18 July 2008
Public service reform is entering a new era, with tailor-made budgets geared to the needs of individuals – and putting users in control
Reform of public services is now getting personal. After fixating on structures and ownership, policy makers and managers are recognising the requirement to involve people directly, putting their needs and nature first when considering service design. Now, personal budgets have caught the government's attention as a mechanism to do this.
These involve funding allocated specifically to meet an individual's needs and either held on a person's behalf or given as a direct payment. In the social care system, local authorities have just been given a major grant to bring in personal support, including personal budgets, to adults, over the next three years. In the health service, under Lord Darzi's reforms, people with long-term conditions have been promised personal care plans. Pilots of individual budgets, which involve funding from various sources, get under way next year.
And in education, personal skills accounts, which inform people of the funds available for them to spend on accredited colleges and training providers, are to be trialled imminently.
So if personal budgets are a solution, what's the problem? Progress in public sector reform has been significant, from providing the most effective services for the money being spent on them, to getting the most out of services to achieve a fairer society. But there is a sense that the use of single drivers to improve public services – from central targets to quasi-markets – has been exhausted.
While these reforms have improved performance, in some areas they have left the workforce alienated and the public uninspired. Practitioners might feel they operate in a different world to that of five years ago, yet the outcomes and the users' experience have not changed as radically. Too often, services that are impersonal are also ineffective and inefficient. The standard way the state provides services – en masse to an identified population through poorly integrated structures – is not always the best way to aid people through current challenges.
Sometimes support is not tailored enough to the person's circumstances. Often the front line is unable to make the decisions or use the resources that would enable them to help citizens. And often citizens are not able to participate in solving problems that affect them.
Public services involve complex and chronic issues, and social needs often overlap or are deep-rooted. At the same time, public services must be accountable, fair, responsive and affordable.
But complex problems don't always require complex policy. Social care – support for people with a range of needs arising from physical or learning disability, old age, or mental health problems – is now leading public service reform in terms of adopting a simple, effective, approach.
Personal budgets – which inform people, following a needs and means assessment, of their funding allocation and allow them to choose the support they need – will be introduced across local authorities. For example, a disabled person might use her personal budget to go away for a short break to an accessible holiday home. This might be a cheaper way for her to be included in society than a respite break offered by the council. She would get a budget allocation based on her needs, and be responsible for getting adequate care, but the support would be of her choosing.
Early trials of personal budgets are promising. The social enterprise company In Control ran 17 local authority pilots, funded by the Care Improvement Services Partnership, the Improvement and Development Agency, the Department of Health and the Cabinet Office. The evaluation of the pilots, by Demos and Chris Hatton of Lancashire University, found positive results across all kinds of care needs in adults and the range of established social care measures. More than 80% of the budget recipients changed the services they used, and only 1% reported a worse quality of life compared with standard forms of care support. Significant public service improvement was achieved without significant structural reform.
The importance of personalisation has led the Institute for Public Policy Research to advocate personal budgets for carers as an 'expense account' to help them in their role. This would enable someone to get a massage for back problems caused by lifting the person they care for, for example, which a direct payment for specified services would not allow. In this way, personal budgets give people control over the services and support they get, which is an outcome in itself.
In employment services, user involvement has been seen more in terms of a responsibility than a right. Choice over welfare services is very limited, which seems at odds with the aim for people to move from dependence on benefits towards employment. Estimates from 2006 find fewer than 2% of unemployed parents participating in active employment support, while New Deals and Pathways to Work are cost-effective initiatives for increasing the chances of people finding work.
One way of getting people the right kind of active employment support would be to give personal advisers greater flexibility over budgets to work with their clients. An individual budget combining employment support with the new personal Skills Accounts could be one way to provide individual packages of support. These could still require people to obtain adequate and appropriate help to get back to work, but allow a wider view of what this means. Those who need the most help to find sustainable work often require specific training, or psychological or care services, which are difficult to access under the current structures.
With skilled, empowered personal advisers, more flexible use of budgets could smooth support from different services, as people go from benefits into work, and enable them to take greater personal responsibility in relation to their services.
But as with any change to public services, there are risks, and personal budgets are no exception. Practical design and implementation must be paramount. There are tricky issues such as the amount of the budget, how and when it is set and the administrative burden that using it potentially shifts on to the user. The 'Kent Card', pioneered by that county council, is one innovative answer. This is a pre-paid Visa card, loaded with an amount agreed through an assessment of care needs and financial means. The card can be used to control individuals' service support from over 800,000 outlets in the UK or withdraw cash if it's agreed with their social worker that this is the best option. The council keeps its auditing role, and users have no financial records to manage.
The skills and powers of professionals in supporting, and often in holding, personal budget allocations will be pivotal to the scheme's effectiveness in any policy area. There is an urgent need to reconsider the role of personal advice and information and the workforce that is to deliver it. Changes in the way that services are organised, measured and monitored will be equally important to achieving the essential change in culture.
A more fundamental risk is that greater personal support undermines public services' ability to be fair to all, and is felt to be fair by all. The fear is that focusing on support for each individual undermines the important focus on the collective. But if designed and implemented correctly, simple, flexible and transparent services could improve accountability to users and the public. Being fair in practice requires applying principles of targeting support (and sanctions) in a way that accounts for the particular circumstances. Standardised, imposed and ineffective services benefit neither individuals nor communities.
And personalising is not privatising. In social care and employment services, for example, there is already a considerable market, in which voluntary and private providers have a significant share: 93% of funds in the case of adult social care. But personal budgets shift the commissioning in this market towards the frontline adviser and user. For this to happen effectively, the management and development of these service markets, including the strengthening of quality safeguards, must become a core responsibility for local authorities.
The introduction of personal budgets should not permit cuts to public budgets. Pilots of personal budgets in social care suggest that they are more efficient – avoiding duplicate assessments and ineffective services, and cutting back-office administrative costs. But without a richer concept of efficiency that recognises the value of a range of outcomes, using personal budgets as a cost-saving tool would quash the spirit in which they have been proposed: to create more holistic and empowering services.
From the independence and inclusion of older and disabled people and family members that care for them, through to achieving sustainable employment and routes out of poverty, personalising support and engaging people will sometimes be crucial if public services are to achieve our shared aspirations for them.
Professional support, collectively accountable and funded services, and market management will become even more important if personal budgets are to achieve their goal. But personal approaches could allow services and professionals to focus more on the individuals that services are intended for. Rather than 'reform' public services, personal budgets could revitalise them by being more centred on, more supportive of, and more trusting in, people. Personal public services are that simple, and that radical.
Pick'n'mix budgets
Personal budgets are a funding allocation given to users, following assessment, which should meet their assessed needs. Users can take it as a cash payment, leave councils to commission the services (while still choosing how their care needs are met and by whom), or take a combination of the two. The funding allocation may be held by a personal adviser or assistant, or the user. This means they offer a potentially good option for people who do not want to take on the responsibilities of a direct payment.
Individual budgets are like personal budgets, but also draw on multiple funding streams, sometimes from different services. The Department of Health is currently piloting individual budgets in adult social care, and an evaluation is due shortly.
Direct payments transfer to individuals cash in lieu of a specific service, such as social care, and are intended to give users choice over their care. The payment must be sufficient to enable the user to purchase services to meet their needs, and must be spent on services that users need. They can be spent only on care services (albeit from a range of providers). Direct payments already exist in many local authorities' adult social care services for older or disabled people; approximately 6% of social care spending comes in this form.
Person-centred or self-directed support is a broader concept than the budgetary mechanism, and involves greater choice and control over services, and the professional advice, information, advocacy and brokerage with other services which that requires. In care services for disabled people especially, it is linked to the concept of independent living, which is based on the principle of equality of control over services, and greater equality and inclusion through services.
Vouchers have been proposed in services not subject to a means test (unlike social care), most notably by the Conservative party in education policy, where they allow parents to choose schools, including to leave the state sector and transfer to the private sector, often subsidising private provision.
Sophie Moullin is a research fellow at the Institute for Public Policy Research. She is author of Just Care? A fresh approach to adult services, available free to download at www.ippr.org
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