Going through the levels
Yesterday I sat in on a conversation about social care involving about twenty people, mainly practitioners from Leicester. They were an impressive group; committed, thoughtful, optimistic about what could be achieved but very aware of the limitations of existing provision.
Personalisation was a recurrent theme of the conversation. Speaker after speaker described the importance of fully understanding someone’s needs. A typical story involved a person with severe learning difficulties who started continually hitting his head against a wall. The behaviour was treated as a regrettable but inexplicable symptom of mental incapacity until a nurse noticed that the person always hit the same side of his head. It was only then that a quick examination revealed a severe but treatable ear infection.
Government strategy on personalisation has for several years revolved around the development of individual budgets. Currently, about a third of eligible social care clients have taken up individualised funding (either through direct payments or managed personal budgets) but take-up has been by far highest amongst those with physical disabilities. Extending individual budgets to people with learning difficulties, mental illness or dementia is much more challenging, though it will often be the carer who is the budget holder. Evaluation of individual budgets is limited but positive. But just because more people have individual budgets doesn’t mean services will necessarily be better, even from the perspective of the service user. The quality of care will depend enormously on the amount of money allocated and what services are available to be purchased.
A key question is how individual budgets might develop to facilitate a reframing of social care. As I listened to the conversation I could distinguish four levels of ambition for publicly funded interventions. Level one – the traditional system – simply involves the bureaucratic allocation of available services to the identified client group. Level two is what is conventionally meant by personalisation: allowing individuals to use allocated resources to choose their own care packages. This is fine for individuals, but many clients need support in making choices, and unless clients and carers come together to commission services, their choices may be very limited. So level three involves working with clients and carers to identify a set of interventions, which in the context of people’s wider personal resources and needs, will offer them the greatest empowerment and wellbeing. An example here is a group of people with physical disabilities and learning difficulties who collectively commissioned fitness classes which are not only tailored to their needs but also offer the opportunity for sociability for both clients and carers.
Level four is the most challenging but arguably the most necessary. This involves exploring the latent resources of care, altruism and ingenuity which exist within a client’s family, friends and wider community and then asking what interventions might best release these resources. This is the kind of thing being explored by a variety of RSA projects ranging from work on social networks and wellbeing to a whole person recovery approach to people in rehabilitation from drug and alcohol dependency.
There is no inherent reason why this social asset approach can’t be pursued within the context of individual budgets. The fact that individuals have to buy into services is a useful discipline to ensure those services are effective and relevant. But without co-ordination and collaboration the danger is that individual budgets end up buying tiny parcels of care from large impersonal providers while local public agencies retreat into a focus on resource allocation and risk management.
As resources are squeezed and needs grow the ambition should be that individual budgets are seen not simply as a way of paying for services but as a means to leveraging collective action and civic commitment. A new deal for social care rests on reframing the relationship at its core from professional and client to community and citizen.
Public services – the stakes are high
The effectiveness of public services is vital to our social fabric and important to our economic competitiveness. Public service policy will feature heavily in the forthcoming General Election campaign, with debate overshadowed by the fiscal deficit.
Looking at this context, surveying innovative practice in public services and reading through the ideas being offered by the parties and their think tank advisors, a number of key trends can be seen emerging. They are:
Resource pooling: After years of discussing better joining up of information, budgets and back office services we will reach a tipping point. The Total Place pilots are already pointing the way. This will be made more possible by technological advances – better data capture and greater interoperability of systems and made more necessary by the squeeze on spending.
The search for legitimacy: Public agencies will continue to search for ways of engaging the public in decision making and service design. This will be made more possible by new techniques for engagement ranging from citizens juries and on-line deliberation to neighbourhood decentralisation. It will be made more necessary by continued public disenchantment from traditional forms of representative democracy (including our ailing poltical parties) and the need to legitimise difficult spending decisions.
Behaviour shaping: Policy makers and service mangers will continue to explore how public investment can be better used to shape the values and behaviours of citizens. This will involve services turning outwards and acting as a catalyst for change in the community. This will be made more necessary as, without encouraging greater self reliance and civic activism, services will not be able to meet growing needs. It will be made more possible as we learn about what shapes behaviour and social norms.
Social infrastructure: The goal of behaviour shaping is already leading innovative public services to try to find out more about what makes communities more or less resilient and resourceful. This will be made more necessary as we see the consequences of weaker social bonds, for example more isolated older people. It will be made more possible as projects like the RSA’s Connected Communities develop ways for agencies to map social networks and develop community tools to strengthen those networks.
From spending on to spending by: Personal budgets for social care are often cited as one of the best existing examples of innovation. Recently, reports from both right and left of centre think tanks have stressed the scope for turning public services into co-operatives or mutuals. These policies have in common the idea that instead of agencies spending money on services for disadvantaged people, clients are able to be the managers of their own services. The potential benefits are more responsive services, empowerment of service users and even scope for welfare budgets to provide the seed capital for emerging social enterprises. This is made necessary by the desire and the need for disadvantaged people to have more control. It is made possible by better, more accessible, data providing information about the cost of existing interventions and helping individuals and organisations to argue that they could use funding more effectively.
Taken overall, these trends see the core role of the state move from service provider to decision maker and strategic enabler. It will not be a smooth process of change ; there will be many pitfalls and dilemmas on the way. A key factor will be the degree of decentralisation. If local leaders are able to experiment then the welfare system as a whole can learn fast about what works (and what doesn’t).
If we get this right we will see wave upon wave of public sector innovation resulting in a smaller but more effective and strategic state alongside a deeper public commitment to collective decision making and social responsibility. If we get it wrong – if, for example, budget reductions are too extreme and too indiscriminate or if Whitehall reacts to tough choices and public concern by centralising control – then we are in for a decade of retrenchment, resentment and a hollowing out of the public sphere.
The stakes are high. The major parties are on their way to this vision but none yet has shown quite the clarity or courage needed. It will certainly be interesting, and even possibly electorally salient, to see who commands this debate in the next few months.
Personal budgets – an update
I have written before in this blog about personal budgets for social care. This afternoon, at a 2020 Public Services Trust event here at the RSA, we had an interesting presentation on this issue from Richard Humphries, Senior Fellow at the King’s Fund.
He made four points:
• The role played in the emergence of personal budgets by campaigning organisations of disabled people. A council chief executive at the meeting said that he believes councils have a role in setting up social movements of this kind to help challenge inertia and professional resistance to change.
• The very slow spread of personal budgets. Still, thirteen years after they were first made possible by legislation (and despite support from Government and opposition parties), only about 5% of social care spending is delivered through personal budgets.
• The importance to making budgets work of the infrastructure of information, advice and support to budget holders. (However, this point was put in question by Peter Gilroy, Chief Executive of Kent CC, who said more and more of his county’s clients prefer to simply receive their entitlement on a payment card and be left free to decide for themselves how to spend it).
• The need for personal budgets to be implemented in the context of a wider consideration of the relationship between citizen and state. Personal budgets raise issues about rights, responsibilities and reputations. The evidence seems to suggest that the councils that have made the most progress (such as Oldham, which channels over 50% of its social care spend through budgets) have done so because they have seen the policy as part of a wider strategy of personalisation and empowerment.
Although the evidence is still limited, Richard also confirmed that personal budgets appear to be popular with clients and a better way of getting money spent on the things that people care about rather than bureaucracy.
Personal budgets may in time prove to be the most radical shift in public service delivery of recent years, with major implications for other services. Over the next twenty years I expect more and more public services to be delivered through budgets directly or indirectly devolved to service users.
RSA Animate
RSA Mobile
RSA Comment- RSA Projects Blogs
- Twitter @RSAMatthew
RSA Bookshop
The RSA Bookshop, in partnership with Blackwell's the UK's leading academic bookseller, offers Fellows and friends an opportunity to purchase books and to explore our speakers’ ideas in greater detail. Visit the RSA Bookshop.