The social care concordat Putting People First set out the ambition that all social care users should have access to a personal budget, with the intention that they could use it to exercise choice and control to meet their agreed social care outcomes. Personal budgets can be taken in a variety of ways:
● As a notional allocation of funding – a transparent amount of money, where the individual can exercise a degree of choice over how it is spent.
● As a direct payment – this mechanism has been available since 1997.
● Or as a mixture of the two.
Some councils are linking a number of income streams together, such as Supporting People and community care, within the existing legal framework to give a greater level of flexibility to the individual. This alignment of income streams is likely to be tested further for disabled people, in pilot sites following passage of the Welfare Reform Bill later this year. This is sometimes called an individual budget.
Key to the personal budget approach is a clear understanding of the amount available to the individual, to allow them to influence or control the spend, in a way which helps them best meet their needs. It is a conscious attempt to shift control away from the provider – often offering a fixed range of services – to allow the individual to design the services, frequently non-traditional, which best meet their agreed outcomes and agreed care plan. Evidence from piloting and early adoption shows that some people will use the new flexibilities to design very different services, while others value the ability to adjust more conventional packages to deliver a service more responsive to their own needs.
In many places, a resource allocation system (RAS) is used to determine the size of the personal budget transparently, so that the service user knows at an early stage what resources are available to them in their personal budget allocation. In that way the desired outcomes drive the spending. Personal budgets can be deployed in a number of ways:
● By the individual.
● By the care manager.
● By a trust.
● As an indirect payment to the third party.
● Held by a service provider.
The personal budget holder is encouraged to devise a support plan to help them meet their personal outcomes. Assistance in developing this plan can come from care managers, social workers, independent brokerage agencies and family and friends. Once a plan has been devised support can be purchased from:
● Statutory social services.
● The private sector.
● The voluntary sector.
● User-led organisations.
● Community groups.
● Neighbours, family and friends.
People can use their budgets to use a wide range of services, including traditional social care, as long as the service meets agreed outcomes and is legal.
The approach to personal budget has been informed by the experience of direct payments and, more specifically, by the individual budget pilots.
In 2007-8, individual budgets based on a number of different income streams were trialled in 13 English local authorities. Research into the effectiveness of the pilot schemes was conducted by the Individual Budgets Evaluation Network (Ibsen). The Ibsen study and other research studies, conducted both in the UK and internationally, have been reviewed in order to draw out messages that will help inform the future development of personal budgets.
The pilots identified that:
● People with mental health problems reported a higher quality of life and potentially better psychological well-being. There were, however, some barriers to entry for this group.
● Younger disabled people gained greatest satisfaction and reported higher quality of care and greater opportunities to build support networks.
● People with learning disabilities were more likely to feel a greater degree of choice and control with the scheme.
● Older people reported lower psychological well-being than of those in the comparison group. In international studies older people have expressed concerns about the quality of information and support on offer. However, follow-up work with older people has identified greater acceptability and the carers’ study identified greater satisfaction among older people and their carers.
Staff expressed concerns about determining the legitimate boundaries of social care expenditure and managing the potential financial and other risks at the same time as being responsible for safeguarding vulnerable adults.
More than half of those on individual budgets in the pilot scheme chose to employ personal assistants and all groups that made this decision reported positive outcomes for satisfaction, quality of life, social integration and health.
Support and brokerage
The types of support needed can be broadly identified as:
● Help with managing money and accounts.
● Accessing the required services.
● Employing and managing staff.
Research suggests the involvement of an independent broker who is able to draw on a wide range of resources, such as family and the local community, to develop a care package shaped to individual needs, can play an important role in simplifying the process.
What research is beginning to indicate is that personal budget schemes from social care funding may have the potential to produce savings for both social care and the NHS but that it can be challenging to achieve the alignment with health funding which is necessary to meet the support needs of individuals, particularly continuing health care for those with complex needs. The forthcoming pilot schemes for personal health budgets are likely to test out these issues further.
There is an assumption that personal budget programmes would improve choice for ethnic minority users of services, but research is yet to investigate this fully.
Potentially, personal budgets would work well in a rural context where there may be a lack of conventional services to purchase but the evidence base on this is still emerging. While take-up of direct payments by people with physical and learning disabilities tends to be higher in areas with lower population density, there may be problems with recruitment and retention in the same areas.
Families and carers
Family and carers are central to personal budget initiatives, as they provide unpaid care and support. Findings from the Ibsen pilot study, backed up by findings from a Carers UK survey on carers’ experiences of direct payments, show that, overall, it appears that personal budget schemes for people using services can have positive effects for carers and families. Clearly they need to be involved in assessment processes and have access to the right information and advice as well as to support services.
Training for frontline staff and first-line managers is essential to the success of personal budget schemes, especially those who work directly with the person using the service and involved in decision making. Valuable areas to cover in training include good assessment practices, equality and diversity awareness and effective risk management to enable a balance between ensuring choice and control and supporting and safeguarding those who lack capacity or have particular vulnerabilities.
The value of personal budgets is widely recognised, alongside the need for the support, advocacy and brokerage service infrastructure, including user-led organisations. The government’s social care reform grant is injecting substantial funds into the system (£520m over three years) to encourage the development of these services, but more needs to be done. Evidence is clear about the benefits to some groups of social care users but it is important to ensure that everyone using social care has the ability to benefit. Emerging findings from the UK are reflecting what the international research suggests: that there is no single personal budget scheme blueprint suitable for all adults needing social care support. They are one approach to personalising adult social care and need to be responsive to individual requirements.
● Personal budgets are part of the strategy to provide personalised, responsive care. They can be deployed and managed in a number of ways, including a direct cash payment, a notional amount or a mixture of the two.
● The individual budgets approach provides users of services with monies from a range of funding streams with which they can develop their care plan and buy services, although research has shown that there were significant challenges in aligning and integrating funding streams within existing legislative frameworks.
● All personal budget schemes are working to balance safeguarding and risk .There are risks at organisation and individual level.
● Personal budgets have the potential to be cost effective and increase satisfaction among some users of services. Younger disabled people and some people with mental health problems derived the greatest benefit from the scheme in the IB pilots, but the outcomes for older people and people with complex needs do not yet appear to be so positive. These groups may need more time and support so that they can get the best from personal budget schemes.
● While personal budget schemes can bring benefits for carers and families, support arrangements are needed to ensure successful implementation.
● Frontline staff may feel unsure about handling new responsibilities. There is strong evidence to show that frontline staff and first-line manager training is vital for the successful implementation of personal budget schemes.
● SCIE Research Briefing 20: The implementation of individual budget schemes in adult social care
● National Centre for Independent Living http://www.ncil.org.uk
Author: JOSEPH ROWNTREE FOUNDATION;
Title: Rethinking social care and support: What can England learn from other countries?
Reference: York: Joseph Rowntree Foundation, 2008. 12p.
Abstract Draws on the experiences of other countries and sets out a number of principles that should underpin reform of care and support arrangements in England. The paper summarises some of the key features of social care; these features are important in determining the appropriate balance between collective, welfare state responsibilities and individual or market responsibilities for social care; spells out a number of principles that should underpin the funding and organisation of social care and support in England, illustrated with lessons and examples from other countries.
Author: ARKSEY Hilary; KEMP Peter A
Title: Dimensions of choice: a narrative review of cash-for-care schemes
Reference: University of York. Social Policy Research Unit, 2008. 25p, bibliog
Abstract This working paper presents the results of a narrative review of the international literature on “cash-for-care” schemes whereby users purchase care rather than receive in-kind services. The paper looks at the primary research evidence in order to examine four questions that are of central importance to social care policy: what can be chosen, what are the barriers, what are the facilitators to exercising choice, what are the outcomes of choice?
Author: GLENDINNING Caroline; et al
Title: The individual budgets pilot projects: impact and outcomes for carers
Reference: University of York. Social Policy Research Unit, 2009. 113p, bibliog
Abstract Individual budgets sit at the heart of government policy for improving choice and control for people needing social care support. Individual budgets bring together a number of different funding streams and offer a transparent way of allocating resources to individuals. Knowing the level of resources at their disposal can help individuals plan and control how their support needs are met. Individual budgets are being piloted in 13 local authorities across England. The implementation is being supported by a team from the Care Services Improvement Partnership (CSIP).
Author: MICKEL Andrew
Title: Where to start with individual budgets?
Reference: Community Care, 8.1.09, pp32-33
Abstract Ealing Council was one of 12 councils running the Dynamite initiative which aims to introduce individual budgets to users with no experience of centrally provided adults’ services. In Ealing, eight young people with learning disabilities are taking part in the pilot. This article looks at the experiences of the staff and families involved.
Author: GREIG Rob; DOWSON Steve
Title:Going for brokers.
Reference: Community Care, 19.2.09, pp.26-27
Abstract The use of individual budgets is increasing the profile of care brokers. The authors, from the National Development Team, look at how the training and regulation of brokers should be improved.