Giving individuals the option to control the money which is spent on meeting their needs feels to me to be self-evidently a good thing. There is great – and massively undervalued – expertise in the social work profession, but social care is not like, say, heart surgery, where I would probably be happy for most decisions about my care to be taken by the experts. Social care is more ambitious than heart surgery. It doesn’t just want to help your body function, it wants to be a route you can take towards living a fulfilling life. A surgeon knows a lot more than I do about how my heart works, but even the most skilled social worker will only ever have a rough idea of what makes me tick.
So if putting me in charge of the social care resources attached to me makes sense, and it’s also a given that budgets are never going to be infinite, what is the simplest, clearest, fairest way of allocating a budget to an individual, which recognises that there have to be some limits on how much people can spend?
The current process in most areas is a little like this:
- The individual is assessed to see if they are eligible for state support.
- They are also assessed to see if they are eligible for that support to be provided free, or if the state will charge them some or all of the cost, according to their income and savings.
- A system (a Resource Allocation System or RAS) is used to give people a rough estimate of how much money they are likely to be entitled to spend on social care. This estimate is proportional to their level of need.
- The individual is helped to plan to spend that money. The RAS is only (in theory) used to produce an estimate, so it might transpire that the individual needs more, or less, than the estimated amount, in order to meet their social care needs. When this happens, the amount allocated to them can be changed to ensure they can afford to purchase the support they need, and that they are not given more money than they need.
Let’s assume that that process happens fairly and transparently and that the professionals involved don’t take short cuts, such as treating the initial budget estimate as the final figure, or giving you a limited list of the services you can purchase, rather than helping you to think creatively about the best intervention to meet your particular needs and wishes. Even done properly, this process still contains three major problems.
The first problem is that you have to prove how vulnerable and helpless you are, before you get anything. You may actually have to wait until your health or wellbeing deteriorates before you become eligible for expensive state support, when a much cheaper preventative intervention could have avoided that need if it had been available at an early stage
The second problem is that it contains an extra step or two of assessment and planning. Those are the steps which translate your needs into an estimated cash total and then into a final cash total, which then still has to be signed off by your council. It’s possible for there to be several rounds of negotiation, as the council and the individual try to compromise between what the council sees as a Rolls Royce solution and what you see as more like a second hand scooter. These extra steps are there because turning needs into resources is an add-on to the existing social care system, rather than a replacement for it. It’s possible that the forthcoming social care Bill will find a way of replacing our cobbled together social care system with one streamlined process which will significantly reduce that bureaucracy.
The third problem is that the system is supposed to get everyone thinking creatively about how to achieve outcomes, but it starts and ends with a focus on money. There is a huge difference between saying, “What ways can you think of to move towards some of your goals in life?” and saying, “How would you spend up to £10,000 a year?”
Ironically, in the old system, really good social work perhaps had more opportunities to focus on outcomes, because it didn’t involve a conversation quite so focused on money. The problem was that there were only a few routes available to achieving those outcomes (council-run social care services) and they weren’t always very good at doing so. If you want there to be more ways for people to achieve their outcomes, including making available interventions which don’t even look like traditional support services (such as the famous season ticket to a football club for an isolated young disabled man, or support to set up your own enterprise as a route into employment), then you need individuals to be able to take resources and invest them as they want, rather than only within the boundaries of a council employee’s imagination.
So what to do? Before personal budgets, the culture of social work was changing, but nowhere near fast enough. It needed a major shake-up. Giving people control over at least some of the money has without doubt positively disrupted the system, changing many people’s lives and giving a large chunk of the sector a new set of ideas about what is possible. But the old system and to some extent the old ways of thinking, were resilient. Never underestimate the ability of an established order to absorb and neutralise radicalism. Councils have been told to give individuals control of their budgets at a time when they have less and less money to spend, so they have asserted control in other ways. I suspect some councils spend more money on gatekeeping their resources than they do on helping people to plan to spend them. We need to find some way of striking a deal between citizens and the state, in which the citizen (and their family and advocates) say, “I’ll be as creative and as frugal as possible in meeting my current support needs and achieving greater independence” and the council says “In return, we’ll trust that you are not fraudulent or extravagant and we’ll keep assessment and approval processes to the minimum.”
Hopelessly naïve? I don’t believe so. I think we just need a different starting point. This blog is getting way too long, so in my next one, I’m going to take those three problems and try to suggest some solutions. In the meantime, I’d be very interested to hear your solutions. Have I even identified the right problems? How are personal budgets and Direct Payments managed in your area? Comments please!
Good interesting and thought provoking blog as ever. My limited experience is council’s are very risk adverse, and individual’s working for them don’t want to be make any decision which might potentially make them look silly (or worse, lose their job). Consequently an appeal for trust viz a viz over monitoring what may or may not be fraudulent, whilst economically sensible, is highly optimistic. The other pertinent point of your post is that the system incentivises and rewards vulnerability and helplessness . I agree prevention is better than cure and the system as you describe it won’t deal with possible pre-cursors (such as loneliness) to mental illness until the problem has taken hold… The worrying thing is it’s quick (and cheap) to dismantle a system such as day centres etc. It’s very expensive to rebuild/provide these services once they’ve been removed.
Thanks for the thoughtful comment Toby – I am a recovering optimist….
A very tricky issue of course. I’m reminded of Churchill’s observation that democracy is the worst form of government apart from all the others. There is always a RAS because decisions about allocation of resources always have to be made. The question is only how. There is some risk of blaming new RAS approaches for things like deficit based assessment when these originate elsewhere. My experience as a care management team leader in the 1990’s was not of social workers undertaking an “exchange model” assessment (see Gerry Smale) with a person, jointly developing desired outcomes and working out how various resources, including those of the state could be used to achieve these outcomes and then allocating those resources for use. It was of time pressured workers completing assessments which proposed service based solutions which then went to panels of senior managers who had secret discussions and finally reached decisions which were eventually communicated to the person who was then placed into a service. A few people experienced something different if they were able to stand up for themselves or had strong support or advocates. Sometimes these people understandably kidded themselves that their positive experience could be replicated for all and that therefore this was the best way of doing things.
The other thing that stood out was that the resources were not allocated fairly ie people with the same kinds of needs in the same place getting roughly the same resources. There was massive variation depending on things like the time of year the service was allocated and the political skills of the care manager.
This is not simply about social work cultures – social workers don’t want to do that stuff. RAS approaches developed in the past few years have, as you say dropped into systems and ways of working that are still too often not transparent and which remain controlling and risk averse. We haven’t swept away old ways of doing things (like panels), weve added some new elements in – which is a cause of delay, bureaucracy and immense frustration to people. So lets keep working on this but not kid ourselves that there was any kind of golden age or that this is all the fault of attempts to plan with some idea of the money available instead of plan and then the care manager disappears into the secret resource allocation room again.
Thanks for that really great response Martin – you are of course right that the idea of a “golden age” is well wide of the mark: there was a good reason for direct payments, and again for developing the greater flexibility of personal budgets, and there will not be a perfect way of administering them. I do wonder if the current approach to RAS was the right solution at the time, but not necessarily now….
There has been some debate about this blog entry on the rather wonderful LinkedIn group called “The Personalisation Group to revolutionise social care” http://www.linkedin.com
Simon Stevens • I have always been in favour of outcome based co-produced assessment which I have in Coventry. It is accurate with no winning or losing, and build on trust and a joint responsibility to be value for money.
I asked Steven if he could send me a link to that approach. His reply:
• I wish I could, its being replace by a kind of RAS against better judgement. They taken off the old docs. It was used in their individual budget pilot and while I did not get any more funding, because of the outcomes focus and working together, my support needs was probably properly understood, accepted and embraced for the first time. Before that I got my support because it was fashionable or because I would complain.
My support package is larger than most people with my level of impairment at that time but my outcomes and therefore my needs are far greater as I work comparable to non-disabled peers and therefore outcome focus made this understandable. it also meant if i give up work, my needs may reduce. it is a framework which has allowed my social workers to understand me as a person.. RAS is just itemised billing on a old system and I am not sure it would had empowered me.
Colin Slasberg • If we lived in a rational world, the RAS would have been consigned to history at the point when it was realised that allocating resources before the person’s needs and support requirements are known was both unlawful and made for bad use of limited money. Instead, In Control’s seminal idea, by then swallowed wholesale by New Labour, was kept alive by creating the concept of the “indicative” budget, which is created by the RAS. Advocates of the personal budget strategy, who remain in the ascendency in the national consciousness, claim that the actual budget is only a tweak of the RAS-driven indicative budget. They point to Hartlepool and say that the average actual budget is little different from the indicative budget, which proves its working. But what they seek to overlook is that there are very significant variations up and down between the indicative and actual. That they even themselves out is absolutely not evidence of the accuracy of the RAS. If people got the RAS allocation, it would be disastrous.The mounting evidence is that all the RAS has bought is a pointless and expensive bureaucracy much disliked by practitioners and service users alike. But I think it is worse than that. It has acted as huge distraction to the real challenges facing social care. Councils are still making decisions about resource allocation once they know the person’s needs, outcomes and support requirements. No change – and that is almost certainly right. The key question is whether it is a good thing that people can choose the service that is right for them. Answer – yes. Second question – do you need to know how much money is available before you make the choices. Answer – no. The real changes required are to create a workforce skilled in understanding people (which includes binning forever the wretched tick box assessment and scoring forms), and creating an approach to prioritising needs that enables fair and sensible decisions about allocating resources within what will continue to be a cash limited environment.
Simon Stevens • I totally agree with you Colin. You only need to know how much money you have if you are having a direct payment but even then, the need should be assess, the theoricial ‘service’ should be defined in terms of hours or other expenditure and then since a direct payment is restricted monies, managed by the user and not owed by the user, an accurate calculated in needed. If the budget is managed through direct services, the final amount is not important so long as everyone is happy with what is being provided.
RAS was only designed to work in the decommissing of expensive day care services, where an individual could gain better value from their share of the money saved and gave the notion of freedom to choose. While they is freedom to manage personal support in a Plan B situation so if a member of staff is sick or you have gaps in the ideal rota, you may have a takeaway delivered as your support, they is very little feedom is the agreed ideal support plan, eg full staff team etc.
I argue that it is the job of a good social worker to sell where appropraite using the internet for food shopping and having 1 hour support to put it away is far more empowering and user led than having 2 hours support to go physically shopping. You have improved the quality of outcome by 200% and halved the costs… thats good social work!
Martin Routledge • “creating an approach to prioritising needs that enables fair and sensible decisions about allocating resources within what will continue to be a cash limited environment”.
Ah yes Colin – what shall we call that and how shall we do it?
Colin Slasberg • Its FACS Martin – but having made the changes to get it right. The DH wasted an opportunity in its review of FACS last year to address the fundamental flaws that makes it the dysfunctional system it quickly became. CSCI were right that the fundamental concepts are sound, the problem is in delivery. But the failure in delivery starts with the framework itself, not just the way Councils have worked with it. In particular, the convoluted wording of the bands which makes them meaningless, along with the requirement to recognise only two types of need – eligible and non eligible. This creates an inflexible framework that cuts across the complexity of decision making required to deliver sensible, value for money decisions within a cash limited budget. I am very confident that the changes required are do-able, and will support personalisation, just as long as personalisation is defined by the experience of service users and not the process. The issue is whether there is a will to explore this and get it right.
My take on all of this is that RAS is crucial – but only if used right. Many councils have tried to turn it into an assessment in its own right – but it is not that – the disabled people on the common RAS programme called it a ‘personal budget calculator’ which I think is much more accurate. And the lawyers have confirmed that a needs questionnaire plus a good support plan plus a council decision with someone that the plan is appropriate taken together meet the requirements of community care legislation re assessment – but that none of those components on their own do.
RAS needs to be short and simple – I like those that take no more than 10 mins to complete for the vast majority of people.
It needs to do its job job quickly and easily – that is identify a fair approximate amount of money that someone may have to plan with – preferably immediately – based only on need. And there must be no additional ‘steps’ – the RAS should just do its job without further meddling from anyone.
And RAS needs to operate within the right environment – where councils are using it to ensure a new conversation with people who need support and their families – not ‘what services can you have’ but ‘what life do you want’ or’what do you want to do’. When people and families are in charge of this approach they dont do it in a minimalist financially driven way – they start with the natural supports that are available, and then use the money to fill the gaps.
Im an optimist too!! But the big question I have is whether the ‘system’, even one that has had £.5 billion invested in it will ever reform itself or whether it is time to much more radically reform it – and place RAS and other functions outside of council environments.
Fo rme the RAS breaks open the old care management system and makes possible these new conversations which ensure that people and families are able to define and describe the life thye want to life.