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The government's adult social care green paper sets out the case for a radical rethink of service delivery. Its focus on outcomes and empowerment signals a shift from measuring what is provided to evaluating the benefits to service users. It also emphasises the importance of preventive work and calls for strong links with the voluntary and community sectors to encourage local capacity-building.

These sectors have traditionally been seen as the main providers of social care for people with a visual impairment. One such organisation is Thomas Pocklington Trust, a specialist provider of housing and support for people with sight loss in England. The trust is managed by a board with service user representation and runs sheltered housing, residential, day, home care and community-based services.

Anticipating this new agenda, the trust commissioned the University of Birmingham to evaluate its day services for people with a visual impairment in the West Midlands. The aim was to identify a holistic understanding of users' needs and outcomes and how these might be best met. The core of this was users' own definitions and so the research began with focus groups to explore their experience of visual impairment at home and in the community. For example, one service user spoke about the pain and loss that he experienced when friends no longer greeted him after he became visually impaired. Another spoke of his annoyance that his relatives found it difficult to let him do things for himself. Others talked about how they had worked out ways of establishing what was where in their freezer or the colour of clothes in their wardrobe.

Based on these discussions and academic and inspection literature,(1),(2),(3) we created a schedule of seven areas of potential need. These were: meeting people and friendship; getting information and advice about other services for people with a visual impairment; finding out about special equipment; having someone to talk to about your personal feelings; building your confidence to go out and do things outside your home; re-learning how to carry out everyday tasks in your home; and getting help with practical everyday tasks.

There are parallels between this list and the government's outcomes which emphasise "access to leisure, social activities and life-long learning, and confidence in safety outside the home" and "exercise of choice and control through independence and access to information".

This schedule was then used in interviews with users, other people with a visual impairment and key stakeholders to consider how important these needs were and how they could be best met.

The results have to be analysed carefully as three-quarters of the existing users were over 70, all were white and only a quarter had become visually impaired under the age of 60. In contrast, the potential users were more evenly spread in age, included people from ethnic minorities and 43 per cent were under 60 when they became visually impaired. However, the ranking of the seven needs by the two user groups has some similarities and shows a marked contrast with the stakeholder ratings.

For example, both user groups ranked "meeting people and friendship" as their most important need, whereas this is placed fifth by stakeholders. Stakeholders ranked "re-learning how to carry out everyday tasks in your home" as third, whereas this is seventh and fifth in the two user group lists. How might such differences be explained?

One possibility is that long-term services for people with a visual impairment are not considered a care management priority by many stakeholder organisations. Thus their focus is on the practicalities of information, equipment and doing things in the home rather than longer-term concerns such as social contact and talking about personal feelings. A second possibility is more fundamental. Michael Oliver(4) has argued that professionals tend to define outcomes in terms of people being able to care for themselves (cooking, washing, shopping etc) whereas disabled people talk of being in control of their lives.

The views of many of the users in this research reflected the thesis of the social model of disability(5) which is that it is the way services are run that disables people rather than their own individual characteristics. Thus users suggested ways in which taxi drivers, neighbours and shop staff as well as professionals might be made aware of how they routinely exclude them, and how volunteers could be trained to bring what they see and read to life, acting as "spontaneous sharers".

The evaluation led us to make two distinct sets of recommendations. The first related to strategic developments of the services and the second to operational improvements. Our overarching strategic recommendation was that the purposes and aims of the services should be expressed in terms of outcomes for people with a visual impairment rather than services. Furthermore, we argued that outcomes should both meet individual needs and promote the inclusion of visually impaired people in mainstream provision, reflecting the social model of disability. Examples included training of staff in leisure, libraries, supermarket and taxi firms as well as health and social care about how to include people with a visual impairment.


This could be supported by individualised programmes for people with a visual impairment which empowered them to access relevant mainstream services. Services also needed to address a broader range of user needs, complementing the existing focus on overcoming social isolation. These might include music, arts or sports activities, preparation for employment and the development of independent user-led groups.

In relation to community capacity, we found examples of other local organisations that had successfully recruited up to 500 volunteers providing services such as individual and group support and transport. These organisations invest significantly in recruiting and training their volunteers by employing volunteer co-ordinators.

Operationally, we developed an outcome-focused assessment framework for use by staff and service users working together based on the seven needs outlined above. The resulting action plan is as likely to involve linking users with other groups and services in the community as direct service provision by Pocklington. Services would help people to maintain their independence and live active lives within their own communities and work with relatives and friends to help them maintain and develop their relationships with people with a visual impairment. 

MARTIN WILLIS is senior lecturer at the Institute of Local Government Studies. Graeme Douglas and Sue Pavey are research fellows at the Visual Impairment Centre for Teaching and Research - both at the University of Birmingham

Training and learning
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals' learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

Abstract
The government's plans for adult social care focus on outcomes for service users. The research outlined here demonstrates how a user-led understanding of outcomes for people with a visual impairment can be developed into strategic policies and practice. These should aim to empower users in achieving independence.

References
(1) R Long, J Crews and R Mancil, "Creating measures of rehabilitation outcomes for people who are visually impaired," Journal of Visual Impairment and Blindness, Vol 94/5, 2000
(2) Social Policy Research Unit, Introducing an Outcome Focus into Care Management and User Surveys, University of York, 2000
(3) Social Services Inspectorate, A Sharper Focus: Inspection of Services for Adults who are Visually Impaired or Blind, Department of Health, 1998
(4) M Oliver, The Politics of Disablement, Macmillan, 1990
(5) Social Services Inspectorate, Independence Matters: An overview of social care services for physically and sensory disabled people, Department of Health, 2003

Further information
www.pocklington-trust.org.uk

Contact the authors
Contact Martin Willis by e-mail at m.h.willis@bham.ac.uk or Graeme Douglas by e-mail at g.g.a.douglas@bham.ac.uk