The false narrative about personal budgets in England: smoke and mirrors?

Abstract

Successive governments have supported ‘personal budgets’ as the route to transforming social care. However, this article outlines how the evidence has been constructed in a way that creates a narrative about personal budgets which is misleading. It is a narrative that continues to dominate the national strategy. The consequence is that the care system remains set in a dysfunctional, two-tier state. For the bottom tier, comprising over 90%, we argue there has not been, nor will there be under the current strategy, any transformation.

Keywords:

• Personal budgets
• evidence
• policy
• UK government

Context

The report of the UK Public Accounts Committee (PAC) (UK Parliament Public Accounts Committee 2016) into personal budgets in England showed that the Committee formed a very positive view of the personal budgets policy following a governmental hearing. They saw it as able to:

transform care and improve quality of life for most groups of social care service users. (UK Parliament Public Accounts Committee 2016, 3)

They saw that through personal budgets:

England is leading the world in personalising social care. (UK Parliament Public Accounts Committee 2016, 5)

They understood personal budgets to be:

sums of money allocated by a local authority to service users to be spent on services to meet their care needs. (UK Parliament Public Accounts Committee 2016, 4)

This faithfully reflects the policy that a personal budget is an ‘up-front’ allocation to empower service users to exercise choice in their supports. The amount of money is determined by a resource allocation system.

However, there is a fundamental contradiction which was before the Committee but that its report failed to address. The report that formed the background to the hearing (National Audit Office 2016) found, after some eight years into the policy, that most authorities:

were struggling to develop resource allocation systems. (National Audit Office 2016, 36)

One authority had even dispensed with the resource allocation system altogether. Amongst the rest:

Most staff we spoke with found indicative budgets to be inaccurate and unhelpful, and said they were often ignored. (National Audit Office 2016, 10)

This means that ‘personal budgets’, as the Committee understood them to be, simply do not exist.

The National Audit Office’s findings are not isolated:

•	A survey for the Department of Health into the impact of the Care Act (Personal Social Services Research Unit 2015) also found care managers:

not sharing the information about the indicative budget with users. (2015, 40)

•

Research using the Freedom of Information Act to compare the up-front allocation and what people actually received (Slasberg, Beresford, and Schofield 2012; Series and Clements 2013) found there to be virtually no relationship between the two sums of money. Series and Clements described the resource allocation system as:

Like a cog spinning within a machine with which it does not connect. (2013, 226)

The Committee believed the Care Act 2014 ‘required local authorities to give all eligible users a personal budget’ (UK Parliament Public Accounts Committee 2016, 4). However, they were perhaps unaware that the Care Act does not define a personal budget in the same way as the Committee was led to believe, as already set out. The Act defines a ‘personal budget’ as no more than the money required to meet the needs the council has decided it will meet. Legal precedent makes it clear that this cannot be established until after decisions have been made both about the specific needs that will be met and the specific resources required to do so. The Act makes no mention of up-front allocations.

The following question therefore arises: how can the Committee have come to believe that a policy which has no legal basis and which is not even being implemented is having such a transformational and beneficial impact?

The answer lies in the creation of a narrative that is entirely false. The narrative not only creates the belief that personal budgets, as defined by policy rather than the Care Act, are at the heart of the way social care is being delivered, but that it is having a transformational effect.

Both of the responsible sector leaders who gave oral evidence relied upon the information provided by the national surveys of ‘personal budget holders’ called ‘Personal Outcomes Evaluation Tool’ (POET). These are carried out by In Control and Think Local Act Personal. The former is the charity responsible for creating the personal budget methodology. Think Local Act Personal is the body funded by government to take the personal budget strategy forward.

David Pearson, the most recent past President of the Association of Directors of Adult Social Services, relied on the most recent POET survey to justify to the Committee that personal budgets are having a transformational impact, saying it:

showed that 80% of 4,000 people who were surveyed in 2014 thought it made a significant difference to the quality of their care and the quality of their lives. (UK Parliament Public Accounts Committee 2016, 26)

Jon Rouse, then Director General of Social Care at the Department of Health, under pressure to explain how he evaluated progress, described POET as a ‘rich source of data’ (UK Parliament Public Accounts Committee 2016, 49).

However, the following sets out how the POET surveys have led to a wholly misleading perception.

The POET surveys

There have been three national surveys, the first in 2011, the second in 2013 and the third in 2014. Each of them claimed that the large majority of the ‘personal budget holders’ surveyed had benefitted significantly. However, this is achieved by interpreting what is meant by ‘personal budget’ in two quite different ways to the actual definition already presented:

•	The first is a direct payment used to enable the person to manage their own support system.
•	The second is simply to use ‘personal budget’ as a proxy for the services received.

‘Personal budget’ as direct payment

Direct payments were officially introduced in 1996. There is clear and persistent evidence from research over their 20 years of existence that when used to employ their own personal assistants (rather than use regulated services), and their payments are large enough to meet leisure and social needs as well as personal care needs, people enjoy much better outcomes. This was confirmed most recently by the 2014 POET survey (Slasberg, Beresford, and Schofield 2015). Up-front allocations have never been a requirement or a component of their success.

The numbers of service users who use a direct payment to manage their own support system has always been only a small minority. In 2010/11, 9.3% of service users had a direct payment (NASCIS 2016). However, in the first POET survey 90% of respondents were direct payment recipients, and in the second 89%. Consistent with what had been the case since 1996, this group of respondents reported significantly better outcomes. Conversely, the 10% who were not direct payment recipients, and who received regulated services, did not report significantly better outcomes (Slasberg, Beresford, and Schofield 2013).

It is an irony that this evidence has been used to promote the view that ‘personal budgets’ work whilst in reality it is actually evident that the opposite is the case. The 90% who had better outcomes would have had better outcomes anyway. For the 10% for whom a ‘personal budget’ should have made a real difference, those who used regulated services, it did not lead to better outcomes.

In the third survey, possibly because the POET authors were aware of the criticism of the bias in the samples of the first two surveys, the balance of respondents who were and were not direct payment recipients was not declared. However, embedded in the report was a finding that the people who achieved the better outcomes were those who used personal assistants and who had enough resource to meet leisure and social needs. These are, of course, the very characteristics of people who have been using a direct payment to manage their own support system since 1996. Equally important, once again those who used regulated services did not achieve better outcomes. We have explored this in detail elsewhere (Slasberg, Beresford, and Schofield 2015).

‘Personal budget’ as a proxy for ‘services’

The POET survey methodology does not seek to compare the personal budget process with what it was meant to replace. When respondents are asked about the impact of their ‘personal budget’, this raises questions about what the term actually means to them. It is unlikely they are separating out the elements that distinguish a personal budget from traditional processes. Indeed, by the time of the third survey, only 43% had actually experienced services prior to the personal budget strategy (Slasberg, Beresford, and Schofield 2015).

Respondents will almost certainly equate their ‘personal budget’ with the support they are receiving. They will accept the term ‘personal budget’ in the same way as previous terms such as ‘care package’ were used. What this means is that, when asked about the impact of their ‘personal budget’, respondents are simply comparing life with support with life without support.

The net effect is that POET takes two pre-existing factors known to improve lives – direct payments, on the one hand, and having some form of support on the other – and claims that their impact is due to ‘personal budgets’.

Some councils are doing it well

A key element of the national narrative is that some councils are delivering ‘personal budgets’ well. This has been taken as proof that the strategy can work. This message was taken on board by the PAC report, which stated that personal budgets work only ‘when implemented well’.

This message also derives from the POET surveys. It derives from large variations in positive outcomes amongst respondents between councils that took part in the survey. The second POET survey noted a 30% variation in the best and worst performing councils. However, there was a very similar range of variation between the councils in terms of the proportion of their samples with a direct payment. The proportion of those with a council managed budget ranged from 0 to 40% (Slasberg, Beresford, and Schofield 2013). Thus the spread of respondents between councils reporting better outcomes mirrors the spread of the percentage of respondents with a direct payment between councils. The logic is that if the spread of respondents with a direct payment had been identical between councils, so would the spread of better outcomes reported.

Direct payments today

Under government pressure to make direct payments the default option under the personal budget strategy, the number has trebled and now 22% of service users use a direct payment (National Audit Office 2016). However, it is estimated (Skills for Care 2015) that only 29% of direct payment users now employ a personal assistant. The majority use regulated services. This means that the only change is who pays the invoices. The third POET survey showed that people who used regulated services did not enjoy any better outcomes whether or not they had a direct payment (Slasberg, Beresford, and Schofield 2015).

There are therefore still only about 7% of service users who use a direct payment to manage their own support system through a direct payment. Practitioners have for some time reported that most service users do not wish to have the responsibility of managing staff and their own support. They have often been derided for being patronising and unwilling to relinquish control (Commission for Social Care Inspections 2004). However, the large expansion of people willing and able to take a direct payment but who choose not to take the further step of employing their own staff lends credibility to their view. The National Audit Office (2016) report notes that ability and willingness to self-manage is a limiting factor in take up.

It seems reasonable to believe that any further increase in use of direct payments to authentically self-manage will not be large or rapid. This is especially so given the funding problems facing social care. In addition to the high levels of skills required, there is clear evidence that this group of people have a significantly higher level of resource than the rest; for example, one study found a 44% difference (Woolham and Benton 2013). We have explored elsewhere (Slasberg and Beresford 2015) how, whilst it is plainly inequitable that this group is able to meet more of their needs than the majority, this should not be seen as them having more than they should. They are simply more able to meet their needs in order to have a reasonable quality of life and therefore set the standard for all. The difference in funding levels can be seen as a proxy measure for the level of chronic under-funding of the system.

Conclusions

The national narrative about ‘personal budgets’, most recently expressed through the PAC hearing, relies on two key sources. The first source is personal success stories. Whilst only a small minority enjoy the conditions for better outcomes, they nonetheless create a large pool, in absolute numbers, from which to identify individuals able to be recruited as an advertisement for the policy. They are likely to have no problem in their support being described as a ‘personal budget’, regardless of whether the actual definition of a personal budget applied in their case.

This is then followed by the POET surveys. These have been designed and delivered by organisations with a heavy investment in proving their success. The participating councils have been volunteers, with a consequent bias to councils with leaders most philosophically aligned to the strategy. The councils have selected the respondents, with a potential bias to selecting those most likely to have positive stories to tell.

The surveys have been the basis of a wholly positive narrative about the ability of the ‘personal budgets’ policy to have a transformational impact. However, scratching only a little beneath the surface shows that the way in which the evidence from the surveys has been constructed has led to a misleading picture.

This misleading narrative is sustaining a strategy that is concealing the existence of a two-tier system for whom the second tier, comprising over 90% of service users are no better than they have ever been. It is serving as a fig leaf to cover a service that has been chronically underfunded and failed by successive governments.