Karen C. Jones

Assessing the Role of Increasing Choice in English Social Care Services

This article aims to explore the concept of choice in public service policy in England, illustrated through findings of the Individual Budgets (IB) evaluation. The evaluation tested the impact of IBs as a mechanism to increase choice of access to and commissioning of social care services around the individual through a randomised trial and explored the experiences and perspectives of key groups through a large set of interviews. The article presents a re-examination of these interview data, using three ‘antagonisms of choice’ proposed in the literature – choice and power relations, choice and equity, and choice and the public nature of decisions – as organising themes. The randomised trial found that IB holders perceived they had more control over their lives and appreciated the extra choice over use of services, albeit with variations by user group. However, problems of power relations, equity and the constraints implied by the public nature of decision-making were complicating and limiting factors in producing the benefits envisaged. The focus on choice in policy, especially as implemented by IBs, emphasises an individualistic approach. The findings suggest that addressing broader issues relating to power, equity and an understanding of the public nature of choice will be of value in realising more of the benefits of the policy.

Older people's experiences of cash-for-care schemes: evidence from the English Individual Budget pilot projects

ABSTRACT Cash-for-care schemes offering cash payments in place of conventional social services are becoming commonplace in developed welfare states; however, there is little evidence about the impact of such schemes on older people. This paper reports on the impact and outcomes for older people of the recent English Individual Budget (IB) pilot projects (2005–07). It presents quantitative data on outcome measures from structured interviews with 263 older people who took part in a randomised controlled trial and findings from semi-structured interviews with 40 older people in receipt of IBs and with IB project leads in each of the 13 pilot sites. Older people spent their IBs predominantly on personal care, with little resources left for social or leisure activities; and had higher levels of psychological ill-health, lower levels of wellbeing, and worse self-perceived health than older people in receipt of conventional services. The qualitative interviews provide insights into these results. Potential advantages of IBs included increased choice and control, continuity of care worker, and the ability to reward some family carers. However, older people reported anxieties about the responsibility of organising their own support and managing their budget. For older people to benefit fully from cash-for-care schemes they need sufficient resources to purchase more than basic personal care; and access to help and advice in planning and managing their budget.

Individual budgets and adult safeguarding: Parallel or converging tracks? Further findings from the evaluation of the Individual Budget pilots

• Summary: The transformation of adult social care in England is underway, with the aim of promoting greater control and choice among people eligible for publicly funded social care services. A key part of personalization is the policy move to promote personal budgets. This article aims to investigate the inter-relation of personal budgets with another policy goal, adult safeguarding. A pilot programme of the predecessors of personal budgets, individual budgets, took place 2005–2008 and was evaluated by an independent research team. This article presents findings from the team’s second round of interviews with adult safeguarding coordinators (ASCs) in the 13 pilot sites held early 2008 which are discussed in the context of proposed adult safeguarding reforms in England. • Findings: This second round of interviews with ASCs revealed greater engagement with social care transformation than previously. However, their detailed expertise in adult safeguarding and their local intelligence and experiences were not regularly accessed. This may constitute a missed opportunity to address some of the tensions of personalization in practice. • Application: The interviews reveal that the personalization of social care is often interpreted as relating to greater use of Direct Payments and has yet to consider other facets of this policy transformation that are central to social work practice, including safeguarding.

The personalization of care services and the early impact on staff activity patterns

• Summary: This study examines the early impact on care coordinators’ (care managers’) work activity patterns of implementing the current personalization agenda within English local authorities. The Individual Budget (IB) pilots operated between 2005 and 2007 and provided a basis for personalization that, ultimately, sought to give personal care budgets to every eligible service user in England. Of particular interest was how the pilots impacted upon the roles, responsibilities and activity of care coordinators, who are expected to play a key role in this transformation of social care. A self-administered diary schedule was completed by 249 care coordinators, including teams directly involved in delivering IBs and a comparative sample of teams not involved in the pilots. These data were supplemented by semi-structured interviews with 48 care coordinators and 43 team managers. • Findings: The study found that on most measures there were no differences in working patterns between care managers with and without IB holders on their caseload. However, the results do show that – contrary to expectations – more time was spent assessing needs, and that more time generally was required to conduct support planning activities. • Application: The findings are necessarily dependent upon the early experiences of the pilot phase of IBs. As personal budgets are rolled out across all eligible service users, it will be interesting to examine whether the time-use of frontline staff, and indeed the wider organization, structure and function of local authority frontline teams, changes further.

Joining up government by integrating funding streams? The experiences of the Individual Budget pilot projects for older and disabled people in England

Individual Budgets (IBs) were piloted in 13 English local authorities during 2005–2007. Similar to personal budgets and “cash-for-care” schemes in other parts of Europe and beyond, IBs built upon previous English government initiatives to increase choice and control by users of adult social care services. A key aim of the IB pilots was to bring together resources from different funding streams to which an individual was entitled, and integrate or align those funding streams, thereby reducing the number of assessments and reviews; then allow those resources to be spent flexibly according to individual wishes and needs. IBs, available only to those eligible for adult social care services and support, could include resources from up to five other funding streams which, among them, were the responsibility of three different government departments: Access to Work, Disabled Facilities Grants, Integrated Community Equipment Services, Independent Living Funds, and Supporting People. Qualitative interviews with IB lead officers and funding stream lead officers formed part of the larger evaluation of the IB pilots (IBSEN study) and revealed deep disappointment that only minimal progress with integration had been possible, with the exception of Supporting People. This article explores possible reasons for the failure to integrate funding streams despite strong aspirations at local and national levels: legislative barriers; continuing accountability to individual funding streams; concerns over destabilizing the market; and concerns over the budgetary implications of an expected increase in demand.

Personalization in the health care system: do personal health budgets have an impact on outcomes and cost?

Objectives In England’s National Health Service, personal health budgets are part of a growing trend to give patients more choice and control over how health care services are managed and delivered. The personal health budget programme was launched by the Department of Health in 2009, and a three-year independent evaluation was commissioned with the aim of identifying whether the initiative ensured better health- and care-related outcomes and at what cost when compared to conventional service delivery. Methods The evaluation used a pragmatic controlled trial design to compare the outcomes and costs of patients selected to receive a personal health budget with those continuing with conventional support arrangements (control group). Just over 1000 individuals were recruited into the personal health budget group and 1000 into the control group in order to ensure sufficient statistical power, and followed for 12 months. Results The use of personal health budgets was associated with significant improvement in patients’ care-related quality of life and psychological wellbeing at 12 months. Personal health budgets did not appear to have an impact on health status, mortality rates, health-related quality of life or costs over the same period. With net benefits measured in terms of care-related quality of life on the adult social care outcome toolkit measure, personal health budgets were cost-effective: that is, budget holders experienced greater benefits than people receiving conventional services, and the budgets were worth the cost. Conclusion The evaluation provides support for the planned wider roll-out of personal health budgets in the English NHS after 2014 in so far as the localities in the pilot sample are representative of the whole country.

Provider and care workforce influences on quality of home-care services in England.

Abstract A key trend in home care in recent years in England has been movement away from “in-house” service provision by local government authorities (e.g., counties) towards models of service commissioning from independent providers. A national survey in 2003 identified that there were lower levels of satisfaction and perceptions of quality of care among older users of independent providers compared with in-house providers. This paper reports the results of a study that related service users views of 121 providers with the characteristics of these providers. For the most part, characteristics associated with positive perceptions of quality were more prevalent among in-house providers. Multivariate analyses of independent providers suggested that aspects of the workforce itself, in terms of age and experience, provider perceptions of staff turnover, and allowance of travel time, were the most critical influences on service user experiences of service quality.

Personalisation and partnership: competing objectives in English adult social care? The Individual Budget Pilot Projects and the NHS

As in other countries, improving collaboration between health and social care services is a long-established objective of English social policy. A more recent priority has been the personalisation of social care for adults and older people through the introduction of individualised funding arrangements. Individual budgets (IBs) were piloted in 13 English local authorities from 2005 to 2007, but they explicitly excluded NHS resources and services. This article draws on interviews with lead officers responsible for implementing IBs. It shows how the contexts of local collaboration created problems for the implementation of the personalisation pilots, jeopardised inter-sectoral relationships and threatened some of the collaborative arrangements that had developed over the previous decade. Personal budgets for some health services have subsequently also been piloted. These will need to build upon the experiences of the social care IB pilots, so that policy objectives of personalisation do not undermine previous collaborative achievements.

The costs of change: a case study of the process of implementing individual budgets across pilot local authorities in England

Individual budgets form a key element in the objective of the English Government to promote independence among people with needs for social care support. The initiative was designed to provide greater user control but the wider consequences, in terms of the implications for local authorities and their other responsibilities, remain to be addressed. An evaluation of the implementation of individual budgets in 13 local authorities was funded by the Department of Health, using a mixed methods approach to explore the impact of individual budgets both in terms of service user experiences and the implications for the local authority social services. One aspect of the evaluation concentrated on the cost implications of implementing individual budgets for the local authorities. All pilot local authorities were invited to take part in an interview designed to obtain the resources required to implement individual budget. Twelve of the 13 local authorities were part of the study reported in this article. All quantitative analysis was carried out using SPSS 13. Excluding all expenses that might be at least in part associated with the pilot process, in the first year, the estimated mean average cost was 290,000 pounds (median 270,000 pounds). This article will describe the initial approach adopted in estimating set-up costs, followed by a description of the findings for the first year of implementation and likely subsequent set-up costs. We also identify the range of factors that might affect reported costs.

“My Winchester Spoke to Her”: Crafting the Northern Rockies as a Hunter’s Paradise, c.1870–1910

This article considers the construction of the Northern Rockies as a hunter’s paradise in the latter years of the nineteenth century. It explores the crafting of the region as a game utopia by a cadre of hunter‐tourists, whose writings of what I term “fictionalized reality” celebrated the Rockies as an American Serengeti for sports and a realm of pioneer exoticism. Significantly, it argues that hunting became far more than an exercise in imperial tourism, instead representing a regenerative mechanism through which the sportsman emerged from the game trail, firstly as an exemplar of American masculinity, and secondly, as a fully‐fledged westerner. Stories of nature red in tooth and the “hunter‐hero” thus effectively obscured the political and economic realities of frontier assimilation to present the West as one vast playground for entertainment, adventuring and honorable violence. The article discusses the engagement between hunter and hunted, taking in themes of western tourism, codes of manhood, nature appreciation, gun‐play, and the gaze, before concluding with an analysis of how the “storied past” of hunting literature, photography, and taxidermy broadcast a strident identity for the Northern Rockies that persists to this day.