Made to measure, by Tash Shifrin

25 Oct 07
'Personalised public services' is the Brown government's latest Big Idea. But how are the ambitious plans for round-the-clock GP services, individual health budgets and one-to-one tutoring going to be delivered in practice? Tash Shifrin investigates

26 October 2007

'Personalised public services' is the Brown government's latest Big Idea. But how are the ambitious plans for round-the-clock GP services, individual health budgets and one-to-one tutoring going to be delivered in practice? Tash Shifrin investigates

Under Tony Blair's government, choice and diversity were the favoured ingredients for public services. But now there is a new mantra, and this time it's personal. In Gordon Brown's first Labour Party conference speech as prime minister, he used the word 'personal' 15 times – all in the context of public services.

Public services must be 'accessible to all, personal to all', the prime minister urged. He pledged 'an NHS that is also a personal service' and 'learning personal to each pupil', adding: 'It's time also to make public services personal to the needs of the elderly.'

Brown set out a vision of public services tailored to each recipient. 'Education available to all, not one size fits all, but responding to individual needs,' he promised. No off-the-peg garb for Brown's new Britain.

Chancellor Alistair Darling added his contribution in the Comprehensive Spending Review and Pre-Budget Report, with an extra £250m to help fund personalised services and support in schools. This is in addition to the £400m a year allocated in the Budget to fund one-to-one teaching for pupils falling behind in English and maths.

The CSR also included an increase of £190m for social care, which is supposed to cover increased personalisation, including individual budgets.

But Local Government Association senior policy consultant Mike Heiser is not convinced the money is enough. 'There's probably more leeway for most schools to introduce personalised learning than for social services [to increase personalisation],' he says.

Even so, in education, the overall level of funding is still less in the state sector than for private schools 'where there is more personalised learning', he adds.

'In authorities where there are large numbers of schools on the minimum funding guarantee, there will be questions about whether it's affordable.'

While Brown's speech suggests bespoke might be the government's latest Big Idea, the personal tag is not new. Brown used it in his Labour conference speech in 2004, backing Blair's public sector reforms. 'The public sector reform agenda – more flexibility, accountability and personalisation – will not stall but be stepped up,' he declared.

In the same year, the then schools minister David Miliband – now foreign secretary – provided the foreword to a pamphlet urging personalisation of public services, published by the think-tank Demos.

The government has also implemented a more individualised approach to commissioning through direct payments, which allow service users to purchase their own care. Individual budgets that bring together different funding streams are being piloted in social care, testing an extension of the scheme.

Also not new are Brown's promises to change the school testing regime to allow pupils to be assessed when they are individually ready and to introduce one-to-one tuition. These are being piloted in ten local authority areas under the Making Good Progress scheme announced in March.

Some schools, such as Liverpool's St Silas (see box on page 21), have joined their local pilots because the scheme fits in with a personalised approach they had already adopted.

But the renewed government emphasis on personalised services does suggest a subtly different tone to the Blairite idea of choice and diversity, with its stress on standards, targets and private sector provision.

Some commentators believe it represents a significant shift in policy. Demos researcher Niamh Gallagher says it signals 'a potential transformation of the welfare state, more fundamental than [the introduction of] Compulsory Competitive Tendering and markets in the 1980s'.

The concept is a step on from choice, she adds. 'Choice meant giving individuals a choice between A and B. [Personalised services] means supporting them to make the kind of choice that's right for them – and that might be C.'

Sarah Tough at the Institute for Public Policy Research sees personalisation as a more egalitarian, universalist social policy than choice, which was more easily exploited by the middle classes.

'The evidence does show that the middle class have the skills, knowledge and access to information and therefore engage with the choice agenda a lot more,' she says. 'I think the whole thing about personalisation is that it's about helping everyone. The government is clear it is not just “catch-up” for the weakest.'

This does not necessarily mean there will be less of a role for the private sector, says Carol Propper, economics professor at Bristol University and Imperial College, London, although there could be an impact if the private providers were relying on block contracts.

She says: 'If the choice programme was about saying “thou shalt place a fifth of thy contracts with private suppliers” then clearly independent service providers had a guaranteed role. But I don't see [personalisation] necessarily precluding private providers unless they have entered the market because of guaranteed numbers.'

So what does personalisation mean in practice? The prime minister's speech suggests that matters such as hospital waiting times will now come under the 'personal' brand. 'I want an NHS personal to you because you are seen by a consultant in a matter of days, not months,' he said.

More concrete initiatives include personal tutors and a personal health check for everyone on the NHS.

Further details of the new model emerged in new health minister Lord Darzi's interim report on his review of the NHS and in the plethora of announcements issued alongside the chancellor's PRB and CSR settlement.

Darzi set out some immediate measures to establish 'a personalised NHS – tailoring care to patient needs and preferences'. These centred on the provision of 100 new GP practices in areas with a shortage of doctors, new money for GP-led health centres, open all week but not requiring patient registration, and – with an echo of more Blairite days – 'opening up the primary care market' to ensure half of GP practices offer services at weekends or weekday nights.

The health minister also floated a more radical – and more clearly 'personalised' – measure to be examined in his final review: giving people with-long term conditions individual budgets to help them design their own support packages.

These personalisation measures have received a cautious welcome in the public sector.

At the NHS Confederation, which represents hospital and primary care trusts, policy director Nigel Edwards says he does not think 'anyone has any problems' in principle with the more controversial of the possible NHS reforms: the individual NHS budgets that Darzi is set to report on next year.

He does warn that the vagaries of individual patients' decision-making could make it difficult for NHS organisations to fund their services. 'How do you set the budget? For social care, use of services is relatively predictable. Health care is less predictable. It would be difficult for acute conditions,' he says.

Edwards believes handing patients a complete budget might be 'a clumsy way of doing it', suggesting instead a voucher that could be used by patients to pay for elements of their treatment. But he adds: 'One place where patient budgets would be very good is mental health. If I was going to start anywhere, I'd start there.' The budgets could 'empower' patients by letting them choose a package of services, he says.

The GP measures are likely to require a renegotiation of doctors' contracts, Edwards says. But the early signs are that doctors will agree to the changes if they are funded.

Laurence Buckman, chair of the British Medical Association's GP committee, is keen to dispel the idea that the government is introducing something new. 'Personal care is what I do now. If I didn't offer personal care, my patients would go somewhere else,' he argues.

GPs are not opposed to weekend or evening opening as such. A BMA survey found that 53.3% would offer extended hours if given the resources to do so – although 72.5% think that this is not the best use of NHS funds. 'If that's what the government wants, we'll talk,' Buckman says.

He is sceptical about offering patients individual budgets, though. 'A personal budget doesn't work the moment the risk rises. What if you suddenly become diabetic? You can't afford that.'

The NHS currently 'pools the risk' of patients needing sudden, very expensive treatment, such as heart surgery, Buckman says. Health care needs this, he argues, because of the very variable nature – and cost – of illness and treatment. 'It can be very, very hard to adjust the budget according to how sick people are.'

If the doctors are cautious, however, the teachers are pleased. John Bangs, head of education at the National Union of Teachers, says the union has been pressing for personalised pupil support in schools for some time. Brown's announcement is 'a big victory', he says.

The NUT wants 'an entitlement for all youngsters at key points in their lives' to be able to call on additional expert teacher time to help them to do their best in exams and move smoothly through changes of school. 'That requires a bank of qualified teachers,' he says, which should not be an insurmountable obstacle. 'It isn't going to cost the earth, based on the experience that [finding staff to mark] national curriculum tests hasn't cost the earth.'

In advance of Darzi's follow-up report and the government's forthcoming Children's Plan, the details of the personalisation blueprint have yet to be inked in – and the costs are not yet clear.

Propper says: 'In terms of cost, the design of personalised services hasn't really been thought about yet. It's more of a buzz phrase.'

Collective provision of services offers economies of scale, but personalisation is 'not necessarily' more expensive, Propper says. 'It depends on the service.'

She adds that tailoring services to individual needs does not have to mean a separate service for every person. For example, providing services to help reduce obesity could be done through tailored support on a family or group level. 'That would be less costly than trying to stop one person chomping Mars bars when everyone else is eating them,' she argues.

It is the cost question that concerns Peter Beresford, professor of social policy at Brunel University. He looks to the lessons of direct payments for social care. 'The evidence from research is that people really value it, they do have real benefits in all sorts of ways, people can live better, fuller, more contributive lives,' he says.

But he warns that ministers have sometimes portrayed individual payments schemes as a way to get better services for less. 'The argument that it is cheaper is not evidenced,' he says.

Direct payments are still used by only 50,000 people across the country, while evidence from the individual budget pilots is even more limited. Beresford urges caution in moves to hand NHS budgets to patients who might at times need support to use them. 'We need to ensure there is an infrastructure of support to make it possible to do this,' he says.

And, if public services are really to be delivered in a 'personal' way that genuinely helps their users, the new plans must be 'tested, well-worked through and reliable'.

For Brown's administration, the personal is more political than ever, but it is the practicalities rather than the policy that might come under the sharpest scrutiny.

At your own pace: personalised learning in Liverpool

At St Silas Church of England Primary School in Liverpool, head teacher Jane Ngenda says personalised learning has always been high on the agenda. 'Our school has lots of different pupils with lots of different needs,' she says. Many are from deprived backgrounds, although Ngenda is loath to have them stereotyped in this way. She points out that between them the children speak 23 languages.

The school jumped at the chance to build on existing small-group teaching initiatives by joining Liverpool City Council's Making Good Progress pilot. Liverpool is one of ten local authority areas selected to try out the government programme to allow pupils to be assessed when they are individually ready and to introduce one-to-one tuition. Organising the extra support 'has not really been a problem — it meant a bit of extra planning', Ngenda adds. 'It can mean a slight shift in looking at how the school day is run. You need to be flexible enough.'

St Silas now employs an extra part-time teacher to carry out personalised teaching in small groups and provide individual tuition outside normal school hours — often on a Saturday morning — to 27 children aged ten and 11.

'We want it to be seen as something children want to do,' Ngenda says, explaining that as well as tuition on a Saturday, the children are offered other activities, such as using the computers and sports.

The pilot scheme has been popular all round. 'This is welcomed by staff without a doubt. It's focused and targeted at what each child needs. They're back in class with more self-confidence.'

Parents are also 'very keen for their children to be involved' and get the personal tuition that most could not hope to pay for themselves.

It is too early in the pilot to measure the results, but Ngenda says: 'You can see how the children do make rapid progress.' She adds that the children are also relieved of much of the stress that the testing regime has generated, even on young pupils. 'There's a health aspect, too.'

PFoct2007

Did you enjoy this article?

AddToAny

Top