Choice would be a fine thing

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.