Community development and Self-directed Support/Theory and concepts

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Assessing a community-based approach to self-directed support[edit | edit source]

What is a community?[edit | edit source]

One of the key barriers to discussing community-directed social care initiatives across various stakeholders is the contested definition of community. For many, the role of communities in this space will be taken to mean ‘healthcare in the community’ such as NHS community services or community pharmacy. On the other hand, for some community organisations, community directed health will fall outside the realm of so-defined statutory interventions entirely. For this work, it is therefore important to establish a working definition of community-led initiatives in the context of self-directed support.

A community is a group of people joined together by a common interest, experience or geographical location. There is a distinction between a community of place, focused on geographical location, and community of interest, which can relate to factors such as race, age, faith or health need. The examples in this paper are predominantly focused on community of place, however there is a thread of community of interest.

A recent piece of research by the Kings Fundhighlights that within the specific context of health and care services, the term ‘community’ can be used in different ways:

  • to describe a group of people with similar health needs e.g. a group of people with diabetes
  • to describe a group receiving similar health services e.g. a group of patients receiving the same diabetes intervention
  • a group of people who shape or provide services.

Each aspect of this three-pronged definition can translate to community involvement in self-directed support through:

  • support and advocacy groups for a group of people with similar health needs e.g. the Glasgow Centre for Inclusive Living
  • online or face-to-face network, facilitated by local community partners, to bring individuals together to discuss their support, empower each other to navigate the social care system
  • individuals and community organisations utilising community assets to provide social care support or support to facilitate independent living for those in their locality.

Communities have great insight and intelligence on what is needed in their local area but also what works locally. This knowledge is often under-utilised or under-valued but is a key community asset that can be mobilised to promote fulfilling, independent lives. Community anchors and organisations also able to engage people, including the most marginalised groups within the community who are ultimately most likely to be affected by health inequalities, in identifying the needs and priorities of a particular group or locality (King’s Fund, page 2).

What is community development?[edit | edit source]

Much like ‘community’, ‘community development’ is often understood differently by different stakeholders. Activities can cover community capacity building and the development of social capital. If the community development approach is to take root, it’s important we develop a shared narrative.

Skinner has defined community development as “activities, resources and support that strengthen the skills, abilities and confidence of people and community groups to take effective action and leading roles in the development of communities.” (Skinner: Strengthening Communities 2006). What Works Wellbeing has recently defined community developed as ‘a long-term value based process which aims to address imbalances in power and bring about change founded on social justice, equality and inclusion’ (What Works, page 2).

The Scottish Community Development Centre (SCDC) define community development as a way of strengthening civil society by prioritising the actions and perspectives of communities in the development of social, economic and environmental policy. It is also about strengthening the capacity of people as active citizens through their community groups, organisations and networks. Part of this is building the capacity of institutions to work in dialogue with citizens to determine change in their communities (SCDC website).

Community empowerment is at the heart of many current Scottish Government agendas and is seen as a key aspect of Scotland’s current policies. Community development is already contributing to national and local outcomes across a number of areas including health, economic development and tackling inequalities. Indeed, one of the key national outcomes is that we have strong, resilient and supportive communities where people take responsibility for their own action and how they affect others (SW Scotland, page1). The recent publication of the Social Isolation and loneliness strategy also noted the power of communities and was an attempt to move away from the culture of individuality and independence to a culture of interdependence (SW Scotland, page 7).

If we consider that self-directed support is concerned with greater empowerment of individuals and recognises communities as part of the solution, there are obvious linkages between community development and self-directed support. Building stronger communities is directly linked to the aspirations of self-directed support (Social work Scotland, page5) and community capacity building should therefore be seen as an aspect of self-directed support activity. Resilient, empowered communities may be a pre-requisite for individuals being able to make the best use of their self-directed support, with developed communities giving individuals increased options and advocacy support. A strong community with developed structures of engagement are more capable of placing individuals at the heart of decision making, empowering people to choose appropriate care and support for themselves.

A ‘one-size-fits-all’ approach to community development is impossible and development activity can’t solely focus building upon existing community strengths or assets at the expense of initial investment and development. Given the uniqueness of communities and variability of community assets, it cannot be presumed that all communities are capable of immediately ‘hitting the ground running’ with the opportunities of self-directed support. The Carnegie Trust have highlighted research which points to the need for more nuanced understanding of differences between communities that on the surface appear similar in terms of deprivation. Housing, transport and labour markets are seen as making qualitative difference (Carnegie Trust, 2018). In this way, community infrastructure, assets and the spaces to make and maintain personal connections may be less developed in some communities across Scotland (Carnegie Trust, 2018). Only through working directly with communities, they become more confident and effective in addressing community needs.

Evidence shows that the communities with the highest social care needs remain those neighbourhoods with the least social capital (NDTI, page 3). Not all communities are rich in resources and there is a risk of empowering the empowered unless there are concerted efforts to meet the needs of more disadvantaged communities in Scotland. Some communities experience multiple social and economic challenges, such as substance abuse, poverty or disengagement, and will therefore require support to develop stronger foundations for self-directed support. As stated within the Social Work Scotland report, “there is danger that we look to the community to respond to increasing demands, that we champion community solutions as the way forward, without understanding or investing in the infrastructure of communities.” (SW Scotland, page 7).

What is community-led support?[edit | edit source]

The National Development Team for Inclusion (NDTI) have recently completed projects and research into Community Led Support (CLS). A particular model, CLS involves local authorities working collaboratively with their communities and partners, ideally across the whole authority (not just within social care) to design a health and social care service that works for everyone with changes made to local services and systems to reflect local circumstances. The NDTI described CLS as a “journey” – a transformational programme, rather than a set of consistent tasks which can be replicated in localities across Scotland. While currently been focused on adult social care, the NDTI with partners have explored the possibility of extending CLS within children’s services too.

At the heart of this approach is a set of underpinning principles about how local support should be delivered, ensuring that the detail of what happens (as well as the ‘how’) is determined with and by local people (NDTI, page 7). These principles are intended to be coupled with peer learning to create a genuine momentum for change. The CLS principles are:

  • Co-production bring people and organisations together around a shared vision
  • There is a focus on communities and each will be different
  • People can get support and advice when they need it so that crises are prevented
  • Culture become based on trust and empowerment
  • People are treated as equally, their strengths and gifts build on
  • Bureaucracy is the absolute minimum it has to be
  • System is responsive, proportionate and delivers good outcomes

While the CLS model is proven, useful and produces positive results – this may not be a suitable model for all local areas. Indeed, we advocate for CLS as one model of community support. Despite this, the principles which underpin CLS are useful to community-led indicatives more broadly, even if a different approach is adopted to CLS. The CLS model, when implemented with the support of the NDTI will be a good option for some communities.

The principles underlining the CLS model are tried and tested and are therefore extremely valuable for considering the role of communities in the health and social care space. NDTI found that when these principles were implemented, similar structures emerged in various contexts. In particular, the evidence gathered by NDTI highlights the value of good conversations, hubs and peer support.

Community-directed support - our theory of change[edit | edit source]

Our principles[edit | edit source]

Building on these helpful CLS principles, the principles of self-directed support and the Health and Social Care Standards, our principles linking community activities and self-directed support are:

  • People have more control over their care and social care support both respects and promotes human rights
  • People experience support that promotes independence, resilience and wellbeing
  • Individuals gain easier, more timely access to the right support
  • People know about, can access and shape local community solutions
  • A focus on local implementation enables better use of local resources and communities are more easily able to offer support, both formal and informal, focused on integrating people into the communities and enabling individuals to live independently
  • Regardless of the self-directed support option, individuals are able to access local community support to enable them to live fulfilling, independent lives

Self-directed Support - what are the options?[edit | edit source]

With the emphasis placed on personal choice through the Social Care (Self-directed support) (Scotland) Act 2013, there is potential for greater linkages between self-directed support and communities in a number of key ways:

  • Community initiatives to become viable options to be accessed via self-directed support, primarily under option one and two of the self-directed support act
  • Potential for people to use the flexibilities under option three to tap-in to community initiatives. For example, using your carer or personal assistant to participate in sport, go to cinema or do some volunteering. Even if an individual has arranged care, we would want to encourage the idea that you can still have community involvement if you arrange your care in a certain way
  • Community organisations and peer support in the community guiding individuals through the process of self-directed support
  • Local community organisations work as brokers through individual service funds enabling community organisations to deliver support without Care Inspectorate registration and assisting individuals to access a range of support options, without the added responsibility of a direct payment
  • Community organisations entering a partnership with a registered care provider to deliver community-directed care in their local area, again without registration with Care Inspectorate.

Self-directed support can, and should, enable people to live an independent life. Through self-directed, personalised support, people can realise their human rights to employment, education, family life and become active citizens in their community. Linking self-directed support and community development is particularly important for the realisation of this ambition.

Self-directed support options
Option 1 is a direct payment to the individual, who can use it in any way they choose as long as it secures the support agreed between the person and their social worker as set out in their support plan.

Option 2 is when an individual chooses their support and provider but

the local authority or a third party maintains control of the budget. In order to make an informed choice, individuals should be made aware of all the resources that are available to achieve their support plan.

Option 3 is when the budget and support is managed and provided by the local authority in coordination with the individual. The individual should still retain choice and control over the type of support they receive.

Option 4 is a mix of some or all of the first three options, aiming to provide maximum flexibility.

-Alliance, Personal experiences of Self-directed support, May 2017

While the original focus of this work was purely those in receipt of self-directed support packages, as noted within the principles, community support will also be of real value for those individuals who do not meet eligibility criteria but could benefit from assistance to enable them to live an independent life in their community. Throughout this process, there has been evidence and reports of tightening eligibility criteria across various local authority areas. These changes to criteria has the potential to undermine the legislation's focus on quality of life and instead reduce the impact to 'life and limb' support. There is therefore a need to look beyond those in receipt of self-directed support to wider need. In Audit Scotland’s audit into self-directed support, they also noted that if a person is not eligible, they should be given information or advice about alternative types of support, for example in their local community.

This section will focus on the ways various aspects of self-directed support can be linked to community activity.

Individual Service Funds[edit | edit source]

An Individual Service Fund (ISF) is one way of managing an individual budget available under option 2 of the self-directed support Act giving individuals the opportunity to access the choice and control of a Direct Payment, without the need to take on the full responsibility of becoming an employer (Smith, Brown, page 5). ISFs are seen by many as having ‘untapped transformational potential’ (Smith, Brown, page 1). ISFs are viewed as enabling an individual to draw on a far wider range of resources and opportunities that exist within the persons' own skills, gifts and their families (Smith, Brown, page 19).

ISFs are a valid option for anyone, regardless of their support needs, diagnoses or age and have the added benefit of being able to flex and change as required, which has particular benefits for those with fluctuating health conditions.

As detailed by Smith and Brown, to qualify as an ISF there needs to be:

1.      An upfront individual budget allocation

2.     Flexible support arrangement designed around the person

3.     A budget that is used to focus on a good life, not just a service

4.      Maximum control for the person over decision making.

In research completed on behalf of In Control Scotland, Smith and Brown have pulled together some innovative examples of ISF. For example, moving to their own home, families using weekly laundry services, paying for airfares to take support on holiday or purchasing bespoke furniture. The idea is to advocate for a simple rule that 'if it meets an agreed outcome, doesn't harm anyone or place a person at unreasonable risk and it's legal it should happen'. This motto enables innovative use of community assets to facilitate independent living and realises the ambition of social care in enabling a person to achieve a good standard of living.

In terms of the linkages to community development here, there are opportunities for community-led organisations to play a part in planning with an individual, as a broker, as a service to be accessed via ISFs and in promoting ISFs as an option.

Personal Assistants

While not to say that personal assistants will be the answer for everyone, the experience of the Glasgow Centre for Inclusive Living has been that personal assistants are a means of enabling individuals to live more independently through flexible support arrangements. Through personal assistants, individuals have been able to meet their health and social care outcomes while also contributing to and participating in their local community. Examples from the Glasgow Centre for Inclusive Living have seen individuals being able to volunteer with local organisations, attend college, play sport, see friends and family and find employment. In these examples, using self-directed support to hire personal assistants are the factor which unlocks the opportunities of the community for individuals receiving care.

These benefits are echoed in the example of Silver Age Personal Assistants in Dumfries and Galloway, an intervention which was established in recognition of the fact that some people don't need full time care or support, but rather need assistance with certain tasks and things that were important to them. These personal assistants are able to provide flexible, personalised support.

Hiring personal assistants also gives individuals the ability to choose who works for them, giving them consistency of service and the ability to be involved in all stages of the recruitment process. The Glasgow Centre for Inclusive Living have noted that people are given the opportunity to hire people of a similar age or with similar interests, giving them increased confidence attending social events or participating within their community (Self-directed support way to go! Page 30).

Organisations exist to support with the process of hiring Personal Assistants, including The Scottish Personal Assistant Employers Network (SPAEN) who provide a range of support services to self-directed support users across Scotland, such as employment advice.

Personal assistants can be employed via a direct payment. There is a role for communities in terms of connecting individuals to personal assistants and establishing community-directed agencies which hire personal assistants and focus on the needs of the locality and promoting best practice personal assistant models to individuals.

Direct Payments[edit | edit source]

Direct payments offer the opportunity for people to use their self-directed support package to access local community-directed interventions and alternative support. As long as the use of the direct payment meets the individuals' agreed outcomes, there is flexibility around how this funding can be used. However, the potential of option one is somewhat threatened by reports of a dilution of what is viewed as legitimate spend.

While the experience of direct payments, as noted within the example of personal assistants, has been extremely positive for many, there have been issues for others. There are concerning reports that some local authorities where there are no formal care facilities or providers, individuals are being given a direct payment as default to organise their own service. This is particularly complicated for those who do not have a support network to assist them in accessing support.

More generally, there may be subsequent capacity issues for those who do not have experience of employing staff and for those who may not have chosen an option one direct payment, had all four self-directed support options been available. Community Contacts run by Carr Gomm deal with some of these issues with individuals, for example providing support on recruitment and a helping hand as issues arrive and giving individuals a route to ask questions. It is unclear how many individuals would cope with the issues arising from their direct payment without this additional support. We would therefore resist the option one becoming a default option and note the importance of such community-based assistance for option one.

For communities and community organisations, there is a role in terms of promoting direct payments, providing advice and support around the operation of a direct payment and providing services that can be accessed via a direct payment.

Collective community benefits

The idea of ‘community wellbeing’ is deployed in a recent briefing by What Works Wellbeing where they adopt the working definition of community wellbeing as being the ‘combination of social, economic, environment, cultural and political conditions identified by individuals and their communities as essential for them to flourish and fulfil their potential’ (Wiseman and Brasher, 2008, 358). Self-directed support can further this ambition, bringing wider benefits for the community, not just the person receiving the self-directed support package.

For example, individuals who wish to use their self-directed support direct payment to access art classes, drama classes or sport can open these classes for other members of the community, ultimately establishing a community asset. There are also examples of individuals in receipt of self-directed support grouping together to benefit from collating their money and accessing support together. For example, there have been cases where individuals have come together to hire the same PAs or to collate their budgets to share taxis to attend community centres, allowing their budgets to extend further (Self-directed support way to go! Page11).

Bringing people together within classes and community hubs has a positive impact on overcoming social isolation and we can’t underestimate the benefit people gain from this feeling of inclusion and active citizenship. Community hubs have also been found to have a low cost per person benefiting (What Works, page 5). Also, as people often require more intensive support than anticipated if they do not have personal support networks, there is real value in bringing people together under the community umbrella.

Building these longer-term connections has clear benefits for health, wellbeing and longer-term outcomes rather than focusing on immediate concerns. Using self-directed support also provides greater flexibility to choose the service individuals want to access. For example, families may choose to access a youth centre rather than the local council service due to the additional presence of young people in this centre, allowing family members to connect with a similar demographic. Empowering individuals to live independent lives and become active citizens in their community also enables individuals to access other local interventions, for example the Glasgow Centre for Inclusive Living run a job club and Open Door programme.

Information about self-directed support[edit | edit source]

One of the key messages from Audit Scotland’s audit of self-directed support was that people using social care services and their carers need better information and help to understand SDS and make their choices. It was also a key recommendation from the Alliance’s Personal Experience study that there should be “substantial investment in and promotion of local advice and independent advocacy provision must be made to support people during the SDS assessment process” (Alliance, page 70).

There is a role for the third sector and community organisations to promote self-directed support. For example, the Ayrshire Independent Living Network (AiLN) have a designated team of self-directed support staff within the network will work together to ensure that they are providing individuals with relevant, up to date information on self-directed support. This work includes a payroll workshop for people new to self-directed support and information for existing self-directed support customers who require additional support.

The Evaluation Support Scotland report into Independent Support also showed that, after discussions with Cornerstone, individuals felt more confident to make alternative decisions about their support arrangements while those who had a conversation with a council officer said they were more likely to opt for a traditional support service (option 3).

In making conclusions about Independent Support, Evaluation Support Scotland found that ‘providing effective Independent Support often involves walking a tricky path between local authorities and local communities – particularly during the initial stages of self-directed support implementation’ (ESS, page 25). This indicates that truly independent support cannot, therefore, be provided by local authorities.

There are a number of particular issues relating to information about self-directed support which are detailed below:

Materials[edit | edit source]

It is also necessary to have a range of materials, from easy read options to translated guides to ensure that people are able to understand and process the information about self-directed support to make an informed choice. For example, the Glasgow Centre for Inclusive Living distribute easy read test, BSL/speech DVDs and guides for care managers, Ayrshire Independent Living Network show videos in the town centre in Irvine and Carr Gomm's Community Contacts project give personalised advice and support. SPAEN also produce accessible materials, including videos and cartoon-strips, to explain self-directed support options. There are also numerous examples of voluntary organisations supporting individuals and their families through the process of self-directed support. For example, individuals point to ‘ctrl: South Lanarkshire’ who speed up the process of accessing self-directed support (Self-directed support way to go! Page 11).

There is clearly a role for the community sector here and there exists a demand among the public for organisations to fulfil this advocacy and information role. Independent support includes awareness raising, brokerage, evaluating, reporting and sharing learning, training and development, providing peer support and management of finances.

‘Thank you for talking to us respectfully and not as if we’re stupid. I think if more people explained it like you have to other mental health survivors, then more of us would be confident to take it [self-directed support] up’  (IS evaluation page 7).

Risk[edit | edit source]

Individuals and community organisations should understand that self-directed support can be a managed risk. One of the roles of independent support was to allow people and carers eligible for self-directed support to experiment, make mistakes and find ways to correct them. Community organisations can play a pivotal role in guiding individuals through this process, providing necessary support (Evaluation Support Scotland). This sentiment is echoed in one of the testimonies of personal assistants where it was noted that this model gave the individual ‘a bit more freedom to progress, but also to make mistakes sometimes’ (Self-directed support way to go! Page 19).

Working with trusted organisations, such as your local community centre or organisations such as the Glasgow Disability Alliance, can help individuals to overcome the barriers to choice and control and create something of a ‘safe space’ to take risks with their support. The Glasgow Disability Alliance note that ‘choice and control takes confidence’ and community organisations and spaces are one way of building this confidence. Again, among Development Trusts Association Scotland's membership, there is a desire to play this role.

Lack of understanding[edit | edit source]

From conversations with community organisations, Development Trusts Association and the projects detailed as case studies in this report, it is clear that the lack of knowledge and understanding of self-directed support, among organisations and individuals, is a key barrier to community organisations utilising the opportunities afforded by the legalisation. This lack of knowledge has been documented elsewhere in various research reports. The Alliance found that a third of women said that the information they received about SDS had either not helped to inform their option choice or they were unsure. Additionally, a report by the Simon Community into self-directed support in homelessness highlighted that different expectations exist between service users and providers. They also concluded that there were lots of myths and a lack of information about self-directed support within the sector. There is a feeling that self-directed support is more complicated in practice than it looked for individuals initially (Encompass report, page21).

There is clearly work to be done in terms of addressing low uptake and poor understandings of self-directed support. The Alliance found that, in 2015, only 20% of those eligible were in receipt of SDS. The Alliance also noted that to address this, it might be necessary to deliver a co-designed campaign with the Government, Health and Social Care Partnerships and unpaid carers (Alliance, page 70). While supporting The Alliance's recommendation that Health and Social Care Partnerships and others should make SDS information and support more readily available and accessible in health settings like GP practices and hospitals, there is also scope to expand the understanding of self-directed support among individuals through training anchor organisations and local organisations.

Similarly, Children in Scotland looked at building information and support hubs around school and early years communities to support providers across all sectors to enable children and their families to exercise choice and control over their use of self-directed support at all points in their childhood and adolescence, including transition to adulthood. From this experience, we need to be aware of the messenger, the way the message is communicated and where the message is delivered when we are promoting self-directed support.

The Simon Community also found that service users preferred to receive information about self-directed support face to face so they could ask questions and did not like to receive information online. This is echoed by The Alliance which found that most people would appear to find out about SDS through personal interaction, therefore social work departments should prioritise direct discussions about SDS with people who access services during any contact about reshaping their support (Alliance, page 70). Service users also value peer support and this can encourage others to be more innovative about their care. Value is also seen in organisations working together and learning from each other. There is therefore a role for trusted community organisations to provide information face-to-face when they have other contact with individuals. However, for community organisations to be able to do this, there will have to be capacity building among organisations as a starting point, primarily through training and financial support.

Individuals attending community centres or interacting with community organisations may be more willing to get their advice from these organisations who they trust and know. At present, it isn't clear how these community organisations could access training or gain the necessary level of understanding of self-directed support to fulfil this guidance or advocacy role.

Gender[edit | edit source]

There was little consideration of gender at the stage of designing and implementing the self-directed support Act, despite the obvious gendered dimensions of health and social care. From desk-based research of Scottish Government data conducted by the Alliance there appears to be a very low uptake of SDS by women. Moreover, The Alliance found that women appear to have exercised less autonomous decision-making in choosing an SDS option than men. As such, there should be concentrated efforts to ensure women receive support to consider their self-directed support option.

Women were less likely to have found out about SDS from the Scottish Government or local authority than other sources. A gender difference appears to be that women were likely to find out about self-directed support through a third sector or local organisation. 20% of women found out about SDS through a local Third Sector organisation and of these 20% nearly 80% felt informed about SDS and 50% said it helped them choose an option. There is therefore a clear role for local community-led organisations in fulfilling this role. Existing community networks and connections can support women to take control of their support, perhaps through existing women's networks.

The Alliance research also showed that personal discussions have an impact on women's awareness of self-directed support and social care options.  A higher of proportion of women than men found out about SDS from a family member or friend (15 per cent vs 9 per cent). Creating spaces for these conversations to take place, enabling effective peer support is vitally important.

At present, there is insufficient research providing a gendered analysis of social care, including unpaid care, paid care and the experience of women receiving social care. We recommend that there should be further research to apply a gender lens to social care so that providers, communities and the public sector can incorporate gendered considerations of policy and practice, ultimately delivering a social care system focused on fairness, equality and human rights.

What is currently happening on the ground?[edit | edit source]

The intention of referencing best practice examples in this section is not to establish tick-box exercise or a toolkit to replicate this support elsewhere. Communities and individuals are unique so a tick-list would be a futile exercise. Rather, looking at best practice examples enables us to uncover the critical success factors. We cannot make strong recommendations for the specific approach communities should take, but we can present evidence about the ways of doing things that are more likely to be lead to success.

It is important to note that a lot of this work is already happening in communities and across Scotland, there are strong examples of communities delivering social care support or empowering people to live independently. Evidence also highlights that tackling health inequalities, another of the Scottish Government's ambitions, can only be achieved through both formal health services and wider social policy changes. Priorities in this area such as tackling poverty, improving housing quality and access to transport, are also vitally important here. These are policy areas where communities are already active.

The policy arena is ripe for the changes we are proposing here. Recently, Scottish Government have put additional emphasis on community support. However, beyond the narrow definition of NHS community health services there is much wider range of sectors and services that deliver care and support in the communities (Kings Fund, Reimaging, page2). In terms of the third sector alone, there are an estimated 45,000 organisations across the country, with few that do not have some role in supporting peoples’ health and wellbeing. Fundamentally, if the ambition of shifting the balance of care away from institutions and into communities is to be achieved, then existing third and independent sector organisations need to be better positioned, developed and networked, and new community capacity needs to be created.

A number of projects are worthy of note within this space. There will also be many more excellent examples which have not yet come to our attention and we urge people to highlight other positive examples. Appendix one offers detail across four examples which were visited on a recent community exchange visit organised by the Development Trusts Association Scotland. Other key examples include:

Project Outline Website
Healthy Valleys Taking a broad view of health and looking at wider determinants such as housing, environment, social networks and culture, Healthy Valleys work with communities to address their health needs in a holistic fashion and in the planning development, delivery and evaluation of health services.
Highland Hospcie Recognising that there is a need for support in the wider Highland area and for those who are not in need of palliative care, Highland Hospice are assessing the opportunities around the Highland Home Carers model. Highland Hospice has recently recruited a community connector to facilitate this community work.
Scottish Communities for Health and Wellbeing A collaborative of 74 community-led organisations operating and delivering services. These organisations are embedded in their communities, have established trust and respect and which are governed by boards of local people in their community.
Perth and Kinross Healthy Communities Collaborative Community led health promotion initiative. It works with older people from specific communities and empowers them to improve health and quality of life for themselves and their peers.
Community Contacts Carr Gomm project in Our Community Contacts project in Argyll offering ‘a helping hand with Self-Directed Support (SDS)’ through providing independent advice, information and support to people and their families at every stage of the SDS journey.
Neighbourhood Network Works with people in their neighbourhoods to support each other, to live independently in our own homes. Recently started operating a Community Circle to connect individuals in the community.
Social Work Scotland Detailed five examples in the report 'Building Capacity in Communities- Its links with Self-Directed Support' (pages 9-13) including Silver Age Personal Assistants (Dumfries & Galloway), The Recovery Café (East Dunbartonshire), Tea in the Pot (Glasgow)
Glasgow Centre for Inclusive Living A community business run by disabled people, working for and with disabled people focused on independent living.
South Ayrshire Local Authority One of the NDTI's Community Led Support areas, South Ayrshire have moved to a model of personalised outcomes and effective conversations. South Ayrshire is also using Participatory Budgeting as a means of consulting and empowering local people.
'What Matters Hubs' The Borders local authority is part of a transformational change in social care which sees one hub across five localities to operate a weekly or monthly hub as the first point of contact for individuals. The location of the hub was decided by the community and they utilise community buildings, such as community cafes, centres to overcome issues of individuals' distrust of the health system.
Partners in Policy Making Organised by In Control Scotland, Partners in Policy Making is a leadership programme to increase social inclusion and achieve social justice.
Scottish Personal Assistant Employers Network (SPAEN) A membership organisation support people with disabilities and/or long-term conditions or impairments to use a Direct Payment to employ Personal Assistants. As well as providing employment and financial support for option 1, SPAEN have partnerships with local authorities around enabling people to meet their outcomes through option 2.

Before moving on to the critical factors, it is worth noting some of the key themes of these examples.

Consultation[edit | edit source]

The focus here is clearly co-production and asset-based approaches, meaning the assets of individuals or the assets of communities. For this reason, the first step is thinking about how we consult with communities and how individuals are able to get involved in the decisions that affect their community. This means community organisations, such as Development Trusts, or community anchor organisations are given the resources to engage with their community and to further the National Standards for Community Engagement.

One of the reasons that Healthy Valleys is successful is because of a commitment to community engagement. For example, informal consultation with local people including lunch drop-in consultation sessions where local people come to tell Healthy Valley’s staff their concerns. Equally, Perth and Kinross Healthy Communities Collaborative hold an ambition to bring local people and agencies together to decide on action. This sees them hold orientation events to recruit local people and professionals and they adopt simple methodology (‘Plan, Do, Study, Act’) which support the development of small steps which lead to larger changes in communities. The collaborative conduct questionnaires and hold workshops looking at local need, addressing that need and reviewing the achievements which enables the community to be actively involved in exploring how community assets can become health and wellbeing assets and explore opportunities to localise services.

Using participative consultation processes to identify issues of importance to local people roots community-directed support in the needs and ambitions of the community. There are also examples of services adopting consultative methods with service users. For example, the Falls of Dochart Care Home adopt a consultative approach with residents, enabling residents to participate in decisions from the food menu, activity schedule and the redecoration of the home.

There will be cases where individuals do not want formal services and instead would be satisfied with accessing community support initiatives alone. It's very much about listening to the needs and desires of an individual. For example, NTDI document the case of Jim who was going to be given a full assessment for his learning disability. However, what he actually wanted extra support around housing, to be healthier (diet and fitness) and to overcome loneliness. This is possible via community support, without eligibility criteria and formal intervention, organised by local organisations using local community assets (NTDI, page 9). Equally, the 'what matters hubs' in the borders also follow this model, assisting people on assessment waiting lists to access the support they want, without formal assessment.

The role of Participatory Budgeting (PB) in consultation and sustainable funding requires further research. PB has been viewed as a way for local people to influence what happens in their local area and what happens to the services they utilise. PB can fund the infrastructure for local services which can subsequent be accessed via self-directed support. Different local authorities have adopted different approached to PB, which have resulted in different levels of collaboration. For example, South Ayrshire have held 'decision days' and a marketplace approach to PB while Edinburgh's TSI, Edinburgh Voluntary Organisation's Council, operated a Change Fund participatory budget project called 'Reshaping Care for Older People'. However, there is potential to use PB to consult with communities, to empower individuals and give community initiatives the opportunity to access funding.

Procurement[edit | edit source]

It is also vital that the public sector, primarily the Local Authority, Health Boards and the Health and Social Care Partnership, adopt procurement and commissioning processes which enable community-directed interventions to play a role within the health and social care system. From conversations throughout this research, the respective procurement processes of local authorities were seen as a critical factor in the model adopted by community-led organisation. For example, as detailed in the DTAS Case studies in appendix 1, the lack of traditional procurement was seen as a vital enabling factor in the Highland Home Carers Model.

CCPS are a prominent voice on the need to change the nature of procurement and have conducted research on the tensions between procurement and personalisation. There is little value in duplicating the work of CCPS here and instead we direct you to this research to further consider the role of procurement within the shift to communities.

Social networking and skills[edit | edit source]

There are additional added-benefits to community approaches and one of the benefits frequently noted throughout case studies is increased social networking (Healthy Valley’s Initiative, Making it Happen, page 36). Through building the personal capacity of participants, individuals progress from being a recipient of services to supporting others themselves. This has important implications for realising the potential of individuals – giving local people the opportunity to train and acquire skills necessary to deliver the courses they once participated on (Making it happen, page 34).

The Neighbourhood Networks approach to support is rooted in social networks and developing the skills for independent living. Neighbourhood networks focusing on enabling individuals to live an active, healthy life, safely, within their own homes and be fully involved within their local communities. Members will learn new skills such as independent travel, cooking, life skills and budgeting. Rather than offering a befriending service, Neighbourhood Networks empowers individuals to make connections with each other and to form connections in their own community. Recently starting community circles, Neighbourhood Networks have provided individuals who have come through their projects to continue to connect with one another and to use their skills to assist others in their area.

From the examples above and those detailed in appendix 1, there is a strong emphasis on delivery by local people. That local people are involved in delivery can mean that local residents are more comfortable with being involved in services delivered by people from their community and there is also a belief that local people delivering services will ‘go the extra mile’ (Making it happen, page 35).

Unpaid Care[edit | edit source]

Additional networks of caring, mostly unpaid and within community networks are vitally important, particularly given the tightening of eligibility criteria within certain local authority areas. Scottish Government should not rely on unpaid care at the expense of funding and investment in formal care. However, resources and support should enable individuals to choose to care for loved ones, or to be cared for by loved ones, if that is their personal choice. For this to transpire, it is clear that Scottish Government must support carers, promoting carer’s rights and wellbeing. One way to do this is to invest in community organisations, networks and peer support mechanisms.

Women are grossly over-represented in unpaid caring roles, meaning that policy is this area is an important consideration for the economic and social participation of women. Research has found that at least 59% of unpaid carers in Scotland are women and 74% of Carer’s Allowance claimants are women. There has been little disruption of the social and cultural expectations which lead to women being twice as likely to give up paid work in order to care.

In the examples noted within this paper, in particular Boleskine and Strathdearn, communities have established care facilities where previously none existed. In these cases, it is highly likely that the burden of caring for individuals within the locality fell on the shoulders of women. In terms of promoting gender equality, community initiatives have potential in terms of respite, bringing people together to access support and alleviating the burden of unpaid care, with obvious benefits for the health and wellbeing of those providing care and, indeed, those receiving support.

Critical factors – what makes a community-directed approach work?[edit | edit source]

Examples of best practice vary in origin and nature, but there are a number of common key factors which make these interventions successful. In identifying the critical factors that enable these best practice examples to flourish, we are also able to highlight the barriers that may impact negatively on the growth of these community responses.

Funding and sustainability of community-directed support[edit | edit source]

Social care support should be viewed as an infrastructure investment in the social and economic wellbeing and development of society as a whole. Rather than viewing social care as a drain on public resources, we believe social care should be viewed as a positive, human rights based contributor to a thriving society.

Sustainability funding community interventions is an aspect of this shift in thinking.

There is great variation in how community directed services are provided and how they are funded.  Community service providers face the same pressures as other social care providers, primarily financial and workforce pressures, which impact their ability to meet the needs of their community. Services are struggling to meet current demand, never mind being capable to satisfy further demand for growth. In many ways, when taken collectively, community-led support is surviving, but not thriving. Some of the examples place emphasis on social enterprise models to improve sustainability of the work by reducing the high level of dependency of grants or to supplement the money given via social care contracts. Others are relying on small pots of money, often year-to-year, or working in partnership with other organisations or the public sector.

Funding is a key issue throughout the examples of community-directed support and there exists a harmful attitude where community-directed initiatives are viewed as voluntary, and thus cost-free. A focus on longer-term funding is a critical part of ensuring sustainability of community-directed support. There is a risk in directing individuals to community interventions which are precariously funded given that individuals may come to rely on a service which then disappears. Social Work Scotland highlighted that community initiatives grow out of small scale pilots with short-term funding and while this funding is an important catalyst, there needs to be longer term financial planning to consider how pilots can evolve and resourced (Social Work Scotland, page 15).

There have also been risks associated with the constant drive for growth and for organisations to effectively do more, for less. Befriending services have become a focus within the drive against social isolation, however growth in terms of funding can mask difficulties of recruiting befrienders. Neighbourhood Networks, having highlighted their effective interventions, have also faced problems with being asked to take additional clients for the same funding and have faced issues of recruiting volunteers for various services too. Any growth in clients or service-provision must be accompanied by increasing financial resources and investment. There is also no need to focus on scale-ability, in terms of scaling-up successful interventions). The key point here is that these community-directed interventions have been designed and delivered successfully within that community. It is therefore irrelevant whether these interventions can be scaled or can work elsewhere, the point is that they work for that community. The constant drive for growth can therefore be a distraction.

In other areas, local authorities have placed emphasis on community services as merely plugging gaps in services, rather than considering the potential of longer-term funding initiatives. The King's Fund noted that “it is not realistic to expect reductions in acute hospital capacity to pay for extra spending on services in the community at a time when hospitals are working under intense pressure. New and earmarked resources will be needed to invest in these services” (The King’s Fund Reimagining report page7). Indeed, while investment in preventative support has the potential for longer-term savings, current demand for acute services will not be diminished through the funding of preventative support. Both forms of intervention must, therefore, be sustainability funded. Shifting resources to community should not be framed in terms of reducing the burden on the NHS, although this might be a welcome by-product. The focus must be enabling individuals to live independent, fulfilling lives in thriving communities.

Something to be mindful of when considering funding is monitoring and evaluation requirements. In a recent survey, SCVO members made many comments around monitoring requirements, with respondents feeling that it was often overly burdensome. From this, SCVO recommended that monitoring and evaluation should be kept to a level commensurate with the amount of funding/size of agreement applied for. The Community Capacity and Resilience Fund is a fund for local community-based organisations, with an income of £250,000 or less which is focused on testing out new, creative approaches, develop their workforce and add capacity all with the aim of having a preventative impact on communities. Within this fund, emphasis was placed on having proportional, light-touch monitoring and evaluation requirements. Any funding for community-directed support initiatives could learn from the process of the CCRF, ultimately giving all organisations, regardless of their size or their capacity, to secure funding.

Investment in community infrastructure.[edit | edit source]

Community infrastructure, as recently defined by What Works Scotland, is understood as:

  • Public places and ‘bumping’ places designed for people to meet, including streets, village halls and community centres.
  • Places where people meet informally or are used as meeting places, such as cafes, pubs, libraries, schools and churches.
  • Services that can facilitate access to places to meet, including urban design, landscape architecture and public art, transport and public health organisations (What works Scotland, page 2).

Funding should not be limited to those social care initiatives but also the surrounding and enabling community infrastructure. For some, it appears that community responses ‘just happen’, emerging organically. However, ‘there are important roles for both national and local government, the NHS and community and voluntary sectors in creating the conditions which enable individuals and communities to take more control of their lives and collectively develop community led solutions’ (Social Work Scotland, page 2). The Community Planning Partnership is a key player here, having a role in strengthening the capacity of community bodies, ensuring all bodies which can contribute to community planning are able to do so and secure participation across the community (Social Work Scotland, page 15).

Government, local authorities and communities themselves must be aware that growing community capacity takes time and this is not a "quick-win". This investment would mean longer-term funding for local community organisations and anchor organisations, investment in community hubs and empowering communities to be part of the decisions taken in their local area. Investing in community infrastructure, such as public places, places where people meet informally, and services that can facilitate access to places to meet (What Works, page 2) can help to build more resilient communities and furthers the aforementioned goal of collective wellbeing.

We would like Scottish Government’s commitment to moving resources into communities to mean communities in their broadest sense, rather than healthcare in the community. This means that hospitals, GPs and social care will have to work differently to involve actively involve communities in this process and it is also necessary to have discussions between community organisations and the formal health infrastructure to develop mutual understanding.

Here, there is a need for strategic investment into communities across Scotland, empowering communities and community-led organisations to contribute positively to the health and wellbeing of their local area. There is also a broader discussion to be had around resources, which extends beyond the financial sphere, and also includes investment in community spaces, recruitment of volunteers and training. For example, opening up training for NHS staff to local voluntary sector leaders to increase understanding of self-directed support locally. 

Shared vision and understanding[edit | edit source]

A shared language, as detailed in section one, assists actors and stakeholders to understand what building community capacity is and how this relates to health and wellbeing outcomes. We hope the analysis contained within this paper may help to mobilise a coalition of organisations and people around a shared ambition.

This shared understanding is necessary among communities who recognise their potential but also within Scottish Government, Health and Social Care partnerships to recognise the viability and importance of community organisations and their contribution to health and social care. The case studies and examples contained within this document uncovers some of the potential in this area but there is a need for further discussion and collaboration across Government departments to uncover the potential of communities across various policy areas.

Empower people to take control of their own lives through community directed support[edit | edit source]

Self-directed support focuses on people being able to take control of their own health as far as possible and none of this will work unless the needs and human-rights of individuals is at the heart of this activity. Putting this idea of personalisation and control at the heart of community-directed support from the outset, ensuring decisions are built on the experience, assets and knowledge of the local community, will be a significant step towards realising the ambition of connecting community development and self-directed support.

An aspect of this, as mentioned throughout this paper, is peer support. For self-directed support to work there needs to be the capacity for peer support, sharing best practice examples and enabling people to communicate with each other about what works and what doesn’t work. The Glasgow Disability Alliance found that peer support made all the difference to participants of their Future Visions project as this provided individuals with a new social network, showed they weren’t alone and that others had overcome similar issues. This idea of the “power of we” was motivational, giving individuals support and role models. Bringing people together to discuss options, experiences and possibilities is extremely powerful and can play an important role in empowering individuals. In the SCDC and Glasgow Centre for Population Health work on animating assets, storytelling was seen as being an important part, enabling people to share experiences, ambitions and make connections. These stories were also viewed as helping individuals to understand their local community and challenge perceptions (SCDC, GCPH page 73).

Empower people and communities through consultation processes and participation in services[edit | edit source]

A wider point on empowerment is a focus on empowering people and communities to participate and have their voices heard. Community organisations are able to prevent unnecessary dependency by focusing investment on empowering people and groups, developing confidence and skills, enabling individuals to become leaders and working with the community to take control and find own solutions (Social Work Scotland, page 2). This means directing individuals to other community initiatives and facilitating seamless transitions between services, without unnecessary assessment periods and waiting times. This agile approach is a large part of the success of the CLS model but could be a critical factor for community interventions more broadly.

It’s important that community projects harness the knowledge and skills of local people and utilise local intelligence. Professionals can’t be dropped into communities to build community interventions and there have been examples of professionals duplicating, and thus somewhat undermining, pre-existing community interventions. Investment without community empowerment, collaboration and engagement will not be successful in meeting objectives. Social Work Scotland concluded that “whilst support and investment in communities may be required to act as a catalyst there is strong evidence that what helps is working with local people to help them achieve their goals, rather than delivering predetermined services or solutions.”  (Social Work Scotland page 2­).

A focus on local people should also involve empowering volunteers and service-users to provide a service or to contribute their skills to the project as witnessed with Recovery Café projects. In these models, through building skills and confidence, individuals are able to move from being recipient of services to delivering and supporting others. This builds capacity of an individual and also has a preventative aspect, enabling people to live independent, fulfilling lives. Moreover, community led services have a strong local attachment, delivered close to home and with wraparound support to enable participation – such as childcare and community transport. Ultimately, this means community interventions view individuals in a holistic, whole-person way, designing interventions which satisfy a range of needs within a community setting.

Empower staff to provide local, personalised care directed by individuals and communities[edit | edit source]

A wider point on empowerment is a focus on empowering people and communities to participate and have their voices heard. Community organisations are able to prevent unnecessary dependency by focusing investment on empowering people and groups, developing confidence and skills, enabling individuals to become leaders and working with the community to take control and find own solutions (Social Work Scotland, page 2). This means directing individuals to other community initiatives and facilitating seamless transitions between services, without unnecessary assessment periods and waiting times. This agile approach is a large part of the success of the CLS model but could be a critical factor for community interventions more broadly.

It’s important that community projects harness the knowledge and skills of local people and utilise local intelligence. Professionals can’t be dropped into communities to build community interventions and there have been examples of professionals duplicating, and thus somewhat undermining, pre-existing community interventions. Investment without community empowerment, collaboration and engagement will not be successful in meeting objectives. Social Work Scotland concluded that “whilst support and investment in communities may be required to act as a catalyst there is strong evidence that what helps is working with local people to help them achieve their goals, rather than delivering predetermined services or solutions.”  (Social Work Scotland page 2­).

A focus on local people should also involve empowering volunteers and service-users to provide a service or to contribute their skills to the project as witnessed with Recovery Café projects. In these models, through building skills and confidence, individuals are able to move from being recipient of services to delivering and supporting others. This builds capacity of an individual and also has a preventative aspect, enabling people to live independent, fulfilling lives. Moreover, community led services have a strong local attachment, delivered close to home and with wraparound support to enable participation – such as childcare and community transport. Ultimately, this means community interventions view individuals in a holistic, whole-person way, designing interventions which satisfy a range of needs within a community setting.

Empower staff to provide local, personalised care directed by individuals and communities[edit | edit source]

It is important that staff are empowered to deliver the care that individuals want. This means that front-line staff have been trained in the spirit of the act, rather than provided with a caveated understanding of what’s possible within the resource parameters of organisations or the Local Authority. Ensuring people have job-fulfilment through personal empowerment, training, trust, improved job conditions and employee ownership can afford individuals the time to deliver personalised services.

While front-line staff are vitally important, it’s also important that managers are trained in the legislation so that they can subsequently empower their staff to maximise the potential of the legislation. There have been examples where front-line staff have been hampered by risk-averse managers. Training can help individual managers to understand what self-directed support means for their role and how they interact with staff to enable them to empower those in receipt of services. This training and empowering of staff should take place within community organisations, anchor organisations and social care providers too.

Within the DTAS examples, there were various features noted around staff, including Highland Home Carers employee ownership, Strathdearn and Boleskine using recruitment techniques to recruit from the local area and subsequently enabling individuals to work within a small locality. This flexibility is particularly beneficial for individuals who may wish to work part-time and have minimal travel time between clients and mayhave an impact on women's ability to take-up paid employment. Employees within these organisations are also empowered to give personalised care, for example walking a client’s dog. Empowerment through flexible, personalised models of support can ensure the spirit of the self-directed support act is visible in practice.

It also helps to have an individual who works to promote the community-directed model in the community, working to excite, animate and encourage communities to get involved. This role is present in the Highland Hospice, Highland Home Carers and Braemar. This animator can help to empower staff to provide personalised support.

Community spaces and community hubs[edit | edit source]

Within the CLS project, the setting up of community hubs was not originally an explicit or required element of the programme. However, community hubs is an area that all sites have chosen to develop and has subsequently been found to be a critical success factor (NTDI, page 15). It has been shown that people are more willing to engage in health interventions outside of the traditional spaces of the healthcare system.

Meeting People in a community venue was seen as being of symbolic and practical value to local people and it was viewed as being of importance to both people seeking support and staff involved in CLS programmes that local authorities were not used (NTDI, page 30).

Just the act of using a church, a community centre means we have a presence. It becomes a community thing instead of a social services thing. (Social work manager) or A different venue leads to a different mind-set (Group discussion with council staff members)

Community hubs can promote community resilience in various ways. For example, increasing the interaction between community members, bringing people together across the social and generational divide, increasing social capital, building trust and increasing an individual’s knowledge or skills (What Works, page 3). The importance of being based in the heart of the community is highlighted in the examples of East Dunbartonshire's Recovery Café and The Teapot in Glasgow. In the Borders, when establishing the aforementioned ‘What Matters? Hubs’, the Local Authority asked communities what they viewed as the heart of the community and used alternative buildings such as cafes and community centres. Through this experience, the local authority found that individuals are happier to attend interventions in locations not associated with formal services. There is scope to use pre-existing community spaces, such as cafes and centres, to connect with individuals, providing advice and support. Not only is there scope to do this, but there is a desire in communities to get more involved.

Using trusted community organisations, hubs and anchors can also enable the reaching-out to people who would typically be difficult to reach via health services. One such group is older men who are engaged in various third sector interventions which have an impact on health and wellbeing such as the Men’s Shed Movement, Care and Repair or programmes such as Big Hearts Community Trust.

Building relationships with existing community groups and public sector infrastructure[edit | edit source]

It is necessary to build positive links with other local groups and stakeholders. Mutually supportive, collaborative relationships, driven on a bottom-up basis, clearly strengthen the individual project but can also build stronger communities too. For example, using dedicated community ‘connectors’ and working in collaboration with people who have experience of local communities, their priorities and assets can streamline the process, avoid duplication and bring necessary efficiency (NTDI page 14).

Partnership with external partners, other parts of the local authority and the community, were seen as lying at the heart of CLS. NTDI found examples where diverse partners, such as the library services and the council’s culture service, described synchronicity between their values and goals and those of CLS (NTDI page 15). Also, in establishing their service in Braemar, the community are using the local lunch club to connect with people in the community utilising trusted, valued organisations to access people. Equally, Perth and Kinross healthy communities collaborative used lunch clubs run locally by the groups as an ideal way for professionals promoting health to bring their messages to the heart of rural communities (Making it work, page 48).

From research by the King’s Fund, issues were exposed that community services can be fragmented and poorly co-ordinated so that they are not well integrated with other services in the community, leading to duplication and gaps in service provision (Kings Fund, Reimagining community services, page1). While an intervention can be successful as stand-alone support, for this agenda to be truly transformational there is a need for connections and for organisations to understand how their support or service fits into a wider system of community-directed support.

A key part of this collaboration are strong links with the public sector, as evidenced throughout the best practice examples of this report. For example, Healthy Valleys have strong relationships with integrated children services, social work, primary schools and the NHS Lanarkshire public health team (Healthy valleys, Making it happen, page 32). The sites visited on the DTAS study trip also had strong involvement from former health professionals. For example, a retired GP is the chairman of Strathdearn Community Developments and thus has strong medical knowledge and insight into the process of care and the workings of the health board. Equally, in Braemar, two former members of the health board are members of the board. This ‘inside knowledge’ gives community invaluable insight into the language, processes and parameters of the health and social care system in Scotland. These links with the public sector should be bottom-up partnerships, driven by communities.

A question is how people can discover what’s happening in their area in terms of information support and self-directed support options. One of the suggestions is the development of online directories. In principle, this means people being able to search for specific support or interventions in their local area and utilise contact details. While digital directories, such as ALISS, are seen as a positive by some, it can be very resource intensive to keep these directories up to date. It is also the case that these online directories become dominated by larger interventions as smaller-scaled projects are less likely to have the resource to upload their details. There can also be unintended consequences in terms of ‘marketising’ or formalising interventions which are currently successful informal services.

Perhaps more important than digital directories are making connections with third sector interfaces and having local visibility through local channels. There is also a role for health and social care partnerships and third sector interfaces to map local interventions. Another important option is to bring people and organisations together via online and face-to-face networks where they are able to share experiences, stories and empower each other. In this way, we can bring together knowledge and the idea that something different is not only possible, but achievable if we are to achieve personalised services. We must give people the opportunity to use their imagination and design their own support. Questions like ‘can I really spend my money on that?’ can be answered via peer support and bringing people together to share their experiences.

Empower people to take control of their own health and care[edit | edit source]

None of this will work unless the needs and human-rights of individuals is at the heart of this activity. Self-directed support focuses on people being able to take control of their own health as far as possible and future models of community-based care should also stem from this ambition.

This might involve preventative activity such as encouraging people to lead healthier lifestyles or supporting individuals to manage long-term conditions (e.g. health trainers are co-located within GP surgeries and can support people from certain high-risk groups to set health goals and promote behaviour change).

This also means involving families, carers and communities in planning and delivering care. While the ambition would be that the entire health and social care system be organised and co-ordinated around people’s needs, in the context of this work it is essential that care delivered by local organisations be closely connected to other parts of the health and care system to improve the personal experience and outcomes of care.

An aspect of this, as mentioned throughout this paper, is peer support. For self-directed support to work there needs to be the capacity for peer support, sharing best practice examples and enabling people to communicate with each other about what works and what doesn’t work.