Nicola Moran

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.

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.

Multi‐agency transition services: greater collaboration needed to meet the priorities of young disabled people with complex needs as they move into adulthood

Purpose – Drawing on a wider study about the effectiveness and costs of different models of multi‐agency transition services, this paper aims to present new evidence on the ways in which such services meet the priorities and concerns of young people identified in previous research.Design/methodology/approach – The evidence is based on qualitative interviews with 130 managers and staff in five transition services across England, and a quantitative survey of parents and young people receiving these services (pre‐transition), or having received the services in the last‐two years (post‐transition). In total, 110 pre‐transition and 33 post‐transition parents, and 73 pre‐transition and 24 post‐transition young people, completed questionnaires. Statistical analysis included calculating frequencies and mean values for the responses that measured met and unmet need, and qualitative results were analysed thematically. The consequence of, and reasons for, the low response rate to the family survey are also discussed...

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.

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.

ETHICAL MODELS UNDERPINNING RESPONSES TO THREATS TO PUBLIC HEALTH: A COMPARISON OF APPROACHES TO COMMUNICABLE DISEASE CONTROL IN EUROPE

Increases in international travel and migratory flows have enabled infectious diseases to emerge and spread more rapidly than ever before. Hence, it is increasingly easy for local infectious diseases to become global infectious diseases (GIDs). National governments must be able to react quickly and effectively to GIDs, whether naturally occurring or intentionally instigated by bioterrorism. According to the World Health Organisation, global partnerships are necessary to gather the most up-to-date information and to mobilize resources to tackle GIDs when necessary. Communicable disease control also depends upon national public health laws and policies. The containment of an infectious disease typically involves detection, notification, quarantine and isolation of actual or suspected cases; the protection and monitoring of those not infected; and possibly even treatment. Some measures are clearly contentious and raise conflicts between individual and societal interests. In Europe national policies against infectious diseases are very heterogeneous. Some countries have a more communitarian approach to public health ethics, in which the interests of individual and society are more closely intertwined and interdependent, while others take a more liberal approach and give priority to individual freedoms in communicable disease control. This paper provides an overview of the different policies around communicable disease control that exist across a select number of countries across Europe. It then proposes ethical arguments to be considered in the making of public health laws, mostly concerning their effectiveness for public health protection.

European citizens’ opinions on immunisation

Summary As part of a larger study exploring how European citizens’ balance issues of public and private interest and the extent to which they are prepared to accept State intervention on a range of public health issues, focus group participants were asked whether childhood immunisation should be a matter of parental choice or State compulsion. The question was debated in 66 (of 96) focus groups held across 16 European countries in 2003. Discussions focused on the concept of risk, trust in health professionals and the State, upholding the status quo, fears over vaccine safety and perceptions of infectious disease as a ‘foreign threat’.

From compulsory to voluntary immunisation: Italy's National Vaccination Plan (2005-7) and the ethical and organisational challenges facing public health policy-makers across Europe

Increasing geographical mobility and international travel augment the ease and speed by which infectious diseases can spread across large distances. It is therefore incumbent upon each state to ensure that immunisation programmes are effective and that herd immunity is achieved. Across Europe, a range of immunisation policies exist: compulsion, the offer of financial incentives to parents or healthcare professionals, social and professional pressure, or simply the dissemination of clear information and advice. Until recently, immunisation against particular communicable diseases was compulsory in Italy. The Italian National Vaccination Plan (NVP) (2005–7) paved the way for regions to suspend the sanctions associated with compulsory vaccinations for children when certain criteria are met—for example when immunisation coverage is high and when effective monitoring/surveillance systems are in place—and thus marked a milestone in the move from compulsory to voluntary immunisation. The forthcoming NVP for 2008–10 confirms the liberal approach to vaccination in Italy as it entrusts to the regions responsibility for the achievement and maintenance of herd immunity. This paper reviews the arguments for and against compulsory and voluntary immunisation in relation to the Italian NVP (2005–7) and in the context of the diverse immunisation policies that exist across Europe. It concludes with cautious support for the NVP and an associated shift from compulsory to voluntary immunisation in Italy, and draws similarities between issues concerning regional variation in immunisation policy in Italy and national variation in immunisation policy across Europe and beyond.

Effectiveness of a training program for police officers who come into contact with people with mental health problems: A pragmatic randomised controlled trial

Introduction Police officers frequently come into contact with individuals with mental health problems. Specialist training in this area for police officers may improve how they respond to individuals with mental health problems; however, evidence to support this is sparse. This study evaluated the effectiveness of one bespoke mental health training package for frontline police officers relative to routine training. Design Pragmatic, two-armed cluster randomised controlled trial in one police force in England. Police stations in North Yorkshire were randomised with frontline police officers receiving either a bespoke mental health training package or routine training. The primary outcome was the number of incidents which resulted in a police response reported to the North Yorkshire Police control room up to six months after delivery of training. Secondary outcomes included: likelihood of incidents using Section 136 of the Mental Health Act; likelihood of incidents having a mental health tag applied; and number of individuals with a mental health warning marker involved in incidents. The appropriateness of mental health tags applied to a random sample of incidents was checked by an independent mental health professional. Routinely collected data were used. Results Twelve police stations were recruited and randomised (Intervention group n = 6; Control group n = 6), and 249 officers received the bespoke mental health training intervention. At follow-up, a median of 397 incidents were assigned to trial stations in the intervention group, and 498 in the control group. There was no evidence of a difference in the number of incidents with a police response (adjusted incidence rate ratio (IRR) 0.92, 95% CI 0.61 to 1.38, p = 0.69), or in the number of people with mental health warning markers involved in incidents (adjusted IRR 1.39, 95% CI 0.91 to 2.10, p = 0.13) between the intervention and control groups up to six months following the intervention; however, incidents assigned to stations in the intervention group were more likely to have a mental health tag applied to them than incidents assigned to control stations (adjusted odds ratio 1.41, 95% CI 1.16 to 1.71, p = 0.001). The review of 100 incidents suggests that there may be incidents involving individuals with mental health issues that are not being recorded as such (Kappa coefficient 0.65). There was no statistically significant difference in the likelihood of Section 136 of the Mental Health Act being applied to an incident. Conclusions The bespoke one day mental health training delivered to frontline officers by mental health professionals did not reduce the number of incidents reported to the police control room up to six months after its delivery; however training may have a positive effect on how the police record incidents involving individuals with mental health problems. Our trial has shown that conducting pragmatic trials within the police setting is feasible and acceptable. There is a wealth of routinely collected police data that can be utilised for research and further collaboration between police forces and academia is encouraged. Trial registration ISRCTN (ISRCTN11685602). The authors confirm that all ongoing and related trials for this drug/intervention are registered.