Personalisation: Who cares? Who Pays? Hilary Land Sue Himmelweit Unison, 2010

Personalisation every person who receives support, whether provided by statutory services or funded by themselves, will have the choice and control over the shape of that support in all care settings… …..Self-assessment will also be a cornerstone of personalization. Giving service users the opportunity to assess their own care and support needs and decide how their individual budgets are spent are central parts of the agenda. (Department of Health, Expert Guide to Personalisation, 2009)

Culmination of changes set in train twenty years ago Provision of residential and domiciliary care shifted from public sector (LAs) to the market (private for profit and voluntary) LAs funded and managed care, monitored standards and co-ordinated market Home helps redefined as home carers Support increasingly concentrated on those with greatest needs living in own home to save costs of residential care – thus heavily reliant on family care Social security system ceased funding care directly Personal, as opposed to medical, care means-tested

But important continuities Services still means-tested and under- funded Boundaries between social care and health care shifting and problematic Cost-containment a key policy objective Care from family and friends far outweighs formal care provision

Consequences of 1990s reforms and increasingly tight budgets Interventions became task oriented-packages of care Recipients of domiciliary care have more complex needs those with lower levels of needs not supported High turnover of providers of residential and domiciliary care high turnover of care staff high vacancy rates lack of investment in training, career structure growing dependence on migrant workers Access to services a post-code lottery

Personalisation Seen as a way of ameliorating negative consequences of early 1990s reforms: by shifting choice of service and carer from LA to individual needing care Consistent with Independent Living Movements demand for choice and control over the timing and form of care received as well as who provides it Direct Payments, introduced mid 1990s, most common form of personalisation often spent on employing a Personal Assistant over half DP holders choose to employ relative or friend

Early adopters Both DP holders and their PAs often satisfied However: Across government there are examples of policies accidentally placing workers at risk in vulnerable employment, for example through the introduction of Direct Payments without sufficient support for social care service users to undertake their responsibilities as employers. (TUC Commission on Vulnerable Employment, 2009, p35) many of the success stories in using personal budgets featured new patterns of support often developed with the help of exceptional caring families and of visionary and committed staff (CSCI, 2009, 130). I think the government is exploiting vulnerable parents and calling it empowering. It is actually exhausting. A parent of a deaf blind child (Sense, 2008, p 17).

Care and the market The market is supposed to deliver: Choice for purchasers Market mechanisms to provide value for money Competition between providers delivering high quality at lowest possible cost Personalisation should do this better than privatisation Because purchaser is actual recipient Thus better services can be provided and money saved through personalisation because people purchase only the services that they want those services are provided most efficiently at lowest possible cost

Argument relies on care being a commodity like any other But care involves a relationship Care workers learn how to care for particular people: continuity of care matters making it costly to change care providers Hard to know if better care would be available elsewhere or whether current provider is providing good value for money because relational quality of care cannot entirely be assessed and monitored and is often personal Care needs may give some care recipients difficulty in using the market themselves In practice, choice is often constrained by funding policy Market mechanism therefore in practice costly to use effectively to deliver good quality care

Quality and value for money in care Government recognises information on care quality important for market to work: but such evaluation tends to miss the hard to assess relational aspects of care To compete providers have to lower standards on aspects that are not monitored - race to the bottom at least by private for profit providers But these aspects may be what really matter in care quality Even harder to enforce quality through the market when purchasers are individuals and have little clout (or help with evaluation)

So why might personalisation save money? May not need to pay for some unwanted services Self-fulfilling prophecy in some cases e.g. collectively provided services such as day centres These likely to become uneconomic if current users do not all decide to spend their DPs this way Personalisation will: expand the care labour force by bringing in new carers with low expectations, and skills rather than qualifications use unorganised labour working in isolation Budgets can be cut (or fail to rise in line with costs) more easily when allocated to individuals rather than local authority departments

Using market to deliver value for money Must therefore mean either: Care workers wages fall further behind those in other sectors Care ratios deteriorate Either way: lower quality care Only way to avoid this is keeping spending rising in line with earnings not prices (and increased demand) i.e. must take a rising proportion of GDP

Rising costs an important issue in care Current budgets inadequate Costs will rise because of greater numbers needing care Units costs will rise unless care quality is allowed to deteriorate further Sector in which productivity rises inherently impossible without lowering quality productivity i.e. staffing ratios seen as measure of quality high productivity = low quality Relative cost of care rises because of productivity increases in other sectors

Individual budgets likely to be minimal So corporate providers will have to compete on price have no incentive to train their workers DP recipients may not have sufficient resources/knowledge to train their PAs Care wages, both basic and increments for qualifications, too low to enable/encourage care workers to finance their own training Market mechanism unlikely to work in ensuring skill development, and career structure and thus quality of care