Personalisation: Are personal budgets improving outcomes?

Research published this year found personal budgets were improving outcomes for users. Consultant Colin Slasberg (pictured left) claims the positive effects are not the work of personal budgets but of funding levels. In a response, research author Chris Hatton (right) says his findings are robust

COLIN SLASBERG, social care consultant

The National Personal Budget Survey, published in June, is being used by sector leaders as proof that personal budgets are working.

A majority of the 2,000 respondents report better outcomes in relation to factors such as safety, independence and dignity. However, more than 80% had a direct payment and they, not the people on council-managed personal budgets, are the ones who report the better outcomes. The message could not be clearer – direct payments work, council-managed budgets do not.

The kneejerk reaction is to say everyone should have a direct payment. However, the improved outcomes look suspiciously like the benefits that come with higher levels of funding. In 2009-10, 106,655 people had a direct payment in England and spent £783m between them, an average of £7,300 each. The other 1.35m service users used £5.25bn of community services, which is £3,900 each. This difference is not explained by complexity of need. There are people with low-value direct payments as well as high, but it is likely that their funding will better match their needs than if they did not have a direct payment.

Also, a study by the Office of Public Management of people with a direct payment in Essex shows they – or their representatives – tend to be highly articulate people able to negotiate their way through powerful interests, including council officers. It is likely that this personal powerfulness not only accounts for their enthusiasm to act as their own commissioner, but also explains why they have higher funding than most.

Even if all people were given a direct payment, the better outcomes would not be replicated, not least because higher funding for recipients would not be affordable on a large scale. If all older people alone had the same level of funding as those with a direct payment, it would require a further £1.6bn.

So, if council-managed personal budgets make no contribution and direct payments will benefit only a minority, how can personalisation be made a reality for all? The key lies not in replacing the prevailing system, but transforming it. Action on three fronts is needed.

The first is to create a framework that faces up to the serious mis-match between funding for individuals and their needs. This requires a complete overhaul of Fair Access to Care Services.

Scarce resources should be allocated according to universal human needs, and we should be transparent about needs that we cannot fund. This will invigorate the political process, offering a surer route for funding to get closer to need than the current reliance on the judicial system.

The second is to transform assessment and support planning. Most people do not want to become their own commissioner. They just need practitioners to work differently, to listen to them and be allowed to respond with honesty and creativity. The above action on FACS will open the door to allow this to happen. Councils will also need to free up their resource base from pre-purchased services so that cash is the currency of support planning.

Third is to recognise that most people will continue to look to mainstream services. Councils need to stop thinking that an army of people with personal budgets will change the market. They must learn how to work with providers to develop their services so that they are authentically personalised – a huge challenge.

Social care is being led by people holding on to a false prospectus – that there is some magic within the personal budget process whereby better outcomes will come without cost. Time has been lost in facing up to the real challenges while all the focus has been on delivering the failed personal budget strategy. There is good research about what works and it is time to create the conditions within which best practice can flourish.

Colin Slasberg is a social care consultant and a former social worker and council manager

CHRIS HATTON, research author

Plenty of evidence exists that social care services tend to be directed towards those with the skills, tenacity and resources to negotiate byzantine systems. However, this is not a specific issue concerning direct payments – it is a pervasive one found throughout social care. Slasberg’s conclusion here seems somewhat despairing – rather than trying to encourage “personal powerfulness” more widely among users, social services should retain all the power because to “give” power to some and not others is unfair.

He argues that because most personal budget holders in the National Personal Budgets Survey were using direct payments, and because direct payments are funded at a higher level than council-managed personal budgets, the positive impact of personal budgets is entirely a function of the increased resources received by holders of direct payments.

This is not the case. I did further analysis of the survey database and found costs accounted for, at most, 7% of the variance in people’s reports of impact.

The weekly amount of the personal budget was important for only one of the 14 outcome indicators. Other factors were more important in predicting positive outcomes, most commonly: the person having help to plan their personal budget (seven outcome indicators); the person’s views being considered in their personal budget plan (five outcome indicators); the council making it easy for the person to plan and manage their support (five outcome indicators); and the council making it easy for the person to tell the council what they think or complain (five outcome indicators). These modest links between costs and outcomes are no surprise, as social care research shows such relationships are weak to non-existent.

It is unclear to me why Slasberg’s three-part solution would be an improvement.

Being honest about unmet need so that scarce resources can be allocated in a transparent way is laudable. But I am unclear why such a process is in principled opposition to a personal budget strategy, which should have resource allocation processes that are far more transparent than traditional methods for allocating social care?

I am also puzzled why he thinks changing the assessment and support planning process so practitioners listen to service users, allow them to work with honesty and creatively and with “cash as the currency of support planning” is in opposition to personal budget support planning, which aims to do just this.

It also seems rather naive, and it is odd for Slasberg to accuse proponents of personal budgets to be relying on “magic” when he offers no mechanisms for how this change is to occur. Given that social care policy has been promoting similar aims at least since the NHS and Community Care Act 1990 with limited and patchy success, even in good financial times, it is hard to see how such a magical transformation in social services culture will occur in times of severe resource constraints without the fundamental shift of power required as part of the personal budget approach.

The final part of his solution is that “the majority of people will continue to look to mainstream services” and councils need to work with providers to deliver personalised services. Again, I fail to see how this is in opposition to personal budget strategies, where the person is free to continue to use mainstream services and councils are working with providers and others to shape the market for social care users.

It puzzles me why his hostility is directed towards personal budgets, when his concerns (which I share) about inequality, lack of transparency and accountability, bureaucracy and unresponsive services have been pervasive concerns about traditional social services cultures and practices long before personal budgets came on the scene.

Professor Chris Hatton from Lancaster University is the lead author and analyst of the National Personal Budget Survey for Service Users and Carers

➔ Survey in full

Related articles

State of personalisation 2011

Expert guide to personalisation

What do you think? Join the debate on CareSpace

Keep up to date with the latest developments in social care Sign up to our daily and weekly emails

This article is published in the 6 October 2011 edition of Community Care under the headline “Do personal budgets work?”