Colin Slasberg

Can personal budgets really deliver better outcome for all at no cost? Reviewing the evidence, costs and quality

Political recognition of the parlous state of English social care and the urgent need for radical reform led to calls for new policy approaches that address the two key problems it faced: inadequate funding and poor quality and inappropriate provision. The New Labour government was convinced that it had found a way of dealing with these two competing problems and it embarked on a policy, which has subsequently gained cross-party support. The centre-piece was the concept of a personal budget, and was introduced with a belief that there would be major cost savings while improving service user satisfaction. This article will critically explore the evidence for whether the strategy is fulfilling that promise.

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

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.

Government guidance for the Care Act: undermining ambitions for change?

The UK Government claims to be creating a historic change to social care in England through the Care Act by putting people in control of their support. However, this is fundamentally contradicted by the draft guidance published to support the Act. This amounts to a formula for maintaining the prevailing resource-limited approach to assessing and meeting needs. This reality is obscured by a welter of choice and person-centred rhetoric. However, it need not be like this. Councils with a genuine commitment to being person-centred could refer directly to the Care Act to create an alternative future, while service users and their allies could bring about systemic changes if they use the Act to establish new rights.

Personalization of health care in England: have the wrong lessons been drawn from the personal health budget pilots?

The Government has introduced personal health budgets in Englands National Health Service (NHS). A three-year programme of pilots has shown that personal health budgets have improved outcomes and are generally cost-effective. They are seen as a key step toward creating a personalized service. However, the Government is attributing the success of the pilots to entirely the wrong factors. It believes that a process similar to the one introduced in social care – where it is called self-directed support – based on the person being given a sum of money ‘up-front’ with which to plan their own care – is responsible for the better outcomes. However, this is not supported by the evidence from the pilots which points to quite different factors being at play. The consequences are potentially very serious. The success of the pilots will not be repeated in roll out. Further, there is the potential to greatly weaken the service by creating confused process and practice, and additional dysfunctional bureaucracy. The practice and process implications from a correct reading of the reasons for success within the pilots centre on replacing the consumerist concepts underpinning self-directed support with what we have called ‘flexibility through partnership’. This will require freeing up the resource base as cash and creating a policy framework to enable decisions about how much resource each person should get within a cash-limited budget that will almost certainly be less than would be required to meet all assessed need.

The eligibility question – the real source of depersonalisation?

Abstract There have been a number of high-profile strategies over recent decades to raise social care above what is widely regarded as an unacceptable service in the United Kingdom. Quite apart from all too frequent high-profile scandals, it is seen as a service that is depersonalising and stigmatising. None of the strategies to bring about change, most of them introduced to great fanfares, have delivered the changes they promised. This article sets out a view that the reason why they have all failed is that none of them have identified or therefore tackled the underlying problem, which is the relationship between needs and resources. Underfunding has long been a serious concern for campaigning organisations. The article does not detract from that contention. However, it sets out how strategies to manage the gap between needs and resources, more than the funding gap per se, are themselves the root cause of depersonalised and chronically impoverished services. The unlikely source of these strategies can be traced to the unintended consequences of an Act of Parliament that had the best of intentions.

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.

Strengths-based practice: social care’s latest Elixir or the next false dawn?

Abstract There has never been such a consensus that social care is in crisis in England. However, it cannot be assumed this will result in fundamental rethinking of the future. Social care continues to search for a miracle cure that will painlessly transform it into a system both personalised and will cost less. The current ‘elixir’ is ‘strengths based practice’. This article suggests, however, that the current depersonalising and wasteful practices which strengths based practice is meant to replace are a product of the system within which practitioners work. There is unlikely to be significant change until that system has changed. If the current sense of crisis translates only into short-term action to keep the system afloat, the elixir will most likely be the prelude to the next false dawn.

The need to bring an end to the era of eligibility policies for a person-centred, financially sustainable future

Abstract Attention within the social care sector in England is moving away from consumerist notions of choice towards good professional practice as the route to personalisation. This demands a new focus on how to make practice that is person-centred the norm. The following sets out that this is unlikely to happen until the use of eligibility policies is ended. The lessons are relevant not only to England, but to other countries who may be looking to the United Kingdom as pioneering in the personalisation agenda.