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|04 Aug 2015|
Speaking Up, Speaking Out
These are systems that rely on the judgement of a professional social worker to establish the level of a budget. They decide what support they would normally provide to a person with social care needs and then monetize that service so that it can be offered in the form of an indicative budget.
They start from the basis that it cannot be right to set a budget at any level unless there is good reason to believe that this level is reasonable and that someone could get their needs met with that budget.
Equivalence helps to show that the budget does reflect some real model of how a need might be met. In this system Self Directed Support gives the opportunity to the service user to meet those needs in a way that is even better for them than might originally have been done. They retain the option of asking the local authority to arrange a service of the “equivalent standard.”
18 councils are now running Equivalence in their area and we think it is possible to break these down into two different types of system.
4.2.1 General equivalence – There is an assessment of need followed by the social worker deciding on support levels that the local authority should offer. They then run this service through a ready reckoner for a budget and this discusses options with the client and offers the choice of the 4 options.
Perth and Kinross Council have this sort of equivalence. A person’s outcomes are agreed through an outcome focussed assessment, and the relevant amount for an Individual Budget is then calculated using the full cost of providing the care and support services identified in their personal outcome plan.
Midlothian Council are planning to adopt a similar system by following developments in Perth.
4.2.2 Specific equivalence – There is an assessment of need followed by the social worker deciding on support levels that the local authority should offer. The social worker then can offer variable budgets depending on the SDS option chosen to purchase these supports in the way that client wants.
Highland NHS have this sort of system. A person’s outcomes are agreed through an outcome focussed assessment, and the relevant amount for Direct Payments is agreed through a ready reckoner spread sheet. Individual budgets for options 2 and 3 are assessed on an individual basis depending upon chosen service provider.
East Dunbartonshire Council also have this sort of system. The individual budget is calculated by costing the supports in the service user’s support plan that have been agreed as supporting the individual to meet their needs. The use of a ‘Schedule of Rates’ will be utilised by practitioners to determine the most appropriate ‘standard rate’. This will vary according to whether it is Option 1,2 or 3 and the type of service chosen.
These are systems that try to turn the allocation of funding into a science rather than an art. It is based on the idea that there is mainly a smooth scale of needs, rising up slowly and that if you can work out how to give a points value to each need then you can allocate a budget fairly. Everyone with the same points will have the same budget, even if it was different needs that got them those points.
This first budget is then used for planning processes and where it’s not enough or too much the budget is subsequently adjusted by a more or less arcane process. This can involve a range of meetings with more senior social work staff to which the service user or their representative is unlikely to attend although in some cases, their care manager may make representations on their behalf.
Such systems are usually derived by a semi scientific method of removing “outliers” – those with expensive care packages and then averaging out care costs of between 100 and 300 people.
The principle of people with similar needs requiring similar amounts of money of course has simplistic appeal. But it is likely to not work in social care where social care needs arise from the complex interplay of many factors. Such systems are seen as the antidote to the 'professional gift', whereby the large variations in how much people get was put down to the behaviour of professionals. There is a lack of supporting evidence for this view. Anecdotes about the results are in themselves are not sufficient.
But perhaps the biggest concern is that such systems can build in distrust between councils and services and even their own staff. Two councils told us they would not be giving us details on how their Resource Allocation System would work because services users would use this information to get higher scores and get more support than they need.
There was very little change in the types of assessment being used to look at the needs of carers.
Interestingly some councils said that they did not encourage Carers assessments and suggested that it was better to make sure carers were involved in the assessment of the cared person’s needs and there was no real demand for separate Carer’s Assessments.
East Dunbartonshire Council said “Most carers decline the offer of a separate assessment of their ability to continue to provide care, but almost always wish to have their views taken into account when assessing the needs of the person they care for. Only 1 carer has had a separate carer assessment recorded since 1/4/14 and 84 carers were assessed jointly with the cared for person,” No carers were offered SDS in East Dunbartonshire.
Just about every council in Scotland has introduced a new form of assessment for people who require care and support.
There are three main types:
1.1. Points Based Questions – These are multiple choice assessments which attempt to carry out an overarching assessment in a small number of questions. This assessment is usually marked with a points value being given to each answer. The total value of the points leads to an estimated individual budgets with which to plan support services. These have additional “free text” areas for differing views or comments from other people
For example, Argyll and Bute Council have introduced a new Supported Assessment Questionnaire which covers 9 areas that people need help in with 26 scored sub questions, each carrying a points value that leads to a final budget. The person being assessed is encouraged to comment in each section and at the end of the form there is space for an unpaid carer, an advocate and the assessor to make overall comments.
1.2. Outcome focussed assessments - These are new style of assessment that takes the approach that social work should help people meet particular outcomes in set areas. Instead of focussing on areas of deficiency the assessment focuses on what the person wants in these areas. Once the assessment is complete, the social worker uses the local system to decide on the level of service.
Dundee Council has created such an assessment that looks at 8 separate areas such as independent living and keeping safe. In this case the outcomes part is wrapped around with a number of other more open descriptions on immediate life situations, risk assessments and further actions.
1.3. Single Shared Assessment: A number of local authorities have decided to continue using their current assessment system. This assessment follows a decision on eligibility criteria. This is a system that relies on current social work practice and experience to secure information about a client’s life and then the social worker uses their own judgement about the service offer to meet any identified needs.
Both East Renfrewshire and East Dunbartonshire have said that they will continue to do this and use their social worker’s professional judgement to make a service offer. A method of “equivalency” is used to advise individuals about their options under the 4 SDS options.
In late 2014, the Learning Disability Alliance Scotland along with a number of National Carers Organisations, the Coalition Of Carers in Scotland, Carers Trust UK, MECOPP and Carers Scotland sought information from each council in Scotland about how they were getting on.
We found that many of the developments in Self Directed Support show that it is making some changes around Scotland. Yet the numbers affected by this remain very small compared to the hundreds of thousands of people who use social care support every year.
Concerns over liability, risk, managing expenditure seem to operate behind the scenes of the far more visible outcomes focussed assessment and creative support planning.
For a number of years, the development of the Single Shared Assessment introduced a standardised model of how social care needs would be assessed throughout Scotland. Now with the introduction of SDS, we have almost 32 different methods of assessing social care needs. Each values different things or takes different approaches. While social work professionals will do their best, every craftsman knows they need the best tools. Too many of these tools feel inadequate, with no real way of understanding what is missed or overlooked.
We welcome the move away from the pseudo-scientific approach of Resource Allocation Systems by some councils. This was a concern and worry for thousands of vulnerable people and their families.
Matching points to questions in the way that Points Based RASs do has the outward appearance of rationality, yet overlooks the key question of context. When people in one part of Glasgow or Edinburgh die on average 10-15 years earlier than in another part of the same city, how much more important must the social context of vulnerable people be when it comes to assessing social need. Yet so much of this is missed from the new assessments.
The “Equivalence” models are no panacea for social care but they avoid the worst of the budget cutting approach that might have developed by an over reliance on computer technology. However it is not yet clear how much change will emerge from those councils using the equivalence model.
Much of the opportunity for change the landscape of social care in Scotland lies with the development of Individual Service Funds and more flexible ways of spending these funds. As we have shown few councils have yet committed to taking a flexible approach and this really raises the question of what will, in reality, change.
The biggest challenge in introducing Self Directed Support will be assuming that those who currently receive support are looking for more control or a change in their service. Most just want to keep getting good support. Imposing change on people through reduced budgets or a new system could end up creating new problems which is why we welcome the efforts of a few councils to consider how to speedily resolve differences of opinion over social care.