Individual budgets and tailored services – putting service users in control

Social care looks set to hear more and more about the benefits of personalised care – particularly initiatives like direct payments and individual budgets. Since the late 1980s, policy in relation to the provision of care services in the UK has involved a series of linked initiatives, all based on the idea that the needs of the person requiring services should form the basis of a closely-tailored, responsive and flexible, personal package of care. For the purposes of this article, the following definitions of the systems will be used:

● Care management – the development of individual care plans, based on detailed assessments by budget-holding care managers, taking full account of the service users’ wishes and needs.

● Direct payments – where people, after assessment, are given the money to pay for their own social care, along lines proposed by them and discussed with their care manager

● Individual budgets – a system which involves streamlined assessment across agencies responsible for a number of support funding streams, resulting in the transparent allocation of resources to an individual, in cash or in kind, to be spent in ways which suit them.

The Department of Health, the Office for Disability Issues, Department for Work and Pensions, and Department for Communities and Local Government have been piloting individual budget schemes since 2005 in 13 local authorities across the UK.

Overall, the international evidence on individual budgets contains limited information about the cost-effectiveness of schemes, the relative quality of services provided, or questions of equity. The experience of ethnic minority service users is underrepresented. Most evaluations of individual budgets are linked to consumer satisfaction, the growth in self-esteem by a service user or sense of empowerment that they may feel. Issues of risk and risk management are only tackled by a few. It is also worth remembering that all elements of international research cannot always inform UK policy because of differences in funding, eligibility and overall social welfare policy and philosophy.

Most international research has found a positive attitude towards the idea of consumer-directed care as an option, given the right kind of support. Some studies have looked specifically at the experience of ethnic minority service users but results for these are mixed. In Australia, it was noticed that some recipients found the flexibility of schemes enabled them to access culturally-appropriate services, while others found the barriers to accessing the schemes even higher for them than for other service users.

Many have expressed concern that very low pay among personal assistants may encourage an informal care market to develop. Some Swedish groups addressed this risk by forming an interest group that gives a quality stamp to registered personal assistants, while user co-operatives offer to take over the employment responsibilities of new recipients who open an account with them. Other countries have used lists of approved personal assistants, set up voluntary organisations offering registered personal assistants from a pool, or organised their employment and payment through statutory agencies. These schemes have on occasion given rise to angry protests by some care users, who see them as an attempt to recolonise services.

Noticeably, international research into individual budgets found stark differences in the rationale and objectives for schemes. The Flemish scheme was aimed at reducing the use of expensive residential care, the LAC scheme in Western Australia aimed to combat the fragmentation of service provision in remote rural areas, and the consumer-directed care in the US has been directed partly at solving a shortage of long-term care staff.

The rationale behind the English scheme – to put the person who is supported, or given services, in control of deciding what support or services they get – has received little criticism.

Further information 

* SCIE research briefing 20: Choice, control and individual budgets: emerging themes
* Individual Budgets Pilot Programme website
* Ungerson C. (2005). ‘Direct payments and the employment relationship – some insights from cross-national research”, paper for the ESRC Future of Work Programme

● The development of individual budgets (IBs) in England would increase service options in ways which have been found to be very popular with many service users. They do not replace care management or direct payments (DPs), but add choice and extend autonomy.
● Many schemes with apparently similar objectives have been developed in the EU, North America, Australia and New Zealand. They differ in many ways, but some common themes emerge from the research literature.
● The impetus behind many of these schemes relates both to the empowerment of service users, and the spiralling cost of traditional care.
● Questions of cost-effectiveness and risk management are not yet fully dealt with in the existing literature.
● A review of schemes for older people in the Organisation for Economic Co-operation and Development (OECD) area has suggested that confronting the need for cost-effectiveness from the start may help to promote development.
● The literature raises questions about equity and service quality: more evidence is needed in both cases. In the US, consumer-centred quality-assurance systems are being developed.