OPM Public Interest Seminar: Personalisation Briefing Paper

At the centre of many government reforms is the desire to give service users greater choice and control over the services they receive, improving independence and quality of life as a result. Specific policies include personalisation of targeted and universal services, the development of community capacity and the use of self-directed support backed by personal budgets or self funding. Central government is committed to the personalisation of childrens services, employment and housing support and health and adult social care. Public sector commissioners are working on how to both reshape services and hand over purchasing power to the service user to ensure they have more choice and control. The true test of whether personalisation is working must come from evidence of improvements in peoples lives and whether service users feel more in control. The affordability of a more personalised approach is obviously also important. Evidence from a range of evaluations suggests that whilst personalisation can deliver there are both challenges that need to be tackled and a recognition that, like all practices, it will require continuing active support and development to succeed. Key themes for debate which have arisen out of the evaluation evidence on the use of self directed support and personal budgets and their impact on outcomes for service users include: Psychological well-being of service users Availability of choice Managing a budget Safeguarding Cost effectiveness

In all cases the evidence shows that the experience outcomes, costs and benefits vary between different groups of service users. The remainder of this paper gives a brief overview of the key issues around the headings above. If you would like to discuss any of these issues in more detail or the support that OPM can provide, please contact Ayesha Janjua on 020 7239 7876 or email communications@opm.co.uk.

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OPM Public Interest Seminar: Personalisation Briefing Paper

Key themes and challenges of implementing personal budgets

Psychological wellbeing of the service users
Choice and control is assumed to improve the psychological wellbeing of users. A recent report by the National Audit Office found that service users were having a positive experience of moving onto personal budgets. They were receiving more personalised support, increased choice of activities and suppliers, increased control over the care and support provided and 1 increased satisfaction with the level and quality of their care and support. Evidence shows that in some cases, cash payments have meant that individuals become more independent and 2 therefore reduce the burden on their families . These findings are echoed in the evaluations for the Department for Education (DfE) of the 3 4 individual budget pilots for families with disabled children and the work of In Control . In particular parents reported it enabled our children to have increased independence and allowed them to try something new as traditional service provision was not proving to be effective. In the childrens individual budget pilots a significant proportion of families experienced difficulties in developing and agreeing support plans and budgets. The processes were found to be long-winded and families reported a lack of information. Families in lower social classes C2, D and E were also less likely to experience being more in control. The OPM/ECDP study of 5 adult social care budget holding in Essex produced parallel results . Alongside the many people who have benefited from budget holding the Essex study showed that for a small but significant number of service users, being responsible for budget management considerably raised their levels of stress and anxiety. These experiences are particularly obvious where the service user has experienced a delay in receiving payments or has tried to contact the council to remedy an issue with their payments. The process of contacting the council and not being able to locate the right person to talk to is frustrating for service users and their families.

Availability of choice
The DfE study found that once a plan and budget had been agreed families found it difficult to adjust their plans. In Essex, some individuals also feel less in control as a result of no longer being able to access services via the council. They experienced a sense of isolation, having lost
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National Audit Office (July 2011) Use of Social Care Budgets, Ipsos Mori OPM (2008) Budget-Holding Lead Professional Pilots, DCSF

DfE, (June 2011) Individual budgets for families with disabled children - final evaluation report: the individual budget process, Meera Prabhakar et.al.
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In Control (2010) Personalisation children, young people and families. Briefing 3 Evaluation and outcomes, Nic Crosby
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OPM and ECDP (2011) Longitudinal study of cash payments for Adult Social Care in Essex, Interim Round 2 Report for Essex County Council, Holloway, S, Neville, S, Watts, R.
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DfE, (June 2011) Individual budgets for families with disabled children - final evaluation report: the individual budget process, Meera Prabhakar et.al.

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OPM Public Interest Seminar: Personalisation Briefing Paper the clout associated with the involvement of the council. For example, if a service user cannot rely on a well -eveloped, local market of providers, they feel powerless to complain about a poor service or high costs, due to fear of losing their relationship with the provider and not being able to find an alternative. In these cases, individuals remarked that they would rather that the council was still directly responsible for providing care, as they would be less vulnerable to the decisions of a single provider. Both the In Control and DfE evaluations found that increased purchasing of personal assistants greatly increased childrens ability to access mainstream publicly funded and commercially 7 provided provision. The National Audit Offcie study however found very little evidence of a real shortage of providers, although, they did find that choice of services provided was often limited. For example, some participants only had one applicant when recruiting a personal assistant. Choice can also be limited in rural areas due to a shortage of providers, and also where provision is restricted to approved suppliers often as part of framework contracts.

Managing a budget
Managing a personal budget for some users also brought an increased and unwelcome administrative burden on themselves and their families having to undertake tasks such as completing timesheets or updating and checking budget levels. Where personal budget holders experienced positive outcomes from the services they were then able to purchase, this was largely felt to be a fair trade-off. However it is resented in cases where personal budgets have not yielded access to better services or indeed outcomes. Research also shows that some local authorities are better at supporting users with the more technical aspects of budget 8 management . Some individuals continue to be unsure about exactly what they are and are not allowed to spend the budget on, and fear that they are spending it wrong. Research shows that without easy access to people who can answer their questions, this leads to a level of anxiety, and 9 frustration . This has also been a significant issue for professionals in some areas who do not know what to advise if they are themselves unsure of the boundaries. This can also lead to concerns of how to safeguard vulnerable adults whilst allowing them to have as much choice and control as possible. The National Audit Office report found that local authorities have developed some risk management systems or risk monitoring tools to mitigate the risks associated with personal budgets. For example, to minimise the risks of budget holders misspending their personal budget one local authority has created an electronic payment card scheme, whereby the direct payment is loaded onto a pre-pay bank card. This way, what someone spends their personal budget on can be limited. Another local authority has developed a risk assessment tool that social workers can use to decide with service users and carers what type of personal budget is most suitable for their circumstances.

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National Audit Office (July 2011) Use of Social Care Budgets, Ipsos Mori National Audit Office (July 2011) Use of Social Care Budgets, Ipsos Mori

OPM and ECDP (2011) Longitudinal study of cash payments for Adult Social Care in Essex, Interim Round 2 Report for Essex County Council, Holloway, S, Neville, S, Watts, R.

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OPM Public Interest Seminar: Personalisation Briefing Paper We designed a tool to help social workers weigh up with their clients and carers about, theres like different shaded parts to it and if youre in the red it means youre not really suitable at all to manage a personal budget. If youre in the amber you could with support if 10 its structured and if youre in the green youre definitely a dead cert as it were.

Safeguarding
Evidence on safeguarding vulnerable people suggests that when allocating personal budgets to families, local authorities need to be aware of the challenges of managing the risk of harm that 11 vulnerable adults and children face . For example, relevant professionals should undertake individual family risk assessments looking at whether a service user or a childs self directed support plan properly addresses agreed risks. Care should be taken to ensure that others do not misuse a persons budget. There should be appropriate vetting and monitoring of providers. Safeguarding should be explicitly raised with families and be a focus of all stages of negotiating a personal budget. Safeguarding continues to be a concern. For example how can the Local Autority step in swiftly where there has been a breakdown in the provision of a service but the budget holder manages the purchasing of the service. Does the more arms-length relationship between care managers or lead professionals and service users reduce the ability of staff to respond quickly in crises? How can an appropriate balance be struck between enabling service users to take risks open to others but also ensure they are adequately safeguarded?

Cost effectiveness
Evidence on the cost effectiveness of the personal budgets models currently suggests that there is a potential for them to be more cost effective than the existing approach to providing social care services. The DfE personal budgets evaluation found that the use of such budgets was broadly cost neutral. Hence given the improved outcomes reported by families, they are more cost effective relative to current service provision. However the social class gradient in terms of perceived improvements in outcomes suggests that there is more work to be done. The individual budgets evaluation for the Department of Health found some evidence that the use of individual budgets enabled improved social care outcomes to be achieved at the same cost but found no advantage in relation to psychological wellbeing. The research also explored the outcomes for different user groups. Users of mental health services and physically disabled young people were able to make the most cost effective use of individual budgets in terms of both the social care and psychological well-being outcome measures. People with learning disabilities experienced increased cost effectiveness with respect to social care but only where the service users had a self directed support plan in place. Pre existing social care arrangements appeared to be slightly more cost effective with respect to psychological wellbeing. For older people, there was no difference in cost-effectiveness between individual budgets and standard support arrangements in terms of social care outcomes. Pre existing social care

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National Audit Office (July 2011) Use of Social Care Budgets, Ipsos Mori I pp.21

DfE (2011) Individual budgets for families with disabled children: final evaluation report the IB process, Prabhakar, M., Thom, G., Johnson, R.,

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OPM Public Interest Seminar: Personalisation Briefing Paper support arrangements were marginally more cost effective than individual budgets with respect 12 to psychological wellbeing .

The future?
There is increasing pressure on local authorities, providers and their partners to increase the pace of change and further embed personal budgets in social care, childrens services and health. The formation of the Think Local Act Personal partnership provides sector led improvement and support through a number of publications. There are also increasing calls for the recognition that personalisation is more than just personal budgets and that implementing a personalised approach in interactions with services users (especially those with complex needs) 13 may be more important . This is supported by an expanded role for social capital and local community development, as well as universal services that can ensure citizens can live their lives as they want, where all services meet their personal needs.

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IBSEN (2008) Evaluation of individual budgets pilots programme Department of Health Wood, C. (2001) Tailor Made: Personalisation must work for those who need it most. Demos

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