The recent evaluation of individual budgets found disquiet over safeguarding and transition plans, writes report author Jill Manthorpe in the final article in her series
The period of transformation of social care will be challenging for practitioners, and opinions about how it will go may be overly optimistic or pessimistic. Our interviews with home care providers, for example, revealed that they expected change at several levels. This may affect their willingness to embark on new business, their plans to invest in training and their commitment to work with care plans that do not offer much by way of return or security. Interviews with managers revealed concerns over the potential for change if contracts are tied up and whether they were going to have to fund services that are not working to capacity. Transition in some areas will be drawn out and many other intervening factors may affect what happens.
Uncertainty may magnify the need for advocates and navigators of systems. It may exacerbate the complaints of other professionals that social workers are always in meetings or that it is hard to know who to talk to. Now is the time for adult services to be talking to local networks, especially the NHS, at practice levels.
While there are many areas where there is close contact with multi-disciplinary teams and interprofessional working, there are many in the NHS and beyond who have not heard of personalisation and some who are frankly incredulous that personal budget systems are going to be mainstream.
This confirms the scale of the task in training. There is a huge challenge in bringing personalisation into mainstream professional and practice skills development, into induction and into all other learning. Nowhere is this more necessary than in the area of safeguarding where our interviews revealed the difficult balancing acts facing practitioners of responding to the safeguarding agenda and meeting the risks of the pilot.
Risks of harm
In our research there was widespread concern about potential financial and individual risks of harm for individual budget (IB) holders. Practitioners were concerned about possible poorer quality services, misuse of resources, financial abuse, neglect and harm about the level of responsibility that should sit with service users and about the lack of Criminal Records Bureau checks on people employed or working casually. For the past decade they have been reminded that adult safeguarding is their responsibility and that local authorities are the lead agencies in this area. Our interviews revealed that staff were struggling to fulfil these obligations.
It became clear over the course of the evaluation that monitoring and review systems developed for conventional service delivery arrangements would need adapting to focus more on whether a person is being supported in the way intended (rather than on the delivery or quality of services) to look at a broader range of outcomes and perhaps to review resource allocation in the light of how well outcomes are being achieved.
Additional changes could include:
● Regular reviews of how IBs are being spent against the outcomes achieved.
● Incorporating risk assessments into the support plan.
● Supportive guidance for care managers.
● Better information for individuals and their supporters.
Such measures are likely to increase the confidence of frontline staff and IB holders alike encourage greater creativity and enhance the potential benefits of IBs. But the proof, as they say, will be in the eating of the pudding, not least when serious incidents occur. Will care managers be blamed for lack of monitoring, for careless risk assessments and insufficient attention to best interests guidance?
Integrating funding streams
We noted in the first of this series that the IB pilots had had most success in working with their colleagues in Supporting People on integrating funding streams, and that in some instances there had been positive experiences when working with integrated community equipment services. These may be approaches that will be quick wins for other authorities. It was not the fault of practitioners that there were so few advances when it came to integrating funding with the Department for Work and Pensions or the Independent Living Fund and any disappointment with practitioners here is misplaced.
Practitioners were rightly cautious about raising expectations too high and not acting outside local government policies and legal frameworks.
This helps explain the move from individual budgets to personal budgets. Covering social care only, personal budgets seem to command great support in being wider in scope than direct payments and yet flexible enough to have a range of deployment options. The direct payments option is most widely associated with personalisation but need not be so. Promoting further examples of practice where deployment options are used to good effect and of how they may provide the flexibility required by people whose circumstances change quickly or often, would be helpful.
Given the apparent preference of a substantial proportion of individual budget holders seemed to prefer care manager-held virtual budgets, particularly in the early stages, it is important that these can be used flexibly so that opportunities for choice and control are widely available and well understood, regardless of the preferred deployment option. This will require reviews of local authority commissioning and contracting arrangements and of processes and procedures for the use of internal resources.
For example, many local authorities are developing outcomes-focused commissioning approaches to home care and day care services and these need to be linked to the roll-out of personalisation. Other deployment options, such as provider-managed individual service funds, third-party and trust arrangements also need further development and evaluation, so that their relative advantages and drawbacks for different groups can be assessed.
But there are many other sources of information that we will need to interrogate if the transformation of social care is to be a policy success. Underlying principles about resource allocation will only emerge if resources allocated meet needs within budgets. If, as we have found, more people who are eligible for social care feel that it is now more accessible and more likely to meet their needs, how will social care respond? There may be other groups eligible for social care services who do not currently access social care but can be persuaded that the days of the stigmatising poor law are now largely gone.
Winners and losers
Will there then be winners and losers from personalisation? At the time of the evaluation there were no real losers, not because of savings but because the full effects of the changes had not yet been realised. For practitioners the prospect of people losing services or support will be difficult to manage and for politicians this could feature public disquiet and concern. Issues of equity between user groups in social care have often been disguised but may now emerge more starkly.
Unlike direct payments, IBs may allow close co-resident relatives to be paid for the care they give, although some pilot sites retained their existing direct payment restrictions. This aspect of IBs prompted concern among some care managers it is also a subject of considerable academic debate. Research may help practitioners in thinking about the impact of paying carers through IBs on care-giving relationships, on the quality of care, on the social inclusion of carers, on household resources and on the immediate and longer-term economic independence of carers.
Like many of our findings, the personal and interpersonal elements of individual budgets are the hardest to tie down to gains and losses. But this is the essence of social care and at its heart lie important questions about values, rights and obligations.
Jill Manthorpe is a member of the Individual Budget Evaluation Network team and is director, Social Care Workforce Research Unit, King’s College, London
● Contact Jill Manthorpe at email@example.com
About the research
The evaluation of the individual budgets pilots, published last month, was commissioned by the Department of Health. It was undertaken by the Social Policy Research Unit at the University of York, the Personal Social Services Research Units at the Universities of Kent, London School of Economics and Manchester and the Social Care Workforce Research Unit at King’s College London. Members of the team are Sally Jacobs, Martin Stevens, David Challis, Ann Netten, Caroline Glendinning, Martin Knapp, Karen Jones, Nicola Moran, José Luis Fernandez, Mark Wilberforce and Jill Manthorpe.This article appeared in the 20 November issue under the headline “A work in progress”