SCOPE stories

Transforming complex care
By Iriss
Published in Reports on 2 May 2023

This resource describes a project undertaken by Iriss and the SCOPE team, part of Perth & Kinross Health & Social Care Partnership (HSCP). Iriss and the SCOPE team worked together in 2022 to understand the difference the SCOPE approach is making to the team and those it supports. We captured stories from the SCOPE team members and other partner services about how SCOPE is different, why this matters and the ways in which this is transformational for people with complex needs. This page also presents three short films based on the SCOPE stories, an analysis of the main findings and a set of reflective questions to support others undertaking service redesign and innovation to improve the lives of people supported by social services.


What is SCOPE?

SCOPE and Perth & Kinross Council

SCOPE is a specialist, integrated and multidisciplinary team providing early intervention and ongoing support to people over 14 years with autism and learning disability. The team has been implemented as part of a wider Complex Care Transformation Programme within Perth & Kinross HSCP.

The Complex Care Transformation Programme aims to develop a model of care that provides high quality, financially sustainable support for people with complex care requirements. The ambition is to help people to live as independently as possible with as high a quality of life as possible and reduce the reliance on acute health services and institutional care.

What is the problem SCOPE is trying to solve? 

Every year over £1 million needs to be added to existing budgets to meet increasing demand for care packages. The main reasons for this are young people transitioning to adulthood and increases in existing packages due to carer breakdown or a deterioration in the person’s condition.

The current model often fails to intervene early enough to provide the right support to maximise the person’s independence, identify and address underlying causes of behavioural issues and provides large amounts of social care support that create ‘mini-institutions’ in the community. This often does not support the person to achieve their desired outcomes and does not provide best value financially.

SCOPE are supporting individuals with a learning disability and/or autism with complex needs which are defined in this context as the following:

  • Severe challenging behaviour (it is noted that this may include behaviour which is not severe in itself but becomes severe due to its high frequency)
  • Forensic support needs
  • Profound and multiple disabilities
  • Needs that require packages of care in excess of the cost of a care home placement
  • Requiring additional 1:1 support within a care home placement
  • A new approach, the SCOPE team at its core, was developed and informed through consultation and engagement with clients and carers as well as analysis of local and national data.

A new approach, the SCOPE team at its core, was developed and informed through consultation and engagement with clients and carers as well as analysis of local and national data.

SCOPE stands for:

S – Supporting people with complex needs
C – Community resources
O – Offering choice
P – Person centred planning
E – Enriching people’s Lives

The team provide early intervention to maximise the person’s independence and provide ongoing, specialist advice and support as required including Positive Behavioural Support. This will help ensure people receive appropriate support at the right time and reduce reliance on acute services, large packages of social care and institutional care.

Analysis – SCOPE stories

This section outlines the foundations of the design behind the idea of the SCOPE team, how the origins emerged, and the culture created to sustain those foundations. Based on an analysis of discussions with team members, it unpacks how the team design and culture connect to create a place where support can be transformative for both practitioners and people with complex needs. It will also highlight the SCOPE team's learning, explore how that affects their hopes for the future, and include a set of reflective prompts for those undertaking similar service redesign and innovation work.


The design of the team underpinned the key differences SCOPE wanted to achieve – a specialist team providing life-long support, focused on prevention and improved outcomes for supported people and their families. This section outlines some key aspects of the design and why they’re important including: focusing on outcomes; reframing cost-saving; finding early inspiration; addressing pressure points in the system; and team roles.

Outcomes first

The design of the SCOPE team was grounded in better outcomes for people with complex needs, using evidence gathered from supported people and their families about what was important to them and the way in which they wanted to be supported:

I think that this is what feels different about the SCOPE Team. It’s been established on the back of the views and the voices of the people who social workers are meant to serve. And those who have established the team have taken account of what’s worked and what’s not worked and recognised maybe the issues with generic social work teams. So, I think that that’s a really important starting point. (team member)

Those leading the design of SCOPE were drawing on years of experience working in learning disability, autism and complex needs and a shared vision to improve support. This grounding had an impact on the approach taken to recruitment. The posts attracted those with a passion for working in learning disability and autism, including some with personal experience. Practitioners were also drawn to the team because of the opportunity to specialise and were excited by the long-term nature of the approach.

Each of the design decisions – how should the SCOPE team look, work, feel? – can be traced back to the founding values – that its purpose is to improve support for people with complex needs.

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Re-frame cost saving

Like the social services sector as a whole, those imagining the SCOPE team were in the difficult position of wanting to improve outcomes for supported people while reducing costs. The current model of support for those with complex needs was highly costly. The ambition of the team was that through preventative practice the costs of care packages for supported people could be more cost effective. Early intervention, multidisciplinary working and more efficient referrals could enable faster, more sustainable outcomes for supported people and their families, providing financially sustainable packages of care. However, though there were financial drivers behind the creation of the team, cost saving had to be framed differently:

...we’re not going to be cutting packages, what we’re going to do is stop future packages being as expensive…So, it’s cost avoidance…you want us to stop spending an additional million a year; this is how we’re going to do it… by having the right models in place, we’re providing a more cost-effective way of providing that support. But in addition to that, we’re actually giving that person more independence, a better quality of a life, a part of the community and actually what they want from it; which is fundamentally what we’re here for on a day-to-day basis.’ (team manager)

Avoiding future costs needed to be viewed in both financial and human terms. The added value of the team’s approach was improved outcomes for supported people and their families by intervening early to prevent crisis, providing continuity of care, building relationships and ultimately helping people to focus on what matters to them.

Framing cost saving differently, was facilitated by closely involving finance colleagues early on. This ensured finance colleagues had an understanding of those supported by SCOPE, the aims of the team; and why their way of working was important. This supported positive conversations between the staff team and finance and put the needs of supported people at the heart of strategic and budgetary decision making.

So, very early we identified … we need to have a finance person, dedicated to this piece of work; so, they get it. So, they understand. So, they’re part of it. So, they can stop us going off on a tangent as well and going off in the wrong direction and understanding it and being able to deliver that back to the senior management… But he [finance colleague] knows the clients as well… So, there’s names of people, he understands that and he knows them. So, it’s not figures, it’s people we’re talking about. (team manager)

This relationship also better equipped finance to represent the change for supported people at senior management and strategic levels, and to understand that the savings made are likely not to be on the reduction of specific packages; but instead money is saved, through preventative work, and the cost (both financial and human) associated with crisis responses. It’s important for the team to blend evidence of cost saving with the stories of impact for supported people:

One of Key Performance Indicators is about reducing the time for somebody being in hospital to being back out in the community. But it’s the narrative and it’s the stories behind that, that are the important bit. And our finance guy really got that…so they’re doing their finance bit and then we’re putting the stories behind that to support. …This is the stories we’ve done and this is what difference we’ve made and this is how we’ve managed to stop this from happening as a result of that…that’s fundamentally what we need to be saying because it’s not suddenly you’re going to be cutting off the money. (team manager)

Look for a blueprint

Though SCOPE was a new approach in learning disability and autism, other teams were doing things differently in Perth and Kinross which provided valuable early inspiration. Working as a multidisciplinary team, including psychologists, outreach workers and social workers, the REACH team was delivering improved outcomes for young people on the edge of care in a financially sustainable way. SCOPE management met with REACH colleagues, and were able to use this model as a blueprint for creating their own specialist team, identifying synergies and divergences, thinking through what SCOPE would need to support people:

…that was one of the key things that REACH did, going out and supporting families to stop young people ending up being in care. So, we came up with our outreach workers... And we requested 6 based on the idea that we would be a 7 day a week service for our outreach. (team manager)

Conversation with other professionals, including colleagues in the children and families social work department, helped the SCOPE team to take shape. These discussions allowed the leadership team to explore what was needed and how this translated into a blend of roles.

Address the challenges of the current system

The SCOPE design aimed to address the limitations of the current model of support and draw on what was known already about pressure points in the existing system. For example, transition between children and adult services was a known challenge with negative impacts on people and their families. The SCOPE ambition was to address this by 
providing continuous, life-long care, and avoiding putting supported people and their families through the stress and confusion of navigating service boundaries.

…my vision for SCOPE would be that there’s some continuity about the service provision and some continuity of care in terms of thinking and making that transition, a smoother point of transition rather than one service stops, one service starts …there should be some overlap between those… if you’re moving services, there could be multiple transitions that happen that are adversely impacting on somebody’s psychological wellbeing because they have to adjust to so many areas of change at once. So, conceptually, the idea of continuity of care and a transition where there’s an overlap would be indeed much more suited to that processing of the change… (Consultant Clinical Psychologist) 

This is another example of team design starting from the point of ‘what’s best for the supported person’, not ‘how can that person fit into the existing system’. It also underlines that relationship-building through continuous care was prioritised over the demands of the system.

In-house specialists 

Multi-disciplinary working isn’t a new idea and existing support of those with complex needs involves a range of professionals from across health and social care. However, what’s different about SCOPE is that multidisciplinary roles are baked into the team, with occupational therapists, outreach workers and psychologists sitting within the team alongside social workers. There are significant benefits to this blend for the team and for supported people. The mix of roles enables SCOPE to have in-house access to specialists, providing a speedier response than generic social work teams are able to provide. A faster response means expertise can be deployed directly, preventing issues escalating. The diversity of roles also supports knowledge sharing between disciplines and among professionals, contributing to a learning culture that values alternative perspectives.

Several roles were discussed as having particular significance and enabling the team to work in a new way; these included psychologists, outreach workers and carer support workers.

An in-house psychologist was seen as extremely helpful in providing staff with additional support and professional perspectives on the people they are working with, and in a timely manner. Psychologists are able to work directly with supported people to provide expertise, insight and a fresh perspective. This resource has supported the team in their early intervention approach:

I think we initially thought it was like a training issue where the staff needed some support in training and management. So, we decided I’d go along and do some observations. I did one day of observations and everything had changed. So we realised it wasn’t a case of the staff needing training, it was actually that the individual, what they were doing with him and the activities he was doing were not suitable for him… so now he’s doing more inhouse activities where they can manage him a lot better, the staff feel more supported. I think the staff were able to have debriefs and were able to reflect on the situation, which they might not have done before, and so everything that we went in there thinking it was, it wasn’t, and we were able to keep him in his placements, going to day opportunities still and I think if it wasn’t for that I think we would have seen sort of staff burnout. I think …he could have just lost his place and then he wouldn’t have been supported. (team psychologist)

Outreach workers are also an essential part of providing a fast response and helping prevent issues escalating:

That ability to respond immediately is something we’ve been kind of crying out for … we can be reactive, we can respond when we need. And be that early intervention to be able to make that change but at the moment for me, the outreach workers are the biggest difference. (team manager)

We’ve got the outreach workers that can go out and work with that person that day and fill in and make sure that person is having the day they deserve to have rather than saying, sorry, we can’t send anyone because we don’t have anyone to send. (team member)

As the SCOPE team developed they recognised the importance of including an unpaid carer support role within the team. Having a role specifically focused on supporting unpaid carers acknowledges and appreciates the vital role they play.

At the moment we would do our own carer support plan and there can be a conflict because you’re then kind of torn between supports for the family and the young person and it doesn’t always marry up. And I think we’re doing carers a bit of an injustice, because my carer’s assessments are not very good because I’m so focused on the young person. But carers are really important and they absolutely deserve an assessment within their own right because we need them, because we’d be in a lot of trouble if we didn’t have them supporting young people and families. So, I think, again having that avenue of support of a specialist that can really focus on them, I think will be really helpful. (team member)

As well as having a multi-disciplinary team, SCOPE is ‘aligned’ with other services; speech and language therapy, physiotherapy, community learning disability nursing and dietetics. Having these services aligned to SCOPE rather than posts within the team, allow the team access to these professionals; but without some of the challenges that recruiting to the team would pose. The team can refer supported people to these aligned service specialists, and seek their professional advice and perspective where necessary to their cases.

The mix of roles in the team positively impacts supported people and practitioners. Families and supported people can be confident that their needs will be met by a team of expert professionals, and without some of the challenging waiting times they may experience in other services. SCOPE practitioners feel that having this in-house expertise will help build trust between the team and supported people as specialists are more readily accessible. In this way, the multidisciplinary nature of SCOPE, serves the relational value-base of the team. 


The stories pointed to key aspects of the culture that supported and sustained the team, providing an environment to share energy and motivation. These included the leadership approach; learning culture; peer support; modelling; and investment of time.

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The leadership approach in SCOPE empowers staff. They recognise that their team is led by a commitment to social work values and the value of individual workers. Team leaders and managers recognise the assets practitioners bring individually, to make an even stronger collective overall:’s recognising the different elements of different people in the team and how we can actually recognise the diversity but celebrate that and actually utilise the people in the team for different roles and for taking on different parts of work. And recognising where the gaps are and then supporting people to be able to actually enhance their practice. (team manager)

This translates to staff genuinely feeling valued by their managers, contributing to a sense of shared power among the team. While there are leaders, there is a clear sense that all team members are important and there is parity of esteem between staff and management. Diversification of power in the team is then modelling through support work:

…it's really good for my own learning because I’ll start thinking differently based on her [the team leader] experiences… Actually a lot of learning comes out of that I feel which is good for my own learning but the way I move forward and support the people I work with. So it’s not a hierarchy and it doesn’t matter what role you do, everyone is part of a team and it shouldn’t be that anybody has more power based on their position, it should be that everyone works together to get the best outcomes for the people we support effectively. (team member)

The leadership approach is also fundamental to supporting staff in the new way of working, as they have to move out of their comfort zones and deal with the anxiety that this comes with: 

Because obviously we’re coming out of our comfort zone and there’s that anxiety of not knowing what to expect. So, I think just having a leader who just assures us that it’s going to be fine and knowing that if you get into crisis or something is not okay, you have her there to support; I think that’s been great. (team member)

The leadership style is holistic where personal and professional roles are valued: 

…on a personal basis, she [the team leader] actually cares about you as a person as well and when we have catch-ups with her, she’ll ask first before anything about what’s happening and she’ll remember something that you told her last week and she’ll ask you that again to make sure it’s better or anything like that. She’s always got the person first rather than the work. (team member)

This ‘person first’ approach is a thread through the team, embedded in the design, culture and support delivery. 


The style of leadership in the SCOPE team contributes to a learning culture. Managers not only value the existing expertise of practitioners but actively encourage them to grow in their professional development: 

…I’ve always wanted to be a Social Worker but never been able to get there because I can’t afford the qualification and I’ve got three young children and my team leader said, “Look if you want to do that, speak to Learning and Development, go for it, do it.” So, she kind of gave me that oomph to try and explore the different options that are available and she’s so supportive… her leadership skill is very strong and she’s very passionate about getting it right for people. (team member)

Managers create a safe space through the learning culture, recognising that working in a new way can be scary:

If you’ve got any questions whatsoever, quite often coming into a new role you’re really worried… there’s never a ‘daft lassie’ question. (team member)

Time for formal learning and development is a key characteristic of the SCOPE team. The team value this and appreciates that it is relatively unusual compared to other teams.

When I’ve spoken to Social Workers about their practise, they’ve said that, “We don’t get opportunities like that, we don’t get that.” It’s the same for Learning and Development. Once a month we get…on a Thursday we have deferred opening hours so it’s a chance once a month for learning and development. So, as a team, we all learn something. (team member)

Peer support

Peer support is central to the learning culture of SCOPE and is formalised through mandated, weekly peer support sessions. The team highly values these sessions for both professional development and personal wellbeing. They referred to ‘impassioned, reflective, critical discussions’ during peer support, regularly using language about theory, social justice and human-rights. 

…it sounds like a practical matter to say, every week we meet, but the amount of wellbeing that comes from that, the team support, the reinforcement of your professional identity and the confidence that that brings to go back out into liaising with other partners across the health and social care partnership or further afield, it’s like, I know what I stand for, I know what my team stands for. (team member)

Peer support in the SCOPE team is implemented as a space to build relationships, as well as strengthen team and professional identity which can be clearly communicated to other partners.

Space is also given for the team to develop relationships with other professionals across the locality. This enhances their professional connections and sector knowledge, and underlines another way that the strengthening of the SCOPE team, strengthens the offer of support for the people they work with.

There’s a Learning Disabilities Team that we’ve been encouraged to visit and to build relationships with and they are an amazing team and really passionate as well, but I think it’s also, that is a massive bit for the work that we do but it’s also about the rest of the connections as well and I think that’s something that’s quite unique about SCOPE is they are encouraged to go along to all these different things, different strategy meetings, to be really involved with supporting people and changing things. (team member)

Prioritising learning enriches workers' individual practice and sharpens their sense of professional identity. It also supports the spread of the SCOPE approach to other parts of the system.


Staff identified that their experience of leadership – empowering, asset-based, relational, collaborative, respectful – provides a model of how they work with supported people and their families. Having experienced empowering support, the team see their role as empowering supported people, helping them self-determine the support they need and ‘liberating them from social work’.

…sometimes we’ve seen it whereby the minute people hear Social Worker they’re quite apprehensive and worried about working with you and I suppose it’s about sort of modelling the way our team leader actually behaves with us…everyone’s an equal, it doesn’t matter if you’re a client, it doesn’t matter if you’re a parent of a client, everybody should be considered and I suppose that’s in keeping with a lot of the principles as well that we’re working to… nobody should be made to feel differently based on their circumstances or what’s happening in their lives… we always work on that relationship based practice and I would say that’s key in everything I’ve ever done is building that relationship and taking the time to build that relationship and actually that’s one of the things I do like about the SCOPE idea is that 14 to end of life. (team member)

The SCOPE leadership team have been intentional in their aim to provide a clear value-base and foster a collaborative culture. The result is a team who have trust in, and are positive about their leadership and are empowered to bring respect and high regard into their work with supported people.


Time is a significant investment in the work of the team and is vital to realising the SCOPE vision, operationalising the design and enabling a learning culture. Time is built in for induction, training and peer support which the team feel protects against the burn-out and ‘unmanageable pressure’ they have experienced in other social work roles. Giving time to practitioners and supported people creates the conditions for long-term support, collaboration, relationships-building and growing trust.

The team feel they are given space to deeply listen to client stories and to be more creative with their support. The investment of time signals that relationships and continuity of care are real priorities in the SCOPE approach and part of sustaining a positive culture. Promoting a shift in culture and attitudes is central to the ambition of the team. Team leaders are aware of the flip-side of this and the impact of being in a chronically time-poor sector on culture and, importantly, the supported person:

…what we really want to do is, we want to change cultures. It is so easy to develop and this is no disrespect…but bad cultures whereby, I don’t have time for that, I’m too busy to do that, that’s not my job, that’s not my role. And actually, the person that gets lost in amongst all that is the individual and that’s the person who we’re there all to help. So, again, it’s looking at how we can actually change cultures in a really positive but collaborative way. (team manager)

…I think that the culture change – trying to help the day opportunities and the different providers we work with to have that open mind and to change their perspective on things from more of a psychology perspective… using more tools that can help keep people in the community I think is really important. (team member)

Learning from SCOPE: doing things differently

The SCOPE team has ambitions centred on building relationships, working collectively and most importantly, making a positive difference in the lives of supported people and their families. The team talks about where they would like to be in a year’s time.

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The following prompts, informed by the SCOPE example, aim to support reflection on working differently, to prompt thinking and discussion.

Drivers and blueprints

  • What areas in your team / service would you like to redesign and why? What are your drivers?
  • What levers and barriers are there to doing things differently? 
  • What examples or evidence can you see in other sectors or other teams to help shape change?

Who, when, what

  • Who do you need on board to make changes? (eg senior managers, finance colleagues, the community, supported people and carers) 
  • What time frame do you have for change?
  • What are you prepared to change, and what can’t be compromised?


  • What kind of leadership does your team need to do things differently?
  • What are the roles of leaders and peers?
  • How could you start and maintain conversations about doing things differently?
  • What strengths are there to build on?
  • What feelings/emotions are there about change that you can explore?