Hard-to-reach groups at risk of poor outcomes under personalisation

The coalition wants all users on personal budgets by 2013 but with older people and those with mental health problems left behind and resources drying up, the future of personalisation is in doubt. Jeremy Dunning reports

Today marks the end of the three-year Putting People First programme, for which English councils were handed £520m from 2008 to 2011 to personalise care and roll out personal budgets to at least 30% of their users and carers.

However, this is far from the end of personalisation: Putting People First has been replaced by another sector-led agenda to transform care, Think Local, Act Personal, while the coalition has set a target of having all users on personal budgets by 2013.

But as the social care reform grant runs dry, there are concerns about how this target will be met, particularly for groups that historically have been hard to help, such as mental health service users and older people.

With councils cutting the value of personal budgets, experts argue that the support and advocacy required to make choice and control a reality for these groups will not be available.

“It has become too easy to see personal budgets and cuts in the same sentence when they were never meant to be,” wrote mental health social worker and blogger Fighting Monsters this month. “The truth is that the whole system is failing those who need the support, advocacy and choice the most.”

How councils used their share of the £520m was largely left up to them, but it is clear that some did not approach this as well as others: personal budget rates ranged from 3% to 59% of eligible users and carers across authorities last year, NHS Information Centre figures show.

Particular issues have affected older and mental health service users, as well as substance misusers, for whom personal budget take-up rates last year were 10%, 5% and 2% respectively. This compared with 23% of working-age adults with a learning disability and 20% of physically disabled people.

Some of this disparity has been due to safeguarding fears among social workers and concerns among service users – particularly older people – about the perceived responsibilities that come with having a personal budget, such as employing people, even though these tasks can be left to councils.

However, other barriers exist.

Bureaucracy

Vinny Cowling, chairman of Doncaster-based mental health user group Voice for Choice, has been dogged by slowness and bureaucracy in his attempts to secure a personal budget from Doncaster Council.

Cowling, who has borderline personality disorder and depression, needed an emergency personal budget recently when he had to replace his bicycle and seek counselling. However, he could not access an emergency payment, forcing him to use public transport, which he has a fear of, resulting in him going into crisis, at increased cost to the state.

Last year, Doncaster’s personal budget rate stood at 7%. But it is now up to 28%, just shy of the 30% target that Labour set for April 2011, says director of adults and communities Joan Beck. She says the council anticipates “more people with mental health needs will be accessing personal budgets in Doncaster in the next few months”.

Making personal budgets work for people with mental health problems involves engaging with the NHS, which accounts for 80% of spending on mental health, says personalisation consultant Jeremy Cooper, director of iMPOWER.

However, personal health budgets are still at the pilot stage. With the NHS about to undergo a massive reorganisation with the abolition of primary care trusts by 2013, no-one is available to drive forward the agenda there, he says.

In addition, he says, personalisation risks being undermined through its association with cuts, leaving a “lack of aspiration for positive transformation” of services in councils.

‘No-frills’

Managing the cuts means moving towards “no-frills” personal budgets, which may no longer fund services such as horse riding for disabled people, says Ian Alexander, director of community services at Isle of Wight Council.

“Delivering a personal budget that enables people to meet their needs is where we need to be,” he adds.

Early indications from a survey being conducted by charity In Control and the Association of Directors of Adult Social Services show that personal budgets are working for people across the spectrum of client groups.

However, there are casualties from the ending of the social care reform grant, says Andrew Tyson, policy lead at In Control.

“Many local authorities are disbanding their personalisation and transformation teams and in the short-term there’s a lack of direction in some cases because the people who are leading the process are disappearing,” he says.

Tweak approach

Councils that are doing best are those looking specifically at the hardest to help groups, he adds, but he voices scepticism about the government’s 2013 target.

“Maybe we need to tweak our approach rather than just assuming that everybody can get a personal budget. I do think that by going for it [personal budgets] so quickly and putting the emphasis on hitting numerical targets there’s a risk that we will lose the quality.”

Simply being on a personal budget does not guarantee choice and control or better outcomes, he points out.

However, Tyson remains optimistic. “There are some worrying concerns but it’s not all doom and gloom,” he says. “There’s significant evidence that if you take a few risks and you don’t let the budget issues scare you what you see are good outcomes. People are more imaginative, people find their own solutions.”

‘People are trying to be imaginative and creative’

Hampshire Council was an enthusiastic and early adopter of personalisation.

The county held a commission on care and support in 2008, which produced recommendations on reforming care funding nationally and established a “Hampshire model” of care, combining self-directed support with an emphasis of prevention.

It spent its social care reform grant money on training staff and putting processes into place to underpin personalisation.

However, progress on personal budgets has been relatively slow. In 2009-10, 7% of users and carers had a personal budget – about half the national average – and the equivalent figure for 2010-11 is expected to be 15%.

In recognition of this, its head of self-directed support, Mamie Branthwaite, has seen her job now funded by the council’s mainstream budget, whereas previously it was funded through the social care reform grant.

Mainstream funding will also be used to improve the IT infrastructure behind personalisation, on more training and on reforming the resource allocation system.

To streamline the process of accessing care, it has put a team of social workers in its contact centre, to make initial decisions on whether people are eligible for support, and to divert people to appropriate services and provide them with information to support themselves.

The council also recognises the need to focus on groups that historically have had low take-up of personal budgets.

It has been piloting personal budgets for mental health service users with plans for a roll-out this summer. This will be managed by the integrated health and social care teams the council has with Hampshire Partnership NHS Foundation Trust. As part of this, a peer support development worker is working with a service user network in Fareham and Gosport to help promote personalisation.

“People are trying to be as imaginative and creative as possible [with mental health service users],” she says. “The area that needs more development is with older people.” She highlights the challenges of involving people with dementia in choosing their care, providing people with something more “creative” than day centres and convincing older service users that, with personal budgets, as opposed to direct payments, the council can manage payments.

Despite the challenges, Branthwaite adds: “I’m just glad we are where we are. It was extremely forward-thinking by our leader [Ken Thornber] who said, let’s have the commission on personalisation, that produced our model.”

Published in Community Care 31 March 2011 under headline ‘Goal of choice for all at risk as cuts start to bite’

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