The Commission for Social Care Inspection’s final state of social care report this week issued an “early warning” to councils about the progress they still have to make to deliver personalisation for people with multiple and complex needs.
It concluded that authorities needed to improve commissioning and partnership working, while overcoming cultural barriers to the use of personal budgets for this group (see box 1).
CSCI’s verdict was based on a study it commissioned from academics Melanie Henwood and Bob Hudson, who examined five councils in detail as well as evidence from the 13 individual budget pilots.
Putting People First
Councils are now 10 months into delivering the Department of Health’s three-year Putting People First programme to personalise care.
In guidance last January on the use of the social care reform grant, the £520m fund designed to drive personalisation, the DH said all users should have choice and control over their support, and, over the longer-term, personal budgets, regardless of need.
However, CSCI chair Denise Platt said last week that councils had so far concentrated on people “with more straightforward requirements”.
There are certainly inherent challenges in delivering personalisation for those with multiple and complex needs, such as the estimated 12,000 people with learning disabilities and challenging behaviour.
For instance, many struggle to or cannot communicate.
More demanded of care managers
The CSCI report found self-assessments required more time and greater skills on the part of care managers than traditional assessments, so that needs and aspirations could be identified jointly.
But whatever the challenges of delivering person-centred care to people who may struggle to communicate their needs and wishes, few in the sector doubt the value of doing so.
In a 2007 DH-commissioned report on services for people with learning disabilities and challenging behaviour or mental health problems, Jim Mansell, professor of learning disability at Kent University, said support packages needed to be “highly individualised, to meet the widely differing needs of this group”.
CSCI found that where self-assessment was pursued with people with complex needs it delivered better outcomes.
But while some councils were “engaging with the agenda for people with complex needs”, “others are altogether more limited in their ambitions”.
This includes in relation to personal budgets and direct payments.
CSCI figures show there were 55,900 adult service users receiving direct payments in March 2008, a big hike on the 40,600 of March 2007, and 4,800 people using individual or personal budgets.
With Putting People First having started in April 2008, it is highly likely both figures will have increased significantly since then. But this is a small fraction of the more than one million people supported by councils in community-based services.
Barriers to access
CSCI’s report also found several barriers to access for people with complex and multiple needs, though amid a number of success stories.
Staff expressed reservations about the application of personal budgets to people with severe learning disabilities or challenging behaviour.
This suspicion was evident in Community Care’s survey last year of 600 adult social workers, which found 69% felt the extension of personalisation to all service users regardless of need was inappropriate.
Hostility to direct payments
And in two of the five fieldwork councils examined for CSCI’s study, carers expressed hostility to direct payments on the basis it would be an extra burden for them. Researchers also found some hostility among elected members.
The man charged with helping councils implement personalisation, national director for social care transformation Jeff Jerome, welcomes the study but says it was based on too small a sample of authorities to deliver conclusive findings.
“I just think there’s significant evidence in many authorities of people with high levels of need using direct payments and personal budgets,” he says.
Jerome, whose post is funded by the DH though he works through the Association of Directors of Adult Social Services, cites Oldham, Manchester, West Sussex and his former employer, Richmond, as examples.
However, Simon Duffy, chief executive of in Control, the social enterprise that has led the development of personal budgets, says: “Very few places have applied self-directed support to people with the most complex needs even though self-directed support was designed with those people in mind.”
Support planning key
Jeremy Cooper, adult social care transformation lead at the consultancy Impower, says difficulties in applying personal budgets to people with complex needs has in part arisen from councils focusing on resource allocation rather than support planning.
Cooper, whose team is helping a number of councils implement personalisation, says: “Empowering and supporting individuals to articulate and then creatively plan how to achieve what’s really important to them takes significant training, practical tools and cultural change. Those councils that have done so have seen increased complexity mean increased potential for personalisation to transform lives not just the system.”
According to David Congdon, Mencap head of policy and campaigns, the key barrier is the level of resources. He warns councils are rationing what they can provide through personal budgets, limiting access to the specialist care required by people with high needs.
He says: “You think about difficulties of communicating with people who can’t communicate. You’ve got to have empathy and you’ve got to understand the technical side. You can’t expect staff earning just above the minimum wage to do that.”
Jerome says there needs to be a more comprehensive look at the take-up of personal budgets which he says the DH and Adass aims to do.
Another issue raised by CSCI is inadequate commissioning – specifically the use of expensive, out-of-area placements for people with complex needs, an issue also raised in Mansell’s 2007 report.
Negative reasons for placements
CSCI said such placements were typically made for negative reasons, such as placement breakdown and problems with local services, and tended to disrupt family relationships.
All the councils in the study were aiming to reduce their dependence on out-of-area placements, and Jerome emphasises that such efforts are being made widely.
In his 2007 report, Mansell said councils needed to “work with service providers who are committed to developing the capability to serve people well in spite of their challenging behaviour and who can provide services locally”.
Independent providers not engaged
However, CSCI found independent providers were not engaged in developing strategies on personalisation.
Martin Green, chief executive of care home body the English Community Care Association, says “Commissioners haven’t been able to engage or engage enough in developing services locally.”
Like Congdon, he says resources are inadequate: “If a local authority says to me, deliver personalisation I will say ‘why are you only paying £390 a week [for services]’. Personalised care requires personalised resources.”
Jerome says market development is the “biggest single challenge” in delivering personalisation, but claims that “there’s good engagement with care home and home care providers”.
There will be no shortage of DH encouragement for councils to deliver on personalisation for people with complex needs in the coming months with a raft of policy due out (see box 2). The challenge for councils will be to put this into practice over the final two years of the Putting People First programme.
Cooper warns that “some may take the report as evidence personal budgets won’t work for those with complex needs”, adding: “That is totally misguided; personalisation is all about dealing with our complex lives better.”
As Platt says: “If we get it right for people with complex needs, it is likely that we’ll get it right for everyone.”
More information from CSCI State of Social Care Report 2007-8
More information from Valuing People Now strategy.