5. Enabling the care and support system


5.1 Introduction

The Care Act 2014 requires councils to promote the individual wellbeing of adults with care and support needs and carers in their area by providing or arranging for the provision of prevention/ early intervention services to avoid or delay the development of support needs including specific duties to:

  • provide information and advice
  • safeguard adults at risk of abuse or neglect
  • support the transition to adulthood.

The Care Act 2014 also requires councils to promote diversity and quality in provision of services to meet the support needs of their local population. Councils fulfil these responsibilities by enabling a local care and support system. These consist of access arrangements, the provision of information and advice, assessment and case management arrangements, including professional social work practice, commissioning, both strategic and operational, case review and contract monitoring.

Learning Disability is a lifelong condition and people’s needs change over time. With assistance and developmental support, people can acquire skills and confidence that open new life opportunities up (sometimes referred to as progression). Therefore, the care and support system must include both:

  • time limited, responsive intervention and treatment services for people when they need temporary support to either make positive progress in their life, for example, getting a new job or forming a new personal relationship or to respond to temporary challenges, such as a consequence of physical or mental illness or the breakdown of existing care and support
  • long-term care and support arrangements, in or close to their local communities, including care, support, health and housing arrangements that enable them to be as independent and safe as possible.

Adults with LD&A experience mental illness at a disproportionately higher rate than the general population

Some studies suggest the rate of mental health problems in people with a learning disability is double that of the general population (Cooper, 2007; Emerson & Hatton, 2007; NICE, 2016). The estimated prevalence of mental health disorders ranges from 15-52 per cent, depending on the diagnostic criteria used (Cooper et al., 2007; Emerson & Hatton, 2007; Hatton et al. 2017; McCarron et al. 2017.

It is therefore important that they have better access to suitable diagnostic services and treatment, which may include a range of talking therapies as well as medication.

There are significant numbers of adults with LD&A who have contact with the criminal justice system (CJS), including many in prison. Research shows that their experience of the CJS is often bewildering and frightening and many feel isolated.

It is important that the needs of people with LD&A who are offenders, or accused of offences, are recognised, and supported in the CJS, by the wider care and support system.

Despite Government policy, the way we currently support adults with LD&A is still overly dependent on specialist bed based residential, nursing or hospital care, often away from their home area, particularly for those who display behaviours that challenge services, including those with mental health conditions. It is therefore essential that all local authorities are actively working to deliver Transforming Care Partnership actions.

The care and support system should be rights-based, incorporating, as a minimum, the PANEL principles of Participation, Accountability, Non-discrimination, Empowerment and Legality.

The PANEL approach is founded in a philosophy that people are entitled to be fully involved in all decisions about their own lives. It incorporates an awareness of the rights of people with a learning disability, families, and carers and how these are affected by strategic choices and practice decisions.

All assessment, care and support Staff need to be aware of their obligations to respect human rights and are measuring outcomes, including quality of life, against agreed standards. It is critically important that staff understand the Human Rights Act (1998) AND council responsibilities under the Mental Health Act (2007) and the Mental Capacity Act (2005), Mental Capacity (Amendment) Act (2019), including Liberty Protection Safeguards, as well as the Care Act (2014) and Autism Act (2009)

Guidance

For further information on the issue of human rights in care settings see: Equally outstanding: Equality and human rights – good practice resource. How can a focus on equality and human rights improve the quality of care in times of financial constraint? by CQC (2018)

The PANEL Principles

  • Participation – Is more than goal; it is the means to achieving this end. Participatory strategies emphasise community voice and prefer “bottom up” approaches and ideas from experts by experience (Ife, 2008).
  • Accountability – Is achieved through monitoring  outcomes as well as processes and testing them against the PANEL principles.
  • Non-discrimination – Adults with LD&A should be seen as citizens in their own right, able to contribute to society with a right to support.
  • Empowerment - Should be reflected in a strategic approach that ensures staff and people who use services have the knowledge/skills to realise rights.
  • Legality - Concerns compliance with all relevant legislation, including human rights obligations set out in the Human Rights Act. It is necessary to identify the human rights implications in both the challenges a person presents and responses to those challenges; considering the principles of  fairness, respect, equality, dignity, and autonomy.

5.2 What good looks like

The best councils have access arrangements that respond to adults with LD&A who contact them with information that is suitable and adapted to their specific needs at every point in the care and support journey. (See 8. Operating efficient and effective systems and processes).

They ensure staff undertaking assessment and care management roles should have a level of specialist knowledge in respect of learning disability and autism and appropriate skills in working directly with individuals from these groups and their families as required by the Care and Support (Assessment) Regulations 2014(10) (See 6. Developing the care and support workforce)

They ensure staff have a thorough knowledge of Care Act responsibilities, including people’s entitlement to Direct Payments, managed Accounts, Individual Service Accounts and Individual health Budgets

They facilitate timely access to skilled and effective advocacy for adults with LD&A.

They recognise that some adults with LD&A may have complex communication difficulties and cannot easily speak for themselves and ensure each adult with LD&A with complex communication difficulties who cannot easily speak for themselves has a communication passport. This collates complex information (including the person’s own views, as much as possible) to help other people to get to know the person and interact with them. They also put suitable arrangements in place to work with each person with communication difficulties and ensure communications tools are available to staff trained to use them effectively.

They ensure social work practice is rights based, strengths-based and outcome focused. It sees people with a learning disability as citizens, able to contribute to society and with a right to support.

Their practice model focuses on the skills, strengths, and capacities of individuals, their families and support networks and their communities. It promotes equality and non-discrimination because it is empowering and non-pathologising. There is ongoing reflective evaluation of each individual social worker’s practice to ensure it aligns with the practice model and is focused on improving individual and community access to human rights.

They work hard to develop and maintain a cultural and organisational commitment to strengths-based working beyond frontline practice. For example, leadership (See Part 3) and administrative and management systems (See 8. Operating efficient and effective systems and processes) are aligned with a rights and strengths-based practice model which ensures that how health and social care workforce (including allied professionals) work is in line with their values, skill set and vocational calling.

They make practice and resource allocation decisions transparent and ensure they are consistent with legal requirements, including the Human Rights Act (1998), national and local policies. Case recording shows the basis for decision making and is of a sufficient standard to meet legal challenge.

They enable social services staff work effectively with NHS colleagues to ensure that an adult with LD&A has a fully co-ordinated care, support and treatment plan that has been created as a result of a process of multi-disciplinary assessment and co-production with the person.

They ensure adults with LD&A who experience mental health problems receive joined up support in compliance with NICE guidelines on the prevention, assessment, and management of these conditions. Social Services staff working as part of multi-disciplinary teams use reviews to ensure that medication prescribed by team members, especially anti-psychotic drugs, is being used appropriately and reviewed in line with good practice requirements.

They ensure assessment and the care, support and treatment plan addresses short and longer-term goals that reflect the aspirations of the person and supports people to safely maximise their independence and achieve a good quality of life. This is always co-produced with the person and they encourages support plans that are innovative and creative in relation to achieve the agreed outcomes.

They routinely consider the use of assistive and other technologies during the support planning process to facilitate achievement of outcomes and to manage risks. There is access to staff who have been trained in the use of personalised technologies to help people live the lives they want to.

They have suitable and effective means to identify the most cost-effective options to help people to achieve their aspirations and outcomes agreed in their care, support, and treatment plans.

They have effective brokerage arrangements, which may include an independent brokerage function, to support adults with LD&A to create innovative ways to achieving outcomes and to use their support resources (direct payments, Personal budgets, Individual service funds, managed accounts etc.) effectively.

They ensure care, support and treatment plans enable adults with LD&A to positively manage the risks they will encounter in their lives. Plans are regularly reviewed to check if the outcomes are being achieved and are changed if necessary. These regular and timely reviews to monitor of ongoing care and support are aligned with contract monitoring to ensure that resources are delivering value for money.

They take a strategic approach to development of an integrated accommodation, care, and support pathway. They offer a range of support options to meet all needs within the population including time limited services that meet short-term support requirements, for example those that support confidence building and independence skills development and facilitate the person to progress towards life goals, as well as longer term support requirements. See 4. Understanding demand, prevention and early intervention.

They ensure there are effective working relationships with the strategic housing function of the council and with housing providers. It enables sufficient and timely supply of suitable accommodation for adults with LD&A. Systems and processes for securing accommodation are reasonably adjusted to enable adults with LD&A equal access to the systems and processes.

They have an accommodation and support model that is flexible to vary support as people’s needs change without disrupting their lives unnecessarily. Registered residential or nursing care options are used only exceptionally. They prefer models of support that can be reduced/increased as required, for example, as people acquire confidence and skills, or to meet additional needs that develop.

They have a treatment and intervention model that has the capacity and capability to deliver additional short-term support to adults with LD&A, their families, carers or providers at times of crisis or exceptional high need and seeks to reduce the need for hospital admission.

They have fewer admissions to hospital because of behaviours that challenge, including mental health conditions. No person with LD&A stays in hospital longer than necessary.

All people on the Transforming Care Risk Register have the person-centred assessments and plans in place or planned. These will be in line with NHS England’s Care and Treatment Review Code and Toolkit 2017.

They ensure practice and commissioning decisions always use the least restrictive options. Where there are instances of deprivation of liberty within the meaning of Article 5(1) of the European Convention on Human Rights (ECHR), and the person lacks capacity to consent to the arrangements, Liberty Protection Safeguards are used to enable care or treatment in compliance with the Mental Capacity (Amendment) Act, 2019.

They work with staff in the criminal justice system (CJS) to ensure that adults with a LD&A involved in it are well supported. For example; if they are accused of offences, convicted or are witnesses they are supported to understand the process and overcome any disadvantage they may experience because of their disability.

They support an employment pathway for adults with LD&A. The council has a scheme to directly employ adults with LD&A including, but not limited to, roles as experts by experience. and monitor actual employment rates. They ensure that all assessment and care management functions routinely consider each individual’s employment options.

They work with providers to ensure that there is a sufficient and timely supply of support available in the local area to meet the needs of all adults with LD&A as close to their local area as possible. Where local demand is insufficient to sustain a local specialist resource, commissioners work regionally and sub-regionally to seek to minimise the need for use of resources a long distance from any individual’s home area. This may include commissioning of the specialist service and direct service provision.

They check each provider’s capability to meet the specific needs of an individual before support is agreed and the delivery of the care support and treatment is governed by an individual service agreement that sets out what is expected of each provider involved in a person’s care, support and treatment.

They encourage the asset building in the community and development of the local market to offer new approaches in response innovative support plans and support the use of personal budgets.

5.3 Expected outcomes

Councils that are implementing good practice should find that the:

  • The quality of life experienced by/reported by adults with LD&A is improving.
  • The quality of life experienced by/reported by carers of adults with LD&A is improving.
  • Number/proportion of adults with LD&A supported by Hospital/Res/Nursing Care Services is reducing.
  • Average length of stay where Hospital/Res/Nursing Care Services are used is reducing.
  • Number/proportion of adults with LD&A who live in their own home or with their family is increasing.
  • Number/proportion of adults with LD&A with long term support Out of Area is reducing.
  • Number/proportion of adults with LD&A who have control over their daily life is increasing.
  • Number/proportion of adults with LD&A with self-directed (including direct payments) support is increasing.
  • Number/proportion of adults with LD&A in employment (paid or voluntary), education or training is increasing.
  • Number of for adults with LD&A who return to live In-Area from Out of Area places with support from the local Transforming Care Partnership will be in line with local targets.
  • Number/proportion of adults with LD&A accessing annual health checks, participating in public health initiatives, accessing health screening programmes, and with up to date medication review is increasing.
  • Experience of adults with LD&A and their carers at their first point of contact with the council and in specialist access functions is improving.
  • The number and proportions of adults with LD&A and their carer’s who contact ASC have their enquiry resolved by the access function through receipt of information and advice is increasing.
  • Adults with LD&A are treated as equal citizens, experience less discrimination, and exercise control and choice, rather than being passive service recipients.
  • Adults with LD&A and their carer’s have an improved experience of care and support and report they: o Are “Living the life I want, Keeping safe and well”.
    • Have as much social contact as they like.
    • Are included in discussions about their own care or/care of the person they care for.
  • Percentage of individual agreed outcomes in (a) Long-term support plans, and (b) Short-term support plans of adults with LD&A achieved in each year compared to previous years is increasing.
  • Average waiting list/wait time for advocacy is reducing.
  • Local communities and support markets offer an increasing range of new approaches in response to innovative support plans.
  • Timely supply of suitable support and accommodation for adults with LD&A is improving.
  • Council’s relationship with support providers is improving.
  • Number of unplanned permanent or temporary service/placement breakdowns or disruptions is reducing.
  • Incidence of emergency hospital admissions for adults with LD&A is reducing.
  • Incidence of behaviour that challenges care and support arrangements is reducing.
  • Incidence of restrictive practices is reducing.
  • Adults with LD&A in contact with the criminal justice system increasingly receive appropriate support.

5.4 Enabling the care and support system

Outcome indicators

Outcome Indicators

Aim

National/Local

ASCOF (1J) Adjusted Social care-related quality of life re. the impact of ASC - Split LD&A adults out 

Improving Life Quality

National data

ASCOF (1D) Carer reported quality of life by carers – Split LD&A adults out 

Improving Life Quality

National data

ASCOF (1B) Proportion of people who use services who have control over their daily life - Split LD&A adults out 

Increasing percentage

National Data

ASCOF (1E) Proportion of adults with a primary support reason of learning disability support - In paid employment

Increasing percentage

National Data

ASCOF (1G) Proportion of adults with a primary support reason of learning disability support - Who live in their own home or with their family

Increasing percentage

National Data

Percentage of adults with LD&A supported by service type e.g. Hospital/Res college/ Nursing care (NC), Res Care (RC), assessment/treatment (A&T), Supported Living (SL), Domiciliary Care (DC) and Shared Lives

Balance to shift from bed to community

Local data

Trend in recent years of percentage of total adults with LD&A with LT support who reside Out of Area (OOA) by model of support e.g. Res College/ RC/ NC/ A&T/ Hospital

Decreasing percentage

Local data

ASCOF (1C) Proportion of people using social care with self-directed support/or receive direct payments - Split LD&A adults out    

Increasing percentage

National Data

Number of for adults with LD&A returned In-Area from OOA through the Transforming Care Partnership

Flow of returnees

Local data

Number/proportion of total new adults with LD&A placed OOA. Analyse by Res College/RC/NC/A&T/Hospital

Decreasing percentage

Local data

Number/proportion of total new adults with LD&A supported in Res College/RC/NC/A&T/Hospital

Decreasing percentage

Local data

Percentage of adults with LD&A accessing annual health checks and percentage leading to health action plans

Increasing percentage

Local data

Proportion of those participating in public health initiatives who are adults with LD&A versus local targets

Increasing percentage

Local data

Proportion of those accessing health screening programmes who are adults with LD&A versus local targets

Increasing percentage

Local data

Percentage of adults with LD&A on medication with an up to date medication review each year

Increasing percentage

Local data

 

Individual Experience Indicators

Aim

National/Local

ASCOF 3A – Overall satisfaction of people with LD&A who use services compared to previous years.

Increasing percentage

National Data

ASCOF 3B – Overall satisfaction of carers of people with LD&A who use services compared to previous years.

Increasing percentage

National Data

Trend in average waiting list/wait time for advocacy

Shorter waiting times

Local data

Undertake research with people who use services and carers to assess their experience compared to the Making it Real “I” statements regarding Living the life I want, Keeping safe and well. 

Increasing % answer “positively”

Local data

Percentage of individual agreed outcomes in (a) Long-term support plans, and (b) Short-term support plans of adults with LD&A achieved in each year compared to previous years

Increasing percentage

Local data

ASCOF (1I) Proportion of people/carers who report they had as much social contact as they like - Split out adults with LD&A 

Increasing percentage

National Data

ASCOF 3C Proportion of carers who report who report that they have been included or consulted in discussions about the person they care for - Split out adults with LD&A 

Increasing percentage

National Data

Trend in average length of stay in Hospitals, A&T, Residential care, and nursing care for adults with LD&A

Lowering length of stay

Local data

 

Financial/Value for Money Indicators

Aim

National/Local

Plot ASCOF 1A (Social care related quality of life) versus total current gross expenditure p.h. of population aged 18-64 on support for adults with LD and benchmark against comparable councils

Life quality to improve relative to expenditure

National Data

From ASC FR001 calculate and benchmark with comparable councils, current gross expenditure on long-term support for adults with LD per:

  • Head of the adult population by service e.g. RC, NC, SA, DP, HC, SL, Other
  • Per adult with LD&A with LT support population by service e.g. RC, NC, SA, DP, HC, SL, Other
  • Per unit of support by type of support e.g. RC, NC, SA, DP, HC, SL, Other

Improve performance against local targets

National Data

Profile current gross expenditure on long term support costs pw for adults with LD&A in £100 cost bands compared to the previous reporting period

Improve profile against local targets

Local data

From ASC FR004 split out current gross expenditure on assistive technology (AT) for adults with LD&A.  Calculate AT expenditure for adults with LD&A p.h. of adult population & per adult with LD&A who is supported

Improve performance against local targets

National Data

Current gross expenditure on LD&A advocacy per head of the adult population aged 18-64

Improve performance against local targets

Local Data

From ASC FR002 calculate and benchmark with comparable councils, current gross expenditure on short-term support for adults with LD&A per: Head of the adult population, per adult with LD&A with short-term support, per unit of short-term care to maximise independence, and per unit of other short-term care

Improve performance against local targets

National Data

 

5.5 Self-evaluation questions

How to rate yourselves against the self-evaluation questions:

For each chosen section the DASS should consider each statement about good practice that follows and work with their senior management team, representatives of key partner organisations and local experts by experience to rate how close the councils approach to supporting adults with LD&A is to the best practice described using the following 5 point scale, where 1 means it is far away from best practice and 5 means it is already using best practice.

The scale to be used is as follows:

1. Commitment

The importance of this best practice has been recognised. Conversations are taking place internally or with partners including experts by experience, but work has yet to begin.

2. Developing

Work on this best practice has commenced internally or with partners including experts by experience, but it has yet to be signed off, is only in the planning stages and with resource identification is still in progress.

3. Implementation

An agreed fully resourced and commissioned (where relevant) plan is in place. Implementation has started, but best practice is not yet fully operational.

4. Operational

Best practice is in place and is being used, albeit implementation is at an early stage, and further refinements in line with the learning from implementation may be needed before expected benefits are fully realised.

5. Sustainable Delivery

Best practice is in place and is working well. Long-term funding, resources and structures are in place i.e. best practice now represents “business as usual” and continuous improvement processes are in place.

Enabling the care and support system

Score 1–5

Basis of score

1 The council ensure that enquirers are offered information and advice. This is provided in ways that are suitable adults with LD&A and include details of more general community resources, as well as those that are specific to their individual support requirements.

 

 

2 The council ensures staff undertaking assessment and care management roles have a level of specialist knowledge in respect of learning disability and autism and appropriate skills in working directly with individuals from these groups and their families.

 

 

3 The council recognises that some adults with LD&A have complex communication difficulties and cannot easily speak for themselves. It ensures arrangements are in place to work with, record and make available information that helps other people to get to know the person and interact with them. For example, communications:

  • Tools/aids are available; and staff are trained to use them effectively.
  • Passports are routinely used.

 

 

4 The council ensures adults with LD&A have timely access to skilled and effective advocacy when needed, for example, during assessments, reviews, safeguarding enquiries.

 

 

5 The council ensures assessment and care management and social work practice is strengths-based and outcome focussed by ensuring:

  • The administrative and management systems, including supervision are strengths-based and aligned to the practice model (See also Part 8 for more about this).
  • Practice and resource allocation decisions are transparent and consistent with legal requirements, national and local policies. Case recording shows the basis for decision making and is of a sufficient standard to meet legal challenge.
  • Social services staff work effectively with NHS colleagues to ensure that each adult with LD&A has a fully co-ordinated care, support and treatment plan created through a process of multi-disciplinary assessment and co-production with the person.
  • Where the person’s care and support may be eligible for Continuing Health Care Funding the appropriate process has been employed.

 

 

6 The council ensures each person’s assessment and care support and treatment plan addresses short and longer-term goals, reflect their personal aspirations, and supports them to safely maximise their independence and achieve a good quality of life by ensuring:

  • Assessments and care, support and treatment plans are co-produced with the person.
  • Strengths-based approaches succeed in the development of innovative support plans.

 

 

7 The council ensures the use of assistive technology is routinely considered during the support planning process to facilitate achievement of outcomes and manage risks by:

  • Making staff trained in the use of personalised technologies available to support adults with LD&A, carers, support providers, PA’s, and social work colleagues.
  • Ensuring there are no barriers to the procurement of personalised technologies that can improve the cost effectiveness of an individual’s care and support.

 

 

8 The council’s practice ensures that least restrictive options are used at all times e.g. by ensuring Liberty Protection Safeguards are used to enable care or treatment are used in all instances of deprivation of liberty within the meaning of Article 5(1) of the European Convention on Human Rights, where the person lacks capacity to consent to arrangements.

 

 

9 Council assessments and care, support and treatment plans enable adults with LD&A to positively manage the risks they will encounter as they live their lives.

 

 

10 The council has a suitable and effective means of identifying the most cost-effective options open to people to achieve their aspirations and outcomes identified in the assessment process and in care, support, and treatment plans:

  • Brokerage arrangements, which may be, or include an independent brokerage function, that supports adults with LD&A to create innovative ways to achieving outcomes.
  • Each provider’s capability to meet the specific needs of an individual is determined in advance of any commissioning decisions.
  • Registered residential or nursing care options are used only exceptionally. The preference is for models where support can be flexibly reduced, for example, as people acquire confidence and skills, or increased to meet additional needs, as needed.

 

 

11 The council has effective care and support review and monitoring and contract monitoring arrangements to ensure care and support continues to be appropriate, effective, and good value for money:

  • Care support and treatment plans are regularly reviewed to check if the outcomes are being achieved and flexibly adjusted, as necessary.
  • Case reviews and case monitoring are aligned and interdependent with contract monitoring to ensure that resources are delivering value for money.

 

 

12 The council has arrangements to secure suitable accommodation for adults with LD&A:

  • It has effective working relationships with the strategic housing function of the local authority and with housing providers.
  • There is a sufficient and timely supply of suitable accommodation for adults with LD&A.
  • Systems and processes for securing accommodation are reasonably adjusted to meet the needs of adults with LD&A.

 

 

13 There is a contractual basis for governance of each person’s care support and treatment. For example, through an individual service agreement and this is used as part of contract monitoring and used to hold providers to account.

 

 

14 The council supports adults with LD&A to have work:

  • An effective pathway to support adults with LD&A get and sustain employment 
  • A scheme for employing adults with LD&A at the council.

 

 

15 The council supports adults with LD&A to have access to Education/Training opportunities? Young people are supported to stay locally and pursue tailored educational opportunities that enable their independence and ability to enter employment where appropriate

 

 

16 The council ensure short-term support developmental support is available when required to enable individuals to make “progress” towards achieving a personal aspiration, having more control over their life or being less dependent on commissioned support.    
17 The council ensure short-term treatment and intervention support is available and has the capacity and capability of delivering guidance and additional short-term support to adults with LD&A, their families, carers or providers at times of crisis or exceptional high need and seeks to reduce the need for hospital admission.    

18 The council works with NHS staff in multi-disciplinary teams to ensure compliance with NICE guidelines regarding the prevention, assessment, and management of mental health problems in adults with LD&A. All people supported by the CLDT:

  • Have sufficient access to talking therapies so that, where clinically desirable, mental illness can be treated with alternatives to medication.
  • prescribed medication recommended by CLDT have up to date, NICE compliant, medication reviews at least annually.
  • Prescribed antipsychotic medication have its use reviewed as often as is clinically needed and at least annually.
   

19 The council has arrangements in place to provide appropriate support to people with LD&A who are in contact with the criminal justice system to:

  • Prevent offending behaviour.
  • Work with criminal justice professionals and to support those accused of offences. or witnesses to offences.
  • Help to rehabilitate offenders.
   
20 The council ensures all people on the Transforming Care Risk Register have the person-centred assessments and plans in place or planned. Where appropriate these include a: Person centred support and risk management plan, Positive behaviour support plan, Crisis contingency plan, and Communications plan supported be a communications passport.    

 

Who is good at this?

In 2017 Milton Keynes decided it needed to transform its day services in line with its future vision to have local and community based long-term care and support arrangements wherever possible. An underpinning principle was that services provided direct by the Council should be very specialist to ensure there is capacity to meet complex needs in area.

To ensure solutions were personalised and to allay understandable fears about change a very co-productive process was used.

The impact has been very positive. Milton Keynes used to have 150 regular users of day services with a wide range of abilities.

It now has just 50 regular users of day services. All have profound/multiple support needs or behaviour that is highly challenging for providers. Each now has tailored specialist support. The other 100 now have support to access/use Universal services or have jobs. See also full case study in Part 10 - Case Studies