Problems with personalisation run deeper than ‘gaming’ targets

After a report revealed how one council used 'questionable' tactics to meet a personalisation target, CC takes a look at the current state of practice

The personal budget target was set out in the government's Vision for Adult Social Care, published in 2010

It’s been six years since the government set a target designed to trigger a radical shift in the way adult social care was delivered – and three since most councils claimed to have met it.

Councils were told to move 100% (later reduced to 70%) of eligible, community-based service users and carers onto personal budgets by April 2013.

The target symbolised a shift in power from the state to individuals and their families, and promised people more choice and control over the support they receive.

But just last week, a report released to Community Care under the Freedom of Information Act threw the validity of this target – and the performance reported by councils – into question.

The report was commissioned after Somerset council’s personal budget figures rose dramatically from 7% in 2012-13 to 33% in 2013-14. Auditors brought in by chief executive Pat Flaherty in 2014 found this increase had largely been achieved by sending a letter to 3,000 clients in receipt of home care services, telling them how much the council spent on their care.

The report suggested that a similar approach was also being used elsewhere.

The auditors concluded the tactics were ‘questionable’. Former care minister Norman Lamb described the findings as ‘appalling’. Sector leaders ADASS declined to comment.

‘Failed delivery’

But for many the real issue here is not ‘gaming’ statistics, it’s the underlying culture.

The personalisation agenda was about more than just rolling out personal budgets – it required a shift in staff attitudes towards empowering service users to make decisions for themselves, considerable reform of local authorities’ financial and management systems, and a reduction in the use of inflexible block contracts so that people could have a choice of providers.

The Somerset report (produced in August 2014 but never published) simply confirmed what personalisation experts knew all along – the true principles of the policy were not delivered.

More recent publications, including a report from the National Audit Office on personalisation in adult social care, suggest some of the same problems persist.

The NAO found that some staff they spoke to did not distinguish between a council-managed personal budget and a situation where a person did not have a personal budget at all. It concluded that this implied that “the move to a personal budget can be administrative and not reflect genuine personalisation”.

‘No strength in the system’

Simon Duffy, director at the Centre for Welfare Reform, says the responsibility for this failing lies with the Department of Health and its flawed strategy for implementing personal budgets.

“The buck stops with the Department of Health. These targets were defined in ways that were easy to reach, so that’s what everyone did.

“If everyone is doing it and the DH sets the system up and pressurises councils to effectively arrange their numbers, then I don’t see how you can blame local authorities.”

You can ask why ADASS and other bodies haven’t raised it as an issue though, he adds.

“Local authorities have been hit massively by cuts that they’ve not been able to defend themselves from, so what we’re talking about here are public bodies with no effective strength in the system, they are the weakest parts of the welfare state.

“They are utterly unable to defend their basic economics, so expecting them to be able to also insist on some integrity from the Department of Health is impossible.

“It’s a sad way of looking at it, but that’s the truth.”

‘Insufficient challenge’

The other issue, Duffy says, is that local authorities have never been supported to change their existing contracting and commissioning arrangements.

“Local authorities and people committed to an old fashioned way of doing things in social care didn’t want to change the contracts they had with domiciliary care providers.

“If they had moved away to either direct payments or individual service funds, things would have changed radically. The target allowed them to maintain their old procurement processes.”

Indeed, figures published by NHS Digital (formerly the Health and Social Care Information Centre) show that council-managed personal budgets remain the dominant form of budget. In 2014-15, 350,000 (57%) of the 609,000 people receiving support in the community had a council-managed budget, while a further 115,000 did not have a personal budget at all.

Duffy argues that more local authorities should look at individual service funds (ISFs) – a mechanism that enables a person’s budget to be managed by a third party.

“So many people with disabilities and their families are saying ‘I want flexibility, I want control but I don’t want a direct payment’ – so why the hell haven’t councils been encouraged or challenged to shift their commissioning arrangements to the use of individual service funds?

“ISFs were successfully implemented in Glasgow 20 years ago. They are associated with very high outcomes and many providers [not all] want to work in this way, but are told they can’t because they have to work to these fixed, tendered contracts.”

Figures quoted by the NAO show just 4% of service users had an ISF in 2013-14 and research published by the Think Local Act Personal partnership found they were poorly understood and that many providers were not contracted in ways that allowed them to offer flexible support.

Duffy adds: “The issue that has therefore really been at stake for local authority commissioners is maintaining those structures set up in the early 90s, the model of buying blocks of care en masse in very restricted ways, defined by process and number of hours.

“That whole way of thinking hasn’t been sufficiently challenged.”

‘Lack of transparency’

The principles of personalisation are of course now enshrined in the Care Act 2014, which places a duty on councils to ensure anyone whose needs they must or chose to meet receives a personal budget. The act itself defines in administrative terms – as the cost to the local authority of meeting the person’s needs – rather than as an instrument of personalisation.

But this objective is made clear by the statutory guidance, which states that individuals must be given clear information about the money that has been allocated to meet their needs, be able to choose from a range of options for managing their budget, and have a choice over how they are supported, and by whom.

John Waters, research lead at disability organisation In Control, says the act is a welcome development, but councils are still falling short on delivering personalised care.

“We have a picture here where the statute is correct, it’s saying how the relationship should look and feel, the power should rest with disabled people with the support of their social workers, and the role of the local authority should be an enabling one.

“Where we’re falling down it appears is with delivery and the worrying element of that is the inability of councils to demonstrate whether or not they are achieving the degree of choice and control that’s being expected of them – and there’s no easy way of measuring that.”

Waters points to recent research carried out by In Control, which found “a number of typical types of restraint” were happening in relation to how people are supported.

“The places where people can be supported, the ways in which they’re supported, who supports them, and the amount of money available for a particular period of care are all being constrained. This runs counter to the Care Act guidance, which is a concern.”

‘Reducing choice and control’

He adds that “all too often” councils are failing to be transparent about what personal budgets should look like, but acknowledges this is largely due to financial pressures.

“It’s no surprise given the pressure local authorities are under with the cuts. There’s huge unprecedented cuts being raged on them in a way that is uncalled for, unwarranted, and that certainly leads to the frustration of the good developments we’ve seen.

“You’ll see councils reducing commissioned providers in vague attempts to make savings, which will deny individual choice – people can sort their own solutions out better then we can – but local authorities are being forced into acting in ways that ‘reduce’ control.”

These issues need to be addressed and Waters believes the answer lies in frontline practice. He calls on social workers to be honest with individuals about how systems are working, how resources are being allocated and the extent of choice and control available.

“That’s a fundamental role social workers can play – be transparent about what the rules are, but also internally urge their own authorities to be transparent with local people.

“It’s no good having guarantees and rights in law, if you don’t know what those rights are.”

5 Responses to Problems with personalisation run deeper than ‘gaming’ targets

  1. Tim S August 24, 2016 at 6:20 pm #

    The main problem with providing flexibility in care provision is that most people want regular calls. So when one person wants a different call time on different days of the week, most service providers simply cannot do it. Service providers are also required to ensure that staff are earning at LEAST the living wage, so leaving them with large gaps in their working shift is simply not legal.

    In addition, most LA’s cap the hourly rate at an unrealistic rate, but users with Direct Payments are entitled to have the LA source their care, potentially with the SP that they previously had a private contract with at a higher hourly rate.

    So service providers have shrinking income, whilst having to spend more time arranging more complex packages of care.

    THEN – The government is surprised that the system is not working!!!

    • Julie Owen August 25, 2016 at 10:47 am #

      You’re absolutely right Tim.
      I’m a carer and have been for many years, but I’ve also run my own Care Agency and it was an absolute nightmare.
      What we encountered was Social Workers making ludicrous claims to families in order to get them onto Direct Payments solely to save money.
      Few families or carers were given accurate or realistic information. Everyone being encouraged to employ Personal Assistants regardless of how feasible that really was.
      Then when the PA scheme doesn’t work out Service Users and their carers are forced to turn to agencies and almost invariably become frustrated and angry that agency workers cannot behave in the unprofessional informal way that a PA can.
      Flexibility is nothing more than a myth as all workers require regular hours.
      Choice is rapidly becoming a myth as LA are cutting services left right and centre.
      In reality Personal Budgets only really work for people with large Care Packages and those who are able to employ relatives.

      • Mel August 25, 2016 at 4:43 pm #

        It isn’t true that it needs to be a large package of care but it does need to be consistent. I think DP can also work well for respite for informal carers as well as they don’t need to wait for a social worker to be allocated to give the green light on respite.

        I don’t think DPs necessarily save money though either, sometimes I find it is more appropriate to advise on what someone actually needs without a discussion about money/budget firsthand and then I simply advise whether there budget allows for that, what’s left over for contingency. With a DP in my LA they’re not set up by social workers and you are simply told you can have the full budget, and who wouldn’t look at how they could spend their full budget?

        I don’t have an issue with people spending what they are entitled to of course, however the way budgets are generated in the first place sometimes results in a person’s budget being too large or too small because check boxes simply don’t pick up the details that make a budget personal.

  2. Katharine August 28, 2016 at 6:59 pm #

    I agree with the above. How can people get all the flexibility they want and also the workers get the hours they need. As a care provider it is extremely difficult to balance these two things…… but we do. Until now, the council have cut our fees by another 10%, oh dear, our profit margin was less than that.
    Solution, run everything tighter, clients get less choice, staff have to train for the job in their own time etc etc.
    I think we may give up soon. Such a shame but what can you do, if the costs are greater that the income, you can only cut back on costs so many times until it’s unfeasible.

    Another very important issue with Personal Budgets, which always seems to get overlooked is that of VAT.

    If you purchase care from a provider (day care, PA community support – any care provider who doesn’t provide personal care in the individual’s own home ) they cannot be regulated by a body such as CQC, they do not fall under the VAT Welfare Notice and therefore they will have to register for VAT.

    So, if you take a “managed budget” the council pays your invoice, they don’t count VAT as part of your budget as the council, also being registered for VAT can claim it back.

    Simply speaking if your budget is £100 then you get £100 worth of care as long as the council manage it.

    However, if you take a “Cash / Direct payment” YOU are liable to pay that VAT.

    So, with a budget of £100 you actually get £80 worth of care and you get to give £20 of your personal budget to the VAT man.

    I have tried to engage with the council over this as it is blatantly unfair and discourages people from taking a personal budget.

    I have received email from them saying, yes so what, we don’t care (pretty much those words!)

    As a day care provider we have 55 service users and only around 5 of those take a direct payment, mainly because of the VAT issue, they would have to take less service from us if they changed to a cash payment.

    Unfortunately, although The Government has promoted Personal Budgets, it is cutting private providers back so tight that one by one, all the small, caring places fold and it’s left to big business who can take the cuts because of economies of scale and the fact that the people making the decisions never see the people who receive the care.

  3. Isabel Ros August 30, 2016 at 9:48 am #

    I agree with a lot that has been said. I would like to add that:
    • Whilst personalisation presupposes the user to be in charge and at the centre of social care processes and decision making, this is most often not the case. The culture has not changed sufficiently and many practitioners can behave as if they are in charge and the disabled person is somehow making up their needs.
    • The position of social worker colleagues is compromised by having to act as gate-keepers for resource allocation, instead of having the service user as their main concern.
    • Users with independent support and advocacy tend to get their needs met more so than those who do not have access to these.
    • Currently need for and access to independent support/advocacy is determined by the local authority and not the user (not a lot of choice and control).
    • Independent support/advocacy services have been cut beyond the bone. At the same time, any understanding that advocacy needs to be specialised e.g. disability, age, has all but gone.
    • A large proportion of disabled people feel disbelieved about their support needs.
    • An increasing proportion of disabled people fear their reviews coming up and their hard fought for support plans being cut to the bone.
    • Social care funding increasingly covers personal care and what many users call “being fed and watered” with little attention being paid to emotional wellbeing and the need to be supported to go out and meet other people, keep in touch with friends and relatives, have aspirations.
    • Last, but not least, most social care providers are not ready to provide Independent Service Funds (ISF), largely because they cannot make their management charge disappear. Whilst direct services cost more than direct payment (DP) provision, DP grant recipients are expected to be able to pay for an ISF out of their DP. This is not possible. The Govt./Dept. of Health (and local authorities) need to
    o Fully educate the workforce/s in Disability and Diversity Awareness to ensure that users get treated with real dignity and respect.
    o Fully acknowledge individual support needs to ensure a person’s physical and emotional wellbeing.
    o Have transparent Resource Allocation Systems that reflect a truly co-produced budget for individuals i.e. reflective of everything the individual and any carer/s provides, to give a more truthful reflection.
    o Truly fund diverse ways to hold a personal budget to enable users to have real choice and control and providers to actually be able to afford to provide the much trumpeted but hardly implemented ISFs.