidence that those authorities that have made more progress on the implementation of SDS are achieving better outcomes? There are 31 partnerships, plus the Highlands. Are we spreading best practice? What are the arrangements for that? Who is doing that? Is it the Improvement Service? Is it happening? I am very conscious of all these points about whether the system is working as well as it was intended to work and should be working. Clearly, there are a number of issues that need to be addressed but, even with its faults, is it making a difference to outcomes?
Erik Sutherland will know what has happened in his area, but I do not think that a national picture exists to show whether it works better when people get SDS. I think that there is lots of sharing of good practice. We have loads of examples and most organisations that are working in and around SDS will have case studies in which it can be seen that life has changed for the better for an individual after having a good SDS conversation. Sometimes that is a case study that also shows, “Oh, and it costs a bit less”; sometimes it may cost the same, and sometimes it may cost more, and sometimes that is okay. There are lots of examples of good practice and individual cases, but I am not sure there is anything that says, “Do you know what, folk are meeting better outcomes now”—I would be interested to know if there are authorities that have said that. The Scottish Government is in the process of starting what is called an evaluability study, which will look at some of the gaps in evidence. Whether that national picture will come out of that, I do not know.
Just to reinforce what Jess Wade has said, there are national networks where people are able to share good practice. East Ayrshire has certainly engaged positively with those. Throughout the implementation of the act, we have undertaken self-evaluation and audit activity to understand the impact that it is having on individuals, looking at costs, as Jess Wade said, but also at how well individuals’ outcomes are identified and how well that equates to the budget that they get at the end. We have been doing on-going self-evaluation and audit.
Does that show that self-directed support of itself improves outcomes?
I think that we can say that through case studies and examples. To make a global judgment, we would need to be better at capturing and codifying outcomes.
We never counted outcomes or evaluated against outcomes before, so we are starting from a very low base from that perspective. We made assumptions that things were going well and going right for people. As to whether we can answer the question about the effect of the legislation in a systematic way—Erik Sutherland touched on this—the answer is probably no. We are certainly not doing that in Glasgow, but we have significant volumes of case studies and examples of people routinely writing to me and my local managers just to say thank you. They might write in because their daughter or son has gone from being a young person in transition through to adulthood, and through our local area co-ordinators support or an activity has been put in place that has been life changing. That support may not cost an awful lot of money but, not long ago, that young person might have ended up just going to a daycare centre for the rest of their days. There is a qualitatively different experience that is increasing and we get very few complaints—that is another way of putting it.
I think that that is a key point, convener. SDS is not just a quantitative thing; more importantly, it is a qualitative improvement. That is the most difficult thing to measure, obviously.
I have a question for David Williams. In response to Alex Neil, you said that you were compliant with the act but you could not evidence that and you were not able to give an indication of when you could. To me, that is a bit of a red flag. Are you going to do something about that?
Yes. I have written it at the top of my bit of paper here.
Thank you for that.
I think that Jess Wade mentioned the situation of a finance department having to make a choice between this payment and that payment. How would it make that choice? That brings me on to what Colin Young said—that of course it should be in the interests of the individual. If that does not come through from the top of the organisation, we do not have much chance of fulfilling the requirements of the act—not just the requirements, but the spirit.
We have heard that if you are immersed in this topic, it is easy to use jargon. Even here, we have heard a few things such as community capacity and natural assets, and some acronyms that may be very familiar to all of you, but are not so familiar to me. That leads me on to what Jess Wade was speaking about—user-led independent bodies. Can you tell me a bit more about them? Is there a structure for them or is it just ad hoc?
I would love to tell you more about them. There is not necessarily a particular model, but most of our members follow a relatively consistent model. There are different set-ups in different authorities, which are based on what is needed locally and what the priorities are. Different organisations have come into existence in different ways. GCIL in Glasgow is possibly the oldest such organisation in the country and came about through a mix of campaigning from disabled people themselves and their collective voice and support from key people within the council for the set-up of that organisation. That is what got it off the ground. Some of those people are now working in and around the fringes of social care and SDS—many, many years later—and many of the disabled people themselves have gone on to work in other user-led organisations around the country. You can trace the start of that back to the seeds of GCIL.
In different areas, there are other examples. AILN in Ayrshire is also user-led and it covers three authorities, which is great, because it gives some kind of consistency while working across the different areas. In Edinburgh, we have the Lothian Centre for Inclusive Living, which covers four authority areas. There are slightly different approaches. Most of those organisations will be registered charities, which are registered with the Office of the Scottish Charity Regulator. They will have a governance structure where the highest level of governance, whether it is the management committee, the board of trustees, or the board of directors, consists of the service users—disabled people. In some organisations, that might include carers of people who are accessing services; in other organisations, it might include people who are disabled but are not receiving services; and sometimes, it will only include people who are receiving services.
Are there some black spots where there are no bodies?
Yes, there are definite gaps. There are gaps where either there is no—
Can you name them?
I should have brought a list. That would have been good. We have a mapping website that covers the whole of Scotland so that people can search for what is in their area, but there are definitely key authorities where either there is nothing that is user led or there is maybe nothing at all that you can just go straight to for support. There might be organisations where you have to be entered first.
How do you enter into this? Would somebody in the care system suggest that you go or do you have to find out for yourself?
We know from feedback from our members that ideally, you should get a referral at the point when you think that you need support. If you tell somebody in social work that you are thinking about getting support, most of our members would really love that social worker or whoever it is to say, “Oh, did you know there is an organisation in your area that can help you think about your options?” so that you are able to speak to that organisation as well. Potentially, you would then have that support from somebody all the way through your journey.
The work that these organisations do involves anything from somebody sitting in an assessment with you—not necessarily saying something, but just sitting there—to helping you prepare for an assessment in advance. They can help you think about what support you would benefit from in your life and so on.
Do social workers give that type of advice to people they are speaking to?
Yes, where it is available.
We found that only around a third of the 100 people we surveyed had not heard or did not know that they had a local advice centre.
How many had or had not?
A third had not heard of a local service and about a fifth did not know what we were talking about. I do not think it is very widespread knowledge.
It is very important that user-led organisations are involved in this process, because they bring the direct lived experience of the users of services to the table. That is much more significant than having somebody like me who can give advice or advocacy. Having that lived experience is very important.
The key thing about user-led organisations is that they are run by disabled people themselves. That is significant. I will add an important note of caution—a lot of disabled people’s organisations in local areas are suffering from significant cuts in funding. In many areas, they are going to the wall because they are not getting support. Sometimes that is because an organisation was providing a service for the local authority but the service has gone out to tender and has been awarded to another organisation—usually a large disability organisation such as Capability Scotland or Enable Scotland—instead and therefore the organisation is no longer able to provide the other good-quality stuff that it provides as a disabled people’s organisation.
If you are looking at health and social care integration and self-directed support in the round, you need to think about who you support in a local community in order to ensure that the voice of disabled people is heard at the table.10:30
Coming back to the question of significant gaps, another key issue is that the Scottish Government is currently funding a lot of independent information and support at local level, and there would be a lot more gaps if that funding was not available. There is going to be another round of funding, so work will be funded, but the question is about funding in the long term and whether that should be done locally, as at present, or centrally. The funding that is being put in by the Scottish Government is very much for a period of change, and it is local authorities’ responsibility to make sure that the provision is there. In the areas where there were gaps before the funding started, will those gaps remain when the funding goes? Organisations are very concerned about that and about their independence if they are receiving funding locally.
I should point out that signposting to those organisations is built into our public information, our assessment process and our guidance to practitioners, and it is constantly reinforced.
That is fantastic. We want to see more of that in other areas, because we know of organisations operating in certain areas that are not necessarily getting signposted to as a matter of routine. As Colin Young has said, folk might be getting services, but they did not know that there were organisations that might have made the process easier for them.
I am interested in Jess Wade’s slightly contradictory comment about the anxiety over Scottish Government funding for these organisations. It should happen locally, but there is also a concern about the extent to which this should be put at arm’s length. From that perspective, I am not sure that we can have it both ways.
A general issue is that, technically speaking, the self-directed support legislation has created a business risk for provider organisations. We have heard about block contracts and the big packages of inputs and outputs-based support for an individual going to a particular organisation. Self-directed support necessarily creates a business risk if people have complete choice and the ability to switch providers left, right and centre, and that needs to be managed really carefully if we are not to create a lot of uncertainty and instability in the marketplace. As we know, one of the issues for social care is the ability to recruit staff of the right quality and with the right skill set to meet people’s needs. The challenge with the current system is how, with the best will in the world, we can fully implement this kind of properly principled piece of legislation in the current context.
How are you changing your commissioning strategies to cope with that?
Again, it links to the opportunities provided by integration. There is the commissioning responsibility that comes through IJBs—and much more than that, a spirit of partnership. For example, as part of the co-produced commissioning that we in Glasgow have embarked on with our homelessness services, we are looking at developing something called alliance commissioning, which will give provider organisations an awful lot more control and responsibility with regard to coming up with a specification for tenders. We have to go through tenders for big bits of work—and there is nothing that we can do to avoid that—but I think that the integration agenda with regard to partnership working creates an opportunity in that respect.
Do not get me wrong—developing something like alliance commissioning is by no stretch of the imagination straightforward, simply because of the constraints on local authorities as well as on the system in finding different ways of procuring work. As I have touched on, we need to move away from procuring services on an hourly basis—or some other time basis—because that is absolutely about inputs and outputs.
As for the story about the calculator that Mr Kerr referred to, you can see how that sort of thing can happen. If somebody had an individual budget of £10,000, you would, if you knew the hourly rates of your provider, be working out what you could deliver for that. Immediately, though, you would be in an inputs-and-outputs mindset instead of focusing on what it would be right for you to do. There are parameters to take into account, but we are trying to change that kind of environment.
As some of us will have seen in our constituency casework, a ceiling is being put on certain care packages that might be more complex than others. Iain Smith rightly identified resource as the elephant in the room, and I am keen to know whether that is the case across the board and whether there is any flexibility in that respect. Indeed, I am curious as to whether your organisations are routinely counting unmet need, because to me that tells a story about what we should be funding but cannot afford to.
I will start with the local authorities.
For us, the bigger challenge is finding a different way of shaping the market and community capacity on the basis of people realising their outcomes. If people are creative in that respect, we will get a way of commissioning that is truly outcomes focused. We are looking at our current provider landscape and services and shaping them according to the different ways in which people are realising their outcomes, but, for me, that is the real big challenge in how all of this works.
Alongside that, the issue is about collaborative and alliance commissioning. The two approaches are different, but they mean that, instead of local authorities and providers having some kind of paternalistic relationship, we are having much more of a conversation about what outcomes get met, how we do all this together and how we set measures on that basis. I would come at your question, then, from the other way—
I know, but perhaps we should come back to the way in which I put it.
The outcomes need to be positively realised, which in turn will influence commissioning. After all, people will want to realise their outcomes in many and varied ways.
I absolutely understand that, but the fact is that you will have a finance director sitting on your shoulder. Is there an upper limit on the care packages you can offer?
Not in that way.
In what way, then?
There is no ceiling.
So are you telling me that you can offer people an unlimited amount to realise their outcomes? Do you have no unmet need in East Ayrshire?
I am not saying that at all.
Okay, then. Do you count unmet need?
Not scientifically, no. We have moved away from doing that. These things are looked at in terms of whether outcomes have been met or partly met or are unmet, but we do not do that sort of thing as we did previously through formal assessment-type documents.
Before personalisation, we would have counted unmet need; we would have had a list of people whose needs we were not able to meet as a result of the disproportionate and inequitable system for allocating resources. For example, people were coming out of the big hospitals with big packages; in the following years, the allocations to people with equivalent need in different parts of the city became hugely disparate, with some people not getting anything. Once upon a time, we were able to count that sort of thing. However, with the move to personalisation before the legislation came in, we were partly seeking to recognise the increasing inequity in how the budget was being distributed and the need to assess equivalent need across the city to ensure that we had a more equitable and fairer system of distribution.
That is why in Glasgow we went down the resource allocation system model instead of the equivalence model, which is the other route for allocating resources that many authorities have taken. However, it is essentially what we had before, so it will give you the same again. The move to a resource allocation system created some challenges for us from individuals early on, but it works on the basis of comparing an individual’s assessed need with what is broadly the level of need across the city and giving them a budget of X.
With the outcome-based support planning approach, then, you can look at how that allocation of resource can contribute to your outcomes. There is a conversation on a co-produced basis and a dialogue with the individual; that discussion might be about whether any increase is required, which does happen. Senior managers are trying to establish a consistent approach across the city, but they have the capacity and scope to provide some nuance in that respect and personalise things for individuals. It is very rare for an individual budget to be reduced in the city, given that it is based on individual need, but there is a variety of good reasons—say, implementation of choice—why that might happen.
As for the question whether there is a limit, I simply point out that, two or three weeks ago, I signed off on a package of support for someone coming through transition that was well in excess of £250,000 per year. That figure is way off the RAS score. We will meet need when we need to meet it.
The problem with defining unmet need is with how need is defined in the first place. We would argue that, because the criteria have shifted—there is now a much higher level of need before someone receives any support—there is a lot of unmet need below the level at which people get support. You could have a definition that says, “We have assessed these people as having a need—they are in critical need, and we are meeting that need.” However, the people who are lower down the chain, who we think should be getting support so that they can live independently, are not getting support. That is unmet need, but it probably would not be measured under any definition because the assessed need is being met.
I would say exactly the same as Iain Smith just said. I would add that, with changing eligibility, those with substantial need, who might previously have got a package that they could have had SDS conversations around, might now only get that support if they have critical need. The same applies to those with moderate need, who might now only get a package if they have substantial need. Do we really believe that local authorities were previously giving out lots of money to individuals who did not need it? I do not think that authorities were doing that, but if they were, why were they doing that? We know that there are folk who would have got money previously but who will not get money now. As Iain Smith said, that is where the unmet need really is.
Does David Williams think that the bar is getting higher?
The bar probably is getting higher out of necessity, because of the resource issue. However, I think that we need to take a balanced approach to assumptions around what need equates to. I take fully on board what Iain Smith and Jess Wade have said, but I refer again to the letter that I received a couple of weeks ago from parents whose daughter has Down’s syndrome. Their daughter has been provided with support through the week. That does not involve any social work funding at all, and they are completely content with it. We need to be clear that we are not making the assumption that, just because somebody has a learning disability, a physical disability or a mental health issue or is elderly, they require a social work intervention. It is about that clear professional judgment, coupled with the opportunities that are around that might provide the support that people need.
I echo that. That is absolutely how that conversation takes place. If we are having conversations around people’s natural assets—I apologise for the jargon—and community capacity, that is where that conversation starts. If people do not need statutory intervention, we may well have been overprescribing in the past.
I cannot speak to how unmet need is identified, but we have heard of examples of when unmet need has been identified and an indicative budget has been suggested, but people were still not getting that budget. The local authority assessed the person and identified need, but it was not being met, despite the person requiring support.
Another aspect of unmet need relates to the substantial waiting times for assessments in some local authorities and the time for which people have to wait after having been assessed before they receive the package that they have been assessed as requiring. That is an unmet need that is quantifiable.10:45
What I am picking up in every area that we have discussed is that there is inconsistency across local authorities that really should not be happening. It depends on the postcode lottery—to use that horrible term. What service someone gets depends on where they live.
If there are no final comments on taking an outcomes-based approach rather than a resource-led approach, I will move on to the final theme, which is on removing the barriers to successful implementation. I will kick off. Despite the evidence from the two partnerships represented today, we recognise that not everything is perfect. What do we need to do to change things? Is it a problem with the legislation or is it a problem with implementation? Does resource have anything to do with it, or is it cultural? Who wants to kick off? Erik Sutherland smiled, so he is going first.
I think that the problems are culture, which is a huge aspect, and implementation. It is about workforce development and organisational development, and making sure that you have the capacity to support people to operate in the different way that is required under the legislation. It is also about permission and support from senior leadership for implementation within the spirit and the letter of the law. That is my take.
I think that the issue is implementation. However, there is also an issue with local authorities being required to implement the self-directed support legislation at the same time as they are being required to implement health and social care integration. Integration has probably taken up a lot of senior management focus because, as David Williams mentioned, it is a fairly major piece of work. There are concerns within the disabled people’s movement and the independent living movement that health and social care integration is very much focused on the health side, and not focused enough on the social care side. The concern is that the wider role of social care in enabling people to play an active part in society is being lost and that it is more about healthcare in the community rather than social care. We will have to wait and see how that plays out once integration is more fully bedded down, with self-directed support perhaps becoming more part of the things that health and social care partnerships deliver. However, I think that there is an issue there about just how much of the problem is because local authorities that are under pressure are trying to deliver SDS at the same time as integration.
Are local authorities under pressure, David?
Clearly, that does not apply to us. [Laughter.]
Are you saying that Glasgow has enough resources?
No—of course it applies to us. We are always under pressure. The fact is that the day job has not gone away just because of the integration of health and social care. Integration has required us to organise ourselves in a measurably different way in terms of the planning and delivery, and the receipt and experience, of health and social care across the entirety of the age range in Glasgow. It is not necessarily replicated everywhere, but that is certainly true across the entirety of the age range. As I said, for us in Glasgow in particular, as a consequence, there are huge opportunities around co-production that are completely consistent with the self-directed support legislation. For example, I am thinking of alliance commissioning, how we have worked in a co-produced way in relation to homelessness services and addiction services or our work with providers. That has all happened as a consequence of the beginnings of that work to embed at a very local level a locality-based approach to the delivery of services, and it has come through the self-directed support legislation.
I just want add to what Erik Sutherland said about culture. Culture is absolutely an issue in relation to self-directed support because it has meant change in how people deliver and receive services. That has been a challenge for everybody and we are still working through it.
My next point links to the previous point on the approach not being resource led. Some members of the committee will be aware that, as part of our implementation work around personalisation in Glasgow, five learning disability day centres were closed, with just two remaining. The centres were cherished, and wanted, particularly by carers. Some service users had been attending the centres for up to 25 years. We clearly wanted to demonstrate that just because, once upon a time, someone had a particular need identified, that did not mean that we should not be striving for something better and different for them. Literally hundreds of people have been supported into a different form of support, which has given them lots more opportunities—and better outcomes as a consequence. However, the cultural challenge across the system and across the community in relation to the prospect of the closure of learning disability day centres was not straightforward. It is therefore not just about local authority social workers.
To pick up on the acting convener’s question, the report that underpins our conversation today contains various recommendations on pages 6 and 7 as to what various bodies could be doing. Does any of you have a view on whether those recommendations will move SDS forward? Assuming that they will, are the various bodies that are required to undertake the recommendations actually undertaking them?
A report is going to our IJB this very afternoon setting out the recommendations, which will guide the activity of our thinking differently programme board, which is the successor to the SDS programme board—I note that that met throughout our integration process. The recommendations will inform the work programme of the thinking differently programme board, which will be taking forward that workstream—
Forgive me for cutting in, but I want to look at the wider question. Is what you describe replicated across Scotland, or is it just something that you have been particularly good on?
I cannot speak for the rest of Scotland. My understanding is that there are similar programme-type arrangements in other partnerships. We set it up in 2013 and it has been transformed into a broader programme board.
I took a report on the Audit Scotland report to our IJB’s finance and audit committee on 6 September—literally within a week or two of the publication of the Audit Scotland report. In our report, we set out some draft responses to each of the recommendations. Therefore, in Glasgow we are certainly driving forward an acknowledgement of the findings, the conclusions and the recommendations. As colleagues from Audit Scotland are aware, I organised a meeting with them shortly after the publication of the report, so that I could find out what the specific issues for Glasgow are. We are absolutely engaged in that.
Glasgow does not have a specific programme board for self-directed support or personalisation. That is because the issue is seen as business as usual. It is the primary route into adult social care and social care for children with disabilities. We had in place extensive scrutiny and planning arrangements for a number of years following our implementation of personalisation in 2011. Those were multi-stakeholder arrangements and were linked to the council’s responsibilities. There was a sub-committee of the health and social care policy development committee, which was only disbanded in February or March of last year when the integration legislation came into effect in Glasgow city.
The recommendations in the Audit Scotland progress report are really solid; the question is whether everyone will follow them. For me, that comes back to the point about the disconnect around implementation between central Government and local government. I think that the legislation is sound, but to what extent is it being followed? Sometimes when we get in touch about things happening in local authorities that are not necessarily within the spirit of the legislation, the response is, “It is open to interpretation.” It is very difficult to say that what the local authority should be doing is quite clear when the response is that it is up to the local authority to decide. What will happen with the recommendations? Will people have to feedback on what they have or have not done? It is really reassuring to hear an authority say that it has worked through the recommendations and come up with what it is going to do, and it would be great to see that for all 32 authorities.
You mentioned central Government in your answer. Do you have any view on what the Scottish Government specifically should be doing to help implementation?
I would like to see greater leadership for authorities but I think that that will be very difficult for the Scottish Government to do, given the set-up in Scotland at the moment. It is very difficult for the Scottish Government to give quite strong direction to local authorities about where they need to change or improve—at least, it seems that way, sometimes.
Does David Williams have a view on that answer?
On the initial question, I think that the legislation is fine. There is guidance and there are statutory instruments that local authorities are required to follow. Beyond that, it is difficult to see how much more direction could be provided to local authorities by the Scottish Government. The Scottish Government has discharged its responsibilities; implementation is up to local authorities. I expect the findings in the Audit Scotland report to appear imminently in IJB committee or board papers—as has happened in Glasgow and as Alex Neil said is happening in East Ayrshire. That is not an unreasonable expectation because this is a transparent process that we need to engage with. That is the spirit of the legislation; that is what integration is about. I do not see why it would be any different with SDS.
That is quite a worrying answer if you look at the context. The whole premise of self-directed support was to introduce control. We are seven years into the strategy and Scottish Government figures show that only 27 per cent of people have been offered choice and control. Never mind whether that is leading to outcomes, the actual action of making sure that people have choice and control is still having shockingly low results. The alliance recommended that if there is not a substantial increase in the near future—and we have only two years before the SDS strategy comes to an end—we would look for a review and try to push forward the implementation of conversations, at the very least, to increase uptake.
We have talked a lot about the inconsistency in the information that is available and in monitoring. The Scottish Government has a fundamental role in ensuring a more consistent approach across local authorities to recording options and a more consistent approach to monitoring the implementation. That needs to be done by the local authorities but it also needs to be done by working with the people who receive services to find out how they think those are working for them. That will allow us to get data on whether outcomes are improving, which is not there. There is not a consistent approach across Scotland, and the Scottish Government has a fundamental role on that.
Another crucial recommendation from Audit Scotland is on working in partnership with the service users, to which there are quite a number of references. We need to ensure that service user organisations have the resources to be able to do that, which means that we need to build the capacity of disabled people’s organisations and local communities to ensure that they can support their members to participate in all those significant areas where Audit Scotland rightly says that service users should be involved in the process.11:00
Another barrier that the Auditor General identified relates to recruitment, training, remuneration and retention of social care staff, which is clearly a huge issue. Short of the obvious points about making more money available and making more of a career path and structure for people who want to go into the sector, how can we make improvements there?
Some of the things that you have just mentioned are key to making improvements. The shared ambition document that Iain Smith mentioned talks about that as well. It is about seeing social care completely differently and seeing it as an asset across the country. The job should not be seen as the dregs or what have you; it should be seen as an important career that provides opportunities for progression. Even without progression, it should be seen as really important work that needs to be well paid. People need to feel valued for doing it.
A lot of people who we work with employ personal assistants directly, and they have much more consistency in their workforce than exists in organisations. That is because there is a personal relationship and people get to work together. When it works really well, folk understandably want to stay in that situation and do not want to leave it. Where direct payments and personal-assistant employment work well for people, that can lead to greater consistency. However, there are a lot of difficult issues.
When you talk about enhanced remuneration, I presume that you are talking about carers and providers. All the evidence shows that, with social care providers, the issue is about not just remuneration but a lack of career development, which in some instances is a bigger barrier to progress than the levels of remuneration.
Yes, that is a difficult issue. Obviously, the introduction of the living wage is a big step towards making sure that people are paid more, but unfortunately if a package is not increased to reflect that, we sometimes find that the worker is paid more per hour but their hours are reduced. We do not disagree with paying the living wage at all, as it is important, but we need to look at everything in the context. There can sometimes be unintended consequences.
I am a little surprised by the comment about people having their hours reduced as a consequence of their salary going up, because in the past couple of years the Scottish Government has made available resource to fund the increase to the Scottish living wage, so it should not have had that impact. However, we should not shy away from the fact that it might be okay for there to be less paid-persons’ time going into somebody’s life if things such as technology-enabled care can be used in a constructive way to provide a different type of overnight care support to individuals.
We are going to have to address that issue, anyway, as a consequence of decisions that have been made in a different part of the system on the payment of hourly rates for sleepovers. We are going to have to do things differently, but that is consistent with striving for an outcomes-based approach to helping people to live independently and to move on with their lives, regardless of levels of ability. The key of course is to ensure that we do that jointly and in a co-produced way, rather than just putting it in place. We need the capacity and time to have that dialogue.
Our concern is that the money that the Scottish Government keeps telling us has gone into supporting increased social care is primarily there to support the living wage and does not increase the sum total of social care that is available. Obviously, we are not against the living wage, but I am very concerned about the comment that David Williams just made, because he seemed to suggest that, because of the overnight care wage ruling, we might have to look at how overnight care is provided. That sounds like a resource-based approach rather than an approach based on doing what is right. I am not saying that telecare might not be appropriate for some people—indeed, it might be better for some people—but it is not good if it is done on the basis that we have to save money because we have a ruling that we have to pay people more for overnight care. I hope that he is not suggesting that that is going to happen.
I will not answer for David Williams, but I can tell you that that is already happening. It does not necessarily happen in his local authority, but it happens in others.
We cannot separate out the resource available to us from the need to deliver services. Our responsibility as leaders is to ensure that we maximise the available resource. The ruling from Her Majesty’s Revenue and Customs on sleepovers would have an impact on Glasgow city by increasing the budget immediately by £5 million, just to pay for that difference in sleepovers. I therefore have a responsibility to look at how we can absorb that additional potential spend in different ways so that it does not negatively impact on budgets elsewhere. It is okay to do that if it involves engaging in discussion and dialogue.
Another point, which links to the discussion about recruitment, is that the sleepover decision has created a workforce impact on provider organisations. Historically and traditionally, the people who did the sleepover did a back shift, slept over and then did the early shift. Those people cannot now do the sleepover. There are recruitment issues in relation to being able to provide that cover, even if we had the money available to pay it as a sleepover. We have a responsibility to look at how we can move that on.
We could spend the next hour talking about sleepovers and whether resource should come from the Scottish Government to local authorities to help with some of that. I am not going to go there, because that would be a whole other discussion, but that will exercise people in future.
We will be taking evidence from the Scottish Government and the Convention of Scottish Local Authorities, and you have helpfully suggested areas that we can question them on. I am not going to extend the meeting to explore any more issues but, if you think of something as you are walking out the door or when you get back to your desk, I would be grateful if you would email us, because we are interested in putting your points to the Government and COSLA.
I thank each and every one of you for coming. It has been a productive session. As I say, we could have gone on for longer, but discipline means that we will not, because we have First Minister’s question time shortly.11:07 Meeting continued in private until 11:23.