Care services minister Ivan Lewis has recently announced that the Department of Health will develop personalisation in social care by “seeking to achieve it everywhere” rather than through piloting individual budgets. Support for personalised budgets has also come from the prime minister at the Labour Party conference, in the comprehensive spending review and in Lord Darzi’s interim report into the future of the NHS.
The message is clear – it is not a question of if individual budgets are to be rolled out, but how and when.
The transition towards a personalised budget model and establishing the culture, structure and process to support it will take longer than five years, develop unevenly, and require several supporting factors.
The first step in responding to the new agenda is to recognise the enormity of the challenge – this is not so much an extension of direct payments as a shift in the paradigm that underpins how we think about the relationship between citizen and state in respect of welfare services and support.
At the heart of this new paradigm lie three key ideas: user control, choice of service and flexibility of support. It will require a transfer of power and responsibility from organisations and professionals to service users and carers for personalised budgets to breathe life into these ideas. It is at this point that the “old” and the “new” paradigms collide.
Research we carried out for the Department of Health sheds light on some of the challenges for councils.
The ways in which policymakers, managers and practitioners understand personalised budgets, and the judgements they make about their desirability and feasibility, are crucial. While almost all respondents interviewed supported the principles of control, choice and flexibility, this did not always lead to support for developing personalised budgets.
Some people were adamant that change should be undertaken in a proportionate and manageable way and were cautious about the “evangelical” approach they believed was coming from some quarters. Introducing personalised budgets alongside the established system of social care also presents difficulties. While for some respondents this underlined the need for a strategic process of managed change, for others the risks of moving to an unknown system were judged to be too high.
The willingness and enthusiasm of staff for the new model will shape the pace of change. For some social work staff (particularly those who have been in the profession for some time) the model may have some appeal in offering a return to traditional social work activity. But for more recently qualified staff whose only real experience is of care management, the transition could be seen as more threatening. The research also identified several “ideological obstacles” to the new paradigm (see panel, above).
Service users are keen to experience greater control, choice and flexibility in their lives. While this would imply support for personalised budgets there is also evidence that they too have concerns about finding their way around such a system, and may therefore choose to stick with traditional services. Professional staff in turn often have concerns about whether service users – especially older people – can cope with the demands that might be placed upon them. Overall, we found views ranging from outright support, through qualified support, to qualified opposition and actual hostility.
A change as substantial as personalised budgets will not be achieved without rigorous organisational preparation and planning. Local preparation has been focused on developing approaches to self-assessment, and trying to relate this to a resource allocation system (RAS) that provides money, staff and time to the individual budget.
RAS is a demanding undertaking that highlights the shortcomings in existing financial and service information, as well as making transparent many decision-making processes that would otherwise be hidden. In particular, there are institutionalised inequalities in the resources allocated to different groups of service users. The RAS could also indicate a need for higher allocations of resources provided by traditional assessment, while reducing services to those with higher and more complex needs.
Charging policies and practices were also issues in developing RAS models. It was not clear how these should be addressed but treating all RAS allocation as if it was ordinary social care expenditure and charging accordingly was viewed as unsatisfactory.
Role of NHS cash
The absence of health service monies from the table was also viewed as limiting and perverse. Hitherto the government’s position has been that the inclusion of some NHS resources into personalisation is strictly out of bounds, but Lord Darzi’s recommendation in his NHS interim report may signal an end to this restriction, and his final report will be keenly scrutinised.
Although much of the focus on personalisation has been upon the role of service users as micro commissioners, this will be of little consequence if there is no market from which to purchase forms of support. With people poised to assume greater individual responsibility for purchasing social care and support, there will be a major change in the role of the local authority that could cease to be the dominant purchaser or commissioner of such services.
None of the local authorities in our study had fully embraced the implications of this changed state of affairs, but there is more realisation that there needs to be a proactive stance to supporting the market to develop as evidenced by the recent Commission for Social Care Inspection study of this issue.
Vision and commitment
Ultimately, successful local implementation depends upon the commitment, vision and talent of local practitioners and managers. The creation of dedicated officer time to project development has been important, but also costly for organisations. Where it has been possible to create new appointments this has been particularly beneficial, rather than trying to develop the agenda alongside existing day jobs. Support for service users is recognised as important – whether from professional staff operating in assessment and care management roles, from direct payments support staff, or from user-led groups.
In the sites that formed this study, progress was variable, but even in the most advanced there was little evidence of the impact of change upon people’s lives. However, this should change dramatically over the next year or so, and the lack of concrete progress is not so much a criticism of the measures that have been taken, but rather of the difficulties inherent in securing a major paradigm shift of this nature. The potential of personalisation in social care (and in other public services) is immense, however, it will need more than mere ministerial injunction to accomplish effective change.
● The “giving and doing” tradition: whereby social workers do as much as they can for service users and secure them the most support possible (often running counter to the requirements of the Fair Access to Care criteria).
● The loss of collectivism: where there is an apparent tension between the emphasis on the individual rather than on collective objectives.
● The conflation of needs and wants: a largely unfounded suspicion that the new approach addresses people’s extravagant wants rather than their professionally assessed needs.
● The mistrust of service users: suspicion that people will seek to get as much out of the system as they can while the professional has a responsibility to protect public funds.
Melanie Henwood and Bob Hudson, Here to Stay? Self-directed Support: Aspiration and Implementation. A Review for the Department of Health 2007
This article appeared in the 15 November issue under the headline “The road ahead”