Separate reports have looked into the introduction of personal budgets in five local authorities. Alison Petch sums up the findings
Title: Steering My Own Course: The Introduction of Self-Directed Support in Cambridgeshire
Authors: John Waters, Mike Hay
Affiliations: In Control and Cambridgeshire Council
Title: My Budget My Choice: Implementing Self-Directed Support in the City of London
Authors: Mark Peak, John Waters
Affiliations City of London and In Control
Title: It’s Your Life – Take Control: The Implementation of Self-directed Support in Herefordshire
Authors: Tony Edwards and John Waters
Affiliations: Herefordshire Council and In Control
Title: This Time It’s Personal: Making Self-directed Support A Reality for People with Learning Disabilities in Northamptonshire
Authors: Sarahlee Richards, John Waters, and Brian Frisby
Affiliations Northamptonshire Council and In Control
Title: Doing It Your Way: The Story of Self-Directed Support in Worcestershire
Authors: Jenny Pitts, Vivien Soave and John Waters
Affiliations: Worcestershire Council and In Control
These five reports explore the introduction of personal budgets in five local authorities. They are further contributions to the unfolding story of implementing the agenda of self-directed support, building on the earlier reports from In Control on the experiences of the initial pilots.
They are described as “critical self-evaluation of our progress to date”, an opportunity to reflect on practice and to build the learning into development.
All adopt a broadly similar format, outlining the local formulation of a resource allocation system (RAS), the development by individuals of their support plans and evaluation based on the In Control framework of the impact of the personal budget on the individual, on family carers and on the care managers who had been involved in the support planning.
In Worcestershire, Time4People, a family-led organisation, conducted additional in-depth discussions. Consideration of impact accords with the final step of the seven-step model of self-directed support, “seeing how it worked”.
The scope and scale of the evaluations varied across the five areas. Most focused on people with learning disabilities, with 56 individuals in the Cambridgeshire pilot, 66 in Hertfordshire, 17 in Northamptonshire, and 46 with personal budgets implemented in Worcestershire.
Different groups of individuals were targeted: in Northamptonshire, all required new accommodation and support arrangements; in Worcestershire, an arm’s length partnership, Doing It Your Way, was established between staff from learning disability service Bild and Mencap, which responded to the individuals that came forward after a range of information sessions.
This included a number of people leaving school and therefore in transition to adult services, and two people from ethnic minority communities. In the City of London, 10 individuals formed the pilot, – four with mental ill health, three with learning disabilities and three older people – half of whom previously received a direct payment.
Most of the reports contrast the inconsistency of the relationship between resources made available to individuals and their needs under the former care management system, with the more appropriate match of needs and resources achieved after the RAS.
It is also shown that the support plans that are implemented often achieve savings against the indicative costs. In Hertfordshire, the average indicative allowance was £32,441 a year, but the agreed sum following the detailed support planning averaged out at £26,278. Likewise, in Northamptonshire the RAS indicative cost was £27,629 but the actual budgets were £22,927.
This in turn was a saving of 18.7% on the average cost under the traditional service of £28,206. In Worcestershire the average for the personal budget was £560 a week, 16% lower than the traditional £670.
The exact format of the questionnaires to personal budget users varied slightly from project to project in terms of the domains addressed and the rating used. Most asked for better, worse or the same, although the City of London adopted a five-point satisfaction scale. Overall, results were positive, most particularly for the individual users, but also for the family carers and for the staff.
There could be nervousness among carers as to the potential demands, while for staff there could initially be increased calls on their time until users adjusted to having greater control. All the reports make powerful use of individual stories to supplement the questionnaire responses, illustrating in particular the transformation achieved in the living arrangements and lifestyles of a number of individuals.
The City of London report outlines how admission to residential care for a woman with Parkinson’s disease was averted through the provision of live-in support, which allowed her to continue living with her partner.
Further dimensions were explored in several of the reports. In Hertfordshire there have been changes to the model of commissioning. In Worcestershire the council has funded training for people from a number of agencies and roles to become accredited support brokers with the National Brokerage Network.
The pace for implementing self-directed support as part of the wider personalisation agenda is accelerating. Nonetheless, as highlighted by the report from the Association of Directors of Adult Social Services and the Local Government Association on the first year of Putting People First, the average local authority expenditure on personal budgets is only 5% of their total social care budget.
A commentary by Jon Glasby in Community Care (28 May, 2009) has highlighted the range of critical perspectives directed towards the personalisation agenda and the various standpoints that may influence any appraisal of it. There can also be a tendency to favour the status quo, not necessarily evidence-based, over the uncertainties of change.
Nonetheless, each of these authorities is now committed to ensuring that personal budgets are widely available – for example, for 8,000 people across all groups in Hertfordshire by April 2010 and in the City of London to 50% of service users by the end of next year.
In Northamptonshire, the next phase includes offering personal budgets to everyone now in residential care who want more independence, choice and control, to people now using day services, and to 96 people now in NHS long-stay provision. The need to ensure particular attention to those with complex needs and those from ethnic minorities is highlighted.
These reports represent a different approach to evaluation from that of the formal evaluation of the 13 Department of Health individual budget pilots. They are designed to assess developments as they unfold and to encourage the reflective thinking that ensures that practice can be advanced. Northamptonshire, for example, lists 12 detailed points to be addressed. Methodological debates can rage as to the robustness of reports such as these, to the value of self-report and to the validity of individual stories.
Such debates are often misplaced because the different approaches can be complementary. The need is to understand the strengths and limitations of each. For example, the In Control evaluation questionnaire asks for a simple record of whether various dimensions are “better”, “worse” or the “same”.
Staff in some areas have already indicated that this may depend on the extent to which new styles of practice are already part of existing services. And, if satisfaction is measured over time, the possibility of changing expectations also needs to be factored in.
As has been shown with people moving from long-stay institutions, as people’s expectations rise they may confusingly express greater dissatisfaction. Only careful triangulation of different data sources and the accounts of individual narratives can allow accurate interpretation.
The use of stories as a methodological approach is gaining increasing attention (see Practice Implications, above). Although these In Control reports would present them primarily as illustrative case studies, their role, as explored further in the resources cited below, should not be underestimated. The trick is to ensure that their purpose is clear and that their presentation is not as journalism but as data.
Alison Petch is director of Research in Practice for Adults
LINKS AND RESOURCES
● The reports can be downloaded from the In Control website
● Callahan S (2006), How to Use Stories to Size up a Situation
● Dart J and Davies R (2003), “A dialogical, story-based evaluation tool: the most significant change technique”, American Journal of Evaluation, 24, p137-155
● Girard J P and Lambert S (2007), “The story of knowledge: writing stories that guide organisations into the future”, The Electronic Journal of Knowledge Management, 5(2), p161-172
● Haines C and Livesley J (2008), “Telling tales: using storytelling to explore and model critical reflective practice in integrated children’s services”, Learning in Health and Social Care, 7, p227-234
Reflective practice, encouraging individuals to consider the rationale and impact of their intervention and support, should be embedded as routine. Agendas for the implementation of developments such as personal budgets should include regular mechanisms for review and response. This should include the chance to address unintended effects and to respond rapidly to areas of concern or omission. There should also be attention, as with these reports, to disseminating emerging experience early on.
Much of the initial energy for personal budgets has focused on individuals with learning disabilities; expansion to other groups should seek to eradicate concerns about differential allocation of resources across different ages and impairments through the development of a consistent resource allocation system. Eighteen local authorities are taking part in the proposal to develop a national RAS.
Many of the stories told in respect of personal budgets have highlighted the unusual and the exceptional. There is a need to illustrate how the more routine and mundane aspects of daily life can be transformed through self-directed support.
Stories can provide detail on different mechanisms for managing budgets, on the use of mixed models that combine personal budgets with local authority commissioned services, and on the use of dimensions such as support brokerage.
Evaluations of emerging practice should avoid false debates about different methodological approaches. There is a place for both quantitative assessment and qualitative report and the most comprehensive understanding is derived from a combination of different approaches.
Despite the aspirations for the transformation agenda in particular and for personal budgets in particular, they remain as yet a relatively small proportion of the total social care budget.
A careful overview of the total activity and of the dynamics of the individual elements within it should be maintained so that there is an understanding of the whole system within which personal budgets are being developed.
This article is published in the 2 July issue of Community Care magazine under the heading How effective so far have personal budgets been?