Personalisation: challenges and opportunities wiki

In this article, Richard Gutch discusses the challenges and opportunities created by increasing personalisation of public service contracts.

Over the past few months, I have interviewed 100 chief executives of third sector organisations about the challenges and opportunities they are facing.

An opportunity and a threat

Apart from funding and commissioning, one theme came out more strongly than any others in my interviews - personalisation and individual budgets. Paul Farmer, chief executive of Mind, described it as the ‘elephant in the room’, both an opportunity and a threat.

On the one hand, it holds out the promise of truly independent living for disabled and older people, whilst, on the other, it means the, relative safety and security of block contracts could be replaced by the vagaries of market demand. ‘The days of one size fits all are over’, said Jackie Ballard, chief executive of RNID. ‘In future it will be all about person-centred planning and delivery.’

Policy questions

Personalisation provides challenges for providers, commissioners and service users alike. Overarching these challenges are some important policy issues, which are still being worked through. It is still unclear who the policy will ultimately apply to.

People with learning difficulties and physical impairments have taken part in the first pilots, but people with mental health issues and other long term conditions, and older people, are also expected to be part of the new arrangements. All these people will eventually have their own budget, which they will then have the option of either leaving with the local authority to manage or directly controlling themselves.

Individualised budgets

Anne Roberts, chief executive of Crossroads National Association, said it was still unclear whether carers would have their own budgets or whether there would be shared budgets. She reported that areas like Essex are already moving rapidly towards 80% of services being funded through individualised budgets.

Bryan Sheppard, chief executive of BID Services assumed that social workers, employed by the local authority, would assess people’s needs. He was concerned this could limit the scope for people to define their own needs and therefore be less empowering than some people are envisaging- on the other hand he accepts there has to be a way of controlling costs.

Conditions and constraints

One of the big policy issues is whether there will be restrictions on what the budget can be used for. The budget is a ‘conditional resource entitlement’ and must be used to achieve positive outcomes for the individual (as opposed to being used for gambling or for illegal purposes), but some local authorities may seek to impose further constraints on its use.

Simon Gillespie, chief executive of the MS Society, told me about the person who was offered help with getting dressed, whereas what he wanted was help with ironing. What he wanted cost £4,500 pa, whereas what he was offered cost £14,500 pa. Eventually, he got what he wanted and is now successfully running his own business.

Cleaners, gardeners and handymen are likely to be as much in demand as traditional carers, not to mention trips to the pub and to football matches or the installation of air conditioning to help reduce asthma attacks, all of which have been reported in the press as early examples of how budgets are being used.      

Running costs

Neil Betteridge, chief executive of Arthritis Care, was concerned about where the money was going to come from to pay for the new arrangements. Early evidence suggests that the per capita cost of the new system will be less than current arrangements, but, because of increased demand from service users in response to a more progressive system, the overall bill may be higher.

Concerns have also been expressed by Lesley-Anne Alexander, chief executive of RNIB, and others, that local authorities’ infrastructure costs for running the new system (eg for planning , brokerage, budget allocation) may be excessively high and be top sliced from the budget.

Budgeting framework

Up to now the pilots have been taking place in something of a budget policy vacuum, but, at some point, the new system will have to be set within the overall budgeting framework for social care, following debate on the forthcoming Green Paper.

Some people think the budget could eventually become part of the benefits system. Neil Betteridge expressed concern that there could then be a raid on incapacity benefit to pay for it. He also felt there was still some important details to be clarified by those promoting the concept of co-payment.

A cautious welcome

Underlying all these policy issues are some more fundamental concerns. Bill Albert, chief executive of Norfolk Coalition of Disabled People, welcomed the overall policy, but was concerned that it may prove to be a Trojan Horse for privatisation and cost-cutting.

Liz Sayce, chief executive of Radar, strongly supported increases in individual control, but saw some potential similarities with the Care in the Community agenda of the late 1980s, which was right in principle, but sometimes led to people being discharged into the community without adequate support, when rhetoric was not matched by effective implementation.

Provider issues

Third sector organisations, used to negotiating block contracts with public sector commissioners, will have to get used to marketing their services direct to consumers, as well as introducing far greater flexibility into their service offer. In the words of Victor Adebowale, chief executive of Turning Point, they are moving from being a wholesaler for public sector agencies to being a retailer for individual members of the public.

In practical terms, as Liz Tilly, former chief executive of Options for Life in Sandwell pointed out, people may want their support from 3-10pm rather than 9-5pm. How will this fit with care workers’ own family responsibilities? People are also likely to want to exercise more choice over who supports them, even though they may not necessarily wish to be the employer themselves.

Marketing capacity

Most third sector organisations are used to marketing direct to individuals for securing donations rather than for selling services. Some organisations, like United Response, have already started making the shift by marketing their services to the parents of people with learning disabilities and producing videos/DVDs describing their services for potential users.

For many organisations, developing marketing capacity will require significant investment, which funds like Futurebuilders, or the Health Social Enterprises Investment Fund, are well placed to provide, but it will also require major cultural changes. As Anne Roberts, chief executive of Crossroads National Association, commented, for many providers used to operating a service that is ‘free’ at the point of delivery the whole concept of charging people for services may feel alien.

Accountability

On the other hand, it has been pointed out that being directly accountable to service users, may bring providers greater loyalty and security than is possible under the vagaries of current commissioning and procurement arrangements.

Regulation

Internet shopping is likely to be a major part of the new arrangements. Organisations like the Disabled Living Foundation already provide information and advice on daily living equipment and there is a growing range of web-based systems for selling equipment and personal care services, bringing with it issues of quality control and reliability. Again, the potential downside to a market-based system is that people may get exploited or ripped off. Appropriate regulatory systems, and personal support, will need to be put in place to guard against this.

Clare Gilhooly, chief executive of Cambridge House in Southwark, also wondered whether community-based approaches to meeting people’s needs would survive the new arrangements, with group work losing out to individual provision, although there is nothing to stop providers marketing collective solutions to individuals.

Organisation structure

Some providers, like RNID, are restructuring their organisations to ensure they reflect the person centred approach to service delivery. Mark Lever, chief executive of the National Autistic Society, envisages that staff will need to be retrained to develop the new skills that will be required and that physical changes will need to be made to their facilities.

Sue Sayer, chief executive of United Response, is concerned that the costs of training may not be adequately reflected in the resource allocation system.

Commissioner issues

Commissioners may have to try and manage the market to ensure there is the right range of provision to meet individuals’ needs, as they will still have duty of care to the community.

Early indications are that many people will want to stay with their current service provider(s), but it is unclear whether block contracts will be the appropriate mechanism for financing this in the future, since the risk of low take-up would then be transferred direct to the commissioner. At the same time, commissioners may need to stimulate the development of new suppliers and help them get access to development finance to reconfigure their service offer.

Speed of implementation

The speed at which the new arrangements are being implemented concerned Jo Williams, chief executive of Mencap. It has taken the leading authorities like Oldham and West Sussex four years to get to their current stage of development and they still have some way to go. It is probably a 5-10 year process not a 1-2 year one, despite Minister’s hopes.

Initiatives like ‘In Control’ are providing valuable support to local authorities (but not so much to the third sector), but there are still huge changes required in systems and working methods, not to mention mindsets, before the new arrangements can be fully implemented across the board. If this is rushed too quickly, service users could be the ones to lose out.

Service users

The new arrangements have the potential to realise the goal of independent living for many disabled and older people, but often they may need help from others in identifying the most suitable package of support to meet their needs. Another disabled person, who has already been through the process, may often be the best person to advise on this.

The government’s policy is to have at least one user-led disabled person’s organisation, such as a Centre for Independent Living, for each local authority area, that can provide this advice. Victor Adebowale, chief executive of Turning Point, is concerned that without adequate support, there may not be sufficient demand from service users to make the whole system work.

Advocacy

It will be essential to include the cost of independent advocacy in the new arrangements, but it is questionable whether current forms of advocacy, which are not usually directly controlled by service users, will still be appropriate in the future. Existing third sector advocacy schemes may have to adapt and change rather than user-controlled advocacy simply being another element in the mix.

The third sector must also ensure that other types of advice are developed to meet needs. Stephen Burke, chief executive of Counsel and Care, is working with Help the Aged, Elderly Accommodation Counsel and a financial services agency to provide ‘First Stop Care Advice’ to address this need for older people.

Both Sue Sayer and Victor Adebowale expressed concerns about the lack of any form of regulatory framework for the provision of advocacy, which, potentially, left service users open to exploitation and/or poor advice. They accepted this risk is inherent in the ‘free market’ system of personalisation and individual budgets, but hoped that good brokerage schemes would go some way towards mitigating these risks. 

Conclusion

One thing that was clear from the chief executives I interviewed is that the personalisation agenda will dominate much of the debate over the next few years around the provision of services for disabled and older people. It is a development which they are all keen to embrace, albeit with a degree of apprehension about how it will unfold and what it will mean for their own organisations.

The sector’s leaders will need to demonstrate a positive and energetic approach to tackling these issues and to show they are fully embracing the new world, rather than expressing worries about the loss of the old one.

Acknowledgement: Richard Gutch thanks Simon Duffy, National Director of In Control, who read and commented on an early draft of this article.

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