by Andy McNicoll and Rachel Carter
A council has been accused of “deception” after a confidential report revealed it used a ‘questionable’ strategy to boost performance against a government personalisation target.
Auditors were called in to review Somerset council’s actions after the number of service users it said were receiving personal budgets rose dramatically from 7% in 2012-13 to 33% in 2013-14. At the time councils were under pressure to meet a government target for 70% of service users to be put in charge of their own social care support by April 2013.
The report, carried out by South West Audit Partnership – a firm jointly owned by Somerset council and 12 other local authorities, reveals the sharp rise in the council’s performance “unfortunately” drew attention. This forced Somerset’s chief executive Pat Flaherty to request an audit after he took up post in May 2014.
Audit findings
The report was kept secret but has finally been released almost two years after Community Care requested a copy under the Freedom of Information Act. The document reveals:
- Somerset’s improved performance was based on a claim that 3,000 more homecare service users had been moved on to personal budgets in 13-14.
- This claim was “questionable” as the 3,000 homecare recipients had in fact only been sent a letter telling them how much the council spent on their care.
- The letter only met one of three official criteria required for someone to be classed as receiving a personal budget (see box below).
- The council’s claim that “an immense amount of work had been undertaken” to improve performance was misleading as “in reality we had sent out 3,000 letters to homecare clients with little expectation that there would be any take-up, or that the process would add any true value”.
- The approach had allowed the council to report a “satisfactory number” without providing meaningful budgets to service users.
- Staff felt under pressure from the council’s then chief executive to improve the self-directed support figures as Somerset had the worst performance in the country against the indicator in 2012-13.
- The actions to improve the figure were taken with the full knowledge of the then chief executive and followed discussions with sector leaders, including the Association of Directors of Adult Social Services (ADASS).
- Feedback from national leaders suggested Somerset’s approach “was not inconsistent” with that of other councils. The report does not specify which national leaders provided this advice.
‘Undermining trust’
The performance figures were collected as part of the official social care data collection – the Adult Social Care Outcomes Framework (ASCOF). The government has described it as a “robust” measure of performance that fosters greater transparency and supports ministers in discharging their accountability to the public and parliament for services.
Liberal Democrat MP Norman Lamb, who was care minister at the time of Somerset’s dramatic improvement, described the audit report findings as “alarming”.
He said: “It totally undermines trust in the data. The approach they’ve taken makes no positive difference to anyone’s life. It completely fails to deliver what personalisation is trying to achieve – this should be about a genuine transfer of power from bureaucracy to people.
“If organisations think that they can hoodwink people by looking good on paper but changing nothing of substance then it’s a total failure on their behalf. It amounts to a deception really. It is an outrage and it’s alarming that it appears other councils are doing similar things.”
ADASS declined to comment on the report’s findings that Somerset’s approach was taken after seeking advice from the organisation and similar tactics were deployed by other councils.
No records of the advice national leaders gave Somerset council at the time were kept.
The authors of the report approached the ADASS personalisation network co-chair and the former director of Towards Excellence in Adult Social Care (TEASC) for their views as part of the audit. The report states: “As expected, neither individual would commit to an endorsement of the approach taken by Somerset council, both stating that it is for the council to decide whether the approach adopted is appropriate”.
‘Peer pressure’
Simon Duffy, a personalisation expert and director of the Centre for Welfare Reform, told Community Care the approach adopted by Somerset was widespread at the time, chiefly because it meant councils did not have to change their contracting arrangements.
“This was commonly understood to be the quickest and easiest way of getting high numbers of personal budgets, without having to do anything real,” he said.
“What was at stake here for councils and people committed to an old fashioned way of doing social care were the commissioning arrangements – they didn’t want to change the contracts they had with domiciliary care providers and other service providers.
“If they had moved away to either direct payments or individual service funds, those things would have changed radically.”
Another factor for councils would have been embarrassment, Duffy added.
“The policy was driven by people who were primarily interested in things appearing to be different, even if substantial change was not achieved, and for local authorities – this is the case with Somerset as well – it would be embarrassing not to have figures that are along the same lines as their peers. What happens in this situation is a form of peer pressure.
“As far as I understand it everyone saw this as a straightforward mechanism to raise their figures.”
Dispute over target
Duffy said the Department of Health’s implementation strategy for personal budgets was “flawed to begin with” and the 70% target was “meaningless”.
“The Department of Health should be held to account – they set the system up and it was designed in a sense to be a meaningless exercise, so I think ultimately the responsibility is with them,” he said.
“They knew what people were doing, everyone does it – so this is not really to do with councils. The reality is senior civil servants did not like this policy and their role at the time was to make it as easy as possible to achieve the targets, without having to change anything fundamental.
“Everybody looked good, but nothing real was happening – and that’s where we are today.”
Lamb defended the introduction of the “ambitious” personalisation target and said setting objectives was an important part of driving change.
“But you always have to be aware of the risk of gaming. Sadly in any system you will have cynical people who think they can just meet a target and get people off their back using a mechanism like this,” he added.
“You have to address that and expose it like you’re doing today. Hopefully by exposing it, this will force the council to rethink its attitude and give people genuine power and control [over their care and support].”
A Somerset council spokesperson said in light of the report’s findings it had “downgraded” its 2013-14 figure from 33% to 12% and take up of personal budgets had “steadily increased” since then.
The ASCOF dataset for 2013-14 has not been revised and Somerset’s performance remains recorded as 33%. The personalisation outcome measures were altered from 2014-15 onwards meaning comparable data for subsequent years is not available.
A spokesperson for NHS digital (formerly the health and social care information centre), which publishes the dataset, said it offered councils guidance on recording but “local authorities are ultimately responsible for the accuracy of their figures”.
How Somerset’s letter fell short
What were the criteria?
Somerset had to meet three criteria to record a person as receiving a personal budget:
1. The person (or their representative) has been informed about a clear, upfront allocation of funding, enabling them to them to plan their support arrangements;
2. There is an agreed support plan making it clear what outcomes are to be achieved with the funding and;
3. The person can use the funding in ways and at time of their choosing.
These have since been superseded by the Care Act 2014 statutory guidance, which uses different wording, but broadly demands the same of local authorities.
What did the auditors find?
Criteria 1
The report concluded that “it could be argued” that Somerset’s letter met the first criteria, because it informed service users of the value of what the council spends on their care.
However, it did “not necessarily reflect” the full amount spent on an individual for all of their care needs, the report said.
Criteria 2
The auditors did not undertake any testing to confirm Somerset’s compliance with criteria two.
The letter contained a series of FAQs, including ‘What is my care and support plan?’
The 3,000 clients were in receipt of a home care package, so it’s possible to assume that they all had a care plan in place. However, the report concluded that it was unclear whether the wording in the letter was “an implied acknowledgement that not all users have been given a plan, or whether this is an invitation to get an up-to-date plan produced”.
The crux here is that the care and support plan should be agreed through a meaningful conversation between the individual and their social worker. Personalised care planning should identify what is most important to a person for them to achieve a good life and ensure that the support they receive is designed and coordinated around their desired outcomes.
Criteria 3
The auditors said it was “questionable” whether the letter satisfactorily meets criteria three.
In the letter, direct payments were referred to and explained, but there was a lack of detail about the choices available to people with a personal budget, the report said.
“It is not likely that this will be fully understood by the recipient to enable them to make an informed choice,” the auditors concluded.
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I am a social worker in Somerset and was during this time. We have been encouraged to put in direct payments and personalised budgets but our older population are very reluctant to take them up.
Younger disabled and people with LD use them well. But busy families and older people with dementia do not want the responsibility of the finances and most would prefer adult social care to ‘sort it out’ in my experience.
With the lack of domiciliary care in the county direct payments, personal budgets and the use of micro providers is becoming a necessity.
Surely true personalisation is giving the service user the choice.
This is poor practice by Somerset but perhaps it is a better use of our energy to question why we have these false targets for personalised support. I accept that personal budgets have helped a number of people very much but for the majority it is meaningless and increases administration or, even worse, transfers it to their family or to service users. The original vision of personal budgets liberating service users to choose their own care and support has been destroyed with the catastrophic cuts affecting many councils.
A truly radical approach would redesign services from a perspective of human rights, recovery and choice rather than obsessing about financial instruments for charging and commissioning, which is what PBs have increasingly become.
It’s the old everybody’s doing it argument. Others got away with it because they were careful not to draw attention to themselves by showing such a dramatic improvement in performance. This is what happens when too much emphasis is put on performance targets at the expense of making genuine improvements.
Somerset County Council deserves credit for recognising its own ineptitude in this area, as does Community Care for drawing attention to a report which is not yet in the public domain
The 70% target was always an arbitrary target with no evidence base to support it. This will not be the only LA to have engaged in gamesmanship to meet it. Others may have been more subtle.
Many service users like and can benefit from the flexibility of direct payments but for others it is simply a way for LAs to pass responsibility for difficult reduction decisions to vulnerable persons.
For people with cognitive impairment personal budgets often mean that a person other than the one to whom they are said to be personal is actually managing the money and taking the decisions. If there is a LPA or Court Appointed Deputy in place; that may be entirely appropriate but that in my experience is rare. Good luck may provide a caring and responsible proxy budget holder but checks are often not rigorous.
There seems to be a great deal of skepticism about the value of personal budgets in the comments section and also the idea that older people actually want them. I find these attitudes patronising and dismissive. Social workers will feel very different when they come to need help themselves and want some choice in how it is provided.
My mother in law has a personal budget and receives a direct payment from an English local authority.In theory she can spend this any way she wants using her payment in card to pay for care which she has been assessed as needing. The reality is extremely different. The local authority don’t want her diverting money which they think is for domiciliary care to pay for more social trips out even though the social worker has agreed she has social needs in connection with social isolation. They have also queried spending from legitimate retailers for physical adaptations which will help with her assessed needs even though she has receipts.
I theory she has personalised care which is under her control. The reality is that the local authority are giving her the payment account but dictating every detail of how the money is spent. To top it off she has never actually seen her care plan.
My mother in law is perfectly competent to manage her own care but her local authority have only paid lip service to the principles of the Care Act.
Two and half decades on we still haven’t even achieved the ambitions of the Community Care Act.
This debacle helpfully reveals how to manipulate numbers in order to appease an organ grinder, in this case the DH. The resulting changes are the inevitable consequence of commissioning by outputs. Applying Systems Thinking principles to this at the outset would have shown the policy to be fundamentally flawed because it would create waste.
Measures (not KPIs) that drive better outcomes from the health and care system must be demand led, focusing on giving individuals the care and support they want, in ways that matter to them, and at times that are important to them and their informal carer networks. This may involve a personal budget. It may not. For this to be personalised, it should be a matter of informed choice.
QED – dictating more outputs will change behaviours but never the system. The challenges for managers – at all levels – are:
* to actively act on the system
* to understand that expanding the number of personal budgets in both health and social care requires significant system and culture change
* to accept that sincere aspirations to create change WILL lead to turbulence along its journey and therefore the acceptance by all, of risk
* doing nothing will not fix the problem.