Personalisation for older people and direct payments – time to re-discover person-

centred care?

John Woolham, Guy Daly, Nicole Steils, & Katrina RittersFaculty of Health and Life Sciences

John.woolham@coventry.ac.uk

Structure1. From person centred care to personalisation2. Personal budgets and direct payments3. Perspectives:

a. Policy analysis of issues arising from PBs & DPs b. Policy analysis of issues arising from PB and DPs

specifically to older peoplec. Research evidence

4. Conclusions

1. From person centred care to personalisation

• ‘Person-centred’ support easy to describe • ….but hard to achieve

– Case /care management for older people– IPPs & shared action planning for people with learning disabilities– Person-hood for people with dementia– Transference of learning from project to service always difficult

• The term ‘personalised’ has replaced ‘person centred’ – Often seen as the same by practitioners but

• Greater emphasis on some values: ‘self-direction’, ‘user empowerment’, ‘personal choice’,

• ‘Support’ is now used alongside or instead of ‘care’• User rather than professional definitions of need

– Adult Social Care staff refer to people with social care needs as ‘customers’ not ‘clients’ or ‘service users’

1. From person centred care to personalisation

• Definitions vary.

‘Personalisation means thinking about care and support services in an entirely different way. This means starting with the person as an individual with strengths, preferences and aspirations and putting them at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives’.

Carr (2011) p. 3.

‘Individuals not institutions take control of their care. Personal budgets, preferably as direct payments are provided to all eligible people. Information about care and support is available for all local people, regardless of whether or not they fund their own care’

Department of Health Vision for Social Care. Nov. 2011 p. 8.

2. Personal budgets and direct payments

• Direct payments and personal budgets seen as the means by which personalised care and support will be delivered.

• A (very) short history of personal budgets and direct payments– Independent living fund, cash for care– Campaigns by younger disabled people for more control over care– Direct Payments Act 1997– ‘In Control’ and campaigning for self-directed support

• Attracted local authority support• Led to plethora of small scale local studies from local authorities• In Control Evaluations 1 & 2.

– DH endorsement • Commissioned IBSEN• £500m ‘Transformation Grant’

2. Personal budgets and direct payments

• Transformation Grant was announced without reference to research evidence (so much for ‘what works’!)

• Some important findings from IBSEN ignored.

• Subsequent research & policy guidance largely about how to make PBs and Direct Payments work - not whether it was the right approach.

‘….older people did not find the individual budget system used in the pilot as easy to use as the other groups, and they did not appear to like the idea of managing their own support’.

 Extract of IBSEN team summary

 ‘Since this research was undertaken more support has been put in place for older people and early indicators have shown that this has transformed their experiences of using individual budgets. We will conduct further research to investigate the impacts further.’Phil Hope M.P., Minister of State for Care

Services

3. Views: a. Policy analysis of issues arising from PBs & DPs

Advocates•Better outcomes for social care users •Greater empowerment of recipients, thereby conferring more dignity and personal responsibility •fuller citizenship and greater inclusion•more contestability/competition (aimed at using market mechanisms to improve quality) and diversity in local care economies leading to:•greater choice and more effective use of public money through: •greater efficiency in targeting of care and: •reduced CASSR care management input •Response to failures of care management

Sceptics•Agendas of disabled people subverted by government •Public services should not be about delivering ‘choice’•Citizenship and universality undermined by consumerism and choice•Downsides to choice •Transfer of responsibility from state to individuals & privatisation of risk•links to wider disquiet about public sector reform:

– shrinking the state,– replacement of universal social rights with

(increasingly rationed) consumer choice, – the dominance of managerial not

professional cultural values in CASSRs, – potential fragmentation of care provision

following marketisation.

3. Views: b. Policy analysis of issues arising from PBs & DPs specifically

relating to older peopleOlder people are the largest consumers of social care services.

Values underpinning key policy documents (e.g. PPF 2007, Shaping the Future of Care 2009) are problematic for older people

•People who can exercise independence and self-determination & those who can’t: ‘choiceandcontrol’ vs ‘careandprotection’

(Barnes 2011)

•Re-defining of care as a way to restore people to play a role as active citizens – reshaping a fundamental human need to something instrumental and narrowly defined.

(Lloyd 2010)

• Older people personal budget and citizenship‘For many older people, achieving full citizenship is not an ‘aim’ in the same way as…for many younger disabled people. Most older people have already experienced citizenship in the form of an active role in family, work and community life: it is not an unrealised aspiration’.

(Orellana 2012)

Are older people being ‘squeezed into a one-size-fits-all model of personalisation’?

3. Viewsc. Research evidence

Glasby (2012)•both sides appealing to evidence (advocates = any evidence will do, sceptics = not enough, evidence, evidence not good enough)•Calls for a move away from formal and quantitative research towards a more inclusive approach, combining research with practice wisdom.•But… not all findings created equal

• Not many quantitative but many qualitative: too little attention to quantitative not too much

• Tendency to generalise too much from qualitative studies

3. Viewsc. Research evidence

Reviews:Manthorpe et al (2011) 161 studies. •Many studies small scale•Some were commentaries not empirical studies•Some reported on experiences of people most likely to be offered /take up a budget so bias to positive findings

Zamfir (2013) 68 studies specifically focused on older people•Little evidence PBs had improved lives of older people•Where improvements had occurred this was because support was adequate

3. Viewsc. Research evidence

Empirical studiesIn Control (x 3) •First two studies low numbers, sampled from people likely to be favourably disposed to PBs•Third study (POET) found older people less likely to respond positively to budget ownership but a precondition was effective support.

IBSEN•Best study to date•Evidence that PBs can work for younger adults•No evidence they work for older people

3. Viewsc. Research evidence

Own work:•No evidence of benefit to older people compared to younger adults•Much larger budget size did not translate into much better outcomes for older direct payment users compared to ‘traditional’ users (Woolham & Benton 2012) •Outcomes not significantly different for older DP and MPB users (2014, unpublished)

Figure 4. ADL and cost scores for older respondents 65+ comparing bootstrapped

data for ‘traditional’ package users (left) and budget holders (right).

Figure 5. GHQ and cost scores for older respondents (65+) only, comparing

bootstrapped data for ‘traditional’ package users (left) and budget holders (right).

Figure 8. Spider graph showing profile of ASCOT social care related quality of life outcomes for direct payment users (Overall SCRQoL = 0.75)

Figure 9. Spider graph showing profile of ASCOT social care related quality of life outcomes for managed personal budget users (Overall SCRQoL = 0.70).

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100Accommodation

Cleanliness

Food & Drink

Safety

Social

Occupation

Control

Dignity

0102030405060708090

100Accommodation

Cleanliness

Food & Drink

Safety

Social

Occupation

Control

Dignity

Conclusions:

Do Direct payments and personal budgets work for older people?

•Campaigns for direct payments and self directed support led by younger adults -not older people•Older people do not achieve such good outcomes as younger adults when given a Direct Payment.•The ‘model’ of personalisation and use of direct payments as the means of achieving personalised support doesn’t suit many older people:

• The size of the direct payment doesn’t enable people to have much more than their basic care needs met

• Self direction and choice and the organisation of the direct payment is often mediated by a relative

Conclusions:

• Restoration of lost abilities to enable full community participation isn’t always realistic

• Independence isn’t always what older people people want.

• Empowerment may mean the ability to ask others to do things for or with them rather than them having to do it themselves.

• Control may be more effectively exercised through opportunities for older people to develop relationships of trust and friendship.

• To achieve this we may need to think less about choice and much more about what good care looks like.

Good care depends on the quality of the care relationship.

‘Commissioning on the basis of ‘time

and task’ has excluded the costs of the emotional labour needed to build a relationship with the user’

Lewis & West 2014 p.5.

This has been largely overlooked by English policymakers.

Conclusions

The effective use of direct payments and user control reinforces a view of care-as-commodity in which customer-is-king.

Our research suggests that though older people want choice and control, they want to exercise it in a different way.

Person-centred care may offer a better approach than personalised support to the kinds of issues facing older people but would require

•Skilled staff•Matching carer with person with care needs to enable relationship building•Adequate remuneration

Selected references• Barnes, M., (2011) ‘Abandoning Care? A Critical Perspective on Personalisation from an Ethic of Care’. Ethics and

Social Welfare 5(2). p. 153-167. • Beresford, P. (2009b) ‘Whose Personalisation?’ Compass: Direction for the Democratic Left Think Pieces, No. 47 p.

1-5. • Boyle (2013) The Barriers to Choice Review. How are people using choice in public services . London, Ipsos MORI. • Carr, S., (2013) Improving personal budgets for older people: a research overview. Adult Services Report

63London, Social Care Institute for Excellence. • Clarke, J., Smith, N., and Vidler, E. (2006) ‘The Indeterminacy of Choice: Political, Policy and Organisational

Implications’, Social Policy and Society 5(3), (p.327-336).• Clarke, J., Newman, J, and Westmarland, L, (2008) ‘The Antagonisms of Choice: New Labour and the reform of

public services’. Social Policy and Society, 7(2) p.245-253.• Daly, G., (2012) Citizenship, choice and care: an examination of the promotion of choice in the provision of adult

social care. Research Policy and Planning Vol. 29 (3) p. 179-190. • Department of Health (2003) ‘The Government’s Expenditure Plans 2003 Local Authority Personal Social Services

Gross Expenditure by Client Group, 2001-02’. Chapter 6. p.73. • http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/

dh_4072527.pdf. Gateway ref: 2003 accessed 14.01.10. • Department of Health (2008) Making personal budgets work for older people: developing experience.

Department of Health, Gateway ref. 10733. • Department of Health (2008) Local Authority Circular letter 2008 (1).Transforming Adult Social Care Department

of Health Gateway ref. 9337 • Department of Health (2010) A Vision for Adult Social Care: Capable Communities and Active Citizens. London,

Department of Health. • Duffy, S., (2006) Keys to citizenship: a guide to getting good support for people with learning disabilities.

Birkenhead, Paradigm ltd. • Duffy, S., (2008) Personalisation in social care Consumer Policy Review Vol. 18 (5) p.132-136)• Duffy, S, and Waters, J. (2008) ‘The Economics of Self Directed Support’, in Poll, C, and Duffy, S. (eds), A Report

on in Control’s Second Phase Evaluation and Learning 2005-2007. London, In Control Publications

Selected references• Ferguson, I. (2007) ‘Increasing User Choice or Privatizing Risk? The Antinomies of Personalization’, British Journal

of Social Work 37(3), p. 387-403. • Glendinning, C, Challis, D, Fernandez, J.L, Jacobs, S, Jones, K, Knapp, M, Manthorpe, J, Moran, N, Netten, A,

Stevens, M, and Wilberforce, M. (2008) ‘IBSEN: Evaluation of the Individual Budgets Pilot Programme, Final Report’, Social Policy Research Unit, University of York).

• Hatton, C, Waters, J, Duffy, S, Senker, J, Crosby, N, Poll, C, Tyson, A, O’Brien, J, and Towell, D. (2008) A report on In Control’s Second Phase Evaluation and Learning 2005-2007 London, In Control Publications.

• Hatton, C., and Waters, J. (2011) ‘The National Personal Budget Survey’. London, In Control and Lancaster University.

• Hatton, C, and Waters, J, (2012) Older people and personal budgets: A re-analysis of data from the National Personal Budget Survey 2011 Centre for Disability Research, Lancaster University.

• Health and Social Care Information Centre (2013a) Personal Social Services Expenditure and Unit Costs in England 2011-2012: Final Release table 6.1. http://www.hscic.gov.uk/ accessed 23.05.14.

• Health and Social Care Information Centre (2013b) Community Care Statistics, Social Services Activity, England - 2012-13, Final release [NS] 11:37 May 29, 2014 - 09:30 December 17, 2013Publication date: December 17, 2013. http://www.hscic.gov.uk/ Accessed 23.05.14.

• HM Government (2007) Putting People First: A Shared Vision and Commitment to the Transformation of Adult Social Care. London, HMG.

• http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081118 accessed 08.10.11.

• H.M. Government (2009) Shaping the Future of Care Together. Green Paper, Gateway ref. 1774 • http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_100819.pdf accessed

13.01.10• Leadbeater, C. (2004) ‘Personalisation through Participation: a new script for public services’., London, Demos.• http://www.demos.co.uk/files/personalisationthroughparticipation.pdf?1266491309 accessed 07.07.11.• Leadbeater, C, Bartlett, J, and Gallagher, N. (2008) ‘Making it Personal’, London, Demos.

Selected references• Lewis, J, & West, A, (2014) Re-shaping social care services for older people in England: policy development and the

problem of achieving ‘good care’ Journal of Social Policy 43 (1) 1-18. • Lloyd, L. (2010) The Individual in Social Care: The ethics of care and the ‘Personalisation Agenda’ in services for older

people in England. Ethics and Social Welfare Vol. 4 (2) p.188-200.• Manthorpe, J, Hindes, J, Martineau, S, Cornes, M, Ridley, J, Spandler, H, Rosengard, A, Hunter, S, Little, S, and Gray, B.

(2011) Self Directed Support: A review of the Barriers and Facilitators (Edinburgh, Scottish Government Social Research).

• Moran, N, Arksey, H, Glendinning, C, Jones, K, Netten, A, and Raibee, P, (2012) Personalisation and Carers: Whose rights? Whose Benefits? British Journal of Social Work 42, 461-479 doi:10.1093/bjsw/bcr075.

• Newbronner, L, Chamberlain, R, Bosanquet, K, Bartlett, C, Sass, B, and Glendinning, C. (2011) ‘Keeping Personal Budgets Personal: learning from the experiences of older people, people with mental health problems and their carers’. Adult Services report 40, London, Social Care Institute for Excellence.

• Orellana, K., (2010) Personalisation in Practice: lessons from experience: Making Personal Budgets, support planning and brokerage work for people in later life London, Age UK.

• Poll, C, Duffy, S, Hatton, C, Sanderson, H, and Routledge, M. (2006) A Report on In Control’s first phase 2003-2005. London, In Control Publications.

• Raibee, P, (2013) Exploring the Relationships between Choice and Independence: Experiences of Disabled and Older People. British Journal of Social Work 43, 872-888 Advance access April 2012 DOI: 10.1093/bjsw/bsc022.

• Roulstone, A & Morgan, H (2012) Neo-Liberal Individualism or Self Directed Support: Are we all speaking the same language on modernising adult social care? Social Policy and Society Vol. 8. (3) p 333-345 doi: 10.1017/S1471746409004886.

• Slasberg, C., Can Personalisation be a reality for older people? (2010) Working with older people Vol14 (3) p.15-22. • Slasberg, C., Beresford, P. & Schofield, P. (2012) How self-directed support is failing to deliver personal budgets and

personalisation. Research Policy and Planning, Vol. 29 (3) p. 161-178.• Woolham, J. & Benton, C., The Costs and Benefits of Personal Budgets for Older People: Evidence from a Single Local

Authority. (2012) British Journal of Social Work, Advance Access, published July 20th 2012 p. 1-20. Doi:10.1093/bjsw/bcs086.

• Zamfir, M., Personalisation through Personal Budgets: its Effectiveness for Older Adults in Social Care Services. Findings from an English based literature review (2013) Research Policy and Planning 30 (2).