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The government’s green paper Independence, Well-being and Choice promises nothing less than to turn adult social care on its head: rather than rationing services, social workers will be enablers and facilitators. Rather than passive recipients of whatever services happen to be available, service users will decide what they get and how they get it.

 

At the same time, renewed emphasis on prevention will demand unparalleled leadership and engagement with services well beyond the walls of health and social care. It is a tall order.

 

To discuss the challenges posed by the green paper, and different ways of meeting them, we have assembled a team of experts (pictured right) to focus on the main themes over the next six weeks. Our experts are drawn from the Inter-Agency Group on the green paper, a coalition set up to analyse the impact of government policy on adult social care.

 

And we want you, our readers, to join in the debate by contributing your views to our online discussion forum (see panel right). Service users are this week’s theme and in the coming weeks we’re examining the role of professionals (26 May), leadership and the adult social services director (2 June), refocusing on prevention (9 June), performance management (16 June) and strategic commissioning (23 June).

 

 

John Dixon, Association of Directors of Social Services’ disabilities committee

 

“The green paper will establish a new relationship between the state and those who need social care services and their families. But while it is long on vision, it is short on mechanisms for implementation, and shortest on finance.

 

One challenge is transfer of control and risk. Talking to service users and carers, I sense more appetite for the former than the latter. The care business is risky and where it is not risky it can be immensely bureaucratic. People want the freedom to get on with their lives. How they can have control without the hassle is the challenge for local authorities.

 

There are those who will want nothing to do with the support and relative security we could offer. They will often be those who currently use direct payments; who are willing, in effect, to run a business, including recruitment, payroll and workforce management.

 

But for the other 95 per cent, we should be excited about the possibilities of individual budgets. They can leave as much risk or budget management with the local authority as the service user wishes; and they can even buy their services from councils, unlike under direct payments. We should rise to this challenge by setting up assured provider arrangements: lists for people to buy from, instead of having to go into the marketplace themselves. We should allow people to buy off our block contracts and so provide security for users as well as stability for our providers. It would give an entirely new discipline to our strategic commissioning.

 

But perhaps the greatest challenge lies with assessment, which has come to mean two things: finding out people’s needs, and rationing. In recent years we have put in huge efforts to make the assessment process more user-centred, and the green paper’s emphasis on self-assessment makes sense here. But breaking the link with rationing will be complex, especially in a post-Gershon world”.

 

Jeni Bremner, programme director, education and social policy, Local Government Association

 

“Local government will lead, develop and co-ordinate the complex web of support and services that need to be in place to deliver social care in the 21st century. This will involve all sectors, including local government and the NHS, voluntary and community organisations and crucially, the users of services and communities. Most areas already have a strong range of partnerships in place which give a good basis for taking forward the green paper agenda.

 

The green paper boosts the ability of service users to choose and direct their care. The use of direct payments and individual budgets is a key vehicle to deliver this. It is an exciting prospect, but we believe that individual budgets, which can be used to buy in-house services and which don’t bring with them the burden of direct payments, could be brought in sooner than 2012. We also believe that direct payments must not be restricted to social care as service users will look to have the same level of flexibility and choice in other services, including health care, as this agenda progresses.

 

The provision of community-based health care such as district nursing and chiropody can be fundamental underpinnings of independence. It is essential that the choice agenda in the NHS and other areas of public service keeps pace with the social care agenda as it develops.

 

Self-assessment will be the first contact for many service users and their carers in the future and they need to be properly supported in this process. It will be important that people do not under-assess as effective prevention can depend on early provision of support. It will also be important to ensure that a proper risk management framework is in place.

 

But the prevention agenda is not just about the provision of social care services. Social regeneration initiatives such as time banks, social enterprise, public interest companies, and social capital can build community capacity, providing real opportunities within our communities”.

 

Jo Webber, policy manager, NHS Confederation

 

“The green paper offers the prospect of a long-term commitment to social care services in line with the choice and personal control direction already outlined for the health services that our members are delivering for patients.

 

However, we need to examine the implications of giving people a greater say over their health and social care, whether that is through self-assessment, direct payments or individual budgets – choice is worthless unless it is an informed choice.

 

That means patients need better information, and services need to be signposted more clearly, so that they can make a distinction between what is on offer. Users may choose a different approach to the one professionals would choose for them.

 

The crux of this aspect of the green paper is simply this – what is the balance of risks between allowing individual choice and protecting vulnerable people? Would statutory bodies stand by while, under a system of direct payments, a service user chooses not to purchase what they would deem necessary for their future well-being?

 

How much risk can be tolerated when all statutory bodies are bound by regulation, performance management and governance, not to mention professional standards?

 

And will the clamour for choice clash with the need to contain costs and even staff shortages or a lack of service provision options in local areas?

The NHS Confederation advocates putting people in control of their care but it’s not always as simple as it sounds”.

 

Heléna Herklots, head of policy, Age Concern England

 

“Older people are the biggest users of social care services. The green paper could bring about a significant change in older people’s relationship with social care, moving from one of being ‘done to’ to one where older people’s own knowledge and expertise in what they need is recognised and acted upon. But will this happen?

 

The scale of change needed is huge. Despite many people’s best efforts, age discrimination is rife in social care and is institutionalised into its very structures and funding. Less is being spent per head on older people than on any other age group. For the green paper to deliver on its promises of independence, well-being and choice for all, fundamental changes are needed.

 

The government proposes individualised budgets and an expansion of direct payments as key levers to bring about change. Older people will be seen not as vulnerable adults, but as active consumers able to exercise choice. This raises the crucial question of how protection and freedom to take risks should be balanced; one on which the green paper invites comments, and encourages debate. It also requires expansion in the services available for people to buy, if consumer choice is to be more than an empty promise.

 

Currently less than 1 per cent of the 662,000 older people who receive help to stay at home use direct payments. Individual budgets may prove more attractive, and should help to improve the transparency of the system to its users. If people can really obtain the mix of services and support that they want then individual budgets will have succeeded. But they must be introduced with imagination, and a real commitment to ceding power to those who use services”.

 

Angela Greatley, chief executive, Sainsbury Centre for Mental Health

 

“The green paper pledges services based on the assumption that everyone has a contribution to make to society and a right to control their own lives. People with mental health problems have called for these values to inform services for well over 20 years. So far action has been slow. If this green paper is to succeed where others have failed it will need clear mechanisms to make a reality of the rhetoric.

 

The green paper suggests three key mechanisms for achieving change: providing much needed information and signposting; increasing the take-up of direct payments; and individual budgets. Experience to date is not good for mental health. Direct payments have a low take-up. Workers doubt the capacity of people with mental health problems to manage their own affairs and make implicit assumptions about risk to self and to the public. Individuals may not see the relevance of the system because treatment still takes precedence over support to achieve an ordinary life in the community.

 

Services will have to draw on the few good practices that exist and engage with service user groups nationally and locally to agree how to implement direct payments and individual budgets, taking into account the often fluctuating nature of mental distress.

 

This will require additional financial investment to provide information and support to people to manage their own care. The green paper is silent on investment. Without clarity about resources, the green paper’s laudable ambitions could stumble and under-serve the people for whom greater autonomy could make the greatest difference”.

 

Independent view

Simon Duffy, director of In Control, a national programme which aims to improve disabled people’s lives by transforming social care into a system of self-directed support by providing information and advice

 

“Individual budgets could transform the social care system into one of self-directed support; one where disabled people will be able to decide for themselves how they want to live and participate in community life and how they want to be supported to do so.

 

First, people with cognitive disabilities must not be excluded from individual budgets; effective supported decision-making must ensure that everyone is supported to control their own money. Second, people must be able to use their funding flexibly; people should be free to experiment and develop forms of support that are integrated into their lifestyle, community and home life. Finally, the level of individual budgets must be set in a way that enables people to find out, using self-assessment, what level of funding they are entitled to. This must be enough to meet their needs.

 

In Control’s work over the past two years suggests all of this is possible”.

 

 

Training and learning

Questions about this article to guide discussion in teams are at www.communitycare.co.uk/prtl Individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

 

Abstract

This article presents the hopes and aspirations of leading professionals from across the social care sector for the adult care green paper.

 

Take part in the debate…

…and visit  which is mounting a green paper campaign in tandem with this series of articles, including an online discussion forum for all our readers to air their views on each week’s theme. We will compile your views into a report to be discussed at our green paper conference, Power to the People: Will the adult green paper deliver?, taking place in London on 27 June. Empowerment of service users raises many questions. Tell us what you think.