Personalisation and its effects South West of England Regional Housing Learning and Improvement Network: Wednesday 4 th March Martin Stevens, Social Care Workforce Research Unit, King’s College London

Evaluation Team Caroline Glendinning; Nicola Moran LSE branch: Martin Knapp; José-Luis Fernandez University of Kent branch: Ann Netten, Karen Jones University of Manchester branch: David Challis; Mark Wilberforce; Sally Jacobs Jill Manthorpe; Martin Stevens

Introduction  Personalisation  Individual Budgets Evaluation findings  Housing 21 – broadening the debate report  Implications

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Government goals  Better prevention and earlier intervention for improved health and well-being  More choice, control and a stronger voice  Improve access to community services and tackle inequalities  Better support for people with longer term needs – better partnerships and more integrated services Source: Care Services Improvement Partnership presentation: ‘Department Of Health Direction of Travel – Policy Framework’

Principles underlying IBs  Greater role for users in assessing needs  Users should know resources available before planning how needs met. Resource Allocation System (RAS) recommended  Encourage users to identify desired outcomes and how to achieve these  Support individuals in using IBs  Test opportunities to integrate funding streams and simplify/integrate/align multiple assessment processes and eligibility criteria (NB No NHS)  Experiment with different ways of deploying IBs

The IB pilots  13 local authorities  representative mix but higher than average take-up of direct payments  Mix of user groups (OP, LD, MH, P/SI)  Mix of funding streams  Target numbers onto IBs by June 2007 (for evaluation)  Implementation support from CSIP

How were IBs evaluated?  Randomised trial – IB and comparison groups (but lots of flexibility within those groups re deployment)  Baseline data from local authority records  Follow-up interviews after 6 months  some challenges (logistical, instrumentation, interviewee exhaustion, proxies)  In-depth user interviews – support planning process  Interviews with IB leads, providers, funding stream lead officers, other managers  Interviews and diaries, front-line staff and first-tier managers  Add-on study of impact of IBs on carers

Evaluation findings  Processes  Inputs  Money  Outcomes  Cost effectiveness

Processes  Growing use of self-assessment and outcomes focus  Most sites (not all) developed RAS  Care managers spent more time helping plan IBs  Role for independent brokers  Care managers expressed more satisfaction with user relationship  More role for users and carers in planning support  Boundaries and legitimate use of social care resources  Monitoring and reviewing developing

Excluding NHS resource from IBs  Extensive partnerships with PCTs and providers  ‘Missed opportunity’  NHS Continuing Care – threats to personalised support  IBs and mental health  Integrated services and budgets  Indivisibility of ‘health’ and ‘social’ care outcomes  Cost-shunting

How much money from where?  The average annual gross value of an IB was found to be £11,450.1  Varied by service user group  People with physical disabilities £11,150  People with learning disabilities £18,610  People with mental health problems £5,530  Older people £7,860  Almost all (99%) included social care funding  11% had Supporting people; 8% Independent Living Fund; 1 Access to Work; No Disabled Facilities Grants ££££££££££ ££££££££££

Outcomes of IBs  Interviews at 6 months; only 45% had IB support in place  Overall quality of Life (single QoL question)  MH – IB group reported better QoL  Psychological wellbeing (GHQ)  OP – IB group lower well-being

More outcomes of IBs  Social care outcomes (Adult Social Care Outcome Toolkit measure)  Higher levels of ‘control’ in IB group, particularly for people with learning disabilities  Satisfaction with services provided  IB group more satisfied with outcome  Especially people with physical disabilities  Older people  Concerns about managing budgets?  Anxiety about change?  Lower budgets, more personal care, less flexibility?  Level of IB affects outcome

Cost effectiveness?  Some evidence of cost-effectiveness in the overall sample with respect to social care outcomes  Weaker evidence of cost-effectiveness with respect to psychological well-being  But picture varies significantly by user group  IBs appear more cost-effective for People with physical disabilities or mental health problems  No evidence of cost-effectiveness for older people  Mixed pattern for people with learning disabilities, slightly lower costs, slightly lower outcomes

User responses to choice and control  ‘I don’t want anything different’  Anxiety or unwillingness to manage money  ‘Carers are all laid on for me at the moment and I haven’t got the time and I haven’t got the brain really to work out financial details or anything like that, and I’m quite happy with the arrangement I’ve got.’ (Older person)  Able and willing to handle finances without stress  ‘so I thought, right, well I can do this cheaper myself so … I went to a smaller, cheaper and far superior agency.’ (Older person)

Perceived areas of risk  Poorer quality services  Service users being overwhelmed by the need to manage the IB  IB used inappropriately and unproductively  Hiring suitable and firing unsuitable workers  More open to physical and financial abuse  Loss of collective ‘voice’

‘Building Choices’: Personal Budgets and Older People’s Housing  No specific research on implications for social housing (particularly specialist provision)  Housing strategy – chimes with choice and control goals  Stakeholder workshop aimed to:  Identify issues  Share good practice  Broaden debate on personal budgets and housing

Themes from Housing21 report Organisation and expertise Landlord duties Risk Funding issues Diversity considerations

Organisation and Expertise  More active tenant role  Housing providers may provide brokerage  Quality of Information  Supporting People budgets pooled – tenants opt out of housing related support?  Core and add on schemes  opt in/opt out? –  Impact on sheltered housing staff  Closer involvement with care providers  More involvement in advising on care and financial issues?  More of a floating role

Landlord duties  Responsibility for risk  Response if residents opt out  Duty of care to third party providers?  In relation to equipment and adaptations  To those not taking up personal budgets

Risk to providers  Risk to extra care housing package  Choice of provider  Opting out of night care for example  Sheltered housing – changes in terms of increased flexibility reduce ‘24 hour’ availability?  Regulation – risk of recategorisation and inspection  Better understanding of the market

Risk and the built environment  Developing PEEPs?  Sustainable communal areas and facilities  Progressive privacy designs  Risks and security  Leasing/rental agreements in respect of specialist facilities and equipment  Insurance/liability  Training  Charging

Funding issues  Block contracts/individual contracts  Increased costs  Staff recruitment/retention  Uncertainty over contract duration  Minimum ‘sign up’ periods (incentive to purchase else where?)  Cost transparency – personal budgeteers  Increased commercialisation  Consolidate or speculate?

Diversity considerations  Personal budgets more attractive to people from BME groups?  Equity across groups  Mental health and capacity issues – a two tier system?  Increasing diversity with age

Implications  Safeguarding  Commissioning  Cost neutrality  Practice  Policy

How can we move forward on safeguarding and personalisation?  Not just a council affair  Nor even statutory sector  Way of revitalising adult safeguarding  But there will be decisions about monitoring (over and under protection)  And the safety net of social care may be tested.

New commissioning roles for local authorities  Informing the market – both supply and demand  Supporting providers through change  Promoting standards  Managing tensions efficiency vs personalisation

Can IBs remain cost-neutral?  Resource allocation  Managing the ‘winners and losers’  From bulk purchase to individual buyers  Integrating funding streams  ILF review  Increased demand for IBs  Mental health services

Practice issues  Managing change  Information  Training  Champions  Involve stakeholders  Managing risk  New ways of deploying IBs  Spread understanding of different approaches  Managing finance arrangements  New roles for social workers/care coordinators

Issues for policy  Resource allocation – underlying principles  Funding streams – personal budgets (social care only)  NHS budgets?  FACS and charging policies  Personal Budgets available for residential services  Individualism over collectivism  The legitimate ‘boundaries’ of adult social care

Conclusion  IBs – developing example of personalisation  Suggested positive outcomes  Identified areas of concern  Managing change  Integrating safeguarding  Balancing individualism and collectivsim  Implications across public services

Contact details Martin Stevens Social Care Workforce Research Unit King's College London Strand London WC2R 2LS