Building on the original strengths of direct payments to create a better future for social care

Abstract

Confidence in the prevailing In Control model of personal budgets in the United Kingdom is beginning to waver. This raises the question of ‘where to next?’ for social care. Will we be returning to the monolithic system that typified services at the turn of the millennium – a system that is deeply oppressive for the great majority who lack the support and confidence to escape it by accessing a direct payment to manage their own support system? The Care Act has made no change to the basic process whereby it is councils that will decide what a person’s needs are, which will be met and with what resource. However, we argue here that the situation is far from hopeless. In Control’s analysis, while attractive to a neo-liberal political ideology, was based on a serious failure to understand the reasons for the success of direct payments. Whilst policy-makers saw it as a triumph for consumerist notions of choice, it is better understood as a triumph for needs-based planning, but carried out in a person-centred way. Learning the right lessons offers a new way forward to deliver a respectful and flexible service within the context of the Care Act.

Keywords:

• Care Act
• personalisation
• direct payments
• person centred
• needs based planning

Context

Needham and Glasby (2014, 4) note how ‘personalisation’ in the United Kingdom has come to be defined by the two mechanisms created for its delivery: ‘direct payments pioneered by disabled people themselves’ and ‘personal budgets, developed initially by a social enterprise In Control’. Various commentators have noted how, despite the government portraying them as natural bedfellows, direct payments and personal budgets are highly divergent. Ferguson (2012, 58) talks of ‘two discourses or ideologies, independent living and neo-liberalism’. This paper expands on that view at a pragmatic level. While In Control saw personal budgets as a natural progression from direct payments, they seriously misread the factors behind the successes of direct payments.

In Control were right to look at direct payments (as they were first conceived) as a key source of learning. As noted by the Joseph Rowntree Foundation, ‘The benefits of direct payments for users and local authorities are undisputed and widely researched’ (Hasler and Stewart 2004).

There was, however, concern that take-up remained very low. In Control’s view was that ‘direct payments are likely to be more attractive when greater flexibility is allowed’ (Poll et al. 2006, 11). They believed this would be achieved through up-front allocations of money that would enable transfer of power from the professional to the person by allowing the person to choose their own supports. Thus, personal budgets were defined. In Control anticipated ‘100% take-up’ (2100, 11).

However, evidence has been mounting that the theory is not working. The political consensus that supported personal budgets’ implementation is fracturing. Andy Burnham, Shadow Health Secretary, expects ‘a continuing role for personal budgets, but at the edge rather than at the centre of the system’ (Guardian 2014). This echoes the sentiments of Needham and Glasby (2014, 191) in summarising the contributions from a range of commentators that a ‘more genuine and longer lasting revolution’ is required ‘in which direct payments and personal budgets are potentially only a small part’.

Here we seek to address the search for something new and sustainable. Our argument is that In Control was right to base their model on learning from the direct payments initiative, but wrong in the lessons drawn. Rethinking these may offer a basis for the systemic change required.

Learning the right lessons

In Control’s remedy derives from a view that the success of direct payments was based on the exercise of choice through consumer power. What was required was a major increase in those elements. An alternative hypothesis to explain their success is that it followed from three factors: support plans built from accurate assessment of needs, sufficiency of resource and flexibility of provision.

Support plans built from accurate assessment of needs

Disabled people, imbued with the vision of independent living – the right to live on as equal terms as possible as non-disabled people – could be very clear about what needs they had to achieve independent living and the resource they required to meet them. There were no formulaic approaches to either needs or resource requirements. The uniqueness of each person’s needs was fully acknowledged. It is perhaps an irony to understand the process as a needs assessment. Needs assessments had become greatly discredited under the Community Care reforms. Service user ‘choice and control’ were seen as a necessary alternative. However, the way disabled people set about the process may best be understood not as an alternative to needs assessment, but as a more helpful approach to it. Slasberg (2013) notes that the 1990 National Health Service and Community Care Act created a two-stage process whereby all a person’s needs should be assessed first, and then a decision made about which of them to meet. However, national policy created a fear of not meeting an assessed need. This led to the two stages being conflated into one. The imperative for councils became to constrain assessments to affordable need only. Thus ‘need’ was always seen through the prism of resources. The disabled people’s approach to needs assessment is perhaps most aptly described as ‘person-centred’, as opposed to the ‘resource-led’ approach that still generally applies.

Sufficiency of resource

Pearson, Ridley, and Hunter note that direct payments developed by the disabled people’s movement were ‘intended to be set at a level that would enable independent living’ (2014, 5). When the legislation was passed, however, it contained no right to the required level of resource. Direct payment recipients would be subject to the same process of resource allocation as all others. It was therefore entirely fortuitous that the belief that all assessed need must be met became embedded in councils. The soundness of the person’s own assessment of their needs, often allied to assertiveness supported by advocacy from user-led organisations, rendered councils unable to resist the assessment. Councils then believed they were legally bound to meet all their needs. This has become manifest in spending patterns. Slasberg, Beresford, and Schofield (2012) showed prima facie evidence that spending on direct payment recipients was some 80% more per head than others.

Flexibility of provision

The Wanless review of social care funding (Poole 2006) noted that the majority of direct payments spend was on personal assistants. This was key to the achievement of better outcomes. It allowed the service user to have control over the tasks carried out, how and when they were undertaken. However, only a small minority of people opted for this route and the responsibilities it requires. While the number of people with a direct payment has more than doubled under the personalisation strategy, Skills for Care (Fenton 2014) estimate that only one-third of them now employ a personal assistant. Two-thirds simply purchase regulated services. There is no research evidence that when direct payments are used in this way they improve outcomes. It is therefore no surprise that the third national personal budget survey (Waters and Hatton 2014) should find that direct payments are no longer consistently associated with better outcomes, although employing a personal assistant is still strongly associated with better outcomes while using regulated services is not.

A new way forward

The above discussion provides a template for a more helpful way forward.

Person-centred assessments

The vision of independent living provided the key to a holistic assessment of need for disabled people who used direct payments. This can be understood as a person-centred strategic outcome. This safeguards the person’s human and civil rights and prevents the perception of need from being distorted by resource availability. A person-centred strategic outcome should be declared as the overarching vision for the service. Independent living has a number of definitions. However, they may all be too specific to working-age disabled people. A more generic option might be more appropriate, for example, for everyone to have a quality of life comparable with others in their community. Independent living would be how such a generic outcome would be applied to disabled people. All assessments must set out the range of a person’s needs to deliver the strategic outcome for them.

Sufficiency of resource

This issue was initially ducked by the disabled people’s movement when it secured the direct payments legislation. Needham and Glasby note how ‘campaigners drew on a cost cutting rationale’ (2014, 14) to attract support from government. They relied on research by Zarb and Nadash that claimed cash payments were ‘30 and 40 percent cheaper than equivalent service based support’ (1994, 6). However this referred only to the hourly costs. The report’s summary failed to mention that people with cash payments had some 45% higher amounts of service. This enabled them to meet a greater range of needs. Thus, the cost was actually greater.

Having failed to secure either a legal right or political commitment to sufficiency of resource, disabled people seeking to secure independent living achieved sufficiency of resource by competing successfully against other service users in the manner described above. Ultimately, this can be neither fair nor sustainable. Clements (2013) shows how efforts to secure sufficiency of resource through the judicial system have failed, notwithstanding new human rights and equal opportunities legislation. Levels of funding remain firmly a political matter.

It would be unrealistic to expect a political guarantee in the short term to fund all the needs required to deliver whatever strategic outcome is declared as set out in the previous section. Spending of such an order will be subject to normal democratic decision-making processes. However, it would not be unreasonable to expect the political system to act differently in two key ways.

First, in the short term, to acknowledge the extent to which the prevailing funding level is or is not enabling people to meet the strategic outcome. In other words, to acknowledge unmet need and thus the funding gap. Second, to commit to fully funding the meeting of the strategic outcome in the long term. This would be subject to democratic decision-making processes. However, crucially this would be informed by real-time information about needs. Under the current regime, political leaders are able to deny the existence of unmet need. Paul Burstow, as Minister for Care, when confronted by the Health Select Committee in 2012 about a funding gap of ‘£5, 6 or 7BN’, was able to say all eligible needs are met and there is no gap (Health Select Committee 2012). Under a system where needs are defined by resources, that is a statement that will always be true.

Flexibility of response

Whilst direct payments makes it possible for people confident they have the skills and energy to manage their own support system, the evidence is that the majority will continue to choose regulated services. In 2013/14, 1,048,660 people used community services. Of those, 156,495 had a direct payment (NASCIS Pf2 [NASCIS 2015]). If only 33% of them purchased a personal assistant as set out above, 95% of people are relying on regulated services. Person-centred support plans will be of little value if commissioning practices continue to create markets unable to work flexibly and responsively.

Can it happen?

The authors have set out previously (Slasberg and Beresford 2014) how the provisions of the Care Act 2014 support the changes proposed above. However, we also noted how government guidance sets a course to perpetuate the prevailing resource-led culture, notwithstanding a welter of rhetoric proclaiming the opposite.

The changes proposed could happen under one or both of two conditions. The first is that individual councils choose to break from government guidance to better serve their community. Recent experience of high levels of compliance with government strategy suggests that it is not likely many will take this route. The second is that service users and their allies seize the opportunity created by the Care Act to demand a holistic assessment of need as a legal right, and lobby councils to use the information about unmet need to inform future funding and commissioning decisions.

Disclosure statement

No potential conflict of interest was reported by the authors.