Adult care social is at a turning point. From April, councils in England will be judged on their ability to give people more control over their care, through self-directed support.
Under the government’s Putting People First concordat, councils must, by 2011, ensure that many more users are assessing their own needs and have set up a system for giving users personal budgets, providing a transparent allocation of resources for their adult care needs. In the longer term, all users, apart from in emergencies, should be using personal budgets, with the possibility of extending these into other funding streams, through so-called individual budgets.
While the agenda is not new, evidence about what works is relatively slight and progress gradual, according to major research published today (Thursday) on In Control, a model of self-directed support, which began in 2003 in six English councils.
In his foreword, care services minister Ivan Lewis says of In Control: “Its innovative and ground-breaking work has been a major factor in ensuring that self-directed support and personal budgets are now at the heart of a radical social care transformation.” The findings, however, reveal many uncertainties beneath the rhetoric.
“If many more authorities – or indeed the national system – now seriously take up the goal of total transformation, we shall be in deeply uncharted territory,” the report states.
While results from In Control between 2005-7 are “encouraging”, only about 3,500 people – out of more than one million adult users – are getting self-directed support from the 100 English councils involved.
Despite the small base, the report’s findings are the strongest evidence yet that self-directed support does work.
A survey of 196 users across 17 councils found almost everyone felt they had control over how their personal budget was spent. Almost half reported improvements in general health and well-being, with a similar number reporting no change, and just 5% said their general health had worsened.
Most also reported improvements in time spent with people they liked, quality of life, and taking part in and contributing to their community. Three-quarters of people found improvements in the choice and control they had over their lives.
But the findings, as researchers make clear, were “not resourced or designed” to be a full-scale, comprehensive evaluation. The snapshot is also “heavily weighted” towards a small number of councils and people with learning disabilities.
There is also no new information on the costs of providing self-directed support compared with traditional models of care, although previous research has indicated they may be lower.
Self-directed support is also at “an early stage of implementation” in England, with most participants using the model for less than six months. There are also “big varations” in the numbers using self-directed support across authorities.
Julie Stansfield, managing director of In Control partnerships, believes councils are “passionately willing” to embrace the change, but will need proper guidance to make it work. And she adds: “Throughout our experience with In Control we have seen how councils must be given the chance to constantly learn, test, revise, and test again.”
She warns against a”rigid blueprint”, given different local circumstances, and says the key guiding factor should be service user satisfaction.
But she says risks of “watering down and corruption” of self-directed support are high if councils are pressured to do too much too soon.
However, she points to successes featured in In Control’s evaluation, notably in Oldham: “They show that self-directed support can be achieved within a relatively short period of time.”
Paul Davies, Oldham’s director of adult social care, says about 1,500 people are now getting self-directed support as the council reaches its third year using the model. It is also one of the 13 Department of Health individual budget pilot sites. “We expect to have all adult social care users – around 4,000 – using self-directed support within the next 12 months,” Davies says.
Davies, who is also a trustee of In Control, believes the government’s timescale for implementing personal budgets is “realistic”. He adds: “Once councils go down the route of self-directed support it will change everything they do, in terms of care management, procurement and service provision.”
Davies is adamant that budgets “are well under control, and can’t escalate out of proportion” as they come from the existing funding pot.”The difference is people know how much money they have for their care,” he says.
Oldham has also ensured “flexibility”. If people do not want to direct their own support, they have the option of a care package or a mixture of the two. Davies says there were initial workforce concerns, but “honest discussions” with unions and staff led to acceptance of the changes.
Oldham is a pioneer, but many councils – particularly those not involved in individual budget pilots or In Control – “are not ready” for the personalisation drive, according to Sue Bott, director of the National Centre for Independent Living.
She claims councils “never really got hold of” the principles of direct payments, and that councils have not yet embraced the necessary cultural shift to ensure wide-scale change. She says: “Commissioning shows most social care resources are still tied up in bulk contracts, and councils are going to have to dismantle the whole edifice to give people real choice.”
She says change is inevitable: “Can any council say hand on heart that the current system is working? I believe not.”
Professor Caroline Glendinning of York University, who is leading the DH’s evaluation of the individual budget pilots, says there are “still big questions” for councils.
“There are questions around how this will be implemented including the consequences for people who do not want to use individual budgets. There are questions around sustainability and costs. Individual budget pilot sites have been asked to deliver within their existing financial envelope, and our evaluation will be looking carefully at whether they have been able to do that,” she says.
Glendinning’s team is due report to the DH by the end of this month, and a separate evaluation of the impact on individual budgets on carers will be published later in the year.
For now, councils will “just have to get on with it”, according to Davies, advising them to use In Control and share information with fellow authorities. “Getting leaders onside is also vital. Any chief executive would be delighted to see the levels of customer satisfaction from self-directed support,” he says.
Councils undoubtedly have their work cut out as they embark on a “very long journey,” Stansfield says. But for service users and their families “change cannot come soon enough”.
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This article appeared in the 13 March issue under the headline “In Control: we are in uncharted territory”