By Simon Duffy
At the end of March 2015 97,000 people in England were using a direct payment for some or all of their support, figures from the Health and Social Care Information Centre show (see table 2.5 of linked document). That’s 20% of those receiving long-term support for more than a year.
Also, 92,000 carers also received a direct payment during 2014-15, which is 67% of all carers who received ongoing support during that year (table 3.1). The number of people who received a social care service from English councils fell by 509,000 (29%) from 2008-9 to 2013-14, under the impact of austerity. However the numbers receiving direct payments has continued to grow, increasing by 80% from 2009-14, show HSCIC figures (table 4.3).
But despite this growth, there are significant questions about whether personalisation is fulfilling its promise to open up lots of different support options for people. In 2014-15, HSCIC figures (tables 2.10 and 2.11) show that the proportion of English councils’ adult social services expenditure spent on residential care was 40% (£6.8 billion). The other major service, domiciliary care, is often criticised for being constructed from minutes of support from contracted service providers.
Not social workers’ fault
None of this is caused by social workers. Instead, as Stephen Sloss, ex-director of social services at Blackburn, describes, social workers find themselves having to work within the narrow constraints of the system:
“Procurement and commissioning systems often leave social workers offering people restricted choice over their home care services or providing people with a list of Care Quality Commission-registered residential service providers,” says Sloss, now chief executive of Salvere, a social enterprise that helps people develop support plans, and a fellow of the Centre for Welfare Reform. “This approach is dictated by the old systems of commissioning where tenders determine what is purchased and social workers would be deemed to be threatening commercial contracts or placing the authority at risk of showing favour to one or another residential supplier if they recommended particular services or did not make use of pre-purchased services.”
Between rock and hard place
In fact social workers find themselves between a rock and a hard place. They are being encouraged to promote direct payments, although they can see that many people need more support to manage their own budgets. At the same time they are being told to be person-centred and creative, while they have fewer tools to be so. Procurement and commissioning systems are undermining the positive role social workers can play.
There is an alternative to this way of working. There is evidence that support providers can work as flexible partners with people and families. For example, Inclusion Glasgow, which I founded 20 years ago, developed a model where support was designed around the person’s needs within a fixed budget, but responsibility for employment and budget management could be left with the organisation.
More recently Choice Support converted a large block contract for care home and supported living services for people with learning disabilities into 85 individual service funds. Not only did this increase efficiency and improve outcomes, but the researchers also found that the social workers involved thought the change “the most significant initiative” of their working lives. These changes are also beginning to benefit older people using home care. Calderdale council has now developed a new range of flexible contracts that allows it to commission a home care provider to work to a fixed budget. Now the home care agency develops and changes support solutions, with the person, working with the agreed individual service fund.
In line with Care Act
The idea of an individual service fund may seem radical, but the statutory guidance on the Care Act makes clear that people should be offered “a managed account held by a third party (often called an individual service fund or ISF) with support provided in line with the persons wishes” as one way to manage their own personal budget.
Furthermore, last year’s best practice guidance on implementing ISFs under the Care Act from Think Local Act Personal (TLAP) makes clear that commissioners do not need to define how services are delivered. Instead they can create systems where social workers can help people find the right provider and allow the person and provider to develop the best solutions. The social worker facilitates and reviews this relationship, but the details can be largely left to people themselves.
Radical change in thinking
These changes do require a radical change in thinking at a local authority level. Support providers need to be trusted to develop plans with people and change support when necessary. Social workers need to be trusted to help people find the right support for them. But these changes are absolutely essential if social workers are to fulfil their primary professional duty, as set out by the Health and Care Professions Council, to “act in the best interests of service users”.
There are service providers out there already working flexibly and trying to provide personalised support. But this form of practice is so rare that they do not get their voice heard. For this reason the Centre for Welfare Reform has launched a survey to identify support providers who are striving to provide personalised support. If you know such an organisation please encourage them to complete the survey. The survey will end on the 30 June 2016.
Simon Duffy is director of the Centre for Welfare Reform