Personalisation has dominated social care for the last 20 years or so, since direct payments were first made legal by the Community Care (Direct Payments) Act 1996. The disability movement has been campaigning for more choice and control since the 1960s (Barnes, 2007).
However, take up of direct payments (seen as the key vehicle for personalisation) still remains relatively low, particularly for older people, who, as Rabiee et al note, tend to opt for managed personal budgets.
In the introduction to the article, there is a description of the aim of personalisation being ‘to give people choice and control by making the support they receive more tailored to individual needs, preferences and aspirations’ (p2). This goal describes the aims expressed by the disability movement (Barnes, 2007).
Another goal of personalisation was reducing state involvement in the provision of care, increased marketisation and transferring risk and responsibility to the individual (Ferguson, 2012).
This context is important to help interpret the findings presented by Rabiee et al. The article reports part of an interesting, small scale, qualitative study that provides useful insights into the types and degree of choice available to older people and the processes and structural barriers that help and hinder choice and control.
The research aimed to examine support planners’ and care managers’ practice and the experiences of home care agency managers.
The article reports on the findings of three focus groups, involving 19 support planners and care managers, held in each of three participating local authorities.
Interviews were undertaken with 15 home care agency managers, from services within the three councils.
The article mentions ‘Framework’ analysis, although little detail is given about any reliability and authenticity checks.
Support planning and brokerage processes
The findings are presented three sections:
- ‘the experiences of support planners’,
- ‘home care agency support planning’ and
- ‘Ongoing service provision: Responding to changes’.
Support planning and brokerage are separate functions in each of the councils. Support planners work with older people and their carers, to work out a basic plan that identifies the extent of home care. The plan is passed to brokers who identify the most appropriate provider.
This process appears to be a far cry from the idea that service users with their carers are enabled to choose providers, and as Rabiee et al note, appears very service led.
Council support planners
Support planners were routinely aware of the amount of the personal budget in only one of the three councils (despite this being seen as definitional of the process).
Budget restraint and shortages of care workers often severely limited the content of plans to basic personal care and the eventual service provided was often quite different to the original plan, despite creative thinking initially.
Furthermore, the introduction of brokers created potential communication problems, which meant the support planners often worked directly with providers, potentially creating duplication as well.
Home care agency managers
All managers reported that they and their senior staff developed detailed support plans and risk assessments for which basic personalisation and care planning training had been mostly been received.
They also reported communication barriers with brokers, in relation to information sharing about individual service users and brokers’ limited knowledge of the service user.
Despite wanting to support choice and control, they reported how councils restricted the kinds of services they could offer.
However there was some flexibility possible – some authorities allowed ‘time banking’ for example, where older people could ‘save up’ visits they missed or decided not to have, so that they could have more support for particular occasions, although this was limited.
Ongoing service provision – responding to changes
Councils reviewed support plans at 4-6 weeks and then annually, barring other problems, whereas agency managers believed that plans needed 6 weeks or so to resolve ‘teething problems’ (p12), so also undertook reviews and 3, 6 and then 12 months, although any changes arising from agency reviews would need council approval, creating delays.
The authors conclude that
new commissioning and brokerage arrangements have the potential to give older people using managed personal budgets greater choice and control over their support. However, resource constraints, new communication barriers, restrictions on the use of managed personal budgets and inadequate training for practitioners limited opportunities for support planners to act more creatively in helping older people to exercise choice.
Strengths and limitations
The authors themselves note that the study is limited in that they only examined practice in three local authorities. However, the small number of sites in the study allowed for a concentrated, in-depth analysis of how personal budgets are working in practice for older people.
Although the three councils may not be representative of all local authorities, their implementation of personal budgets was not unusually innovative or ‘leading edge’, so they present a picture of issues that may be ‘replicated elsewhere’.
Four important limits to choice and control for older people receiving managed personal budgets are identified in the research.
First, there is usually not enough money allocated to personal budgets, making it very difficult to provide anything other than basic personal care.
Second (and related to the first) are council restrictions on the kinds of support that personal budgets can be used to purchase.
Third is the limited opportunity to ‘bank’ time, so that higher levels of support can be provide for particular activities.
A final limitation is the requirement for all changes in support plans to be approved by the council. This appears to run counter to the spirit of personalisation, placing control firmly back with councils and not individuals.
Some positives were identified, in the potential of more efficient liaison between councils and providers offered by the brokerage system and looser plans developed by support planners, allowing home care agency to develop detailed support plans.
The chief impression from this article is that older people opting for managed personal budgets have quite limited choice and control. Many of the barriers are structural and difficult to address, for example, there is no sign of any increased funds being allocated to social care.
Thus, this suggests that more progress has been made in the aim of reducing state involvement in care and transferring responsibility for care from the state to the individual or family. However the aims of promoting choice and control, for older people, in particular, those not wishing to take up direct payments (still a large majority), appear to have progressed a lot less.
Rabiee, P., Baxter, K. and Glendinning, C. (2015) Supporting choice: support planning, older people and managed personal budgets, Journal of Social Work (23rd April 2015) DOI: 10.1177/1468017315581529 [Abstract]
Barnes, C. (2007) Disability activism and the struggle for change: disability, policy and politics in the UK. Education, Citizenship and Social Justice. 2: 3, 203–21. DOI: 10.1177/1746197907081259 [Abstract]
Ferguson, I. (2012) Personalisation, social justice and social work: a reply to Simon Duffy, Journal of Social Work Practice: Psychotherapeutic Approaches in Health, Welfare and the Community, 26:1, 55-73, DOI: 10.1080/02650533.2011.623771 [Abstract]