Two social care experts have two very different opinions on personal budgets, which allow individuals to decide how to spend their social care money.
Peter Beresford: There is no dispute that personalisation of social careis an important objective. However, two pieces of published research I have written with Colin Slasberg and Peter Schofield show that the government’s strategy for delivering it, by giving people a “personal budget” to “self-direct” their support through a resource allocation system (RAS), has created a distraction from this challenge – and at great cost.
Simon Duffy, former chief executive of In Control, the organisation that pioneered the concept of self-directed support and developed individual budgets (now called personal budgets) and encouraged the government to adopt this system, recently issued a public apology for it.
Our first study, Can personal budgets really deliver better outcomes for all at no costs?, shows how claims that personal budgets are achieving better outcomes are simply untrue. They are based on the success of the small minority of service users whose personal budget takes the form of a “direct payment”. Direct payments have been around since the 1990s. People who have the necessary time, energy, skills and, crucially, support, have enjoyed great success. Critically, they are also far more likely to have the level of cash required to meet all their needs. In 2010, this group comprised just 7.7% of all service users, but commanded 13.7% of the spending.
An illusion that personal budgets work has been created by unrepresentatively packing survey samples with this small group of people. In a high-profile survey of 2,000 “personal budget” holders in 2010, about 90% were from this group. Crucially, the 10% who did not have a direct payment did not experience any better outcomes. Yet it is this 10% who truly represent most service users.
Our second study, How self-directed support is failing to deliver personal budgets and personalisation, reveals a major fault with the strategy. Its fundamental building block is the RAS – which Duffy calls a “disaster area” – that tells the person “upfront” how much money they will have to plan their support. However, councils have legal obligations in relation to meeting certain levels of need, and to manage their budgets within a cash limit. These decisions can only be made once the actual costs of meeting needs is known. This in itself makes a mockery of “upfront allocation”. A freedom of information request to a number of councilssuggests that the upfront allocations are wildly different from what people actually get. This makes them meaningless. It has taken a huge investment in bureaucracy to create these allocations.
Since 2007, the study found councils have significantly increased staffing levels to administer this, while the volume of support delivered has reduced. The loss of productivity is as much as 20%, costing in the region of £400m a year, which can be added to the £500m spent on introducing this system.
But all need not be lost. If the government faces up to the failure of this strategy, it can set a new direction that will work. The RAS, in all its forms, should be dropped, along with the consumerist philosophy that underpins the strategy. Most older and disabled people need to work with an infrastructure of advice, advocacy and administrative back-up to achieve the best approach to their support. The government must create the environment within which this can happen. While it is possible to pursue personalisation within existing resources, the government must accept that achieving the best outcomes requires people to have the level of resource that is right for them.
Julie Stansfield: For decades, people in public services talked of shifting control and sharing power. Disabled people and their allies invented ways of making this happen – the social model, independent living, inclusion movement, direct payments – but the pace of actual change remained painfully slow. Service systems and cultures restricted progressive change.
Since 2007, personal budgets have given the system a shake. Thousands more people now receive direct payments (the way of using a personal budget that improves outcomes most). Many provider organisations are working hard to personalise their care offer to people – partly because this is the right thing to do but also knowing that people will have the ability to choose to go elsewhere. New innovations are starting to appear such as individual service funds, which offer a way for people who do not want to, or can’t, control the money for their care, to still get increased choice and control via a chosen provider.
Sally explains how a personal budget allowed her mother with dementia to live at home rather than in a care home where she had been put to bed every day at 3.30pm. “We used this budget to bring Mum back to her own home. She now, has her independence back and has her own staff so can choose what time she wants to go to bed. Mum feels safe in her home and is in control of her finances. She just needs a little help to make sure things run smoothly. I am convinced that Mum would not be here today if it were not for her personal budget,” says Sally.
The problem is not personal budgets but rather their poor delivery in too many places. Findings from the National Personal Budgets Survey clearly show that even those people receiving managed personal budgets achieved positive outcomes overall (although not as good as direct payment or individual service fund users). The analysis also clearly shows that improved outcomes are not simply the result of higher spend.
More important is the growing weight of wider research and evidenceshowing the potential of personal budgets and good and bad outcomes. Most recently, the independent evaluation of a three-year pilot of personal budgets in health showed significant improvements in wellbeing. Crucially, the findings about what works replicated those in social care. To achieve the best results, personal budgets must be delivered according to the principles of self-directed support – that is, people need to know the budget they have to plan their care with, be able to choose the mechanism for managing the budget and have maximum flexibility in use of budgets.
This is really important. Personal budgets are just a mechanism; the principles of self-directed support are the critical thing. But this is also where the real problem lies. Our advice line is inundated with people telling us these principles don’t apply where they live. It is in these places we find the over-complex resource allocation systems; burdensome support planning approaches; rigid rules on spend; social workers not trusted to make judgments; people left without information, advice and advocacy. We share the concerns about too much process and bureaucracy, and we are afraid that the situation is getting worse. But these problems don’t result from the model of self-directed support itself, but from difficulties public services have in transferring power to their users. We need to make common cause and fight together for personal budgets that truly shift power to people.
• Julie Stansfield is chief executive of In Control, pioneers of self-directed support