By Catherine Needham and John Tizard
12 August 2010
There is a consensus that personalisation is a significant way to reform public services. Central to New Labour’s approach to social care services was the belief that services should be tailored around the people who use them, and this is also increasingly integral to reform in the NHS.
The coalition government has indicated that it wants to continue the pace of personalisation, and of personal budgets in particular, and there is interest in how this approach can be applied to housing, employment, training, education and criminal justice. It seems to be a major element of Cameron’s ‘Big Society’.
With this change in emphasis, people are looking to social care to see what can be learned about how such budgets work in practice. Within social care, the pace of implementation is being dictated by a national indicator that states that 30% of eligible people must be on personal budgets by April 2011 and 100% by April 2012.
Anyone who meets the fair-access-to-care criteria is entitled to a personal budget, which can be used to purchase anything that is likely to achieve an agreed outcome. Much of the excitement around personal budgets comes from the creative ways that people are improving their quality of life, and often saving money into the bargain.
The Department of Health has been cautious about how much personalisation can save, noting that savings on individual care plans might be offset by the increased need for training and infrastructure. Other advocates of personalisation have been more bullish about the potential for savings. For example, Simon Duffy, director of the Centre for Welfare Reform, has provided evidence from a range of local pilots to show that personal budgets have cut costs. Given the current financial context in the public sector, the message that personalisation could lead to a more effective use of resources is a very powerful one.
However, more detailed probing into social care shows that personalisation is at an early stage in most councils. According to Care Quality Commission figures for 2008/09, only 6.5% of adults who receive care use direct payments or personal budgets.
This means that many of the difficult challenges around personalisation – its radical promise of remaking public services – have yet to be realised. In many areas, councils are running dual systems, allowing innovative purchasing by a small number of service users on the fringes, without disinvesting in traditional services. However, this approach will become unsustainable in an environment in which the government is demanding cuts of more that 25% in social care budgets.
A recent report from the Public Management and Policy Association, the Centre for Public Service Partnerships and Queen Mary, University of London looked at some of the issues that need to be addressed if personalised commissioning is to be meaningful. These include: getting support planning right; shaping the market; decommissioning; workforce considerations; dealing with the risks; and redrawing the citizen-state relationship.
If personalisation is to work for more than a few motivated users, there needs to be access to effective information, advice and advocacy. Many councils are currently devising advocacy models, and there are debates about how far this should be in-house or provided by external partners, such as user-led organisations. Effective support planning is likely to be resource-intensive and it is not yet clear how this is to be funded.
Alongside this, council commissioners are expected to redeploy their energies away from negotiating block contracts and towards stimulating and supporting local provider markets. The public sector role is expected to encompass assessment of need, budget allocation and business development of the supply market. It will then be the job of budget holders to decide what they want to purchase. This will create substantial organisational and financial challenges for providers, as they shift from a wholesale to a retail model.
And as users make choices about the services that they wish to purchase, some existing facilities will become redundant and/or unviable. They might have to be decommissioned and closed. For local politicians, there could be difficult political battles about closing high-profile day centres of long-standing, for example.
Individualised commissioning will also create new workforce problems, with a potential shift away from qualified social workers and home care staff towards support planners and personal assistants. Home care staff, already perceived as vulnerable and low paid, might take on personal assistant roles in which budget holders do not provide training or meet legal requirements on employment terms and conditions. New forms of regulation would be required and groups of staff might consider forming mutuals to provide their services.
There could be potential risks outside of decommissioning and workforce changes, which include the potential for abuse of budget holders, informal carers or employees. There is uncertainty over what to do when users exhaust their individual budgets but still have needs: will they be entitled to free NHS provision? If service users are able to top up their individual budgets, what will the impact be on one of the core values of the welfare state: equity and fairness?
Getting the regulation right for personalisation – avoiding excessive audit and regulation mechanisms while providing appropriate protections – will be a difficult balance. Social workers might feel more exposed as they sign off support plans over which they have less control than traditional care plans, fearing that they will retain responsibility if things go wrong. There will need to be a certain amount of courage from managers and politicians when the media gets hold of a story about abuse of a budget. There also needs to be some clarity about the extent to which personal budgets could and should be spent with no strings attached, in the same way as benefit payments. There seem no compelling reasons why this should not be the case, but a debate is essential.
Finally, there is the need to redraw the citizen-state relationship. Personalisation, and the broader approach of self-directed support, has been described by some as ‘a new Beveridge’. It creates unresolved questions about equity, for example. Will this be an agenda that benefits sharp-elbowed, articulate service users, or is it a way to rebalance the system towards those whose voices are not currently heard? Will council-funded service users have access to the same choice of services as self-funders (who constitute the majority of care users)?
What is the balance between user empowerment and responsibility: for example, should access to a budget be conditional on behaving in certain kinds of ways? What opportunities exist for service users to pool budgets and foster approaches based on mutualism and community, to avoid the claim that personalisation is just a tool for individualising the welfare state? To what extent should the state offer approved lists of suppliers and ‘smart payment’ cards, or should it leave individual purchasers to make up their own minds about where to spend their money? This all has to be debated.
The government has signalled its intention to proceed rapidly with personalisation. Frustrated disability campaigners also feel that the time for debate is over: any ambiguities in the approach need to be worked through in the process of implementation.
For a lot of people though, the radical possibilities are only just becoming apparent. There are many issues to be addressed before it is clear what public services based on the principles of personalisation will look like. All we know is that they will look radically different from today’s welfare state. We need an urgent debate now.
Catherine Needham is an associate of the Centre for Public Service Partnerships and a lecturer in public policy at the Queen Mary, University of London; and John Tizard is director of the Centre for Public Service Partnerships
12 August 2010
‘Personalisation’ is about to be rolled out across the public services. And it could be an effective way to empower citizens and cut costs. But what is the track record so far in social care? Catherine Needham and John Tizard report
There is a consensus that personalisation is a significant way to reform public services. Central to New Labour’s approach to social care services was the belief that services should be tailored around the people who use them, and this is also increasingly integral to reform in the NHS.
The coalition government has indicated that it wants to continue the pace of personalisation, and of personal budgets in particular, and there is interest in how this approach can be applied to housing, employment, training, education and criminal justice. It seems to be a major element of Cameron’s ‘Big Society’.
With this change in emphasis, people are looking to social care to see what can be learned about how such budgets work in practice. Within social care, the pace of implementation is being dictated by a national indicator that states that 30% of eligible people must be on personal budgets by April 2011 and 100% by April 2012.
Anyone who meets the fair-access-to-care criteria is entitled to a personal budget, which can be used to purchase anything that is likely to achieve an agreed outcome. Much of the excitement around personal budgets comes from the creative ways that people are improving their quality of life, and often saving money into the bargain.
The Department of Health has been cautious about how much personalisation can save, noting that savings on individual care plans might be offset by the increased need for training and infrastructure. Other advocates of personalisation have been more bullish about the potential for savings. For example, Simon Duffy, director of the Centre for Welfare Reform, has provided evidence from a range of local pilots to show that personal budgets have cut costs. Given the current financial context in the public sector, the message that personalisation could lead to a more effective use of resources is a very powerful one.
However, more detailed probing into social care shows that personalisation is at an early stage in most councils. According to Care Quality Commission figures for 2008/09, only 6.5% of adults who receive care use direct payments or personal budgets.
This means that many of the difficult challenges around personalisation – its radical promise of remaking public services – have yet to be realised. In many areas, councils are running dual systems, allowing innovative purchasing by a small number of service users on the fringes, without disinvesting in traditional services. However, this approach will become unsustainable in an environment in which the government is demanding cuts of more that 25% in social care budgets.
A recent report from the Public Management and Policy Association, the Centre for Public Service Partnerships and Queen Mary, University of London looked at some of the issues that need to be addressed if personalised commissioning is to be meaningful. These include: getting support planning right; shaping the market; decommissioning; workforce considerations; dealing with the risks; and redrawing the citizen-state relationship.
If personalisation is to work for more than a few motivated users, there needs to be access to effective information, advice and advocacy. Many councils are currently devising advocacy models, and there are debates about how far this should be in-house or provided by external partners, such as user-led organisations. Effective support planning is likely to be resource-intensive and it is not yet clear how this is to be funded.
Alongside this, council commissioners are expected to redeploy their energies away from negotiating block contracts and towards stimulating and supporting local provider markets. The public sector role is expected to encompass assessment of need, budget allocation and business development of the supply market. It will then be the job of budget holders to decide what they want to purchase. This will create substantial organisational and financial challenges for providers, as they shift from a wholesale to a retail model.
And as users make choices about the services that they wish to purchase, some existing facilities will become redundant and/or unviable. They might have to be decommissioned and closed. For local politicians, there could be difficult political battles about closing high-profile day centres of long-standing, for example.
Individualised commissioning will also create new workforce problems, with a potential shift away from qualified social workers and home care staff towards support planners and personal assistants. Home care staff, already perceived as vulnerable and low paid, might take on personal assistant roles in which budget holders do not provide training or meet legal requirements on employment terms and conditions. New forms of regulation would be required and groups of staff might consider forming mutuals to provide their services.
There could be potential risks outside of decommissioning and workforce changes, which include the potential for abuse of budget holders, informal carers or employees. There is uncertainty over what to do when users exhaust their individual budgets but still have needs: will they be entitled to free NHS provision? If service users are able to top up their individual budgets, what will the impact be on one of the core values of the welfare state: equity and fairness?
Getting the regulation right for personalisation – avoiding excessive audit and regulation mechanisms while providing appropriate protections – will be a difficult balance. Social workers might feel more exposed as they sign off support plans over which they have less control than traditional care plans, fearing that they will retain responsibility if things go wrong. There will need to be a certain amount of courage from managers and politicians when the media gets hold of a story about abuse of a budget. There also needs to be some clarity about the extent to which personal budgets could and should be spent with no strings attached, in the same way as benefit payments. There seem no compelling reasons why this should not be the case, but a debate is essential.
Finally, there is the need to redraw the citizen-state relationship. Personalisation, and the broader approach of self-directed support, has been described by some as ‘a new Beveridge’. It creates unresolved questions about equity, for example. Will this be an agenda that benefits sharp-elbowed, articulate service users, or is it a way to rebalance the system towards those whose voices are not currently heard? Will council-funded service users have access to the same choice of services as self-funders (who constitute the majority of care users)?
What is the balance between user empowerment and responsibility: for example, should access to a budget be conditional on behaving in certain kinds of ways? What opportunities exist for service users to pool budgets and foster approaches based on mutualism and community, to avoid the claim that personalisation is just a tool for individualising the welfare state? To what extent should the state offer approved lists of suppliers and ‘smart payment’ cards, or should it leave individual purchasers to make up their own minds about where to spend their money? This all has to be debated.
The government has signalled its intention to proceed rapidly with personalisation. Frustrated disability campaigners also feel that the time for debate is over: any ambiguities in the approach need to be worked through in the process of implementation.
For a lot of people though, the radical possibilities are only just becoming apparent. There are many issues to be addressed before it is clear what public services based on the principles of personalisation will look like. All we know is that they will look radically different from today’s welfare state. We need an urgent debate now.
Catherine Needham is an associate of the Centre for Public Service Partnerships and a lecturer in public policy at the Queen Mary, University of London; and John Tizard is director of the Centre for Public Service Partnerships
