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.
Getting old in an ageing society – why we need a revolution in attitudes
I spoke this morning to the Resolution Foundation, an impressive new think tank focusing on issues facing the low paid. The conference was looking in particular at social care so I chose to focus on ageing and attitudes to old age.
If we continue to stigmatize the old and treat social care as a Cinderella service we are in for a grim time. Over the last five years local authorities have systematically rationed social care to only those with the very highest need. There is virtually no state funded provision focused on maintaining independence; it is about managing dependence. And this is at a time of rising budgets.
Over the next few years budgets will be squeezed and squeezed again and a crisis-ridden social care sector will be competing with virtually every other public service in it’s pleas for more cash. In terms of a new funding settlement, the Government has delayed its social care green paper yet again. It is difficult to see what ministers can hope to come up with given that any solution will require more contributions from individuals at a time when we all feel just as squeezed as the state.
Which is why I urged the conference delegates to seize the opportunity provided by the economic crisis, and the soul searching accompanying it, to restate and refresh the argument for a revolution in social attitudes to ageing and the aged
Drawing on new evidence and argument about how human beings operate, what motivates us and what brings us well-being, it is time for us to define the good society as a society where people can look forward to old age. It is time also to recognise that full citizenship involves a understanding and accepting our inter-generational responsibilities (a particular challenge for the resource-guzzling baby boomers) , and that individual well-being cannot be achieved while we view the natural process of getting old with fear and disgust (if you think I am overstating the problem with current attitudes and lives try reading AA Gill’s vivid essay in this week’s Sunday Times). I urged the conference to focus just as much on changing attitudes in society as policies in Government.
These are only the top lines of what I said, if anyone is interested I would be happy to lay out more of the substance later in the week.
The dilemmas of dementia
I find myself supporting both the good intentions of the Government’s National Dementia Strategy and sympathising with the doubts of campaigners in the face of extremely limited extra funding. The strategy recognises that the costs of dementia will rise by about £1billion a year for the next 30 years, while only making an extra £150million a year available over the next two years. Without major advances in prevention and treatment it is difficult to see how even today’s patchy standards of care can be maintained.
I know from my own experience the incredibly challenging nature of Alzheimer’s for carers. A close friend has been caring for her mother for two and a half years and I try to help out whenever I can. The slow deterioration of her mother’s memory is sad and difficult but it is something to which you can adjust gradually. Everyone who comes to the house knows about the condition, understands they may not be recognised, that even simple things have to be explained carefully and repeated endlessly. Indeed, as the Government strategy points out, sufferers can enjoy a good quality of life for years (looking back my friend thinks her mother first started showing obvious symptoms about six years ago).
But things get much harder when the mood swings kick in. As the sufferer declines they start to lose insight into their condition, feeling frightened and frustrated. They often get angry, assuming that other people must be responsible for them feeling confused or excluded. It is this that creates a tragic dilemma for many carers.
My great aunt recently moved to a nursing home. She resisted fiercely for years, until she had virtual round the clock care in her tiny flat, but, in the end, after yet another fall at home, she gave in. But Eileen is still mentally alert. I enjoy visiting her and, with the pleasant staff and surroundings, her TV and radio, she is settling into a reasonable, albeit sedentary, quality of life which could last many years.
But for the Alzheimer’s sufferer it is much harder to achieve such a transition. If she is moved to a care home she is very likely to become disorientated, alarmed and even aggressive. This is why patients suffering from dementia are so often put under the so-called ‘chemical cosh’ of powerful sedatives. It’s not – as is sometimes imagined – because the care home staff are uncaring or lazy but that the sufferer is genuinely disturbed and likely, for example, to try to leave the home despite having no idea where to go.
So for carers, often young middle-aged people with their own growing children to think about, the moral dilemma is that even as the caring gets harder and harder (and with few moments now to brighten up the experience) the carer knows their relative will deteriorate much more rapidly once they go into a home.
This is why high quality day and home care is so vital, making the task for the family manageable for as long as possible. But it costs, and the costs keep rising. This isn’t just a problem for Government, or for those immediately affected, it is a challenge for the whole of society.
The chances are there will be someone in your street caring for a dementia sufferer. To have friendly neighbours who are willing to sit with the sufferer for a few minutes while a carer pops out or does something in another part of the house can make a big difference. As well as all the good ideas in the Government plan, and as well as hoping for a medical breakthrough, we must somehow make these kinds of tiny acts of community support the norm – not the exception.
Civil society – its unexplored potential
Notwithstanding my Kerry Katona like mood swings, I find myself increasingly convinced that the economic downturn is going to be very, very bad; so much so that our lives and our country will never be the same again. Even if we have seen the beginning of the end of the problems in the financial sector (and there is still a huge amount of leveraging to unwind), and even if the economy starts to pick up slowly towards the end of next year, we then face severe cuts in public investment. On the one hand, this could kill off any recovery (as we now know, much of the job creation of the last decade has been in the publicly funded sector) while on the other, we will all suffer diminished public provision and many will face real hardship.
As the Conservatives inadvertently underline every day, there is no alternative; things are going to be grim. What we must do – the ‘we’ in this case being society in general and organisations like the RSA – is make better use of the under-used capacity which exists in society.
Innovation is very often precisely about this mobilisation of capacity. So, as I was saying to Leonard Cheshire Disability this morning, individual budgets for social care work in part because they tap into the previously unseen and unused capacity to manage their own lives and services which exists among social care clients and carers. Another example, which I heard in Leicester from a Fellow called Nigel Lothrop, is a successful scheme in which young people who have been in trouble or have dropped out of school clear and maintain the gardens of people unable, for one reason or another, to do it themselves. Using a time bank mechanism the young people then trade the hours donated to the gardens for time getting one-to-one tuition in the basic skills they often failed to pick up in formal education. Apparently, the scheme is proving too successful in that the barrier to it now is not the need for or supply of volunteers but the capacity of the local authority and third sector to manage the scheme.
If we are to improve the quality of our lives, protect the most vulnerable and strengthen communities we need these kinds of experiments to be taking place everywhere. However much capacity we are going to lose in the private and public sector, it is dwarfed by the unexploited potential of civil society. Mobilising this capacity should be a priority for policy makers and a new raison d’etre for the RSA Fellowship.
The economy: how do we adapt?
There is page after page of newspaper analysis and comment of yesterday’s mini budget but the top line critiques of the package may be rather confusing to those without the time or inclination to dig deeper. Darling is criticised simultaneously for doing too little to boost the economy (there is widespread scepticism about the impact of the VAT cut), for borrowing too much and for raising taxes in two years to help pay for that borrowing (in fact, the Government’s main medium term strategy to tackle the deficit is tight restraint on public spending from 2010 onwards).
There is a widespread view in the print media that the Government has somehow cheated in managing to achieve higher popularity ratings while the economic news worsens. Today is payback time. George Osborne is back on form and no one is asking whether, at a time when we should be boosting people’s confidence, it is responsible for him to say everyone earning over £19,000 will soon be worse off. In fact someone on that salary will – according to the Conservatives’ own figures – lose five pence a week!
But Labour can’t complain. Whatever the merits of yesterday’s package we shouldn’t be starting from here. It’s true – as I have said in the past and Larry Elliot said more elegantly than me yesterday – that most of us played our part in fuelling the debt bubble. It is also true that by wanting low taxes and action to tackle inequality and improve public services, public opinion created the political dilemma to which more Government borrowing was the answer. But politics is about leadership. This Government, and those like me who have advised it since 1997, have to take responsibility for not explaining the real choices and stopping the party before it all got out of hand.
Unless the whole of society is willing to follow the Government’s model and go deeper into debt, it is difficult to see how things will improve. Indeed the best bet must be for a very long period of sluggish growth. Even if things do pick up slightly next year, with interests rates already very low and the Government not able to offer any extra fiscal stimulus, it is difficult to see how a crawl back to recovery will become a march.
So we are back to the question of how we adapt. On the one hand, we have to lower our expectations as private and public sector consumers. On the other, and more positively, we must explore and exploit untapped social capacity.
To take one example, there is already a social care funding crisis. Unless we can reduce unnecessary dependency and increase voluntary effort the care gap will grow into a chasm. Public funding won’t help us out, nor can we expect people to suddenly start saving lots more for their old age. If there is an answer it involves some combination of mobilising voluntary effort, increasing the productivity of public investment (especially so it goes into maintaining people in independence rather than paying for dependency), fostering innovation (so, for example, we can create an effective intermediate labour market of people, many of whom may be retired themselves, being paid for a few hours caring work here and there), and much better collaboration between the different agencies and NGOs working in the field.
If things are going to be as tough as many people suspect, social care is only one of the many needs that are only going to be met thought this combination of pro-social behaviour and innovation. As I will be telling an RSA meeting in Leicester tonight, there couldn’t be a more important time for the RSA and particularly its talented and conscientious Fellowship to be turning outwards and asking what difference it can make.
Twitter @RSAMatthewRSA 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.