Problems with personalisation run deeper than ‘gaming’ targets

It’s been six years since the government set a target designed to trigger a radical shift in the way adult social care was delivered – and three since most councils claimed to have met it.

Councils were told to move 100% (later reduced to 70%) of eligible, community-based service users and carers onto personal budgets by April 2013.

The target symbolised a shift in power from the state to individuals and their families, and promised people more choice and control over the support they receive.

But just last week, a report released to Community Care under the Freedom of Information Act threw the validity of this target – and the performance reported by councils – into question.

The report was commissioned after Somerset council’s personal budget figures rose dramatically from 7% in 2012-13 to 33% in 2013-14. Auditors brought in by chief executive Pat Flaherty in 2014 found this increase had largely been achieved by sending a letter to 3,000 clients in receipt of home care services, telling them how much the council spent on their care.

The report suggested that a similar approach was also being used elsewhere.

The auditors concluded the tactics were ‘questionable’. Former care minister Norman Lamb described the findings as ‘appalling’. Sector leaders ADASS declined to comment.

‘Failed delivery’ 

But for many the real issue here is not ‘gaming’ statistics, it’s the underlying culture.

The personalisation agenda was about more than just rolling out personal budgets – it required a shift in staff attitudes towards empowering service users to make decisions for themselves, considerable reform of local authorities’ financial and management systems, and a reduction in the use of inflexible block contracts so that people could have a choice of providers.

The Somerset report (produced in August 2014 but never published) simply confirmed what personalisation experts knew all along – the true principles of the policy were not delivered.

More recent publications, including a report from the National Audit Office on personalisation in adult social care, suggest some of the same problems persist.

The NAO found that some staff they spoke to did not distinguish between a council-managed personal budget and a situation where a person did not have a personal budget at all. It concluded that this implied that “the move to a personal budget can be administrative and not reflect genuine personalisation”.

‘No strength in the system’

Simon Duffy, director at the Centre for Welfare Reform, says the responsibility for this failing lies with the Department of Health and its flawed strategy for implementing personal budgets.

“The buck stops with the Department of Health. These targets were defined in ways that were easy to reach, so that’s what everyone did.

“If everyone is doing it and the DH sets the system up and pressurises councils to effectively arrange their numbers, then I don’t see how you can blame local authorities.”

You can ask why ADASS and other bodies haven’t raised it as an issue though, he adds.

“Local authorities have been hit massively by cuts that they’ve not been able to defend themselves from, so what we’re talking about here are public bodies with no effective strength in the system, they are the weakest parts of the welfare state.

“They are utterly unable to defend their basic economics, so expecting them to be able to also insist on some integrity from the Department of Health is impossible.

“It’s a sad way of looking at it, but that’s the truth.”

‘Insufficient challenge’

The other issue, Duffy says, is that local authorities have never been supported to change their existing contracting and commissioning arrangements.

“Local authorities and people committed to an old fashioned way of doing things in social care didn’t want to change the contracts they had with domiciliary care providers.

“If they had moved away to either direct payments or individual service funds, things would have changed radically. The target allowed them to maintain their old procurement processes.”

Indeed, figures published by NHS Digital (formerly the Health and Social Care Information Centre) show that council-managed personal budgets remain the dominant form of budget. In 2014-15, 350,000 (57%) of the 609,000 people receiving support in the community had a council-managed budget, while a further 115,000 did not have a personal budget at all.

Duffy argues that more local authorities should look at individual service funds (ISFs) – a mechanism that enables a person’s budget to be managed by a third party.

“So many people with disabilities and their families are saying ‘I want flexibility, I want control but I don’t want a direct payment’ – so why the hell haven’t councils been encouraged or challenged to shift their commissioning arrangements to the use of individual service funds?

“ISFs were successfully implemented in Glasgow 20 years ago. They are associated with very high outcomes and many providers [not all] want to work in this way, but are told they can’t because they have to work to these fixed, tendered contracts.”

Figures quoted by the NAO show just 4% of service users had an ISF in 2013-14 and research published by the Think Local Act Personal partnership found they were poorly understood and that many providers were not contracted in ways that allowed them to offer flexible support.

Duffy adds: “The issue that has therefore really been at stake for local authority commissioners is maintaining those structures set up in the early 90s, the model of buying blocks of care en masse in very restricted ways, defined by process and number of hours.

“That whole way of thinking hasn’t been sufficiently challenged.”

‘Lack of transparency’

The principles of personalisation are of course now enshrined in the Care Act 2014, which places a duty on councils to ensure anyone whose needs they must or chose to meet receives a personal budget. The act itself defines in administrative terms – as the cost to the local authority of meeting the person’s needs – rather than as an instrument of personalisation.

But this objective is made clear by the statutory guidance, which states that individuals must be given clear information about the money that has been allocated to meet their needs, be able to choose from a range of options for managing their budget, and have a choice over how they are supported, and by whom.

John Waters, research lead at disability organisation In Control, says the act is a welcome development, but councils are still falling short on delivering personalised care.

“We have a picture here where the statute is correct, it’s saying how the relationship should look and feel, the power should rest with disabled people with the support of their social workers, and the role of the local authority should be an enabling one.

“Where we’re falling down it appears is with delivery and the worrying element of that is the inability of councils to demonstrate whether or not they are achieving the degree of choice and control that’s being expected of them – and there’s no easy way of measuring that.”

Waters points to recent research carried out by In Control, which found “a number of typical types of restraint” were happening in relation to how people are supported.

“The places where people can be supported, the ways in which they’re supported, who supports them, and the amount of money available for a particular period of care are all being constrained. This runs counter to the Care Act guidance, which is a concern.”

‘Reducing choice and control’

He adds that “all too often” councils are failing to be transparent about what personal budgets should look like, but acknowledges this is largely due to financial pressures.

“It’s no surprise given the pressure local authorities are under with the cuts. There’s huge unprecedented cuts being raged on them in a way that is uncalled for, unwarranted, and that certainly leads to the frustration of the good developments we’ve seen.

“You’ll see councils reducing commissioned providers in vague attempts to make savings, which will deny individual choice – people can sort their own solutions out better then we can – but local authorities are being forced into acting in ways that ‘reduce’ control.”

These issues need to be addressed and Waters believes the answer lies in frontline practice. He calls on social workers to be honest with individuals about how systems are working, how resources are being allocated and the extent of choice and control available.

“That’s a fundamental role social workers can play – be transparent about what the rules are, but also internally urge their own authorities to be transparent with local people.

“It’s no good having guarantees and rights in law, if you don’t know what those rights are.”