strategic planning and progress under the all wales strategy: reflecting the perceptions of...

Strategic planning and progress under the All Wales

Strategy: reflecting the perceptions of stakeholders

S. Todd, D. Felce, S. Beyer, J. Shearn, J. Perry & M. Kilsby

Welsh Centre for Learning Disabilities Applied Research Unit, University of Wales College of Medicine, Cardiff, UK

Abstract

Nominated representatives from the various stakeholder

interests, i.e. social services, health, education, voluntary

organizations, parent groups and self-advocacy groups,

involved in the implementation of the All Wales Strategy

for the development of services for people with

intellectual disability were interviewed 2 years after the

end of the initial 10-year phase. Interviewees were asked

to reflect on the strengths and weaknesses of policy

implementation, including: changing priorities, planning

arrangements, agency roles, central guidance and

financial mechanisms, consumer participation, and the

impact of more recent policy or structural

developments. Despite recognition of the leadership of

the Welsh Office, the shift in thinking achieved, the

developments made in joint agency collaboration and in

consumer participation in planning, and an increasing

competence to plan effectively over time, the overriding

perception was that more could have been made of the

opportunity afforded by the clearest and best resourced

central government policy within the UK in this area. At

the heart of this judgement lay concerns about

pragmatic rather than strategic planning, a failure to link

annual service developments to a final comprehensive

end point and a related failure to integrate planning to

meet community needs with hospital resettlement.

Factors which may have contributed to these

weaknesses are discussed, as are lessons for subsequent

community care policy.

Keywords All Wales Strategy, perceptions ofstakeholders, planning, policy

Introduction

The All Wales Strategy for the Development ofServices for Mentally Handicapped People (AWS)was launched in 1983 to `correct the historicanomaly which left the bulk of public serviceprovision in large and, for many, remote hospitalswhilst the great majority of mentally handicappedpeople and their families receive little or no supportin their homes where it is most needed' (WelshOffice 1983, p. i). A wholesale restructuring ofservice provision was signalled, as well as the casefor the development of new service processes atplanning, management and operational levels. Inadopting the principles first stated in the model ofcare chapter of the Report of the Committee of Inquiryinto Mental Handicap Nursing and Care (DHSS1979), it was the first national policy in the UK tomake the commitment that people with intellectualdisability should have a right to experience normalpatterns of life within the community, howeversevere their disability. Therefore, the AWS was

Correspondence: Correspondence: Stuart Todd, Welsh Centre for

Learning Disabilities Applied Research Unit, University of Wales

College of Medicine, Meridian Court, North Road, Cardiff CF4

3BL, UK. E-mail: [email protected]

# 2000 Blackwell Science Ltd

Journal of Intellectual Disability Research

VOLUME 44 PART 1 pp 31±44 FEBRUARY 200031

widely seen as an important acceptance andlegitimatization by national policy makers of theviews of those who had been advocating community-oriented reform for some time. Matched by acommitment to significant resource investment, thisnew alliance of policy makers and reformers wasgreeted as a major opportunity to develop a patternof local services and support arrangements. Someyears into its implementation, the AWS was stillseen as offering `bold and imaginative proposals fora radical new service' (Audit Commission 1987,p. 8). The present paper is concerned with thisnational experiment in strategic change. Specifically,the thrust of this analysis is to understand theopportunities and challenges posed by the AWS forthose whose place it was to respond to it.

The transition from institutional to community-oriented thinking was not in itself new but Britishpolicy had not previously moved to embrace theinevitability of wholesale reform. Griffiths (1988)observed that `community care has been talked offor 30 years and in few areas can the gaps betweenpolitical rhetoric and policy or between policy andreality have been so great' (p. iv). Previous nationalpolicy (DHSS 1971) had contained a specification ofgeneral principles, but had failed to face theinconsistency between the existing nature of serviceprovision and desired outcome. This reluctance togenerate a sufficiently radical reform agendaconsistent with articulated principles removed theability of Government to establish effective controlover policy implementation (Webb & Wistow 1982).

The AWS overcame this problem by embracingthe logic that a progressive redefinition of theoutcomes to be achieved for people with intellectualdisability in society implied wholesale servicereform. The incrementalism of previous jointfinancing arrangements was swept away bydesignating local authority social services as the leadagency and by projecting revenue investment at arate more than sufficient to pump-prime change intraditional services. Deinstitutionalization was not anexclusive focus of policy. Indeed, meeting the needsof people living in the community was made apriority. The transfer of resources from traditionalforms of care and from health to local authoritieswas anticipated to reinforce the direction ofdevelopment. The availability of central funding toallow community service development and

institutional reform to go hand in hand created anunparalleled opportunity for broad-based strategicplanning.

A possible blueprint for the required nature, finallevel and pattern of services consistent with AWSprinciples had been set out by the Working Partywhich had reported a year before the launch of theAWS (Welsh Office 1982). Estimates of service needwere derived from epidemiological informationextrapolated to population data. This plan was thencosted and provided the basis for calculating andphasing resource investment. Ultimately, the cost ofservices would need to increase four-fold withoutallowing for inflation. An interim goal of reachingthe half-way point was set for a first 10-year phase,which required the investment of an additional £26

million recurring revenue at 1983 prices tocomplement an approximately equivalent amountwhich was already being spent. There was anexpectation of slower growth in expenditure in thefirst years and an acceleration towards the end of thedecade as planning became more assured.

The Welsh Office oversaw the progress of theAWS. Officers from the Health and Social ServicesPolicy Division were responsible for scrutinizingplans from counties and for the funding strategiesrecommended to ministers. In addition, anAdvisory Panel, modelled on the NationalDevelopment Group, was established torecommend good practice and advise the Secretaryof State and the Welsh Office. Legislation enabledthe Welsh Office to make ring-fenced allocations tosupport agreed projects. Therefore, the WelshOffice retained an effective financial sanction bywhich to ensure compliance with the overall servicephilosophy being promoted. Initial Welsh Officecontrol over the funding of proposals was close,although it was later moderated to allow countiesdiscretion over project priorities within an overallagreed programme.

Although driving the AWS centrally, the WelshOffice also wanted to shift ownership of the policyto the local level. Therefore, a balance needed to befound between central and local determination ofservice development. The Welsh Office sought thecreation of County Joint Planning Teamsrepresenting local authority departments, healthauthorities, relevant voluntary organizations, andpeople with intellectual disability and their families

Journal of Intellectual Disability Research VOLUME 44 PART 1 FEBRUARY 2000

S. Todd et al . Strategic planning under the All Wales Strategy

# 2000 Blackwell Science Ltd, Journal of Intellectual Disability Research 44, 31±44

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to prepare a single, agreed plan for each county,and issued detailed guidance on the way these planswere to be formulated. Indeed, throughout the firstphase of the AWS, the Welsh Office refined itsplanning guidance and requirements for reportingprogress repeatedly in an attempt to stimulateplanning in line with the AWS. Members offledgling County Joint Planning Teams werebrought together in a series of workshops in eachcounty, received an induction to the AWS and werehelped to establish a broad framework for theirfuture planning. The identification of need was tobe localized, with professionals and consumersmeeting to consider the requirements of individualsand families. This information was to be collatedand fed into area and county planning. Early grantswere made to establish a planning and professionalinfrastructure in local areas. Most countiesappointed development officers and a rapid andwidespread introduction of multidisciplinarycommunity teams was achieved to coordinate thelocal assessment of need.

Aims of the research

The present analysis interprets the strengths andweaknesses of policy implementation since theinception of the AWS through the experiences andperceptions of the agency personnel and otherstakeholders committed to taking it forward atcounty level. Interviews with the representatives ofthese vested parties were held at a point in thecourse of the AWS which promoted reflection. Thefirst 10-year phase of the AWS had ended andparticipants were assessing its future shape andscope in the light of more recent guidance (WelshOffice 1996), which was widely interpreted to showless central government commitment. Anticipatingthe future of the AWS was further encouraged bythe implementation of Local GovernmentReorganization (LGR), a reform which re-emphasized the significance of the equality of servicedistribution at the local level by the division of theprevious eight Welsh counties into 22 new unitaryauthorities. The progress made within Wales interms of quantified service change is describedelsewhere (Evans et al. 1994; Perry et al. 1998).

On one level, such an analysis is specific to Welshpolicy and circumstances. On another, the AWS is

but one example of a wider reform movement whichhas affected the developed countries of the world inremarkably similar ways (Hatton et al. 1995; Mansell& Ericsson 1996). The ideological and applieddevelopments upon which the direction of reformencapsulated in the AWS were predicated wereneither exclusive to Wales nor necessarily betterrepresented in Wales. The direction of reform wasalso not unique to Wales, but rather, paralleledreform, or at least, aspirations for reform elsewhere.However, Wales and the AWS do provide a casestudy of a concerted intent to achieve such reform.Lessons concerning the success of the planning,financial and administrative mechanisms adopted inthe furtherance of policy aims have a generalrelevance.

Moreover, this relevance is reinforced by thelessening status of the AWS as a distinctive policy.Wales has not been isolated from other policydevelopments which have affected the UK. Themost significant in recent years have been the globalchanges in the organization of health and social careembodied in the NHS & Community Care Act 1990

(NHSCCA). To some extent, the AWS was seen asa forerunner of the arrangements put forward in theWhite Paper, Caring for People (Secretaries of State1989) which predated the NHSCCA. Caring forPeople and the AWS share the rhetoric of promotingindividual choice and independence. Both sought toclarify responsibilities, giving local authorities leadagency status for social care provision. Bothadvocated the assessment of need and coordinationof service arrangements on an individualised basisand both sought to change service culture away froma focus on congregate residential provision. Bothalso implied a more varied and responsive range ofservice supports. The lessons from the AWS haveclear relevance for the further pursuit andimplementation of the Care in the Communitypolicy in the UK.

Analysis of the effect that the implementation ofthe NHSCCA has had on the progress of the AWSis also of general relevance. The NHSCCAintroduced a variety of new arrangements, such asthe purchaserprovider split and systems of caremanagement. Whether such developments havereinforced or cut across organizational and planningmechanisms originally set in place under the AWSsuch as joint agency strategic planning,




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multidisciplinary person-centred service planning atthe local level, and the involvement of service usersand their families as equal partners has considerableimplications for the welfare of people withintellectual disability both within and outside ofWales.

Methods

Data for the present study were obtained frominterviews with representatives of key stakeholders inthe implementation of the AWS in the then eightWelsh counties. Stakeholders were defined as thedifferent agencies or interests involved in county-level strategic planning, i.e. social services, healthauthorities, education, the voluntary sector, parents'organizations and people with intellectual disability.Interviews were generally held with onerepresentative from each stakeholder interest in eachcounty, although some interviews were conductedwith a small group of representatives collectively.Two or three health authority representatives wereinterviewed so as to reflect the views of bothproviders and purchasers.

Representatives from these groups were identifiedby County Planning Groups and interviews tookplace between May and November 1995. A numberof topic areas were developed by the presentauthors. These included changing priorities orphases of the AWS, planning arrangements, agencyroles, central guidance, financial mechanisms,consumer participation, and the impact of morerecent policy or structural developments. Theinterviews were semi-structured so as to allowcommon issues to be discussed with a flexibilitywhich gave participants the opportunity to talk morebroadly. Interviews were audio-taped and took anaverage of about 2 h to conduct. The researchersinvolved in the study each had responsibility forobtaining the viewpoint of a separate stakeholdergroup across all the counties. On completion of theinterviews, comments were analysed by theresearchers as a group and the emerging analyticthemes were refined over several meetings.Illustrative quotations are indented in the sectionsbelow. After each quotation, the stakeholder interestgroup is named and a numeral refers to one of theeight counties.

Results

Establishing local joint agency consensus: a longand winding road

Although the Working Party which led to the AWSmade assumptions about what a comprehensiveservice would comprise, the AWS itself set onlybroad principles and directions for service reform.Planned change was to be determined locally by abroad constituency. However, as in many other partsof the UK, experience of cooperation betweenagencies prior to the AWS was limited and so toowas consumer involvement in planning. Thenumber of stakeholder perspectives made effectivejoint planning a complex undertaking. Establishingmutual trust and understanding added to theambition of the strategic planning task required:

`No one in 1983 was totally prepared. Therewas so much that needed to be done. Godknows what had been going on in the previous50 years. There was a very low baseline . . . andwe spent the first 4±5 years working out whatwe needed.' (Health 2)

The granting of lead agency status to social servicescreated a perception that the AWS was a strategy forinvestment in social services. There was a tendencyfor the other two major agencies, i.e. Health andEducation, to view the AWS with suspicion, and asundermining their past contribution or current policypositions. Health, the dominant provision partner asfar as residential provision was concerned, felt thattheir long track record in the area had been devaluedand that the positive contribution of healthprofessionals was being mistakenly conflated with amedical model of disability:

`There were rivalries and jealousies. There wasa feeling in the health authorities that theywere the poor relations in the early stages. Thewhole of the money seemed to be going onvoluntary sector or social services schemes . . .

It was seen that health couldn't be regarded asan appropriate body to take forward newideas. There were schemes put forward thatdidn't receive approval because they werefrom Health.' (Health 3)

There was also a widespread view that socialservices lacked competence. Such attitudes were a




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clear challenge to conducive and productive jointworking:

`In the beginning, there was a feeling ofprejudice against Health: (1) the healthauthority was the heaviest investor in revenueterms; (2) we knew full well that localauthorities were doing virtually nothing; (3)the health service had made considerablestrides since the likes of the Ely Inquiry; (4)the local authorities did not have theprofessional expertise to handle leadership; (5)local government, through its electiveprocesses, was far slower and could befrustrated by the parochial views ofcouncillors; and (6) there was a feeling at thetime that the senior social services officerswere not up to it.' (Health 7)

The AWS did not add to or change the existingpolicy thrust on the education of school childrenwith intellectual disability, and therefore, did notchange the perception of local education officers asto the source or content of educational policy.Leadership of the AWS itself was vested in theHealth and Social Services Policy Division of theWelsh Office, but coordination with the educationdepartment was seen as lacking:

`The Welsh Office should really have put morethought in coordinating its AWS work across itsown divisions . . . It was as if one hand of theWelsh Office didn't know what the other handwas doing . . . There was one set of advicecoming from the AWS and another . . . [from]the education division.' (Education 6)`There was a failure of leadership on the part ofthe Welsh Office. Clearly, schools inspectors inthe Welsh Office did not share the AWSprinciples and did not pursue that agenda.'(Voluntary 4)`There was no sense in which the localeducation authorities had to accept the valueswithin the AWS and no sense in which they didaccept them.' (Voluntary 2)

Consequently, the AWS was seen in localdepartments of education as mainly a strategy forhealth and social services, and as one primarilyconcerned with adults. Despite the issue of theirlow involvement in the AWS periodically coming

to the surface, education authorities remainedperipheral:

`We thought the AWS wasn't our ball park andthat there was no real money to attract us into it.The main emphasis went on adults . . . So it wasa chance lost in terms of the AWS being acomprehensive strategy.' (Education 8) `I don'tthink Education have been as involved as theycould have been . . . The other issue that has nothelped is that the strategy was always seen asdealing with adults.' (Health 2)

The emphasis on consumer representation alsocaused initial difficulties. It was to beoperationalized by giving parents, voluntaryorganizations and people with intellectual disability aplace at the planning table. The AWSunderstandably generated heightened expectationsof change. Many consumer representatives reportedthat they initially interpreted the AWS as a charterfor them to tell professionals what they requiredthrough their involvement in individual servicereviews, and local and county planning. However,professionals maintained an independent view:

`They [parents] are faced with this demandingneed 24 h a day and they can't step back fromit as can officers. They expected to see thingsdelivered much more quickly. They came sooften with their vast experience andknowledge of their individual situations, butfound it difficult to use that as an exemplar fora broader strategic view. That'sunderstandable. I think they started to getfrustrated as they expected plans to be tailoredto their individual need.' (Health 1)

Moreover, parents were at first seen as aconservative force, resistant to or sceptical of thenature of change the AWS was promoting, and likelyto argue for a greater availability rather than reformof existing services:

`We were all caught up in trying to make senseof all these new ideas. Not that there was a lotof resistance, except from parents. Parentsthought the services we had then were good,but that we didn't have enough of them. So,in the early days, it was about trying toconvince parents of the need for change, andthat change didn't mean taking services away




35

but replacing them with something better.'(Education 2)

This generated a tension between principled andconsumer-driven development:

`There is an issue. People say that they wantsomething and then they are told that it is notavailable because it is not in line with AWSprinciples. You have a choice, but you onlyhave a choice if it is line with Strategyprinciples.' (Health 4)`Social services do not consult the parentsenough, after all we should know what is best forour children. Parent representation is no morethan a tokenistic gesture to legitimize decisionsmade by those in social services.' (Parents 5)

The representativeness of parent activists alsoraised doubts, although their impact on planningwas acknowledged:

`Parental participation has been less successfulin that it is a very small group of parents. A lotof money has been spent and I'm not sure itsbeen best spent. You will only get a smallgroup of activists involved, and that's not thebest way of keeping people informed and intouch. We might have done much better ifwe'd developed an information exchange.'(Social Services 8)Ìt's been good at county level because parentscan actually, because of their numbers,outvote professionals if they want to. Theycertainly have had an input in planning andtheir views are not the same as professionals.That's okay. It's a good thing in many cases.'(Social Services 5)

Achieving user influence in planning has beeneven more uncertain. The involvement of peoplewith intellectual disability had not progressed far inthe first years of the AWS (Beyer et al. 1986; WelshOffice 1987). However, it grew over the course ofthe AWS to the point where the presence of peoplewith intellectual disability on planning groupsbecame taken for granted (Felce et al. 1998). Thiswas seen as a successful AWS outcome in itself:

Ì think People First has had an impact. Ithink people find it quite ordinary that peoplewith learning disabilities should be included. I

can remember at the very beginning of theStrategy people with learning disabilitiesspeaking up for themselves at a conference inLondon. I found it quite astonishing andtouching, whereas now it seems quiteordinary.' (Social Services 2)

Nevertheless, it is not clear what precise impactpeople with intellectual disability have had on theprogress and development of the AWS. Theirmembership of planning groups has created atension in the conduct of business between slowingthe process to achieve informed participation andgetting on with it to meet pre-existing expectationsand time-scales:

Ìn terms of service users, we've had a smallamount of involvement. When we are talkingin committee at speed, I find it difficult tobelieve that they understand what is said. Ifyou want service user involvement, the processis about 25 times slower. It has to be. In aconvoy, you go at the pace of the slowest ship.Everyone, including the Welsh Office, willhave to accept a slower pace.' (Health 7)

Moreover, members of planning teams withintellectual disability believed that their participationwas important . . .

`Now we've got a say in things. It's importantbecause they don't know what is best for us.Only we can say what we want.' (User 3) . . .

but often tokenistic:

`They listen to what we have to say, but theydon't do anything about it.' (User 8)

Ultimately, despite the initial tensions betweenhealth and social services, the changed emphasisassociated with the social care lead role becameunderstood and accepted. The shift in servicemanagement and ethos occasioned by joint agencycollaboration became seen as an enduring success:

`Positively, it has got us away from themedical model to a more humanisticapproach.' (Health 8)`There is a clearer definition now of who'sresponsible for what and it's really helpedclarify that what went on before was notappropriate . . . The people who we work with




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are people with a learning disability, but we'reonly interested in doing business for themconcerning health-related problems. Dealingwith social care is the job of the lead agency,so I don't have any problem with that ± it'sprobably helped firm up how we should moveforward. It's helped clarify roles.' (Health 6)

Role of the Welsh Office: a cohesive force

The AWS established patronage for intellectualdisability and sponsored the progressive view againstthe more traditional:

`Prior to the AWS, learning disabilities hadbeen an impoverished service. It had no powerand no political voice. The AWS was the keyto unlock the political power, and the will andattitudes to change things. If there had beenno strategy, learning disabilities would havestill been competing with the elderly, childand mental health services, and would havebeen bottom of the order for resources.Without the resources, we wouldn't have beenable to change anything.' (Health 3)

As the driving force behind the AWS, the WelshOffice was widely acknowledged to have had playedan instrumental role in focusing the planning effortsof local agencies and communicating the principlesof the AWS:

Ìn the early days, it was to do withreorientation, it was all to do with values andprinciples, lots of training, lots ofdiscussion . . . It was very much focused onchanging attitudes.' (Social Services 3)

This central leadership was broadly accepted:

Ì think it was positive, particularly in the earlyyears, that there was some kind of overallmonitoring . . . If there hadn't been, the moneywould have been gobbled up by SocialServices.' (Social Services 1)

The importance of the Welsh Office was clearlyrecognized by members of planning teams whodeveloped their proposals explicitly to gain theirapproval, and hence, funding. The Welsh Officeacted as guardians of the policy, monitoringproposals for consistency with AWS principles:

Ìt was very much guided by the principles ofthe AWS. Without the Strategy, somethingelse would have happened . . . For example,service officers would have planned non-strategy services, e.g. new units on hospitalsites; parents were adamant about maintaininghospital bungalow provision and preferredtraditional day services.' (Health 4)

The Welsh Office also ensured that localauthorities were accountable for what was done withcentrally allocated finance:

`The annual reviews . . . used to be quite adaunting occasion . . . At one time, you had toaccount for how you were spending the moneyand what services you were providing, andthere were a number of issues that were alllaid out. There were very formal agendas. Atone stage, you couldn't do anything withouttheir [Welsh Office] say so. We were alwaysdependent upon them for the AWS money.'(Health 7)

Pragmatic rather than strategic planning

As conveyed above, developing both new planningprocesses and an understanding of the principledreform agenda took time. Although AWS spendinghad been predicted to begin slowly and increase overthe 10-year period, there was still a considerablediscrepancy between the allocation and take up offunds because of the greater-than-predicted initialdifficulties. Pressure from the Treasury began togrow either to use or scale down projectedexpenditure. Therefore, counties which couldgenerate proposals in keeping with AWS principlesfound a central government keen to occasiontangible change and spend up to allocated levels.This pragmatic urgency may have contributed to asituation where the AWS . . . was managed throughdirect discourse with the Welsh Office and inisolation from mainstream local authority concerns:

Ì think we were very separate. We cut a lot ofcorners. We moved out of what was thedepartmental planning processes. We didn'tuse committees sufficiently looking back. Wesaw it as freedom to get on. The downsidewas that people didn't see us as particularly




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relevant. That was a major failure.' (SocialServices 4)

Pressure to meet the immediate demands ofprogressing the AWS seems to have prevented astrategic sense emerging of how reform was to betackled:

`The AWS has been consistent in beingunable to provide an overview of developmentor strategic thinking about how all these newservices were fitting together. It's alwaysencouraged ad hoc planning.' (Education 4)

The perception that significant central fundingwas easily captured also encouraged a short-termfocus on project development:

`Planning at that stage was still very much ashopping list. I think that did go on as themoney continued to roll in.' (Social Services 2)

The apparent absence of a strategic overviewmeant that service development was poorly linked toa fundamental appraisal of the needed distributionof resources for an area or population:

À lot of people took existing schemes off theshelf . . . some . . . good . . . some less good. Itdid actually prove more difficult later on toweave them into a coherent pattern of servicein terms of the principles of the strategy . . .

There was no proper needs assessment.What we seem to have is a patchwork ofuncoordinated schemes ± nobody has done anappropriate assessment of need.' (Health 2)

Confusion about community development andhospital resettlement

Some of the problems in strategic planning can beattributed to a lack of clarity over hospital provisionand the Health Service role. Although the fundingassumptions of the AWS over the first 10 yearsimplied reinvestment of resources tied up intraditional services, the difficult issues brought to thefore by the prospect of hospital closure, such as thefuture employment of specialist nurses, causedpolicy to remain undecided:

Ìt was something we all had at the back of ourminds, but never admitted. I think for years

there was a hidden tension that we weren'treally tackling the issue of resettlement fromhospitals. They had to close, but politicallythey had to stay open.' (Education 7)

The integration of hospital resettlement within awider community development strategy was notachieved. When the Welsh Office asked for plans forthe future of the hospitals to be formulated in 1985,the request was directed only to the healthauthorities (Welsh Office 1985), confirming anyinitial impression that planning reform of thehospital sector was not part of the AWS:

`There was an anxiety among Health peoplethat they ought to be involved, especiallyfollowing the document on the specialisthospitals. We responded to it by saying, `Àha,this is our bite of the cherry ± we can actuallydo something on the health side now!'' '(Health 2)

Guidance 2±3 years later asked for resettlementplans to be annexed to county plans, reinforcing theidea that planning in relation to the hospitals wasnot an integral part of the county plan and not ledby Social Services. The distinction introduced at thesame time between AWS programme funds andspecial allocations to speed resettlement had thesame effect. Subsequent to the mid-term review ofthe first phase of the AWS, hospital resettlement wasdesignated as one of a number of core areas andbecame an increasingly dominant priority:

`They should hurry up and get all people leftin hospitals into houses. Why have theyallowed some people to move out [of hospital]and not others?' (User 6)Ìt seems that nothing else matters at themoment except getting people out of hospitals. . . The push towards resettlement hashijacked the AWS It's all resettlement now.'(Education 3)

Comprehensiveness: a forgotten objective

Consistent with the impression of pragmatic ratherthan strategic planning, and the failure to integratereplacement of the hospitals within widercommunity development, the AWS was seen byindividuals and their families as characterized by




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shifting priorities, and the opening and closingwindows of opportunity:

`The best way I can describe it is that it islike having the rug pulled from under you ±one minute you are being told that the aim isto provide better services, the next you arebeing told that there is not enough money.'(Parents 6)

As illustrated above, some respondents criticizedthe financing assumptions and mechanisms as notconducive to strategic planning, but ratherencouraging haste. Difficulties of coordinating large,multi-agency joint planning groups were alsoidentified as contributing to poor strategic planningand the absence of a comprehensive view:

`I think the way the planning group was seenas the custodian of the plan probably had animpact. There were about 40±50 people on it,and it's very hard to talk sensibly aboutstrategic direction and resolve complex issuesin a group that large, with individuals puttingforward their own priority and a sort of `horsetrading' occurring . . . Plans were assembledfrom the bids that came forward [accordingto] the pressure that individuals or . . . groupswere applying, rather than from a planninggroup actually saying, ``This is the strategy ±this is the level of services that we require tocover, say, respite care or to deal withpressures of people with mental healthproblems.'' ' (Health 2)

Failure to estimate eventual service need at thepopulation level and to check that the marginal costsof new services were compatible with the totalresource framework initially set out meant that thediscipline of weighing priorities in order to obtainthe most from limited resources was not high on theagenda:

`When someone comes to our planning groupwith a proposal, there's nothing in theirproposals about how services might beintegrated in a coherent package. There'snothing about how they will (affect)mainstream funding . . . The AWS has alwaysbeen treated as something separate in socialservices and we've never developed an

account of how all this money fits togetherinto a comprehensive coherent pattern of localservices . . . If the AWS has failed in anything,it's failed in its strategic functions. Everyonesees it as a bit of extra cash. The intentionswere there. We had the money, the plans andthe commitment, but it all went wrong interms of a strategy . . . It's been a great pitythat the huge surge of goodwill in the earlydays has been dissipated, and a lot of goodwork and effort is being undone because wenever had the skills or the motivation forstrategic planning. The money we had mightnot have been enough to take us to the end,but I think we could've done a lot better.'(Education 4)

The result of this inability to relate proposals tointerim goals can be seen in recent events. Fundingto sustain service development at the trajectory setwas not forthcoming beyond the first 10 years.Evidence of escalating costs within proposals put tothe Welsh Office towards the end of the first phaseof the AWS contributed to the restriction of itsfuture scope:

`The money's run out in terms of offering agood service to people . . . maybe becausepeople were extravagant initially and spent toomuch on the first wave.' (Health 7)

Respondents felt that service coverage was notsufficient or well distributed. Service catchmentareas continued to be larger than necessary, or inother words, the potential for developing localservices was not fully realized:

`The last phase has been frustrating. We'vehad to deal with a lack of funds for the thingswe want to do. We've put down thestructures, built up a vision, worked outdetailed plans, but now its about rationing.'(Education 2)

The late policy and funding focus on hospitalresettlement implied less development for peopleliving in the community, and the needs of carers andtheir relatives not being met:

`One failure of the Strategy was that there wasnot enough long-term planning to consider theneeds of people who were born in the




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community and stayed in the community, andso we had an imbalance of services.' (Health 7)

A strategy which set out to shift resources to thecommunity, and to respond to the needs and fearsof carers was incomplete. After the end of its firstphase, for example, given no increase over the AWSyears in the availability of supported residentialaccommodation, the question remains:

`All people have the right to ordinary housing.What will happen to our son when we die?'(Parents 3)

Discussion

Strengths of the AWS

There can be no doubt that those responsible fortaking the AWS forward had or gained a genuinecommitment to progressive values, and a desire tosee people with intellectual disability and theircarers receive the support necessary to enjoy abetter quality of life. Such commitment wasbacked by resources and the promised financialinvestment was more than delivered. In addition,the AWS was founded on the principles, serviceprescriptions and administrative arrangementswhich advisory bodies and campaigners for reformwanted to see. The Strategy reflected muchconventional wisdom in its definition of acomprehensive service, its role for local authorities,its ring-fenced funding arrangements, and theacknowledged need to achieve a higher priority forintellectual disability concerns throughout thepolitical and service system. The foundingprinciples of the AWS provided a vision of whatwas to be achieved and fostered a commonrationale for service development. The presentauthors' quantitative analysis of servicedevelopment under the AWS (Perry et al. 1998)showed that reform in Wales has been moreextensive than in England in a number of areas,including a greater transfer of serviceresponsibilities from health to social services, widerconsumer representation in planning, a moreuniform commitment to a small ordinary housingmodel in the wake of deinstitutionalization, theemphasis given to domiciliary support services andthe growth of supported employment.

Weaknesses of policy implementation

However, the neglect of the initial vision ofcomprehensiveness, together with the fact that theAWS has been scaled down before the servicedevelopments envisaged by its architects have beencompleted, means that services are still patchy, andthis has an obvious corollary that some individualsand families benefited from the AWS and others didnot. The evidence of the present paper provides apicture of unrealized potential linked to a centraltheme of inadequate strategic planning andmanagement. A number of factors appear relevant towhy the strategic implementation of the AWS failedto match its comprehensive intent. Arguably, primeamong these were the low state of readiness to takereform forward, the time required to build upnecessary planning and operational arrangementsand competency, and a lack of final and interimplanning targets.

Building support for radical change in localservice agencies, and among consumers, theirrepresentatives and communities at large took time,particularly as it was an area that historically had hada low public and political profile. The localauthorities were given responsibilities which theyhad not undertaken before. Although ideologicallysympathetic to change, they had neither a strongtrack record nor in-depth experience in providingthe type of services which the AWS heralded. It isnot surprising that the scale of reform signalled bythe AWS also required time to assimilate. Inparticular, the establishment of joint agencycollaboration and planning was a demandingundertaking.

With the benefit of hindsight, there was a clearneed for a reasonably extended preparation periodto allow local agencies to get ready to implement thechanges which were to come: garnering localconsumer and political support; creating relevantcompetency, particularly within the lead agency;establishing planning arrangements and theprerequisites for local comprehensive servicespecification; and setting out strategic servicedevelopment milestones and costings to indicate thebuild up of different types of service in constituentlocalities. There was an awareness in the WelshOffice that preparation and lead-in time werenecessary, and that investment demands in the first




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years would be lower than subsequently. However,the extent to which the available funding began todrive the implementation of well-intentioned but ill-prepared plans was not foreseen.

It is clearly difficult to announce a politicalinitiative without backing it with funding. Anyequivocation over investment is interpreted as a lackof commitment. Nevertheless, it is arguable thatbetter use would have been made of AWS resourceshad there been a planned delay until localauthorities were in a proper state of readiness toimplement agreed reform. This would have allowedthe Welsh Office to have monitored progress againststrategic intent as well as conformity to AWSprinciples. As it was, the Welsh Office refused tosanction the majority of the first plans broughtforward because these contained service proposals atodds with AWS philosophy, an inadequate attentionto detail, or a lack of evidence of consultation withconsumers and their representatives. Thisimmediately produced delays in implementation(Beyer et al. 1986): only three out of the eightcounty plans were approved between May and July1984, the other five being passed between February1985 and February 1986. Significantly, proposals fordevelopment in two specially selected areas, theVanguard Areas, which were to provide acceleratedprogress to foreshadow the eventual comprehensivepattern of services and to generate lessons for thebroader-based reform which was to come, wereapproved at least a year after approval was given tothe first three county plans. The Vanguard Area ideanever fulfilled its function and the special status ofboth districts was withdrawn in 1988.

Moreover, in not setting targets or norms forservice development, and fostering a culture of localdetermination of need based on individualassessment, the AWS provided only a loose serviceprescription. The Working Party portrayal of theeventual pattern of services was not used as a modelfor counties to follow. Rather, an emphasis ondetermining service need and developing innovativeservice models became part of the AWS experiment.Hence, the most straightforward approach tostrategic planning, namely devising and costing aseries of provision steps between what was currentlyavailable and the desired end state, was invalidatedbecause the end state was not defined. Rather, amore complex and organic process was attempted

whereby plans would reflect local prioritiesascertained through discussion between consumersand professionals. Individual planning was putforward as a fundamental mechanism forestablishing the support individuals and familiesrequired consistent with AWS principles. However,inadequate time and consideration were given to thecomplexity and resource implications of developinga needs-led, bottom-up system of strategic planning.The notion of county planning being theembodiment of locally assessed needs was disabledby the low coverage and fragile implementation ofindividualized planning (McGrath 1991; McGrathet al. 1993; Evans et al. 1994). Therefore, the AWShad a gap at the centre of its machinery fordeveloping and reviewing strategic plans. Servicedevelopment proposals coming forward to the WelshOffice were generally not related to an eventualmapping of services, nor was proposed revenueinvestment part of a costed final expenditureframework. It was impossible to tell whether anyproposed development would fit within the eventualoverall service pattern or whether its proposedcostings were within the resource investmentassumptions of the AWS.

Implications for subsequent community care policy

Even though `relaunched' as recently as 1994, theAWS has largely and effectively been superseded bythe NHSCCA. Current guidance specifically relatingto the AWS (Welsh Office 1996) repeats itsaspirational objectives with virtually no considerationof the precise service infrastructure required to meetits far-ranging recommendations, planning targets orthe financial implications of what it urged localauthorities to do. In general, the new guidancereplaced the previous relatively distinct clarity of theAWS with a return to more traditional non-prescription. However, if the strategic planningweaknesses of the AWS made its implementation lessthan sure despite its original strengths, the NHSCCAwhich has superseded it as the overriding policy seemsnot to have resolved the difficulties. The remainder ofthe present paper points to continuing inadequaciesin the policy framework, at least for those wanting tosee comprehensive provision of support geared toenhancing the quality of life of individuals withintellectual disability and their families.




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The NHSCCA has not reintroduced indicativeprovision targets for service provision at a populationlevel. Browne (1996) has argued that `initiallypopulation needs assessment came second toindividual needs assessment in the implementationof community care, but now it needs to move centrestage' (pp. 63±4). Although service provision normshave been seen as a symbol of the `menu-driven'service allocation approach criticized by reformerskeen to see a move to individualized `needs-led'service design, it has also suited those wanting toconstrain the welfare commitments of the State toavoid guaranteeing a certain level of provision.Recent research has shown that the provision ofresidential support for adults with intellectualdisability in England and Wales is significantlybelow norms set in the 1971 White Paper, BetterServices for the Mentally Handicapped (Emerson &Hatton 1998; Perry et al. 1998). The role given theassessment of individual needs, the proposition thatservices should be responsive to local variation inneed and the devolution of responsibility fordetermining needed service levels in recent policyhave diminished the central governmentrequirement to restate and update provisioncommitments.

At the same time, it is doubtful whether theNHSCCA embodies an open-ended commitment toestablish and meet individual need. Althoughgenerally more vague on questions of individualneeds and rights than was the AWS, where there isclarity, it is a return to professional regulation andrationing. The AWS proposed that the vast majorityof people and their families would be involved in anindividual assessment of need, an aim which cameclose to legitimizing comprehensive cradle-to-gravecoverage, although it was never achieved in practice.Need was an expressed absolute concept, and therewas an expectation that service provision would beorganized and funded in response. In contrast, theNHSCCA envisages much more restricted access toassessment of need, which is framed as a relativeconcept, conditional on service availability andbudgetary considerations (Ellis 1993; Roberts 1997).Moreover, experience under the AWS demonstratedthat, if the goal of comprehensive regular individualor person-centred planning was to be achieved, itwould need to be funded properly. The NHSCCAhas made no move in this direction. Furthermore,

the episodic nature of care review, as conceived bythe NHSCCA, and the separation of needsassessment, part of the purchasing function, fromthe ongoing business of service provisionundermines the culture of participation betweendifferent service elements and service users whichhad begun to form under the aegis of the AWS.These changes were contrary to what manypractitioners in intellectual disability services inWales felt constituted good practice. Reservationsare being expressed about the application of anadministrative model of care management toservices rather than one which genuinely seeks tounderstand the service and community supportwhich individuals need in order to enjoy a typicalquality of life. In the words of five respondents inthis study:

`Community care sounded very similar to theStrategy, but of course it wasn't . . . TheDepartment . . . have great difficulty inunderstanding the difference between acommunity care assessment and an individualplan.' (Social Services 8)`The IP [Individual Planning] system didmake a difference to that individual focus, butI think that the community care process isvery much resource-led and the individualdoes not get anything like the focus now.'(Health 2)`The purchaser±provider split has lessened theinput from the parents due to the purchasingpower of agencies. This is bad because it leadsto social services not informing us about whatis happening.' (Parents 4)`The power of an assessment is held by a caremanager. They decide, they can assess needs,they can decide whether you are eligible for acommunity care assessment. In SharedIndividual Planning, the way we'd alwaysworked, eligibility wasn't an issue, peoplereceived services who needed them.' (SocialServices 8)`Parents and carers have said to me that . . . thecare manager goes away saying, ``Now weknow what you want, but you can't have it.'' '(Health 6)

A strength of the AWS was in the specification ofthe outcomes it sought for people with intellectual




42

disability and their families, and the explicit links itmade between these outcomes and the nature ofservices. Some service recommendations were basedonly on professional wisdom or logical analysis,while others were based on emerging evidence. Inthe interim years, research has strengthened thebasis of evidence on effective service design (e.g.Emerson & Hatton 1994), but the NHSCCA didnot further the idea of evidence-based policy. Theopportunity to get to grips with the necessary level ofdetail generated by research evidence ± therefinements which could now be made to theprocesses of service delivery and the betterunderstanding of the relationships between theindependent variables of service design anddependent outcomes ± was missed. Rather, anyprior notion of evidenced-based prescription wasreplaced by a reliance on market dynamics to driveup standards, a mechanism which itself was notempirically established.

Many commentators have indicated that thecommunity care market differs in character from afree or commercial market (LeGrand 1990; Hoyes &Means 1993; Wistow et al. 1994). The consumer isnot the customer and is not presented with a rangeof substitute `goods'. Rather, the commissioner actsas customer. However, the commissioner may valueoutcomes differently to the consumer and has aseparate self-interest which may not be consistentwith consumer welfare. Competition is mediated bya contracting process which may meet thecommissioner's problem-resolution and financialinterests, but may have little to do with consumeroutcomes. Therefore, the efficiency of a market toregulate quality of outcome is compromised. AsCambridge & Knapp (1997) concluded in theiranalysis of intellectual disability services, informationabout the relationship between the costs ofindividual services, service packages and theoutcomes of these approaches is often missing. Theadoption of the market separation betweenpurchasers and providers does not remove the needfor specialist knowledge related to specifying servicestructures, processes and outcomes. Rather, suchknowledge needs to drive purchasing and thespecification of contracts, and inform qualityinspection.

Finally, there is an obvious fundamentaldifference between the specific nature of the AWS as

a policy concerned with intellectual disability andthe more general NHSCCA. The AWS hadunderscored the priority of intellectual disabilitydevelopments by ring-fenced funding. The planningfocus at local authority level it engendered wasconsiderable, and the common cause createdenabled intellectual disability to emerge from itshabitual Cinderella status alongside other, morepowerful lobbies and command a concentration ofplanning effort which led to an accumulatingexpertise. The evidence in the present research is aclear testimony to the fact that a build-up ofspecialist knowledge and working relationships wasrequired before the opportunities established by theAWS could begin to be realized. The greatergenericism within the organization of social careunder the NHSCCA does not augur well for themaintenance of specialist competency.

Acknowledgements

This research was conducted with support from theWelsh Office (now the National Assembly forWales) and the Department of Health. We aregrateful to those interviewed for giving us theiropinions.

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