Supporting service users to exercise control over their care is at the heart of the role of councils under personalisation. But they must also engage providers in a genuine partnership to make user choice a reality, writes Anabel Unity Sale
The Putting People First agenda is in its inaugural year and councils are already exploring ways of adapting to its demands. Under Putting People First, councils are required to transform services for adults from 2008-11 to ensure they are more sensitive to the user’s needs and wants. This poses significant commissioning challenges for councils, who must ensure users have the support to exercise choice and control and access to the services they want, while encouraging providers to supply those services without the security of block contracts.
Traditionally, councils have purchased care directly, often through block contracts, which have proved cost-effective for councils and offered market security for providers. They have assessed potential clients and placed those users who met eligibility criteria into the existing services that best fitted their assessed needs.
Upside down model
Under personalisation, this model is turned on its head. Potential social care clients are invited to assess their own needs. If they meet eligibility criteria and are awarded a personal budget they can choose direct payments and purchase services themselves. They also have the option of letting the local authority manage their personal budget on their behalf. If a service user does not receive a personal budget, councils should still ensure they have a greater say in the type of service they receive.
In order for service users to take an active role in all of these decisions they will need good information, support and advice, for which councils must take the lead.
Sue Bott, director of the National Centre for Independent Living, believes the success of the new agenda rests on support systems being in place to help users make choices.
“Some people are finebut for others, who’ve never had any choice, it’s going to be difficult – but difficult doesn’t mean it should not be done,” she says.
Service-user led groups
Local authorities must have good quality systems in place to help users think through their options, she says, and one way of doing this is by commissioning service user-led organisations to provide support.
Bott says councils must reassure users that giving them more control over their own social care spending is not just a way of cutting services. “Local authorities have to go out of their way to allay these suspicions,” she says, “and ensure personalisation is developed alongside service users.”
Janet Crampton, national commissioning lead for the Department of Health’s Care Services Improvement Partnership, says the DH is keen for good advocacy and brokerage services to be set up to advise users on how to manage their budgets. She emphasises that it wants to encourage service user-led organisations to play a bigger role.
“Not everyone will be an employer of a personal assistant but they may need help deciding what services they want,” Crampton adds. “Putting People First places an expectation on local authorities that this type of support will be available.”
Veronica Jackson, Oldham Council’s executive director of adult and community services, is well aware of the importance of helping users navigate the service marketplace and providing them with information about managing their budgets.
In April 2006, the council began a two-year individual budget pilot. She says the authority put a lot of effort into going out to service user groups and holding sessions on what individual budgets are and can do for them (see case study below). It is also funding an advocacy service and development forum, 4 Age, which is led by older people and offers peer support. “It is about looking at what’s out there for local people and what gaps do we need to fill,” Jackson says.
Councils must also encourage existing and new providers to supply services that users want. Some providers welcome personalisation. In the past, block contracts have been withdrawn by councils due to budgetary pressures, but dealing directly with customers arguably offers the opportunity to be judged more on service quality.
However, there are challenges posed by the prospect of more users purchasing care directly. First, direct payment users may hire personal assistants who then compete in the market with home care providers. Second, it may be difficult for providers to sell their services to many users with a range of preferences, rather than a single council.
These issues were raised in the evaluation of the individual budget pilots, published last month. One provider said that block contracts had enabled it to train all its staff to NVQ level three because it could plan three to five years ahead. However, as individual budgets were rolled out, it expected it would have to end this training for new staff because it could not forecast demand more than a few months ahead.
One solution to this conundrum is a preferred provider list. Under this, councils recommend a number of providers to service users, thereby increasing their prospects of business. To be put on the list, providers go through a competitive tendering process with councils and must offer bulk discounts, thereby providing authorities with economies of scale, as with block contracts.
However, some providers warned offering bulk discounts necessitated providing the standardised services that personalisation was supposed to end, the evaluation said.
Another option is for councils to support users to commission a service collectively, such as a shared housing scheme, combining user control, economies of scale and security for providers.
The individual budget pilot also cited one council which offered providers a transitional grant if an individual budget holder left their service, to avoid jeopardising services delivered by the provider to other users.
These ideas are at an early stage and councils will continue to purchase a high volume of services directly from providers as personalisation is rolled out. Over the long-term, councils may also need to continue purchasing very specialist provision, for instance for people with autism.
Jeff Jerome, the national director for social care transformation, who is charged with overseeing the personalisation programme, says it is essential for councils to have “closer discussions” with providers. He says any contracts reached must be much more focused on outcomes.
Beware cost cutting
New and existing providers also need to be reassured that personalisation is not an excuse for local authorities to drive down costs, says Martin Green, chief executive of the English Community Care Association. In June, the ECCA, which represents residential care providers, claimed many providers had received sub-inflationary or zero increases in fees in 2008-9, the first year of the Putting People First agenda.
“I have yet to see any commissioning that follows the high ideals of personalisation, it’s now about squeezing more and more for less and less,” he says.
Green argues councils should commission providers “at the right levels” so money can be spent on training staff to help deliver the new agenda and offer activities that care home residents want. He emphasises councils must recognise that personalisation can be delivered in care homes as it is about what a user wants, regardless of setting.
The Association of Directors of Adult Social Services rejected ECCA’s claims on low fee increases, saying this was by no means widely the case and arguing sub-inflationary rises could be justified by the need for councils to meet efficiency targets.
However, Adass president John Dixon says there has been a tradition of councils “patronising providers and pushing them around” and says this has to change.
Also, while councils are adapting current provision to the needs of personalisation, they are also going to have to assess the needs of their whole populations over the long-term and make the necessary changes.
Since April 2008, councils and primary care trusts have been under a duty to conduct a joint strategic needs assessment (JSNA) of the health and well-being of their local communities over a three to 10-year period. Dixon stresses the need to feed the results of the JSNA into the commissioning process and share them with providers.
The JSNA that Oldham Council has just conducted with its local PCT has been helpful for planning, according to Veronica Jackson. She says it has been beneficial because it has pulled together information from health and the council and looked at specific social care needs.
“It is a much broader brush rather than just an historic look at provision,” she says. “It is much more about what needs are and it is a tool to help us work closely together. GPs have found it very useful.”
Personalisation is designed to change the adult social care world in a way that aims to ultimately benefit the most important part of that world: users’ lives. What the next three years will demonstrate is whether local authorities can work successfully with providers and users themselves to deliver the world class support people deserve.