Equivalence Resource Allocation

Created on 5 January 2015

These are systems that rely on the judgement of a professional social worker to establish the level of a budget.  They decide what support they would normally provide to a person with social care needs and then monetize that service so that it can be offered in the form of an indicative budget.

They start from the basis that it cannot be right to set a budget at any level unless there is good reason to believe that this level is reasonable and that someone could get their needs met with that budget.

Equivalence helps to show that the budget does reflect some real model of how a need might be met.   In this system Self Directed Support gives the opportunity to the service user to meet those needs in a way that is even better for them than might originally have been done.   They retain the option of asking the local authority to arrange a service of the “equivalent standard.”

18 councils are now running Equivalence in their area and we think it is possible to break these down into two different types of system.

4.2.1          General equivalence – There is an assessment of need followed by the social worker deciding on support levels that the local authority should offer.   They then run this service through a ready reckoner for a budget and this discusses options with the client and offers the choice of the 4 options.

Perth and Kinross Council have this sort of equivalence.  A person’s outcomes are agreed through an outcome focussed assessment, and the relevant amount for an Individual Budget is then calculated using the full cost of providing the care and support services identified in their personal outcome plan.

Midlothian Council are planning to adopt a similar system by following developments in Perth.

4.2.2          Specific equivalence – There is an assessment of need followed by the social worker deciding on support levels that the local authority should offer.   The social worker then can offer variable budgets depending on the SDS option chosen to purchase these supports in the way that client wants.

Highland NHS have this sort of system.  A person’s outcomes are agreed through an outcome focussed assessment, and the relevant amount for Direct Payments is agreed through a ready reckoner spread sheet.  Individual budgets for options 2 and 3 are assessed on an individual basis depending upon chosen service provider.

East Dunbartonshire Council also have this sort of system.   The individual budget is calculated by costing the supports in the service user’s support plan that have been agreed as supporting the individual to meet their needs. The use of a ‘Schedule of Rates’ will be utilised by practitioners to determine the most appropriate ‘standard rate’.  This will vary according to whether it is Option 1,2 or 3 and the type of service chosen.

 

Points Based Resource Allocation Systems

Created on 5 January 2015

These are systems that try to turn the allocation of funding into a science rather than an art.  It is based on the idea that there is mainly a smooth scale of needs, rising up slowly and that if you can work out how to give a points value to each need then you can allocate a budget fairly.  Everyone with the same points will have the same budget, even if it was different needs that got them those points.

This first budget is then used for planning processes and where it’s not enough or too much the budget is subsequently adjusted by a more or less arcane process.  This can involve a range of meetings with more senior social work staff to which the service user or their representative is unlikely to attend although in some cases, their care manager may make representations on their behalf.

Such systems are usually derived by a semi scientific method of removing “outliers” – those with expensive care packages and then averaging out care costs of between 100 and 300 people.

The principle of people with similar needs requiring similar amounts of money of course has simplistic appeal. But it is likely to not work in social care where social care needs arise from the complex interplay of many factors.   Such systems are seen as the antidote to the ‘professional gift’, whereby the large variations in how much people get was put down to the behaviour of professionals.   There is a lack of supporting evidence for this view.  Anecdotes about the results are in themselves are not sufficient.

But perhaps the biggest concern is that such systems can build in distrust between councils and services and even their own staff.  Two councils told us they would not be giving us details on how their Resource Allocation System would work because services users would use this information to get higher scores and get more support than they need.

Edinburgh City Council said “In order to try and ensure that the indicative budget is based upon an objective assessment of need, staff have no knowledge of the scores attached to specific elements of the assessment or the relationship between scores and financial amounts.”

Moray Council said “If disclosure of this information was made individuals could use this information to increase their scoring and obtain a higher budget unfairly.  It would be likely that some individuals would use such information, which would undermine the scoring system and fair monetary allocation.  This likely abuse would, in turn, substantially prejudice the effective conduct of public affairs.”

It is hard to see how Self Directed Support can be based on trust and co-production when local authorities believe that those vulnerable adults who need care and support are really aiming at “gaming” the system.

12 councils are now running RAS in their areas – Although one of these councils Aberdeen only uses the RAS model for people with learning disabilities.  Other client groups are using the equivalence methods.

We would suggest that there are 4 different types of RAS.

4.1.1          Assessment of need and then Pounds per point

North Lanarkshire Council and Angus Council have such systems.

North Lanarkshire have 8 scored questions with a maximum of 63 points.  Each point is worth £10 per week for support planning.  This amount is adjusted downwards depending on the level of family or informal care currently available and multiplied upwards depending on living context and previous experience.

Angus Council have 11 scored questions with a maximum of 94 points although 3 questions can only score 0 points.  Each point is worth £5 per week for support planning.  This amount is adjusted downwards depending on the level of family or informal care currently available.   A local maximum for support planning has been established set at the level of the residential care rate for that particular client group.

4.1.2          Assessment of need and then Placement on a scale

Glasgow City Council have this sort of system.   Glasgow City Council Support Needs Assessment has 8 scoring questions with a small number of sub questions.   There are 100 points available.  Each score is then looked up on a points scale.  The additional value for each point varies considerably.  Point 82 gains a service user an extra £7.13 per week.   Point 84 gains a service user an extra £24.27 per week.    This amount is adjusted downwards depending on the level of family or informal care currently available.

Scale systems like this are often derived from the original RAS style calculation made many years earlier to establish pilot schemes.  The rationale behind these systems is very hard for new users to understand.

4.1.3          Assessment of need and then Placement in a general band

Edinburgh City Council have this sort of system.  Dumfries and Galloway formerly had this sort of system but have now moved over to an equivalence model.  Their experience was that that this system was hard to control costs under.

Edinburgh Council’s Funding Allocation System uses 7 “domains” of need to assess a client’s needs.  Currently there are 42 points available across all 7 areas.   There are currently 8 bands available in either £50 or £100 ranges up to a maximum value of £500 per week.  This amount is adjusted downwards depending on the level of family or informal care currently available. Budgets above that level will have to be approved by named service managers on case by case basis.

4.1.4          Eligibility criteria linked to assessment  

East Ayrshire have this sort of system.   Their My Life My Plan system has 5 areas that are scored with a maximum of 61 points.  This is a free text assessment that does not use the multiple choice approach.  Each area that has needs this is then multiplied by a factor of 1 to 8 depending on the Eligibility Assessment of that particular area making a total available points value of 488.   Each point is worth £1.35 per week.

 

New report on Self Directed Support published

Created on 5 January 2015

In late 2014, the Learning Disability Alliance Scotland along with a number of National Carers Organisations, the Coalition Of Carers in Scotland, Carers Trust UK, MECOPP and Carers Scotland sought information from each council in Scotland about how they were getting on.

We found that many of the developments in Self Directed Support show that it is making some changes around Scotland.  Yet the numbers affected by this remain very small compared to the hundreds of thousands of people who use social care support every year.

Concerns over liability, risk, managing expenditure seem to operate behind the scenes of the far more visible outcomes focussed assessment and creative support planning.

For a number of years, the development of the Single Shared Assessment introduced a standardised model of how social care needs would be assessed throughout Scotland.  Now with the introduction of SDS, we have almost 32 different methods of assessing social care needs.  Each values different things or takes different approaches.  While social work professionals will do their best, every craftsman knows they need the best tools.  Too many of these tools feel inadequate, with no real way of understanding what is missed or overlooked.

We welcome the move away from the pseudo-scientific approach of Resource Allocation Systems by some councils.  This was a concern and worry for thousands of vulnerable people and their families.

Matching points to questions in the way that Points Based RASs do has the outward appearance of rationality, yet overlooks the key question of context.  When people in one part of Glasgow or Edinburgh die on average 10-15 years earlier than in another part of the same city, how much more important must the social context of vulnerable people be when it comes to assessing social need.  Yet so much of this is missed from the new assessments.

The “Equivalence” models are no panacea for social care but they avoid the worst of the budget cutting approach that might have developed by an over reliance on computer technology.  However it is not yet clear how much change will emerge from those councils using the equivalence model.

Much of the opportunity for change the landscape of social care in Scotland lies with the development of Individual Service Funds and more flexible ways of spending these funds.  As we have shown few councils have yet committed to taking a flexible approach and this really raises the question of what will, in reality, change.

The biggest challenge in introducing Self Directed Support will be assuming that those who currently receive support are looking for more control or a change in their service.  Most just want to keep getting good support.  Imposing change on people through reduced budgets or a new system could end up creating new problems which is why we welcome the efforts of a few councils to consider how to speedily resolve differences of opinion over social care.

You can download the full report which starts with an Easy Read Summary here.  

You can download just the East Read Report here. 

 

Our Findings on Assessment

Created 5 January 2015

Just about every council in Scotland has introduced a new form of assessment for people who require care and support.

There are three main types:

1.1.      Points Based Questions – These are multiple choice assessments which attempt to carry out an overarching assessment in a small number of questions.   This assessment is usually marked with a points value being given to each answer.  The total value of the points leads to an estimated individual budgets with which to plan support services.  These have additional “free text” areas for differing views or comments from other people

For example, Argyll and Bute Council have introduced a new Supported Assessment Questionnaire which covers 9 areas that people need help in with 26 scored sub questions, each carrying a points value that leads to a final budget.    The person being assessed is encouraged to comment in each section and at the end of the form there is space for an unpaid carer, an advocate and the assessor to make overall comments.

1.2.      Outcome focussed assessments – These are new style of assessment that takes the approach that social work should help people meet particular outcomes in set areas.     Instead of focussing on areas of deficiency the assessment focuses on what the person wants in these areas.    Once the assessment is complete, the social worker uses the local system to decide on the level of service.

Dundee Council has created such an assessment that looks at 8 separate areas such as independent living and keeping safe.   In this case the outcomes part is wrapped around with a number of other more open descriptions on immediate life situations, risk assessments and further actions.

1.3.      Single Shared Assessment:   A number of local authorities have decided to continue using their current assessment system.   This assessment follows a decision on eligibility criteria.   This is a system that relies on current social work practice and experience to secure information about a client’s life and then the social worker uses their own judgement about the service offer to meet any identified needs.

Both East Renfrewshire and East Dunbartonshire have said that they will continue to do this and use their social worker’s professional judgement to make a service offer.  A method of “equivalency” is used to advise individuals about their options under the 4 SDS options.

Other issues emerged from the responses to our queries.

1.4       Wider Embedding.   It would be wrong to overemphasise the stand alone nature of these developments. A number of local authorities have embedded either the Supported Assessment Questionnaire or the Outcomes Focussed in a wider assessment.

The law in Scotland currently requires that a social work professional is involved in the assessment.   The level of that involvement may be open to interpretation but to ensure good practice, local authorities have often retained aspects of the previous assessments which contained social work observations and comments as well as self reported needs and wishes.

Councils such as Angus and Edinburgh embed points scoring questions in their wider assessments  “ALL ABOUT ME AND WHAT I NEED” and “My Steps To Support”, respectively.

Councils such as Fife in their Support Self Assessment Questionnaire and Falkirk in their Single Shared Assessment have built in sections of outcomes to be completed at the same time as collecting wider information.

1.5       Eligibility Criteria:   Many of the councils we heard from were worried about how to manage “Eligibility Criteria” for social care.  As the law in Scotland, currently stands anyone can present to the local authority and ask to have their needs met.  The authority can screen them to see if they have “eligible” needs that the council has agreed to meet.  If their needs are ineligible then the council has no obligation to meet these needs.  If the needs are eligible, then the council has to meet these through offering the person a choice of the 4 SDS options.

So far no council we are aware of has made significant changes to the national eligibility criteria framework.  Some councils have adopted it for the first time.

However two councils East Ayrshire and East Lothian have tied eligibility criteria into their assessment process.

  • East Ayrshire will assess each area of need and then give more points to those who are a “critical” level than those on a “moderate” level and so on.
  • East Lothian will use eligibility criteria against each area of need and commit to meet all needs at critical or substantial levels.  Areas of need at moderate or low levels may not be met by the local authority through this process.

Previous work by the Learning Disability Alliance Scotland has indicated that local authorities have been using eligibility criteria to reduce access to social care for a number of years.[1]  It is possible that this may accelerate due to these new processes.

1.6       Assessment Concerns: 

An individual assessment of need is just that – it is based on the premise that each person is unique, as are their needs for social care and the cost of meeting them.   Social care needs arise from the complex interplay of many factors. A good assessment focuses on identifying what the person’s needs and wishes are and what will best help them achieve the outcomes they identify for themselves.  Yet the way SDS is being implemented is working against this principle, making assessments more prescriptive and resource-led

There are a huge number of assessments carried out in Scotland each year.  We received figures from 30 local authorities on how many assessments were covered in the 4-6 month period.   Not all were able to give us the client group details for these so the total amount of assessments is higher than the total of the client groups shown.

Social Care Assessments and options April – October 2014
Client Group No of social care assessments
Dementia 3,479
Mental Health 2,036
Learning Disabilities 1,859
Physical Disabilities 11,652
Older People 17,196
Other 7,300
Total 42,053              (30 councils)
Carers Assessments 1,372                (21 councils)

 

Not all of these assessments related to Self Directed Support. Some would be for admission to Residential Care.   But some will be multiple assessments on the same individual.  Local authorities reported that they may be using as many as 3 assessments on one person – a basic screening assessment, a generic assessment, then a specific assessment.  Other assessments may be carried out by other local authority staff such as occupational therapists for the appropriate aids to independence.

Even where only one assessment is carried out on an individual, it may be a more complicated assessment with the embedding of particular specialist areas or multiple choice sections within it.

As Scotland does not routinely collect information on the number of assessments carried out and what their outcome may be, we are not in a position to assess whether the number of assessments per client has increased.  Over the last few years as personalisation in England has been introduced the number of assessments per client per year has risen to an average of 1.66 and it would be reasonable to assume this is the case here as well.

One council confirmed in a report they sent to us about the high number of assessments.  “There are concerns this information may not be quantitative as it would appear as there are more duplicated assessments than normal.  When explored, the reason for duplication was insufficient budget identified from the RAS, therefore staff were completing a second SAQ to revise the indicative budget.”[1]

Research by Beresford and Slasberg found that in England while the number of social workers carrying out assessments had risen, their productivity had gone down.  It is suggested that the reason for this is that they now have to spend longer doing assessments, planning and finalising budgets.  Social workers were spending more time “controlling” the process and the costs of this extra bureaucracy had risen by 65%.[1]

In addition to the assessment, social workers have a number of other internal meetings to attend and then a series of planning meetings to ensure that SDS options 1, 2 and 4 where chosen are being used properly.

If this additional workload turns out to be endemic to local authorities then Self Directed Support will have introduced a huge additional cost in extra fieldwork staff for local councils.

Moray council has suggested in a Freedom of Information reply that the cost of a full community care assessment was £1,300 each.  Such figures are not unreasonable allowing for an average rate of £30 per hour for a social work staff and an assessment to involve a total of 40 hours input from the lead care manager and supporting staff.  In one instance, a carer reported a total of 50 hours being spent on assessments, at the end of which they were told they did not meet eligibility criteria.

[1] How self directed support is failing to deliver personal budgets and personalisation, C Slasberg, P Beresford, P Schofield, Research, Policy and Planning 29 (3), 161-77Applying this figure to the number of assessment carried out about would indicate a cost of £55 million in social care assessment in the first 4 -6 months of this year from most but not all councils.  We could expect this amount to be more than double that in a full year

[1] Argyll & Bute Council, Highlight Report –   Implementation of the Social Care (Self-directed Support) (Scotland) Act 2013, 18 August 2014.

[1] http://www.ldascotland.org/index.php/stop-the-care-tax/108-20-000-lose-out-because-of-tightening-eligibility-criteria

 

MOST COUNCILS REJECT RAS AND GO FOR EQUIVALENCE IN SDS

Created on 16 December 2014

New research by the Learning Disability Alliance Scotland has found that most councils in Scotland are now rejecting the pseudo scientific idea that complex social care needs can be translated into a single number (like the discredited IQ Score) and bringing back the judgement of professional social workers into working out social care needs.

18  out of 32 councils are now running  an Equivalence model in their area.  Only 12 councils are running the points based RAS in their areas and 1 of these only does it for people with learning disabilities.  2 councils have yet to decide what to do.

“Equivalence” is a  system that relies on the judgement of a professional social worker to establish the level of a budget.  They decide what support they would normally provide to a person with social care needs and then monetize that service so that it can be offered in the form of an indicative budget.Our New SDS report

They start from the basis that it cannot be right to set a budget at a level unless there is good reason to believe that this level is reasonable and that someone could get their needs met with that budget.

Equivalency helps to show that the budget does reflect some real model of how a need might be met.   In this system Self Directed Support gives the opportunity to the service user to meet those needs in a way that is even better for them than might originally have  been done.   They retain the option of asking the local authority to arrange a service of the “equivalent standard.”

Those councils who are developing Resource Allocation Systems are seduced by the simplistic appeal of the principle of people with similar needs requiring similar amounts of money. But it is likely to not work in social care where social care needs arise from the complex interplay of many factors.   Such systems are seen as the antidote to the ‘professional gift’, whereby the large variations in how much people get was put down to the behaviour of professionals.   There is a lack of supporting evidence for this view.  Anecdotes in themselves are not sufficient.

But perhaps the biggest concern is that such systems can build in distrust between councils and services and even their own staff.  Two councils told us they would not be giving us details on how their Resource Allocation System would work because services users would use this information to get higher scores and get more support than they need.

Edinburgh City Council said “In order to try and ensure that the indicative budget is based upon an objective assessment of need, staff have no knowledge of the scores attached to specific elements of the assessment or the relationship between scores and financial amounts.”

Moray Council said “If disclosure of this information was made individuals could use this information to increase their scoring and obtain a higher budget unfairly.  It would be likely that some individuals would use such information, which would undermine the scoring system and fair monetary allocation.  This likely abuse would, in turn, substantially prejudice the effective conduct of public affairs.”

It is hard to see how Self Directed Support can be based on trust and co-production when local authorities believe that those vulnerable adults who need care and support are really aiming at “gaming” the system.

 

Is Self Directed Support Failing

Created on 16 September 2013

A new research paper has been published by Peter Beresford and two other researchers that looks at how Resource Allocation Systems (RAS) are working to deliver personal budgets.

A RAS is a points based system for giving initial budgets and is popular with councils as an easy way of helping people quickly find out what level of support they might get.  It is often linked to a simple Self Evaluation Questionnaire that given points for different levels of needs.

What Beresford and his friends found was that in the councils looked at there was no link between the initial budget people were offered and the final budget that was actually approved.  It was if there were two separate budget setting processes going on.  First was the RAS and then secondly was an old style social work decision making body.  Given the large amount of money and time put into developing a RAS this was highly wasteful.

The following chart shows the deviation between the initial budgets and the final budgets.  In some cases the final  budget differs by a factor of 5 from the original budget.

chart

The research also found that while the number of social workers carrying out assessments had risen, their productivity had gone down.  It is suggested that the reason for this is that they now have to spend longer doing assessments, planning and finalising budgets.  Instead of Self Directed Support putting service users in control, social worker are  spending more time “controlling” the process.  The costs of this extra bureaucracy had risen by 65%,

One of the three researchers, Colin Slasberg had previously found that outcomes were only better for people who had a Direct Payment.  Often those with Direct Payments got more money than those without.   There was no evidence that personal budgets necessarily improve outcomes.  That doesn’t mean that outcomes don’t improve for some people who get personal budgets but we can also say that outcomes improve for some people who just get a standard social work service.

They conclude by arguing that personalisation can be saved by introducing better rights for people needing support

  • There should be a full assessment allowing people  to know exactly what needs councils will meet
  • There should be better Eligibitliy Criteria so it is fairer for people and councils know what they have to meet.
  • There needs to be more person centred planning at the core of social work