▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
From the State to The
Personalization of Social Policy
Dr. Jason L. Powell,
University of Liverpool, UK
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
The
move to personalization in social policy in western
society has been presented as part of consumerist agenda that is increasingly
associated with western social
policy (Powell 2009).
Today, public services in modern society also face new
demand side challenges in a global economic recession. At the same time,
individuals and populations in western culture have expectations of the State
to deliver to meet their health and care needs from resources to services to
provide support. These increased expectations are strongly felt in public
services and challenge the traditional relationship between the State and
vulnerable groups in modern societies such as older people, disabled people and
people with mental illness, and people who are frail and sick.
The traditional focus has been on the State providing
for individuals. Part of a re-casting of that relationship has been on the
entrenchment of personalization as a new language in western culture for the
responsibility for social welfare (Dittrich 2009). To
put simply, personalization is a means to focus more on the individual rather
than the State. Using the UK as a case study, sheds light on wider contemporary
trends on social policy in western society in general.
But is this too simplistic a conceptualization? Why and how is
personalization relevant to social policy and modern society? How is it
researched? How is personalization reconciled in a formidable structural
climate of decreasing public resources? This is not just a global economic
recession but one of which effects all nation states, Many of these questions
can be connected to why personalization services are needed, what is provided
and how it is coordinated. Last year, the Brown Government (2009) in Great
Britain announced it would provide a Social Care Reform Grant over 3 years,
worth £520 million as part of an adult care ‘concordat’, to support the
‘transformation’ of care systems (Dittrich 2009). The aim of the
transformation is to move to personalization in local authority social care
provision to enable the roll out of personal budgets. The personalization agenda offers an
opportunity to make social care (and other services) more responsive and
flexible so that it is actually doing what people who use budgets and services
want and need, rather than being constrained in rigid task and time
specifications (Samuel 2008; Dittrich 2009).
Personalization is inextricably linked to
process that every person who receives support, whether provided by statutory
services or funded by themselves, will have choice and control over the shape
of that support in all care settings (Glendenning et al. 2008). Carr (2008)
suggests its overall aim is for social care service users to have control over
how money allocated to their care is spent. It includes within its remit direct
payments, individual budgets, personal budgets, user-led services,
self-directed support (Glendenning et al. 2008). Self-assessment is a
cornerstone of personalization that gives service users the opportunity to
assess their own care and support needs and decide how their individual budgets
are spent that is a process transforming social care (Carr 2008).
In order to explore the
conceptual, policy and research literature on personalization, this working
report focuses attempts to
set out in more detail what personalization is, what it will mean, how it may
work, and discusses to what extent it is likely to happen. It considers the
opportunities these changes are presenting service users. The paper illuminates
the key research findings from the IBSEN report (2008) that provides a series
of research benchmarks to measure how pilots of personalization and individual
budgets are being experienced.
A word of caution however: overall, it is fair to say that the evidence base
in relation to the critical success factors of personalization is extremely
scarce (Rabies and Moran 2006; Moran 2006; Glendenning et al., 2008).
This also means that it is very difficult to bring evidence together in any
cumulative sense to gain an impression of the overall or aggregate impact of
personalization. A key point to state is that the available literature is on
what the implications would be rather than what the implications evidentially
are. Samuel (2008) makes the cogent point that there has been such political enthusiasm for
individual budgets from both New Labour and
Conservative parties that they have run ahead of the evidence: a whole new personalization
approach to social care policy and invested at least £500,000,000 in making it
happen before even its own research findings were available to offer an
adequate evidence base (Samuel 2008). Hence, greater use of methodological interrogation of experiences
is required in tapping the narrative and experiential contours of
personalization and Individual Budgets (IBs). There have been scarce
longitudinal research designs (Glendenning et al. 2008), in which interventions
and their beneficial/dystopian effects on IB can be studied over time (Carr
2008); or evaluation designs, for example where ostensibly similar
interventions or the work of comparable agencies are undertaken in different
settings as the process is only starting to unfold (Moran 2006; Glendenning et
al. 2008).
‘Taking Aim’ at Personalization
In
the UK, the Brown administration (2007-) has identified personalization to
promote and use as a vehicle to transform the shape of adult social care
services. Personalization is at the heart of the transformation agenda for
adult social care. The relationship between the service user and the State is
one where citizens should be able to take control of their needs through a
range of provision from which they can choose (Leadbeater
2008). This will change social care from a system where people have had to
accept what is offered, to one where people have greater control, not only over
the type of support offered, but also how and when it is offered, how it is
paid for and how it helps them achieve the outcomes that are important to them (Dowson and Grieg, 2009).
Service
users participating to meet their own needs will achieve the transformation of
social care. Indeed, Leadbeater (2004) suggests in
order to understand personalization we must locate it in its broad context of
‘participation’ that changes the way in which social care services are
delivered. It is about enabling the individual, alone or in groups, to
participate in the delivery of a service (Leadbeater
2004). From being a recipient of services, service users can become actively
involved in selecting and shaping the services they receive (Carr 2008).
According
to the Carr (2008), personalization has the potential to reorganize the
way we create public goods and deliver public services. Leadbetter (2004)
for a report for DEMOS suggests that personalization through participation
makes the connection between the individual and the collective by allowing
users a more direct, informed and creative say in ‘rewriting the script’ by
which the service they use is designed, planned, delivered and evaluated. Leadbetter (2004) states a number of over-arching
principles related to personalization and impingement on individual autonomy:
1. Intimate consultation: professionals
working with clients to help unlock their needs, preferences and aspirations,
through an extended dialogue – focusing on facilitating relationships between
professionals and service users.
2. Expanded choice:
giving users greater choice over the mix of ways in which their needs might
be met; to assemble solutions around the needs of service users rather than
limiting provision to social care and services department.
3. Enhanced voice:
expanded choice should help to further unlock the service user’s voice.
Making comparisons between alternatives helps people to articulate their
preferences. Leadbetter (2004) implies choice for
service users simultaneously helps to listen and carry voice of users fused
into partnerships with social care agencies.
4. Partnership
provision: it is only possible to assemble solutions personalised to individual need if services work in
partnership between user groups and social care agencies.
5. Advocacy: professional
social workers should act as advocates for service users, helping them to
navigate their way through the social care system. That means service users
having a continuing relationship with professional social workers that take an
interest in their case, rather than service users artificially engaging in a
series of disconnected transactions, disconnected assessments with disconnected
services.
6. Co-production:
service users who are more involved in shaping the service they receive
should be expected to become more active and responsible in helping to achieve
and deliver the social care service from Local Authorities.
8. Funding: should follow the
choices that users make and in some cases – direct payments to disabled people
to assemble their own care packages – funding should be ‘put in the hands’
of service users themselves, to buy services with the advice
of professionals.
Leadbetter (2004) makes the cogent point that service users should not
be fully dependent upon the judgement of professionals; they should be able to
question, challenge and deliberate with them. Nor are users merely consumers,
choosing between different packages offered to them; they should be more
intimately involved in shaping and “co-producing” the service they want. The
question this raises: what does this actually mean? The answer is fivefold: (i) finding new collaborative ways of working and
developing local partnerships, which (co) produce a range of services for
people to choose from and opportunities for social inclusion; (ii) tailoring
support to people’s individual needs; (iii) recognising and supporting carers
in their role, while enabling them to maintain a life beyond their caring
responsibilities (HM Government, 2008); (iv) access to universal community services
and resources -a ‘total system’ response; (v) and early intervention and
prevention so that people are supported early on and in a way that’s right for
them.
It can be argued that
Individual Budgets (IBs) are the central to the aim of ‘modernising’
social care policy and practice in England (Glendenning et al. 2008). They
build on the experiences of direct payments and In Control and are
intended to offer new opportunities for personalised
social care. Since the1980s there has been growing interest among policy makers
and service users alike in England in developing ways that enable adults who
need support and help with day-to-day activities to exercise choice and control
over that help (Powell, 2005). Growing dissatisfaction has been articulated,
particularly by working disabled people, about the inflexibility and unreliability
of directly provided social care services. These have been argued to create
dependency rather than promoting independence and impede disabled people from
enjoying full citizenship rights (Dowson and
Grieg, 2009). Instead, disabled people have argued for the
right to exercise choice and control over their lives by having control over
the support they need to live independently. This, they have argued, can be
achieved by giving them the resources with which to purchase and organise their own support in place of in-kind provided
services (Samuel 2008).
A rather different set of policies have reflected the attempts of
successive governments to reduce the control of social care service providers
over the composition, timing and flexibility of services and make providers
more responsive to the circumstances of individual service users. Thus the 1993
community care reforms made front-line care managers responsible for purchasing
individualized ‘packages’ of services from a range of different providers,
tailored to meet individual needs and preferences (Powell, 2005). At that time,
the position of monopolistic authority service providers was challenged by the
active encouragement of a ‘mixed economy’ of social care services, funded by
local authorities (and increasingly also by individuals funding their own care
entirely from their own private resources), but provided by a range of
charitable and for-profit organisations (Powell,
2009; Gilbert and Powell, 2010). More recently, policy commentators have argued
for the active involvement of users in the co-production of services.
Co-production is argued to introduce new incentives for providers to respond to
individual demands; and new incentives for service users to optimise
how the resources under their control are used in order to increase
cost-effectiveness. This has been repeatedly stated in key policy
documents including Improving the Life Chances of Disabled People (published by the Prime Minister’s Strategy
Unit in 2005), and the 2006 Community Services White Paper, Our Health, Our
Care, Our Say which announced the piloting of IBs. Personalization had its
early beginnings in Direct Payments introduced in 1997 under the Blair
administration, whereby people who are eligible for social care can choose to receive
a cash sum or service. The model for IBs was largely derived from work
developed by In Control that pioneered self-directed support for people
with learning disabilities and is engaged in supporting personalization
developments in more than 90 local authorities (Glendenning et al. 2008).
Individual budgets (IBs)
are central to Labour Government’s ambitions for ‘modernising’ social care in England, and lie at the heart
of the ‘personalization’ agenda. IBs were first proposed in the Cabinet Office
Strategy Unit (2005) report, Improving the Life Chances of Disabled People and
this commitment was repeated in the Government strategy planning for an ageing
population and impact on public resources. In the same year, a Green Paper on
adult social care called for more opportunities for older and disabled people
to exercise choice and control over how their support needs are met as well as
for the focus of support arrangements to shift from service inputs to
user-defined outcomes. The intention was to build on experiences with two
pre-existing schemes: direct payments (where individuals eligible for social
care support receive cash payments in lieu of direct service provision) and the
pioneering. The move towards self directed support involves comprehensive change:
self-directed support is to become the core way of delivering care and support
to service users. Implementing self-directed support is as much about changing
cultures as it is about changing systems (Gilbert and Powell, 2010).
In order to trace the
research themes that emanate from initial experiences of personalization, there
is a need to trace the key findings. The research is not meant to be an
exhaustive list but rather an overview of some emerging themes. Moran (2006)
suggests that plans to use IBs mainly focus on the employment of Personal
Assistants; but they also include the purchase of equipment, transport,
respite, and leisure services. Interviews in participating sites (Moran, 2006)
suggest that Individual Budgets facilitate a move towards more holistic, user
centered assessment. However there were concerns that service users engaging in
self-assessment may under-assess their needs. Service users are, consequently,
turning to the voluntary sector to act as advocates for users – helping them to
complete the self-assessment forms. In some areas there is also a dual system
of care manager assessment alongside self-assessment. Staff at most sites
expected the introduction of Individual Budgets to be easier among certain user
groups (as was the case with Direct Payments).
Moran (2006) made the point
that people with physical or sensory impairments are most commonly viewed as
‘most suited’ to IB. Professionals, using the experience of Direct Payments,
perceived these people as better able to plan their own support and manage
their own budgets. The inclusion of people with learning disabilities was also
expected to be successful, partly because of the cultural shifts that had taken
place among staff working with this user group and the experience of the In
Control approach to person-centred planning and individualised approach to meeting needs. At the same time,
Moran (2006) cautioned that the inclusion of older people, however, was
considered more difficult. There was also an expectation that health service
staff would be reluctant to offer Individual Budgets to mental health service
users (Moran, 2006).
Following
on from this, research from Rabiee and Moran (2006)
suggest that, as with Direct Payments, pre-existing block contracts can
undermine implementation. Rabiee and Moran (2006)
suggest both the potential of a successful IB scheme, and suggest obstacles
that have to be addressed.
Rabies and Moran (2006) claim that service users
had positive views of IB benefits:
q greater choice and control;
q flexibility;
q self esteem;
q a more transparent process of assessment;
q easier to manage than Direct Payments.
Rabies and Moran (2006) also suggest that
service users had realistic views of IB costs:
q difficult to understand which funding streams are accessible;
q difficult to understand which services IB can be used for;
q need for help in form-filling;
q lengthy application process;
q fear about responsibilities shifted to under-supported carers and families.
q A number of the sites suggested that the budgetary pressures associated
with money tied up in block contracts would take 3-5 years to resolve (Rabies
and Moran 2006).
These two studies by Moran
(2006) and Rabies and Moran (2006) were the first research evaluations of the
implementation of this form of personalised
approaches to social care and its impact on the individuals involved, the
workforce and providers, as well as the support and commissioning processes.
This was influential to the design and implementation of the research frames of
The Individual Budgets Evaluation Network (IBSEN) report (Glendenning et al.
2008).
The IBSEN research report
(2008) provided a national evaluation of individual budget pilots
that have implications for service users, professionals and policy makers. People receiving an IB were significantly
more likely to report feeling in control of their daily lives, welcoming the
support obtained and how it was delivered, compared to those receiving
conventional social care services. However, there were differences between
groups.
q Mental health service users reported
significantly higher quality of life;
q Physically disabled adults reported receiving
higher quality care and were more satisfied with the help they received;
q People with learning disabilities were more
likely to feel they had control over their daily lives;
q Older people reported lower psychological
well-being with IBs, perhaps because they felt the processes of planning and
managing their own support were burdens.
q People who had higher value IBs had better
social care outcomes – but so did people receiving higher value conventional
services. Overall, holding an IB was associated with better social care
outcomes, including higher perceived levels of control, but not with overall
psychological well-being in all groups.
IBSENs (2008) main findings
were:
q The average weekly cost of an IB was £280,
compared to £300 for people receiving conventional social care.
q Costs were lowest for mental health service
users (average £150 per week); middling for older people (£230) and physically
disabled people (£310); and highest for people with learning disabilities
(£360).
q The costs of IBs were higher for people with
greater needs, whether because of problems with daily living activities or
cognitive impairments.
q
Costs were lower for people living with a family carer
and those in paid work. IB holders also reported higher use of health services;
and more contact with a social worker/care coordinator, reflecting the demands
of support planning
q
IBs were cost effective for mental health service users and physically
disabled people with respect to both social care and psychological well-being
outcomes.
q
For people with learning disabilities, IBs were cost-effective with
respect only to social care. For older people, there was no difference in
social care outcomes, but standard care arrangements remained slightly more
cost-effective and people receiving these felt happier.
(ii) Eligibility, assessment and resource allocation
q Formal eligibility criteria for
social care support remained unchanged in the pilots, but care coordinators
took other factors into account when offering IBs such as an individual’s
ability and willingness to make changes, manage money or understand new processes.
q Assessment processes did not
necessarily change greatly, although there were greater emphases on
self-assessment and outcomes.
q In most pilot sites, the sum of
money allocated was determined through a Resource Allocation System
(RAS). This itemised the help needed by an individual
and resulted in a score that translated into a sum of money which equated with
the Individual Budget.
q Deciding how to use an IB was
challenging for service users.
q Care managers helped individuals to
set priorities and identify potential ways of meeting them. Support planning
was often judged to be person-focused and accessible.
q However, some concerns were raised
over the amount and complexity of paperwork and the general slowness of the
support planning process. External support planning organisations
or advocates were sometimes involved.
q Social care staff experienced major
shifts in their roles and responsibilities. Some welcomed these, though others
felt their skills were being eroded. Supervision and training in implementing
the new IB approach were considered essential.
(iv) Integrating funding streams
q IBs were expected to include money
from several funding streams to enhance flexibility and choice. Pilot site senior
managers were enthusiastic about this, but gains were very limited. Barriers
included incompatible eligibility criteria; legal and other restrictions on how
resources could be used; and poor engagement between central and local
government agencies.
q Integrating into IBs the assessment,
resource allocation and review processes for other funding streams was thought
by IB managers to have been most successful in respect of Supporting People.
The IBSEN report also
highlighted some difficulties. It was noted that implementation had been
easiest for people with physical and/or sensory impairment, whilst extending
the pilot to older people had been slightly more problematic. There were
difficulties for people with learning disabilities and widespread difficulties
were reported in relation to people with mental health problems. Examples were
also cited of financial abuse and deception regarding levels of need. Other
concerns were expressed around the costs and complexities of implementing IBs
alongside traditional resource allocation systems and that meeting the demand
for short-notice and unplanned care in a larger IB system would require a
considerable change in the organization of staffing.
Conclusion
The
personalization agenda means a major shift in the way social care and
individual support providers approach service. This article has covered the
conceptual and policy underpinnings of personalization and its relation to
substantive issues in self-directed care. Importantly, this paper has located
personalization through research studies and thematic areas that are crucial as
a baseline for measuring the critical success factors of Individual Budgets. In
particular, the themes that emanate from IBSEN report (2008) can be used as
benchmarks to measure the effectiveness of the pilots of personalization,
social care and IB in UK and other western societies moving towards
personalization processes in social welfare for their populations. This
challenge has only just started…
Association of Directors of Social
Services Making progress with Putting People First, self-directed support (2009)
Carr, S (2008) SCIE Report 20:
Personalization: a rough guide, London: SCIE
Department of Health (2007) Putting
people first –a shared vision and commitment to the transformation of adult
social care, London: DH
Department of Health (2008) High
quality care for all: NHS next stage review final report, London: DH
Dittrich, R (2009)
Personalization and the future of adult social care: the views of Hampshire
residents, Research, Policy & Planning, 27(1), 3-16
Dowson, S and Grieg, R (2009) The
Emergence of the Independent Support Broker Role, Journal of Integrated Care,
17(4), 22-30
Gilbert, T. and Powell, J.L. (2010) Power
and Social Work in the United Kingdom. Journal of Social Work, Vol 10, issue 1, 3-23
Glendinning,
C., Challis, D., Fernandez, J., Jacobs, S., Jones, K., Knapp, M., Manthorpe, J., Moran, N., Netten,
A., Stevens, M. and Wilberforce, M. Evaluation of the Individual Budgets Pilot
Programme: Final Report, Social Policy Research Unit, (York: University of
York, 2008), http://php.york.ac.uk/inst/spru/pubs/1119
/ [accessed 4th March 2010]
HM Government (2008) Carers
at the Heart of 21st-Century Families and Communities, London: HMSO
Leadbedder, C (2004) Personalization through Public Participation, Demos:
London
Leadbeater, C (2008) ‘This Time It’s Personal’, Society, The Guardian, 16.1.08.
Moran, N. (2006) Early
experiences of implementing individual budgets. York,
SPRU
Nutley, S.,
Walter, I. and Davies, T. O. (2007) Using evidence: how research can inform
public services. Bristol: Policy Press.
Powell, JL (2005) ‘Aging and Family Policy in the
UK’, Journal of Sociology and Social Welfare, Vol
32, Issue 2, 63-75
Powell, JL (2009) From "Trust Society" to
the "Risk Society"? The Case of Aging and Welfare in Europe’, Hallym International Journal of Aging, Vol 11, Issue 1, 65-76
Rabiee, P. and
Moran, N. (2006) Interviews with early individual budget holders. York,
SPRU
Samuel, M (2008) ‘Social
Care Experiencing “Its Most Important Year”’, Community Care, 31.7.08.
Social Care Institute for Excellence (2007) Choice, control, and
individual budgets: emerging themes. London: SCIE (Research Briefing 20)
Venables, D.,
Clarkson, P., Hughes, J., Burns, A. and Challis D. (2006) ‘Specialist clinical
assessment of vulnerable older people: outcomes for carers
from a randomised controlled trial’. Ageing and
Society 26 (6) pp 867-882
Waine, B.
(2003) Regulation and Inspection of Adult Social care – baseline study.
Report to the MASC programme (www.masc.bham.ac.uk)
Wanless, D.
(2002) Securing our future: taking a long-term view. London: H.M.Treasury
Wanless, D.
(2006) Securing Good Care for Older People: taking a long-term view.
London: The King’s Fund
Weick, K.
(1995) Sensemaking in organisations.
London, Sage.
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬