Health and social care series
Self-directed support
2017 progress report
Prepared by Audit Scotland
August 2017

The Accounts Commission
The Accounts Commission is the public spending watchdog for local government. We hold councils in Scotland to account and help them improve. We operate impartially and independently of councils and of the Scottish Government, and we meet and report in public.

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Auditor General for Scotland
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Key facts
In 2015/16:
Amount committed by Scottish Government to support SDS implementation^1:
Almost £70 million

Amount spent by social work services^2:
£3.4 billion

Number of people choosing an SDS option (estimated):
At least 53,000

Number of adults who received non-residential support from social work services:
Almost 208,000

Number of children and their families supported by social work services:
Over 17,000

Length of time into the ten-year SDS strategy:
7years

Notes: 1. Amount committed from 2011/12 to 2017/18 by Scottish Government to support SDS implementation. 2. Councils' audited annual accounts, 2015/16.

Summary

despite many examples of positive progress SDS has not yet been fully implemented

Key messages
1.	Our evidence shows many examples of positive progress in implementing SDS. But there is no evidence that authorities have yet made the transformation required to fully implement the SDS strategy. Most people rate their social care services highly and there are many examples of people being supported in new and effective ways through SDS, but not everyone is getting the choice and control envisaged in the SDS strategy. People using social care services and their carers need better information and help to understand SDS and make their choices. More reliable data is needed on the number of people choosing each of the SDS options. Data should have been developed earlier in the life of the strategy in order to measure the progress and impact of the strategy and legislation.
2.	Social work staff are positive about the principles of personalisation and SDS but a significant minority lack understanding or confidence about focusing on people’s outcomes, or do not feel they have the power to make decisions with people about their support. Front-line staff who feel equipped, trusted and supported are better able to help people choose the best support for them. What makes this possible for staff is effective training, support from team leaders or SDS champions, and permission and encouragement from senior managers to use their professional judgement to be bold and innovative.
3.	Authorities are experiencing significant pressures from increasing demand and limited budgets for social care services. Within this context, changes to the types of services available have been slow and authorities’ approaches to commissioning can have the effect of restricting how much choice and control people may have. In particular, the choices people have under option 2 are very different from one area to another. Authorities’ commissioning plans do not set out clearly how they will make decisions about changing services and re-allocating budgets in response to people’s choices. 
4.	There are tensions for service providers between offering flexible services and making extra demands on their staff. At the same time, there are already challenges in recruiting and retaining social care staff across the country owing to low wages, antisocial hours and difficult working conditions.
5.	SDS implementation stalled during the integration of health and social care services. Changing organisational structures and the arrangements for setting up, running and scrutinising new integration authorities inevitably diverted senior managers’ attentions. Some experienced staff are also being lost through early retirement and voluntary severance schemes as the pressures on budgets mount. 
Recommendations
Directing your own support
Authorities should:
•	work in partnership with service users, carers and providers to design more flexibility and choice into support options
•	review their processes for supporting children to transition into adult services.
The Scottish Government, COSLA, partners and authorities should:
•	continue working together to develop:
	the accuracy and consistency of national data on the number of people choosing each SDS option
	methodologies to understand the impact of SDS on people who need support and their carers.

Assessing needs and planning support
Authorities should:
•	provide staff with further training and help on identifying and planning for outcomes
•	work with service users and carers to review their assessment and support planning processes to make them simpler and more transparent
•	establish clear guidance for staff on discussing the balance between innovation, choice and risks with service users and carers and implementing local policies in practice
•	support staff in applying professional judgement when developing innovative solutions to meet individual needs flexibly
•	ensure they are providing information on sources of support to those who are accessing SDS
•	work with service users, carers and providers to review the information and help they offer to people during assessments, reviews and planning discussions.
Commissioning for SDS
Authorities should:
•	develop longer-term commissioning plans that set out clearly how more choice and flexibility will be achieved for local service users and how decisions will be made to re-allocate money from one type of service to another
•	work with service users, carers and provider organisations to develop more flexible outcome-focused contractual arrangements 
•	continue to work with communities to develop alternative services and activities that meet local needs.
Implementing the national SDS strategy
Authorities should:
•	develop targeted information and training on SDS for healthcare professionals who have a direct or indirect influence on people’s health and social care support
•	monitor and report the extent to which people’s personal outcomes are being met and use this information to help plan for future processes and services.
The Scottish Government, COSLA and partners should work together to:
•	review what independent information, advice and advocacy people will need in future, and how that should be funded after current Scottish Government funding for independent organisations comes to an end in March 2018. This review should fully involve users, carers, providers and authorities, and should conclude in time for appropriate action to be taken
•	agree how any future financial support should be allocated, taking into account how authorities' local commissioning strategies will inform future spending priorities
•	seek solutions that address the problems of recruitment and retention in the social care workforce 
•	ensure that the requirement to effectively implement SDS is reflected in policy guidance across all relevant national policies, such as health and social care integration, community empowerment, community planning, housing and benefits
•	routinely report publicly on progress against the 2016-2018 SDS implementation plan and the SDS strategy.
The Scottish Government should:
•	report publicly on the outcomes it has achieved from the almost £70 million funding it has committed to support implementation of SDS.
Background
1.	Social care services provide personal and practical help to improve the quality of people’s lives and support them to live as independently as possible. Social care support describes services and other types of help, including giving carers a break to help them continue in their caring role. Support ranges from assistance with everyday tasks such as dressing and preparing meals to helping individuals live fulfilling lives at home, at work and in their families and communities. In 2015/16, councils spent £3.4 billion on social work services, supporting almost 208,000 adults in non-residential care and over 17,000 children and their families.
2.	Self-directed support (SDS) aims to improve the lives of people with social care needs by empowering them to be equal partners in decisions about their care and support. Four fundamental principles of SDS are built into legislation –
participation and dignity, involvement, informed choice and collaboration.^1 This means social care should be provided in a way that gives people choice and control over their own lives and which respects and promotes their human rights. It requires significant changes to the way social care has been provided in the past. Crucially, authorities should work in partnership with people and communities to design and deliver the services that affect them. 
3.	The ten-year SDS strategy was introduced jointly by the Scottish Government and COSLA in 2010.^2 It is one of a number of national policies designed to empower people and communities to become more involved in designing and delivering services that affect them. The Social Care (Self-directed Support) (Scotland) Act 2013, the Community Empowerment (Scotland) Act 2014 and the Public Bodies (Joint Working) (Scotland) Act 2014 were all introduced following the report by the Christie Commission in 2011.^3 They were designed to encourage significant changes to how services were previously provided, and require public bodies to give people more say in decisions about local services and more involvement in designing and delivering them. 
4.	This demand for change comes at a time when public sector budgets are under significant pressure owing to ongoing financial constraints, increasing expectations and rising demand for health and social care services, and social care workforce shortages. Councils and NHS boards have now created integration authorities, to which they have delegated their responsibility for planning and ensuring delivery of adult health and social care services.^4 Some have also decided to delegate responsibility for other services, such as children and families and criminal justice. In this report we refer to councils and integration authorities jointly as authorities.
5.	In 2010, when the SDS strategy was introduced, councils tended to provide or buy traditional services such as homecare, day centres, care home places and respite care. They would allocate these services to people assessed as being eligible for social care. Following the Changing Lives review of social work in 2006, councils were already aiming to personalise social care services, trying to match people’s individual needs and circumstances to services that would suit them best, ie personalisation.^5 Direct payments to enable individuals to buy their own social care services have been an option for many people for at least ten years, predating the SDS strategy. 
6.	The Social Care (Self-directed Support) (Scotland) Act 2013 was part of the SDS strategy. It gave councils responsibility, from April 2014 onwards, for offering people four options for how their social care is managed:
SDS options |
Option 1 | The individual or carer chooses and arranges the support and manages the budget as a direct payment.
Option 2 | The individual chooses the support and the authority or other organisation arranges the chosen support and manages the budget.
Option 3 | The authority chooses and arranges the support.
Option 4 | A mixture of options 1, 2 and 3.

7.	Councils already had a legal duty to assess people’s social care needs.^6 If they assess someone as needing support and eligible to receive services, they provide, arrange or pay for services to meet these needs. They can require a contribution to the costs if the person has sufficient income. Councils do not have to offer the SDS options to people who do not meet local eligibility criteria. But in those circumstances, councils should inform individuals about where else they can find help, for example voluntary groups and charities, or the local community.
8.	We reported in 2014 on councils’ early progress in implementing the ten-year SDS strategy and their readiness for the SDS Act.^7 We found that councils still had a lot of work to do to make the cultural and practical changes needed to successfully implement SDS. The report identified risks and benefits in the ways councils chose to allocate money to help individuals. It recommended working more closely with people who need support, their carers and families, providers and communities, to involve them in planning, designing and delivering local SDS strategies. 
9.	The Scottish Government continues to have a crucial leadership role to play in successful implementation of this transformational strategy. It should be working together with COSLA and other national partners to provide clear direction and guidance and targeted financial support if necessary. It should also be measuring and reporting on the progress and impact of SDS.
10.	This is now the seventh year of the ten-year SDS strategy. Implementing the strategy is not just about authorities changing their social work processes and procedures, the way they plan and manage their budgets, and how they work with external providers and communities to ensure a balance of flexible, good-quality services. It is much more than that. Authorities must work in partnership with other people and organisations to transform the way they provide social care, so that individuals have as much choice and control as possible over the social care decisions that affect their lives. This transformation needs to involve not only social work services, but other people in the authority, including: elected members and board members; front-line healthcare and social work staff; other staff whose work affects social care services (eg, finance, commissioning and procurement); third and private sector organisations; and people who need social care support and their carers, families and communities.
About the audit
11.	The aim of this follow-up audit was to establish whether councils, integration authorities and the Scottish Government are making sufficient progress in implementing SDS to achieve the aims of the ten-year SDS strategy. We set out to answer four key questions:
•	What progress have councils and integration authorities made in implementing SDS?
•	What impact is SDS having on people with support needs, carers, families and communities?
•	What factors are supporting or impeding effective implementation of SDS?
•	How effectively is the Scottish Government supporting implementation of SDS and evaluating its impact?
12.	Our methodology included:
•	interviews in five case study areas – East Ayrshire, Glasgow, Highland, Perth and Kinross and Western Isles. We met with elected members, chief officers, chief social work officers and senior managers, front-line social work staff, commissioning and finance managers, providers and supported people and their carers
•	interviews with 30 public, private and third-sector stakeholder organisations, including providers
•	an online survey of supported people and carers with 104 responses, and nine focus groups with 55 participants
•	an online survey of social work staff, with 170 responses.
The online surveys were not designed to give statistically representative samples. We have changed people's names in our case studies to protect their anonymity.
13.	The online surveys and focus groups provided us with evidence of people’s experience of self-directed support. Quotes have been used throughout the report to illustrate examples of common themes from these sources.  
14.	We have produced four supplements to accompany this report:
•	Supplement 1: Case study of Thomas 
•	Supplement 2: Audit methodology and survey results 
•	Supplement 3: Checklist for councillors and board members 
•	Easy read summary 
Part 1
Directing your own support

there are many examples of new and effective support with SDS but not everyone is getting choice and control 

Key messages
1.	Self-directed support should be offered to people assessed as meeting local eligibility criteria for social care. More reliable data is needed on the number of people choosing each option and this is now being developed. The number of people receiving direct payments (option 1) has doubled between 2010 and 2016, although it is still only 7,530, less than five per cent of the people receiving non-residential social care services. 
2.	Most people receiving social care services rate them highly. The national Health and Care Experience Survey 2015/16 found that 81 per cent of people receiving formal social care services rated their overall help, care or support services as either excellent or good. Two-thirds of people felt they had a choice over how their social care was arranged.
3.	There are many examples of people being supported in new and effective ways through SDS, and this has greatly improved the quality of their lives. Even a relatively small budget can make a big difference to the life of someone with social care needs and their carers, family and friends. Information and assistance from third sector agencies and organisations is helping people and their families to make decisions and arrange their support.
4.	Not everyone with support needs is getting the choice and control envisaged in the SDS strategy. This includes people with mental health problems, who often need more flexible support. There can be good reasons for lack of choice, including protection from harm or limited options in rural or remote locations, but some people feel they have been denied the opportunity to access more effective ways to improve their quality of life.
Self-directed support should be offered to people assessed as being eligible for social care
15.	In 2016, nearly 208,000 adults in Scotland were receiving non-residential social care services through their local authority.^8 This included people receiving direct payments or having a community alarm or telecare, or housing support. The largest group was frail older people (approximately 78,000), who have a decreased ability to withstand illness or stress without loss of function. The next largest groups were people with physical disabilities (60,000) and learning disabilities (12,000). In addition, there were just over 15,300 looked-after children in Scotland and 2,700 registered as being at risk.^9 
16.	Not everyone who asks for social care or support is eligible to receive it. Each authority is responsible for setting local eligibility criteria for access to social care services. Authorities assess people’s needs using a common framework of four levels of risk – critical, substantial, moderate and low.^10 Most authorities now only consider people assessed as being at critical or substantial risk to be eligible for social care services. This is because there is a decreasing amount of money to spend and an increasing number of people needing support. Assessment should be done in partnership between the assessor, the person with social care needs and, if appropriate, a family member or carer. If a person is not eligible, they should be given information or advice about alternative types of support, for example in their local community.
17.	Self-directed support gives options to almost everyone who is assessed as being eligible for social care. This includes children and families, people with physical, sensory or learning disabilities or mental health problems, and older people. The main exceptions are people receiving re-ablement services, which is short-term support to help people regain some or all of their independence, and people assessed as being at risk or lacking capacity to make decisions for themselves. In these circumstances a family member or friend may apply for power of attorney or guardianship so they can make decisions on the person’s behalf. Exhibit 1 shows the assessment process and the four options for arranging social care services. 
18.	Everyone assessed or reviewed as being eligible for social care can expect their social worker to discuss and agree with them:
•	their personal outcomes, that is how they want their life to improve 
•	what support would best help them to achieve their personal outcomes, which may be support or activities already run within communities, rather than formal services
•	how much money the authority will spend on their services
•	how much control they want over arranging and managing their support and budget. 
19.	Authorities may choose whether, and how much, to charge for services, or what contribution people should make to their budget. Social Work Scotland estimated that income from charging for non-residential social care services was nearly £51 million in 2013/14, less than two per cent of councils’ total spending on social care services.^11 
20.	Personal outcomes are individual so they can be a whole range of things. Some professionals talk about personal outcomes being ‘what makes a good life for you’. They include things like:
•	being more part of the family and being able to do everyday things with the children
•	being able to live at home
•	getting help with personal care (for example getting into or out of bed, going to the toilet, washing, dressing, eating)
•	keeping in touch with friends and family
•	being able to work or to take part in the activities I’ve always enjoyed
•	living independently by getting help with managing day-to-day tasks and finances
•	feeling safe from harm
•	getting the food I like, prepared the way I like it
•	having some time to myself or getting a break from my caring role.
21.	The best way to achieve personal outcomes is also very individual. Each of the outcomes above can be met in different ways. For example, given the choice over getting a short break, a carer may prefer to:
•	have the person they care for supported by a support worker for a couple of hours a week so the carer can do something they can benefit from, like going shopping, having friends round or resting
•	take the person they care for on outings or a holiday, with a personal assistant to help
•	have a short break with friends while the person they care for is looked after by someone else
•	have someone on overnight duty once a week to be able to get a full night’s sleep.
22.	Supplement 1: Case study of Thomas  gives an example of how self-directed support might work when personal outcomes are identified and support is tailored to an individual.
More reliable data is needed on the number of people choosing each SDS option
23.	To monitor progress in implementing SDS, national data is needed on how many people are being offered the SDS options, and how many are choosing each option. The Scottish Government and other national partners are working with authorities to develop this data and authorities are working to improve their recording systems. Authorities had to change how they collect and record the information and some have been slower than others to make the changes, resulting in incomplete data. This work should have been part of the implementation plans for earlier in the strategy in order to understand progress and demonstrate the impact of the strategy and legislation.
24.	The most recent data estimates that in 2015/16:
•	at least 53,300 people made an informed choice regarding their services and support, resulting in an estimated 27 per cent of all adults receiving non-residential care services 
•	11 per cent chose option 1 (direct payment), nine per cent chose option 2
(budget managed by others), 75 per cent option 3 (service provided through the authority) and five per cent option 4 (a combination of options 1, 2 and 3)
•	the combined individual budgets for these 53,300 people amounted to £383 million.^12
25.	Progress with SDS should also be measured in terms of whether people are being offered choice and control, and how well their chosen options are helping them to achieve their personal outcomes and improve their quality of life. The national Health and Care Experience Survey 2015/16 provides some information and SDS Scotland has pilot-tested a survey methodology in three authority areas to provide more detailed information.^13, ^14 
The number of people receiving direct payments (SDS option 1) is rising
26.	Many people have been entitled to receive direct payments for at least ten years and data on the number of people receiving direct payments has been collected since 2000. It shows an increase of over 100 per cent between 2010 and 2016, from 3,680 to 7,530 people (Exhibit 2).^15 Not all of these people had necessarily been offered direct payments as one of four SDS options, as some payments were arranged before the SDS legislation came into effect. In 2016, 38 per cent of people receiving direct payments were older people (aged 65 or over), while 75 per cent of adults receiving non-residential care were in this age group. 
27.	At the same time, the numbers of people living in care homes or receiving homecare services through their authority fell between 2010 and 2016. Across Scotland there was:
•	a decrease of four per cent in the number of care home placements, to just under 35,000 ^16
•	a decrease of ten per cent in the number of homecare clients, to just under 60,000. 
28.	The number of people using direct payments ranges from under 50 per 100,000 population (Angus, Dundee, Falkirk and Renfrewshire) to over 250 per 100,000 in some rural and island areas (Highland, Moray, Orkney and Western Isles) and in Edinburgh (Exhibit 3). This may in part reflect the nature of rural and island communities but there are other factors at play too.
29.	The variation between authorities is not necessarily a clear indication of progress with implementing self-directed support because there can be many reasons for using direct payments. For example, people may choose direct payments because they get the information and advice they need to help them manage their budget and arrange their own support successfully. Or it could mean that the authority cannot provide the services they need under options 2 or 3, leaving people to employ personal assistants or make other specific local arrangements for themselves. 
Most people receiving social care services rate them highly
30.	The national Health and Care Experience Survey 2015/16 found that 81 per cent of people receiving formal social care services rated their overall help, care or support services as either excellent or good.^17 In addition:
•	85 per cent said that people took account of the things that matter to them
•	84 per cent felt the help, care or support they received had improved or maintained their quality of life
•	79 per cent felt they had a say in how their help, care or support was provided.
31.	The 2015/16 survey asked for the first time whether or not respondents had a choice in how their social care was arranged. Two-thirds said they did have a choice (Exhibit 4).
SDS is helping to meet people’s needs in new and effective ways
32.	There are many examples of people’s needs being met in new ways as a consequence of self-directed support, and this has significantly improved the quality of their lives (Case study 1). New approaches to meeting people’s personal outcomes should be possible within any one of the four SDS options, although most of the stories we found were with options 1, 2 or 4. 

I am the boss.
Supported person employing three personal assistants with a direct payment

I can get rid of them if I don't like them.
Supported person choosing his support staff

It has given me independence, enabled me to feel productive and valued once again, and has improved my quality of life.
Supported person

We've already been able to have a more flexible relationship with the service provider we were using. I don't think this would have happened without SDS. Our service was always at their convenience before.
Family member of someone with support needs

Case study 1
Margaret has been able to arrange flexible support with a direct payment and help from a local agency

Margaret is an older person living in a house on a croft on the Western Isles. She needs some extra support as she has suffered two strokes and is no longer as physically mobile as she once was. She has two daughters – one lives on the mainland and the other lives a couple of miles away. The latter was helping to support her mother and taking her to appointments and shopping. 
Margaret was assessed for social care assistance after her husband (who had previously been receiving support) passed away. She now receives seven hours' help a week from two personal assistants (PAs). One assistant spends an hour each Monday and Tuesday to help around the house. The second spends five hours on a Thursday to take her shopping and out to lunch. She has built up a good relationship with both PAs.
Margaret gets the support she needs. Although her daughter who lives locally still helps look after her mother, there is now less reliance, and therefore less stress, on her trying to fit this in while working full time.
Voluntary Action Harris charges an £18 a month fee to organise payslips and general employment of the two PAs, which has taken the burden from Margaret's daughter.

Source: Audit Scotland

33.	A number of parents responded to our user survey with positive experiences of SDS. 

My disabled daughter's life has changed completely due to SDS. She now has a healthy lifestyle which includes a timetable of fitness classes, gym and swim activities that she attends along with her carers. She attends clubs to socialise with friends, goes to the cinema and bowling etc. She now leads the life of other 30-year-old girls. Prior to SDS she stayed home and watched videos! The transformation in her life has improved her health and wellbeing massively.
Parent

34.	There are many examples of where SDS has allowed a relatively small budget to make a big difference to the life of someone with social care needs and their carers, family and friends. A little support can also have a great impact in improving carers’ lives.

We may not get loads of support, 15 hours a week, but it's good respite, at times that are good for my son and for us. He gets to choose what he wants to do.
Parent

My life as a carer has also changed for the better. Now that my daughter has SDS, I have free time to pursue a life of my own. I have time to meet with friends, catch up with household work, pursue some of my own interests and generally have time for myself.
Parent

35.	Authorities and the Scottish Government currently fund agencies and organisations to help people find and employ personal assistants (PAs), or make other suitable arrangements. This help can make a big difference (Case study 1). Individuals and carers we heard from spoke about how helpful support organisations were in providing information and general support to those with budgets under SDS options 1 or 2. 

Having a proper budget and being able to find a small organisation to manage the support has been a godsend. I don't have to worry about organising shifts etc and they are very creative and positive.
Carer

Not everyone is getting the choice and control envisaged in the SDS strategy
36.	Different groups of people receiving social care services are experiencing different levels of choice and control. Our case study work, stakeholder interviews and a user experience survey in three authority areas, found two main groups of people who have less choice and control than other people over the support and care they receive.^18 These are people who do not have carers, personal assistants or friends and family to support them, and people aged 85 and over. These two groups can also overlap. 
37.	Evidence from our case studies and third sector organisations shows that people with mental health problems may also experience less choice and control over the way they receive social care services. Mental health conditions can fluctuate over time and more flexible approaches are therefore needed in order to provide the right support at the right time. With careful planning, SDS should be flexible enough to meet an individual’s changing needs (Case study 2). 

Case study 2
With careful planning, SDS can work well for people with mental health conditions

Matthew was very unwell for around five years and was eventually diagnosed with paranoid schizophrenia. At this time he was told he could not go back to his flat and so he moved in with his mum. As he began to feel better, he and his support team agreed he would move to supported accommodation, where he has continued to improve due to the different kinds of help he receives. 
Matthew chose SDS option 2, with support organised and paid for through his provider. He now has his own flat which is quiet and in an area close to his mum. Support workers have helped him to get into a routine with paying his rent, keeping his flat tidy and ensuring he takes his medication. He also feels that he always has someone to talk to if he is feeling unwell.
Matthew is really interested in football and his support package has allowed him to go to Manchester as part of a supported group to watch Manchester United. He is also now a volunteer coach at a Scottish Premiership football club.
Matthew really feels that he is developing and achieving his goals. He is looking to cut down his current support hours of ten hours a week and planning an independent trip to Newcastle to watch a football match.

Source: Audit Scotland

38.	In our 2016 Social work in Scotland  report we highlighted the challenge of ensuring smooth transitions from children's to adult services.^19 In our focus groups and survey we heard from carers of young adults about difficulties in the transition between the two separate services with SDS, and in particular the different legislation and budget arrangements. 

Transition has been stressful and the process has been drawn out and incomplete.
Parent

Transition to adult services is only a few months away and there is no plan.
Parent

39.	Research carried out by Learning Disability Alliance Scotland (LDAS) looked at the difference that SDS made to people with learning disabilities. It found that people who had a self-directed support budget had more control over their support package and their plans but this had not yet led to significantly better outcomes.^20 
40.	It is up to individual authorities to decide the detail of their social care policies and this can lead to frustrations among individuals and carers about differences in the way that social care and SDS is implemented between areas. This includes both how assessments are made and what people’s individual budgets can be spent on.

I also hear of other people who do get mileage and expenses paid in their budget. There does not seem to be one rule for all when it comes to what you can spend it on.
Parent

Depending on the level of support needs, where you live and what service you can find, it is a bit of a lottery.
Parent

41.	Frustrations about lack of choice or flexibility are not exclusive to particular user groups. We heard through our focus groups and user survey that some individuals and carers in all user groups feel that they don’t ultimately have choice and control over the support they get. Fewer than half of our survey respondents felt that they could change their support if they needed to. 
42.	Some people feel they have been denied the opportunity to access more effective ways to improve their quality of life. The ways in which people feel they are denied choice and control can be quite subtle, for example being told about SDS by their social worker then told: 'You probably don’t want to do that'. Or people can feel they were pushed down a certain route to suit the local authority or to fit in with the provider rather than the person needing support.

The council were horrendous to deal with and at every point tried to talk us out of SDS.
Daughter of older person

43.	It would be unrealistic to expect everyone to have choices in all circumstances. For example, some people may be unable to have the support they wish because:
•	their social worker prevents it for good reasons, eg to protect the individual
•	what they want does not exist or they cannot find it where they live
•	the cost of what they want is more than their budget.
In these circumstances, people and professionals need to work together to find suitable, alternative solutions where possible.
Part 2
Assessing needs and planning support
social work staff need more support to help people be creative about their social care

Key messages
1.	Social work staff are positive about the principles of personalisation and SDS but a significant minority lack understanding or confidence about focusing on people’s outcomes, or do not feel they have the power to make decisions with people about their support. 
2.	People using social care services and their carers need better information and help to understand SDS and make their choices. Many of those we heard from in our survey and focus groups were not aware of SDS before they were assessed. People need the information in the right format and at the right time and place.
3.	The process of getting access to SDS options 1 and 2 can be long and bureaucratic. When this happens people feel frustrated about the process.
4.	Front-line staff who feel equipped, trusted and supported are better able to help people choose the best support for them. What makes this possible for staff is effective training, support from team leaders or SDS champions, and permission and encouragement from senior managers to use their professional judgement to be bold and innovative. 
5.	Creative types of support can introduce some risks or uncertainty for supported people, carers, providers and staff. This means there can be difficult decisions to make. Authorities must also think about how they spend public money when people want to spend their budget on more creative types of support. People and professionals must work together to find an appropriate balance between the risks and the potential benefits in terms of a person’s outcomes. 
Support is not consistently targeted at people’s personal outcomes but this is improving 
44.	Social workers and social work staff have a pivotal role in assessing and reviewing people’s support needs and planning the right support with them. If they do not identify, agree, record and review people’s personal outcomes with them, staff cannot be sure that support is targeted at the right things or whether it is making the best difference to the quality of people’s lives.
45.	The front-line staff we met were generally positive about personalisation and SDS. However, several expressed concerns that not all staff understood what personal outcomes are, and therefore did not identify outcomes and use them to help develop individuals’ support plans. For example, they might record something like 'needs five hours a week of homecare' as an outcome. What the person might actually need is to get help to live at home, and there may be other ways of achieving that besides homecare.
46.	An increasing proportion of support plans set out the individual’s desired outcomes (Exhibit 5). The Care Inspectorate reviewed 1,465 support plans across 15 authorities during its most recent programme of inspections of older people’s services and found that in 2016 and early 2017, 75 per cent of plans set out the individual’s desired outcomes. Our survey of social work staff shows that two-thirds of respondents felt confident or very confident supporting people to identify their outcomes.
People using social care services and their carers need better information and help to understand SDS
47.	In the national Health and Care Experience Survey 2015/16, 76 per cent of people receiving formal social care services said they were aware of the help, care or support options available to them. Many of the individuals using social care services and their carers that we heard from in our survey and focus groups were not aware of their rights under SDS before they were assessed. In some cases their social worker explained it to them. Others were told about it through external support and information organisations or friends and relatives. 
48.	We also heard from a number of individuals and carers that, even at the point of assessment, there was a lack of information and support. Fewer than half of our user survey respondents said they had the information they needed to make decisions about their support. When asked what could be done to improve their experience of SDS, survey respondents said they wanted more information. Authorities and national and local organisations have produced a range of information. However, this may not be available for people in the right format or at the time and place where it is needed. Some people say it is too much to take in all at once.

More information available about support services available, ways of using the direct payment and more help with support planning. I was given no information from my social worker and had to find out about services myself. 
Supported person 

More training for everyone – people using SDS, their families and social workers as there is still not enough informed information freely available. 
Family member of service user with Alzheimer's Disease

We were given a list of organisations to select support from, when queried if we could use organisations not on the list, social worker did not know the answer!! 
Family member

49.	There are also some fears and misunderstandings about what SDS is. For some of the focus group participants and survey respondents, there was a fear that SDS would result in a reduction to services they were already getting. This came from a general awareness that public service budgets are decreasing. 

It feels like a way of reducing costs.
Carer

Don't ask for it [SDS] as you will be reassessed and money and support taken away from you.
Supported person

The process of accessing SDS options 1 and 2 can be long and bureaucratic
50.	Through our user survey, focus groups and discussions with third-sector organisations, we were told that people have to be determined and persistent to access SDS options 1 or 2 because the process can be lengthy, with many stages and forms to fill in. The amount of time taken to get an SDS budget and arrange the chosen support varies. There are many reasons for this, including the complexity of support needs, availability of suitable support, size of the budget to be approved, and whether people feel they have been offered an adequate budget or services. But if people applying for SDS are already at crisis point, any unnecessary delay in getting support puts added pressure on them, their carers and family members.

I manage an SDS budget for my son who has [severe physical and learning disabilities]. I found the process of getting a social worker and an assessment for my son to be laborious and the procedures invoked to be opaque. The whole process between initial calls to social work and payment of a small budget of £1,500 took almost two years.
Parent

It has been messy and over one year just filling the forms and completing the assessments and I still have yet to get a decision from the resource allocation group about budget for my son.
Parent

Applying for this took over a year and caused me more stress that I didn't need.
Parent

51.	Many people who told us their stories through our survey and focus groups were happy with their final outcomes but found the process of requesting support and accessing SDS frustrating and bureaucratic. In some cases, they felt there was a lack of openness around the processes and felt that decisions were made behind closed doors. 

You have to be knowledgeable about it and stand your ground about what you and your young person want from it as councils will be budget led rather than needs led. It was not easy getting the support for our daughter as we are aware it is a significant package however it has changed her life.
Parent

The process by the council is long, unwieldy and bound in secrecy, for example we are not told how the budget was calculated and how the budget decision was reached.
Parent

I feel voiceless and apologetic – that I should be grateful for getting anything.
Parent

Front-line staff who feel equipped, trusted and supported are better able to help people choose the best support for them
52.	We met front-line staff who are well informed about SDS. Over half of respondents in our social work staff survey felt confident or very confident in their understanding of self-directed support and explaining it to people. These well-informed staff feel confident about discussing with people what makes a good life for them, helping to identify outcomes, thinking creatively about how to achieve them, and discussing budget and SDS options. They:
•	had attended training courses designed to inform them and give them space to reflect
•	have team leaders, or SDS champions, or both of these, they can call on when they need help
•	feel they have permission from their senior managers to think differently and use their professional judgement to be bold and innovative.
These staff feel equipped, trusted and supported (Case study 3).

Case study 3
East Ayrshire Health and Social Care Partnership is supporting staff to help people be creative

Practitioners were regularly reminded by managers and directors that they had permission to do the right thing for people and be innovative.
Good examples were shared with the Integration Joint Board and SDS steering group, often inviting people themselves to come and tell their stories.
Peer mentors were in place to help staff who had less experience working with SDS.
Two dedicated finance officers would help social work practitioners with the finance parts they were less comfortable with, and would meet people who use social care services to discuss their budget.

Source: Audit Scotland

53.	We also met front-line staff who are well informed about SDS but do not feel so confident or feel a bit constrained. They feel their training has been good and have SDS experts to consult when they need. But they feel their team leaders and managers may override their recommendations if they try to be creative and some feel that financial pressures take precedence over creativity. These staff do not feel their senior managers are encouraging them to be creative. Some communicate this to the people or carers they work with:

In my view, social workers have become gate keepers for resources – they know the decisions being made at head office are wrong, and in some cases counter to the legislation, but they have no power to do anything.
Parent

54.	Some front-line staff find it difficult to consider anything other than relatively standard services, such as homecare, because their priority is to make sure they keep people safe and well. But given the choice, people with support needs may opt for alternatives that have some risks but achieve better outcomes for them. Alternative solutions can also be cheaper in the long run. It is important therefore that staff consider not only the risks but also the benefits, both in terms of outcomes and costs.
Offering people choice and control is challenging authorities’ position on taking risks
55.	Creative types of support can introduce some risks or uncertainty for supported people, carers, providers and staff. Giving people more control over their budgets and support can also introduce risks. This means there can be difficult decisions to make and not everyone involved will necessarily agree. Social work staff must use their professional judgement but must also consider a person’s right to make their own decisions as they work together to balance the risks with the potential benefits. Being too cautious about taking risks can constrain people’s choices disproportionately; not being cautious enough can go against authorities’ duty of care to people. If something goes wrong, it is the authorities that are held responsible or have to meet additional costs. 
56.	Authorities are also responsible for spending public money properly. They are rightly concerned with how much they are spending on social care and what they are spending the money on. But as people choose more creative types of support to improve the quality of their lives with SDS, social work staff are often faced with difficult decisions (Exhibit 6). If people disagree with decisions, authorities may face negative media coverage or other public challenge. 
Exhibit 6
Challenging scenarios in relation to risk
Authorities and staff face difficult decisions when balancing people's rights to choice and control with their other responsibilities.

•	Asma is a lone parent with two children. Her son has complex support needs and requires round the clock supervision to keep him safe. A social work assessment concluded that Asma needed some respite to help her continue caring for her son. It also recommended that her son would benefit from regular contact with his extended family. However, none of the respite options available were suitable for her son, and Asma has no family living in the UK. A support agency had previously helped her use her respite budget to organise a trip overseas to visit her parents, siblings and extended family. She was able to spend quality time with her daughter while her family cared for her son and got to know him better. Asma wants to do the same again next year.
•	Ruby is eight years old. She is diagnosed with autism and physical disabilities and attends a special school. Her parents receive a small direct payment to help them with holiday periods when she is not at school. They want to spend it on family visits to the cinema and going out for pizzas. It would only pay for Ruby's cinema tickets and pizza, not the other family members. Although it is not for care and support, they feel these family outings meet her outcomes of spending quality time with the family and expanding her experiences beyond her familiar routines, and it gives some respite to her parents.
•	George is 78. He had a series of strokes which have left him less mobile and almost without the use of one hand. He lives alone and has homecare visits three times a day to help with personal care and meal preparation. George chose SDS option 2 because he wanted to choose his support but did not want to employ personal assistants himself. He has recently fallen a few times after tripping on his worn living room carpet. He wants to save his Saturday homecare budget, when his sister can help him instead, and spend the money on a new carpet.
Source: Audit Scotland

57.	It is for councils and integration authorities to decide how best to meet their priorities and responsibilities. But there is a risk that the pressures from rising demand and limited budgets cause senior managers, councillors and board members to be more cautious about what they spend public money on. This is potentially at the expense of better outcomes for people, and possibly at more financial expense in the longer term. For example, a man with mental health problems found that playing golf helped him to manage his symptoms. Had the authority not been willing to pay for his annual golf club membership he is likely to have had ongoing crises, requiring professional help and possibly a hospital admission. But the authority risks being criticised in the local media for paying someone’s golf club membership fee.
58.	Authorities have developed their own local guidance on what people can spend their SDS budgets on, to reflect their own local circumstances and decisions (Case study 4). This means it depends where you live whether you get certain types of support.

Case study 4
NHS Highland and Highland Council issued letters to people using social care services, and carers, about what they can and cannot spend their direct payments on

They did this in response to what was considered inappropriate spending, and to achieve greater consistency of understanding about what is allowed. Staff explained that, previously, budgets could be used to buy items like iPads or garden equipment, to get help with cleaning, or to pay for transport. The letter clarifies that these are not normally permitted without very clear justification in terms of agreed outcomes. Staff and service users interpreted this as a change in the rules, although it was intended only to provide clarification.
For some front-line staff, this perceived tightening of rules has led to further confusion over what they can include in support packages. One front-line worker said: 'At the moment social workers think "I don’t know if we can do that…" and the person thinks "I don’t know if I can do that…" so we end up not doing it. We’re not sure what we’re allowed to do.'

Source: Audit Scotland

Authorities have chosen varying approaches to how they set and approve people’s individual budgets
59.	Our 2014 SDS report set out the risks and benefits of two main approaches to setting individual budgets. The majority of councils were using a Resource Allocation System (RAS), which allocates budgets based on a scoring system for people’s assessed support needs. Each point scored is worth a fixed amount of money. Other councils were using an equivalency model, where people are given budgets based on the equivalent value of the services they would have got before SDS. Since then, some authorities have refined their RASs or equivalency calculations. Whatever the approach they use, they have approval processes to check and authorise each budget and support plan.
60.	Authorities use team leaders, managers and panels – or a combination of these – to scrutinise and approve budgets and support plans. This is to ensure that budgets are spent appropriately and decision-making is consistent across the authority. In 2014, we found that Perth and Kinross Council was alone in its delegated approach to allocating budgets and the authority continues to do this now (Case study 5). One team in Highland is trialling a similar delegated authority approach to allow social workers to authorise packages costing up to £150 a week.
61.	Having delegated authority for budgets makes front-line staff feel trusted and empowered to make professional judgements, seeking help or supervision only when they need it. Staff in Perth and Kinross were positive about this but were also very aware of the authority’s limited budget and felt the pressure to be careful about how much spending they approve. 

Case study 5
Staff in Perth and Kinross have delegated authority to approve individual budgets of up to £200 a week

In Perth and Kinross, social work staff agree a support plan with an individual and then calculate how much it will cost. If it falls within a low cost band, they approve the spending themselves:  
up to £200 a week – front-line staff are allowed to authorise
between £200 and £400 a week – a team leader can authorise
over £400 a week – a service manager must authorise, and may call a panel meeting to consider it before final approval.
Front-line staff reported feeling confident in being able to authorise care and support arrangements for their clients, and in ways designed to meet outcomes. Staff feel they can authorise spending on almost any type of support, activity or individual item that helps to meet an individual's agreed outcomes.
To monitor spending and manage the budget, the system provides team leaders with weekly statistics on budgets approved by staff in their team. This allows benchmarking and identifies any staff approving excessive packages. 
Finance managers had initially feared that staff would approve packages just under the maximum level, but the average package approved is well below that. Front-line staff identified several factors which have helped them reach this position: 
team leaders have been checking work and outcomes to make sure they are outcomes
good examples are constantly shared as they are developed
a buddy system pairs people who are less confident about outcomes with people who have more experience
team leaders challenge their staff about their decisions.

Source: Audit Scotland

Part 3
Commissioning for SDS

changes to social care provision are happening slowly

Key messages
1.	Authorities are experiencing significant pressures from increasing demand and limited budgets for social care services. Councils’ total spending on all services decreased by five per cent in real terms between 2011/12 and 2015/16. At the same time, their spending on social work services alone increased by 8.6 per cent. 
2.	Within the context of these pressures, authorities’ approaches to commissioning can restrict how much choice and control people may have. Authorities do not have clear plans for deciding how to re-allocate money from one type of service to another as more people choose alternative services. There also needs to be flexibility in provider contracts or agreements so that not everyone gets the same service, which may not be the best way to achieve people’s outcomes.
3.	SDS option 2 is not yet fully developed. Option 2 was introduced in the SDS Act as a new way for people to control their support without having to manage the money. Of all the options, it is the most different between authorities in the extent to which people can choose their support and their provider.
4.	Changes to the types of support available to people are happening slowly. Day centres are the main type of service that has seen changes to provide more personalised support. While there is investment in developing new, alternative and preventative types of support within local communities, it is too soon to see the potential long-term benefits from this.
5.	Choice and control within a support service can often mean demand for greater flexibility from staff. This can have an impact on their health and wellbeing and their work-life balance, making recruitment and retention, already difficult, even harder.
Authorities are experiencing significant pressures from increasing demand and limited budgets for social care services
62.	Councils spent £3.4 billion on social work services in 2015/16.^21 We recently estimated that social work spending would need to increase by 16-21 per cent between 2015 and 2020 if councils and integration authorities continue to provide services in the same way as before.^22 Authorities have responded to the pressures from rising demand and limited budgets in the following ways:
•	Significantly reducing spending on other services. Social work spending increased by 8.6 per cent in real terms (taking account of the effects of inflation) between 2011/12 to 2015/16. At the same time, councils’ total spending on services decreased by five per cent (in real terms).^23 Integration authorities now plan health and social care services with a combined budget.
•	Reducing the workforce either by not replacing staff who have left or through voluntary severance and early retirement schemes. 
•	Tightening their eligibility criteria so that fewer people qualify for social care support. The proportion of older people supported in care homes in Scotland has decreased from 38.4 to 33.3 per 1,000 population between 2010/11 and 2015/16; the proportion of people receiving homecare has also decreased, from 60.8 to 49.0 per 1,000 population.^24
•	Reducing the size or scope of people’s individual budgets. This has been seen in Glasgow particularly, where the personalisation programme has met its targets of reassessing thousands of people and making overall savings of 20 per cent. This was not only through reducing individual budgets but by reviewing eligibility and doing targeted reviews of specific types of need and support.
•	Decreasing the scale of their in-house services and expanding their use of services provided by the third and private sectors, which are generally cheaper to provide, often as a result of competitive procurement. In addition, three authorities have set up arm's-length external organisations (ALEOs) to run as separate service providers (Aberdeen City, Glasgow and Scottish Borders). In 2016, almost a third (32 per cent) of homecare hours were provided to people solely receiving authority services, compared to nearly half (47 per cent) in 2010. The proportion varies across authorities. For example, in Perth and Kinross the percentage of homecare hours provided to people solely receiving authority services fell from 44 per cent in 2010 to 11 per cent in 2016, in West Dunbartonshire, the authority has continued to provide over 80 per cent of services from 2010 to 2016.^25 
Authorities’ approaches to commissioning can restrict people’s choices
63.	Commissioning is at the heart of developing and delivering health and social care services. It is the process that determines what services are available to people when they need social care. However, it is about much more than authorities organising and buying services; it also involves planning services for ten to 15  years ahead that will:
•	meet future demands
•	give people the choice and flexibility to direct their own support
•	make effective use of authorities’ limited resources, such as money, skills and equipment.
This long-term, strategic approach can help provide joined-up health and social care services. Well-planned investment in social care can help prevent or delay admissions to relatively expensive hospital or residential care, or help people return to daily life afterwards, in line with Scottish Government priorities. 
64.	The SDS Act makes councils responsible for promoting a variety of types of support and a range of providers so that people have genuine choice about what social care services they receive. Authorities’ actions to promote different types of support and a range of providers should be part of their approach to strategic commissioning. All integration authorities have produced strategic commissioning plans. However, the plans do not make it clear how decisions will be made about re-allocating money from one service to another as more people choose alternatives to existing services.^26 These decisions are especially difficult within the context of the demand and budget pressures. Changing or withdrawing services that some service users are happy with is also a challenge. But without clear criteria for making these decisions, there is a risk that social care services and support are not developed as planned and some people will not get the support they need in the future.
Contracts need to address personal outcomes
65.	When authorities buy social care services or support they normally have a contract, service level agreement or grant agreement. As support is targeted at a person’s individual outcomes, there needs to be flexibility in the contracts or agreements so that not everyone gets a standard service. An individual may want to vary the support they get, who provides it and when they get it. An example is choosing what time you want help to get up in the morning and go to bed at night.
66.	A standard contracted service may not be the best way to achieve some people’s outcomes. If authorities contract providers to successfully meet people’s outcomes, rather than simply to provide a fixed number of support hours, people and providers would be able to work together more flexibly and creatively to personalise the support and target the individual’s personal outcomes. Authorities, providers and service users would have to agree the best support within the budget available. Our case study of Thomas (Supplement 1 ) shows how this can work. 
SDS option 2 is not yet fully developed
67.	If sufficient flexibility and choice is not available through SDS option 3 (the authority arranges the support, often as part of a standard contract), and someone does not want to take a direct payment (option 1), then option 2 may be the answer. Option 2 was introduced in the SDS Act as a new way for people to control their support without having to manage the money. Someone else arranges their chosen support and administers their budget on their behalf, usually a third sector organisation or the authority itself. There were few examples of option 2 when we reported in 2014, and we recommended further guidance on the practical issues relating to option 2. COSLA and the Scottish Government worked with CIPFA to produce further guidance on resource implications and management considerations of SDS for councils.^27
68.	In practice, option 2 looks quite different from one authority to another. At one end of the scale it looks very like option 1 (direct payments) but without the responsibility for handling the money and arranging the services. At the other it is very like option 3 (services provided through the authority) except you get to choose the provider. The closer it is to option 1, the more scope there is for flexibility, choice and control over the type of support.
69.	Many authorities have framework agreements with providers, which means they have a contract, with agreed terms, but no commitment to buy services. Contracts are often awarded through competitive tendering so that every provider with a framework agreement must offer their services at the agreed price per hour of support and to specified quality standards. People who choose option  2 can select a provider with a framework agreement and make an individual contract with that provider for the support they want. The individual contract must be within the terms of the framework agreement.
70.	However, if people who choose option 2 want to use a provider that does not have a framework agreement, or arrange services that are not in the framework agreement, their choices may be constrained. Some authorities, for example Glasgow, confine people on option 2 to providers with framework agreements. Others, for example Perth and Kinross, use framework agreements but will arrange individual contracts with other providers that people choose, if appropriate. Authorities must be clear about both the benefits and constraints in the way they use framework agreements (Exhibit 7). They must also consider the need to sustain and develop a range of provision that gives people choices.
Changes to the types of support available to people are happening slowly
71.	When we reported in 2014, councils were in the process of identifying exactly how much they were spending on different elements of their services, including both in-house and bought from the third and private sectors. Case study authorities reported more changes in the types of services and range of provision between 2010 and 2016. But changes are happening slowly and it is more difficult for authorities to allocate a budget to new developments within the current demand and financial pressures.
72.	Day centres are the main type of service that has seen changes. This is happening in all five case study areas. To attend day centres, typically people are transported by bus or taxi from their homes or residential care. At the centres, staff help them to take part in a range of activities, often with other people receiving support. However, some people are choosing alternatives to day centres or are being referred to community-based activities instead. But not everyone chooses to stop attending a day centre. When day centres close altogether, it can be disappointing and disruptive for people who want to remain and do not want alternatives. 

Things are better now than the day centre, better when you are out with your support. I am the boss of the support and tell them what I want to do.
Man with learning disabilities

Over many years, the council has worked well with service users and their carers…to provide first class services for the learning disabled in the area, including day centre and respite services. Recent developments, linked to the rollout of Self Directed Support, have led to the authority indicating that 'services will become less financially sustainable'…We are very concerned that the services will be closed or reduced significantly.
Parent

Exhibit 7
Flexibility of framework agreements for option 2
Authorities must strike a balance between the advantages of rigid framework agreements and the benefits of additional flexibility.

| Advantages | Disadvantages

Having framework agreements

•	People have a list of providers to choose from, each of which has a contractual commitment to agreed quality standards and price
•	Having an agreement in place beforehand makes the process quicker and easier when people choose their providers/services
•	For an authority with large numbers of service users and providers, it can save a lot of administration time

•	It may be more difficult to develop flexible support or outcomes-focused contracts in future within a fixed framework agreement

Set minimum quality standards

•	Authorities, and people who need support and their carers, have a contractual assurance about the financial stability of the providers and the minimum quality of services they can expect
•	Authorities can introduce standards into the agreement over and above the national care standards, eg length of time to reply to requests or complaints, frequency and timing of payments, or information that must be provided to service users

•	None

Set maximum price per hour

•	Authorities, and people who need support and their carers, know the services will cost them no more than the maximum price

•	High-quality or specialist providers may not be able to provide a service for under the maximum price
•	Providers may use the maximum  price even if they could provide the service for less
•	Having a price based on hours makes it hard to progress to outcomes-based contracts

Set a fixed price per hour | •	Providers need not compete on the basis of price, leaving them to concentrate on the nature and quality of services when they tender for a framework agreement | •	There may be less incentive for providers to compete on quality if they are paid the same price whether the quality of service is at the minimum standard or higher
No set price limits | •	Providers can strike their preferred balance of costs and quality and make this known. People can then choose a provider knowing what cost and quality is being offered | •	In areas where there is a shortage of providers, the prices may be higher than in other areas because there is little competition

Offering framework agreements through competitive tender

•	Providers are incentivised to keep costs down because they are not guaranteed to be on the list, even if they meet minimum quality standards and maximum price requirements
•	Authorities can choose to go through a regular, single tendering exercise, which saves on the costs of irregular, individual exercises

•	Additional flexibility that allows people on option 2 to choose alternative providers incurs extra costs for the authority, mainly in staff time, to arrange a contract with a provider
•	Providers not selected may go out of business, reducing choices for people

Open list of framework providers or frequent opportunities to apply

•	New providers or additional provision can be made available to people whenever it is created
•	If people choose a non-framework provider, that provider can then apply for a framework agreement

•	There is an administrative overhead for authorities each time a provider applies for a framework agreement
•	Reduces the competitive element as there is not a single competitive tender

Closed list or infrequent opportunities to apply

•	Reduces the administrative overheads for the authority, which can be significant in areas with many providers
•	Incentivises providers to keep their quality standards high and costs down, or risk being excluded from the framework with limited opportunity to get back on the list

•	If people are only permitted to choose a framework provider under option 2, the only way they can choose a non-framework provider is to take a direct payment (option 1), with the additional responsibilities, as well as the flexibility, that entails
•	May limit developments or innovation from providers if they cannot immediately apply for a framework agreement.

73.	Where day centres can be adapted or expanded to develop other community-based facilities, it can be a very positive move (Case study 6). Although this is not a new approach, personalisation and self-directed support are helping to encourage changes like this.
Authorities are developing more community-based activities and facilities
74.	The SDS strategy intends that people who are assessed, whether they are eligible or not, should be signposted or referred to community-based supports, activities or facilities if these will meet their needs. Often, community-based services can help prevent or delay people from needing more health or social care support later. In all five case study areas, authorities were working to develop this type of preventative service. For example, in Glasgow, each of the three localities has local area coordinators. In Perth and Kinross, each locality has an early intervention team to put people in touch with community-based support before they reach the point of needing more health or social care support, or both of these. For example, there is a choir for people who suffer from chronic obstructive pulmonary disease (COPD). While it is a fun and sociable activity, it also alleviates the symptoms of participants’ illness.

Case study 6
Expanding day centres into community-based facilities can benefit communities and supported people

In Brora, Highland, a day centre for people with learning disabilities lost a few service users when they chose other types of support or moved away. The community took over the centre and expanded its activities to include the whole community. It is now set up as a social enterprise, with some core funding from the authority to employ a coordinator. It is now a very inclusive centre where anyone is welcome, and is also open during evenings to give young people a place to go.
Perth and Kinross had a traditional day centre which transported people in from surrounding areas by bus. Staff now go out to provide support rather than having everyone transported to the centre. The authority is looking at how it can use the free space now available in the centre, for example by introducing community cafes.

Source: Audit Scotland

75.	In some rural or remote areas, authorities are working closely with local communities. This is not necessarily to develop additional choices or preventative services, but to find ways of providing support to people who otherwise would have none. Individual, local solutions are being developed and greatly improving the quality of some people’s lives (Case study 7).

Case study 7
Local solutions grow from local communities

Macaulay College is a company set up for the benefit of the community based on the Isle of Lewis. The project is run by a couple and started in 2010. It currently has 24 students – all adults with additional needs – aged 16 to late 50s. It provides various activities including animal care, a wood workshop and ceramics.
Boleskine is a rural village in Highland where a group of people were receiving no support services because the integration authority and independent sector could not recruit support staff. A small pool of potential carers wanted to help in their own community but didn’t want to work for the council or a private or third-sector provider. The authority (NHS Highland) asked Highland Home Carers, an independent provider, to help by giving care workers help with employment administration. Now people are able to take a direct payment and buy their care services from local people. There is a similar initiative on the Black Isle in Highland.

Source: Audit Scotland

Providers are at different stages in changing their services to give people more choice and control
76.	There is variation among providers in the extent to which they have prepared for SDS. A recent survey of third-sector providers found that 48 per cent had increased training in personalisation and many felt that their workforce also needed regular refresher training.^28 The most common and pressing skills shortage among their staff is a lack of understanding of outcomes.
77.	Individual staff providing social care have a significant influence on the flexibility and quality of care that people who use the services experience. Choice and control within a support service can often mean demand for greater flexibility from staff. This can cause tensions, as it can mean unpredictable or fragmented shift patterns, rapid and unscheduled changes in rotas, or staff having to be on unpaid standby. These have implications for the staff, for their health and wellbeing and their work-life balance, making recruitment and retention, already difficult, even harder.
78.	If providers do not become more flexible then people who need support may be prevented from choosing or finding the support that will improve their quality of life. Social care staff also have a right to reasonable working terms and conditions.
Workforce shortages are making it difficult to develop a range of services
79.	Many authorities and providers have difficulties recruiting staff, either for in-house services or the organisations they have contracts with. Social care is not widely seen as a positive career choice for younger people, especially in areas where there are other better-paid jobs, such as working in a supermarket. This low pay along with antisocial hours and difficult working conditions are reasons why providers have difficulty in recruiting staff. The cycle of continually recruiting and training staff is costly and could potentially have an impact on the quality of services provided.^29 The Scottish Government and authorities recognised this problem and agreed to begin addressing it by jointly investing in the living wage for social care workers from October 2016, and this commitment has continued into 2017/18. But where employment rates are high, for example in Perth and Kinross where unemployment is 1.2 per cent, there are still difficulties in recruiting and retaining social care workers and the authority is trying new ways to make people aware of social care as a potentially positive career, including targeted advertising.^30
80.	In the Western Isles, there is a relatively large proportion of older people in the population, therefore older people are looking after other older people. It is difficult to recruit younger carers, and also male carers, from these communities. This is not sustainable, and the authority is trying to recruit younger people into the caring profession through joint work with Skills Development Scotland.

Part 4
Implementing the national SDS strategy
Scottish Government, COSLA and other partners are targeting six significant challenges
Key messages
1.	The Scottish Government took an inclusive approach to developing the SDS Act and guidance. Since 2011/12, it has spent £60.37 million on supporting SDS implementation and has committed another £9.51  million in 2017/18. When dedicated funding comes to an end, there is a potential threat to the provision of independent information, advice and advocacy, which helps individuals to choose and control their support. 
2.	SDS implementation stalled during integration of health and social care services. Changing organisational structures and the arrangements for setting up, running and scrutinising new integration authorities inevitably diverted senior managers’ attentions. Some experienced staff are also being lost through early retirement and voluntary severance schemes as the pressures on budgets mount.
3.	The Scottish Government and COSLA have produced a 2016-2018 implementation plan for the ten-year strategy, which they developed in collaboration with partner organisations following a period of consultation and review. It reflects the experience and lessons learned from implementing SDS up to that point. The plan sets out actions for the partners that target six significant remaining challenges. 
4.	Our evidence – from people who need support and their carers and families, social work staff and managers in authorities, and third and private sector organisations – shows many examples of positive progress in many different ways. But there is no evidence that authorities have yet made the transformation required to fully implement the SDS strategy. 
5.	The Scottish Government should provide joined-up, strategic leadership across the range of its policies to ensure that SDS becomes a core part of how people with health and social care needs are supported to improve their quality of life.
The SDS strategy set out an ambitious vision for changing social care by 2020
81.	In the SDS strategy, the Scottish Government and COSLA set out a vision they shared with many people who need support and who provide support. Social care would be transformed so that people could choose how they live their lives and, if they want, control how their support is provided. The strategy set out seven success measures:
•	Better quality of life for individuals.
•	Radical increase in uptake of SDS and direct payments.
•	A sustainable network of advocacy and peer support organisations.
•	A sustainable network of independent support organisations for training and supporting personal assistants.
•	A proficient body of trained, experienced personal assistant employers.
•	An appropriate workforce of trained personal assistants, with regulated employment conditions.
•	Improved partnership working between people receiving support, public bodies and third and private sector providers.
82.	The SDS Act was part of the strategy and was intended to speed up some of the major changes required to successfully implement SDS. In 2014, we reported that at every stage of developing the SDS Bill, regulations and statutory guidance, the Scottish Government consulted with and involved:
•	councils
•	people who use services, and their carers
•	organisations representing people who use services
•	third and private sector providers
•	other relevant organisations.
Participants saw it as a very positive and inclusive approach. 
The Scottish Government has spent, or committed, almost £70 million to help implement SDS
83.	The Scottish Government has spent £60.37 million between 2011/12 and 2016/17 supporting SDS implementation. It has committed another £9.51 million in 2017/18 (Exhibit 8, page 40). It is working with partners to monitor and evaluate the projects it has funded and has published evaluation reports. It has also contracted Inspiring Scotland, a third sector organisation that facilitates and supports innovative projects, to help funded organisations manage and evaluate their projects and share the learning, and to report back to the government.
Exhibit 8
Scottish Government funding for SDS implemention
The Scottish Government has spent £60.37 million and forecasts another £9.51 million in 2017/18.

(£ millions) | 2011/12 | 2012/13 | 2013/14 | 2014/15^1 | 2015/16 | 2016/17 | 2017/18
Support in the right direction fund | 1.00 | 1.50 | 2.60 | 2.30 | 2.90 | 2.86 | 2.96
Innovation fund | 1.00 | 1.80 | 1.90 | 1.60 | 1.20 | 1.20 | 1.23
Local authority transformation | 1.20 | 6.80 | 11.00 | 6.00 | 3.52 | 3.52 | 3.52
Other (including national strategic partners) | 0.00 | 0.20 | 1.90 | 2.10 | 1.00 | 1.27 | 1.80
Total | 3.20 | 10.30 | 17.40 | 12.00 | 8.62 | 8.85 | 9.51

Note: 1. The SDS Act came into force in April 2014.
Source: Scottish Government

84.	The Support in the Right Direction programme funds 34 independent organisations to support people to identify their personal outcomes and make informed decisions about their support. The government reports that in the six months from October 2015 to March 2016: 
•	3,200 people were supported to access their existing community resources
•	2,400 individuals received training and development support
•	1,000 people received brokerage support, ie support from an external agency to buy services.
•	950 people were helped to set up and manage their care packages
•	800 people were helped to employ and manage personal assistants.^31
The Innovation Fund programme is helping 21 third sector social care providers to develop their ability to deliver flexible and creative support and develop their staff. ^32 
85.	The Scottish Government has given no indication yet of what support, if any, it will give from 2018/19 onwards to further support SDS implementation. The third sector organisations involved fear that with no future funding they will be unable to continue supporting people, and authorities feel unable to take over the additional cost of funding them. This poses a potential threat to the provision of independent support for individuals. The Scottish Government should work together with COSLA, providers and people who need support to agree very soon what independent help people will need in future and how this should be funded. 
86.	When developing implementation plans for the remaining years of the SDS strategy, the Scottish Government should work with COSLA and other partners to agree how any future financial support should be allocated. As part of that process, they should take into account how authorities’ local commissioning strategies will inform future spending priorities.
The Scottish Government and partners underestimated the scale of the changes needed and the challenges in implementing SDS
87.	The Scottish Government and partners underestimated the scale of the changes needed and the challenges in implementation, some of which could not have been foreseen in the early years of the strategy. The underestimated work includes:
•	the time and costs involved in reviewing and changing systems and processes, such as changing computer software to incorporate ways of recording and reporting individual outcomes
•	developing resource allocation systems to allocate people their individual budgets
•	training and supporting staff on SDS and on identifying outcomes with people who need support
•	involving staff from finance, procurement, audit, and other council services
•	developing new and more flexible service provision while demand for existing services was rising and budgets were decreasing, making it difficult to release money to pay for new developments.
88.	Work that was not anticipated includes:
•	training and supporting a range of health professionals who contribute to, or influence, SDS implementation within the new integration authorities
•	having to tighten individual budgets and eligibility criteria as a result of sustained budget pressures
•	working with a smaller workforce and losing experienced staff through voluntary severance and early retirement.
89.	At the same time, not long after the SDS Act came into effect, the Scottish Government team began to have less direct engagement with authorities and third sector organisations in order to take a more strategic role in leading the implementation of SDS. This resulted in a feeling among those implementing SDS that it now had a lower profile in the Scottish Government and that implementation lost its momentum during integration. However, the team is now working with its partners to give a clear direction for the next stages of the strategy.
SDS implementation stalled during the formal integration of health and social care
90.	The Public Bodies (Joint Working) (Scotland) Act 2014 required councils and NHS boards to integrate their health and social care services by April 2016. This meant that the senior managers who took the lead in implementing SDS in councils became involved in changes to organisational structures and arrangements for setting up, running and scrutinising the new health and social care integration authorities. The integration work had the effect of diverting the attention of managers already preoccupied with the challenges of increased pressure on budgets. In addition, some experienced staff have left, or are leaving, through voluntary severance and early retirement schemes, leaving gaps in knowledge and in relationships with supported people, carers, and third and private sector organisations.
91.	With integration arrangements now in place, more professionals with healthcare backgrounds have only recently been introduced to social care and SDS. They will need training and help to understand the practicalities of SDS and its potential to help people avoid or delay hospital stays or return to daily life afterwards.
The Scottish Government, COSLA and its partners are targeting six significant challenges
92.	The Scottish Government and COSLA have produced a 2016-2018 implementation plan for the strategy, which they developed in collaboration with partner organisations.^33 They include Self Directed Support Scotland, Social Work Scotland, Scottish Social Services Council, Coalition of Care and Support Providers in Scotland, Scottish Care, Care Inspectorate and Healthcare Improvement Scotland. The plan was developed following a period of consultation and review and reflects the experience and lessons learned from implementing SDS up to that point. It identifies four strategic outcomes and the actions partners will take to help achieve each outcome (Exhibit 9). The actions include specific activities to address six significant ongoing challenges:
•	developing good flexible commissioning and procurement arrangements
•	supporting people to achieve their agreed outcomes creatively while balancing any associated risks
•	managing demand and expectations by using resources, such as money, people and buildings, effectively and developing a shared understanding of how to meet future demand in the context of reduced public funding
•	increasing awareness and understanding of SDS among the workforce, supported people, carers and communities
•	keeping SDS as a high priority within other public sector reform policies and strategies, especially the new integrated arrangements
•	making systems and processes easier and clearer so they work best for people who need support rather than the organisations who help to provide it.
93.	These are broad areas and they include addressing the challenges identified in this report. They also give a clear guide to help authorities, and third and private sector organisations, move forward after the recent stalling of progress.
Authorities have not yet made the transformation required to fully implement SDS
94.	Our evidence – from people who need support and their carers and families, social work staff and managers in authorities, and third and private sector organisations – shows many examples of positive progress in many different ways, but there is no evidence that authorities have made the transformation required to fully implement the SDS strategy. More people need to be better informed and empowered to choose and control their support; a significant minority of social work staff need further training and support to help them develop their skills, knowledge and confidence; commissioning needs to drive changes in services to give people choices and flexibility.
Exhibit 9
Strategic outcomes 2016-2018
•	Supported people have more choice and control: Citizens are engaged, informed, included and empowered to make choices about their support. They are treated with dignity and respect and their contribution is valued.
•	Workers are confident and valued: People who work in health and social care have increased skills, knowledge and confidence to deliver self-directed support and understand its implications for their practice, culture and ways of working.
•	Commissioning is more flexible and responsive: Social care services and support are planned, commissioned and procured in a way that involves people and offers them real choice and flexibility in how they meet their personal outcomes.
•	Systems are more widely understood, flexible and less complex: Local authorities, health and social care partnerships and social care providers have proportionate, person-centred systems and participatory processes that enable people who receive care and support to live their lives and achieve the outcomes that matter to them.
Source: Self-directed Support Strategy 2010-2020: Implementation Plan 2016-2018, Scottish Government and COSLA, 2016

95.	The four outcomes in the implementation plan are difficult to measure and monitor (Exhibit 9). Evidence needs to come from:
•	people who receive social care support
•	their carers and families and communities
•	the workforce, including front-line staff and managers in authorities
•	support providers and their representative organisations
•	national and community-based organisations and groups who support and represent people
•	the bodies that regulate and scrutinise health and social care
•	research and evaluation.
96.	In our 2014 report, we acknowledged that it was too soon to expect to see a major impact. We recommended that the Scottish Government and its partners develop a strategy to measure and report on progress towards the intended outcomes of the SDS strategy. The Scottish Government, COSLA and their partners now have detailed actions and success measures. These are set out in the implementation plan and should be reported regularly. Now that health and social care integration is established, and there are clear expectations on the new authorities to report on their performance, the Scottish Government and authorities should also agree how to report the progress and impact of the significant changes still expected in implementing self-directed support.
97.	Councils, health boards and the new integration authorities are working on a number of national policies, targets and reviews. Consistent and coordinated policy guidance and expectations from the Scottish Government and COSLA will help them to deliver on these major policies. The Scottish Government should work with COSLA and other partners to provide joined-up, strategic leadership across the range of its relevant policies to ensure that SDS becomes a core part of how people with health and care needs are supported to improve their quality of life.
Endnotes
| 1.	Social Care (Self-directed Support) (Scotland) Act 2013.
| 2.	Self-directed Support Strategy, Scottish Government, 2010.
| 3.	 Commission on the Future Delivery of Public Services in Scotland, Christie Commission, June 2011.
| 4.	Public Bodies (Joint Working) (Scotland) Act 2014.
| 5.	 Changing Lives: Report of the 21st Century Social Work Review, Scottish Executive, 2006.
| 6.	Social Work (Scotland) Act 1968; NHS and Community Care Act 1990.
| 7.	 Self-directed support , Audit Scotland, June 2014.
| 8.	 Social Care Services, Scotland, 2016, Scottish Government, November 2016.
| 9.	 Children’s Social Work Statistics Scotland 2015-16, Scottish Government, March 2017.
| 10.	Scottish Government and COSLA guidance on a national framework for eligibility criteria, 2009.
| 11.	 Charges Applying to Non-residential Social Care Services 2016/17, COSLA, 2016.
| 12.	 Self-directed support, Scotland, 2015-16, Scottish Government, July 2017.
| 13.	 Health and Care Experience Survey 2015/16, Scottish Government, May 2016.
| 14.	 Self Directed Support User Experience Survey – What people said, Self Directed Support Scotland, June 2016.
| 15.	 Social Care Services, Scotland, 2016, Scottish Government, November 2016.
| 16.	 Care Home Census for Adults in Scotland, NHS Scotland, October 2016.
| 17.	 Health and Care Experience Survey 2015/16, Scottish Government, May 2016.
| 18.	 Self Directed Support User Experience Survey – What people said, Self Directed Support Scotland, June 2016.
| 19.	 Social work in Scotland , Audit Scotland, September 2016.
| 20.	 Still Waiting: Self Directed Support - Two Years on, Learning Disability Alliance Scotland, 2016.
| 21.	Councils’ audited annual accounts, 2015/16.
| 22.	 Social work in Scotland , Audit Scotland, September 2016.
| 23.	 Local government in Scotland: Financial overview 2015/16 , Audit Scotland, November 2016.
| 24.	 Social Care Services, Scotland, 2016, Scottish Government, November 2016; Care Home Census for Adults in Scotland, NHS Scotland, October 2016; Population Estimates, National Records of Scotland, April 2017.
| 25.	 Social Care Services, Scotland, 2016, Scottish Government, November 2016.
| 26.	 An overview of strategic commissioning plans produced by Integration Authorities for 2016 - 2019, Scottish Government, October 2016.
| 27.	 Guidance Notes on Self-directed Support, Chartered Institute of Public Finance and Accountancy (CIPFA), July 2015.
| 28.	 The enablers and barriers to voluntary sector organisations providing personalised support through Self- directed Support, University of Strathclyde, 2016.
| 29.	 Social work in Scotland, Audit Scotland, September 2016.
| 30.	ONS Claimant Count, Office of National Statistics, July 2017.
| 31.	 Self-Directed Support: Support in the Right Direction Fund, Year 1 Progress Report, Inspiring Scotland, May 2016.
| 32.	 Self-Directed Support: Innovation Fund, Year 1 Progress Report, Inspiring Scotland, May 2016.
| 33.	 2010-2020 Self-directed Support Strategy: Implementation Plan 2016-2018, Scottish Government and COSLA, 2016.