Foundations for self-directed support in Scotland
Foundations for self-directed support in Scotland

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Foundations for self-directed support in Scotland

Challenges to working well together with adults

In this section we explore challenges to working well together, with an emphasis on how health and social care services work together for adults.

Activity 6.7 What are the challenges?

(Allow about 25 minutes)

Watch the panel event and then use your learning log [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] to answer these questions:

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Transcript

Willy Roe
My name’s Wily Roe, role and I’ve been asked by the Open University Scotland if I would be the chair of the session today. I’m delighted to do that, and just a few words of introduction at the beginning before I ask the panel members to tell us who they are and what they do. For some of us, self-directed support might be something completely new, maybe even daunting. Maybe interesting and challenging, and positive.
But for everyone, self-directed support isn’t new, because in fact, the roots of this movement can be traced right back to the activism or disabled people in Hampshire in England in the late 1970s, when direct payments were first introduced as one of a range of solutions to tackle a lack of choice and control that disabled people felt at that time. So for some people this, is a generation’s worth of work they’ve already been doing.
But for others of us, it probably is something quite new. And this edition of question time is designed to help us learn about what is happening, what the pluses and minuses of it might be, and where over the coming years self-directed support might take us in Scotland. So could I ask the panel each to introduce themselves, and just tell us in their own words what personalisation, I suppose, is for them.
And how they feel that this new legislation, the Social Care Self-directed Support Act of 2013 could take forward the idea of personalisation. So tell us a bit about yourself in a few moments, and we’ll go to Allie first.
Allie Cherry
Good afternoon, folks. My name’s Allie Cherry. I manage NHS Lothian Self-Direct Support Test Site. I have to make a disclaimer at this point, I’m not a clinician, and I’m a community education worker. So coming at it from a slightly different approach.
In terms of what personalisation is for me, it’s very much about ensuring that the outcomes for the individual at the centre of any discussion and decision making process, and as far as the impact that the act will have on peoples’ care.
I think for me it’s very much about ensuring that the individual has the information that they need to make an informed choice, and it places the onus on professionals to make sure that that information is accessible to the individual to enable them to make that choice. Thank you.
Willy Roe
Thanks, Allie. Etienne, would you like to introduce yourself?
Etienne d’Aboville
Hello. My name’s Etienne d’Aboville, and I’m chief executive of Glasgow Centre for Inclusive Living. And we’re a centre for inclusive living, a CIL run by disabled people. We provide a variety of services to disabled people in and around Glasgow, including housing, employment, and probably core to the organisation, providing support to between 400 and 500 people using various forms of self-directed support in Glasgow, and also in east Dunbartonshire.
I think it’s very, very pleasing just to hear Willy refer to the origins of direct payments and self-directed support, because I was probably one of those people in the ’80s who was involved in that campaign to bring in the legislation. So my perspective on personalisation is with the backdrop of direct payments being a key part of the campaign, of the independent living movement.
So I see it very much in the context of one of a range of issues that disabled people need to have resolved to enable them to participate in independent living. So housing, transport, education, employment.
A keystone of that is the day to day support that people need. And so for me, it has a kind of collective dimension relating to the kind of empowerment to disabled people, the choice, dignity, and control, ultimately leading to citizenship. Which is effectively what it’s about for people at the end of the day, for me. Thank you.
Willy Roe
Kirstein?
Kirstein Rummery
I’m Kirstein Rummery, I’m a professor of social policy at the University of Sterling. And I’ve been involved in research into personalisation, looking at it internationally and in the UK, and more recently within the Scottish context for not quite as long as Etienne’s been involved in campaigning on it, but it feels that way. And personalisation for me is really about devising systems that provide support for citizens that need that.
But in ways that are quite creative, and ways to put them at the heart of controlling that support. And I think I’m a slight fan of the latest kind of legislation, which is the SDS bill that went through this year, because it is quite evidence based. It does build on a history of good experiences, both within the UK and within Scotland. And as an academic researcher, I’m a big fan of evidence based policy.
And I think it does provide a useful framework for being able to provide better services and support for people that breaks us out of silos that we might have got entrenched into earlier.
Willy Roe
Thank you. And finally, John.
John Alexander
I’m John Alexander. I’m the director of social work with Dumfries and Galloway Council. I’ve been here in that role for the last five years, during which I’m pleased to say I was able to oversee the involvement of Dumfries and Galloway in the Scottish government test sites for self-directed support. I’m a professionally qualified social worker by training.
I’ve worked in local government for 35 years in a number of authorities, and for probably the majority of my career, my interest has been in services for adults and community care services. For me, personalisation I think is a description of a way in which individual citizens are given the opportunity to take control, and to exercise choice about the kind of life that they lead.
And allowed to achieve everything that they wish to achieve in their lives with the support of others. In that sense, I think of personalisation as rather broader as a concept, and self-directed support. But I do agree with other speakers.
I think that the present bill, soon to be enacted and implemented, allows those opportunities for individuals to exercise choice and control in relation to a very important aspect of their life, which is the kind of support and care that they need to, if you like, get them to the starting line to participate in local communities and lead fulfilling lives.
Willy Roe
Thank you very much. Well, thank you all.
End transcript
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  • What challenges do the panel members and the questioner identify as getting in the way of health and social care working together?
  • What do they think needs to happen to enable services to work together better?

Discussion

A number of challenges are discussed by the panel: Etienne talks about the need for 'a massive cultural change' and the development of a shared service culture that values human rights, independent living and citizenship. Kirsten Rummery emphasises the need for personalised approaches such as self-directed support to be mainstreamed, especially in the health service. And Colin, the questioner, reminds us that money is a key issue: a shift towards personalisation, of people having control of their own budgets, means a loss of control of funds for large organisations like the health service (much the 'dominant partner' when thinking about health and social care). Interestingly, it is suggested that the introduction of self-directed support legislation may be an important driver for better service integration.

We now go on to explore in more detail three of the key challenges that the panel identified:

  • budgets
  • professional cultures
  • structures and organisations.

Budgets

Figure 6.5: One of the key challenges is having sufficient resources to make working together for personalisation a reality

There may be many reasons why different practitioners and organisations find it difficult to work together to provide a coherent service; one of the key challenges is money. Money can be the root of argument in even the most intimate of relationships, and the same is true for organisational bedfellows. This is particularly true of the funding of health and social care.

In 1999 the Royal Commission on Long Term Care reported that:

The current system is particularly characterised by complexity and unfairness in the way it operates. It has grown up piecemeal and apparently haphazardly over the years. It contains a number of providers and funders of care, each of whom has different management or financial interests which may work against the interests of the individual client. Time and time again the letters and representations we have received from the public have expressed bewilderment with the system – how it works, what individuals should expect from it and how they can get anything worthwhile out of it. We have heard countless stories of people feeling trapped and overwhelmed by the system and being passed from one budget to another, the consequences sometimes being catastrophic for the individuals concerned.

(Royal Commission on Long Term Care, 1999, p. 33)

Since this was written there have been some important funding changes in Scotland (such as the introduction of free personal care for people who are over 65), but many of the same problems persist. Thirteen years on, the Scottish Government stated that addressing the challenges of separate – and sometimes disjointed – systems of health and social care will demand:

commitment, innovation, stamina and collaboration from all of us who are involved, in different ways, in planning, managing, delivering, using and supporting health and social care services.

(Scottish Government, 2012, p. 8)

The passing of the Public Bodies (Joint Working) (Scotland) Act 2014 is an important step in the Scottish Government's steady move towards greater health and social care integration.

Cultures

Figure 6.6: Particular clothes, locations, ways of talking and goals mean that different occupational groups may have quite different professional cultures.

All professions develop particular ‘cultures’ – sets of values, beliefs, attitudes, customs and behaviours that evolve over time. These reflect the history of each profession, the characteristics of the people that join the profession (like gender and social class), and how professionals are trained. Professionals tend, for example, to develop their own language – or jargon – that can be difficult for members of other professions to understand. Differences in professional cultures create potential for the fragmentation of health and care services.

Professional cultures can also exclude professionals themselves from decision-making processes. Viewpoints that do not share the knowledge base of the dominant profession in a particular setting can be more easily dismissed. Status boundaries, for example, between nursing and medical staff, and social care and health care, and the public, private and third sectors, are, as you learned in Section 1 , continually being negotiated and renegotiated.

Of course, the need for working together is not new and a lot of work has been done in Scotland and elsewhere, to try to make sure that services ‘join up’. This is particularly important when a person must frequently use both a number of different services. For example, when somebody has a long-term mental health problem they are likely to need a range of different kinds of supports, including medical, nursing and social care. Sometimes these services work well together, but differences in knowledge base, power and professional cultures may frustrate collaborative working – to the detriment of a good service for the person who is being supported.

In this section we’ve emphasised the difference in professional culture between ‘health’ and ‘social’ care. This distinction is important but it is not the only cleavage between professional groups. For example, how an occupational therapist ‘sees the world’ and how a social worker ‘sees the world’ may differ – and this can create difficulties in collaborative working even if they work for the same local authority department.

Structures and organisations

Sometimes difficulty in collaborating is not about different professional cultures; rather, it is about how a whole society thinks things should be organised.

Demand for government-provided services, such as health, grew at a great rate during the 1950s and 1960s, and at the same time people increasingly felt entitled to these services as a matter of right. The organisations responsible for service delivery grew and became ever more complex and expensive, and there have been regular restructurings of health and care services in response to successive changes in community care policy.

Whatever the motivation for structural change, if the organisational structure becomes central to the desired change then service users cannot be central, as these quotes from Alison Petch at the Institute for Research and Innovation in Social Services (IRISS) and Chris Ham at the Nuffield Trust indicate:

There is clear evidence that structural integration does not deliver effective service improvement. The emphasis should be on service integration rather than on organisational integration. Moreover the focus should be on the specific aspects of individual partnerships which deliver particular outcomes for identified groups.

(Petch, 2012, p. 10)

The journey towards integration needs to start with a focus on service users and from different agencies agreeing a shared vision for the future, rather than from structures and organisational solutions.

(Ham, 2009, p. 1)

We now go on to look at the potential consequences for service users and carers if services do not start with the service user, but instead work separately with differing aims and working practices.

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