In an entry a couple of weeks ago, I identified three problems with the current way in which an individual’s needs are assessed, then their ability to pay, and then their social care entitlement converted into a cash amount, which they are helped to spend. I suggested that, even done well, the system had these problems:
- The assessment of your needs is based on you proving how bad things are. You might even have to wait for things to get worse before you become eligible for expensive support, when making cheaper, preventative support available would have been much more cost-effective.
- The addition of extra assessment and planning stages to the existing system, in order to convert your needs into an appropriate cash personal budget, has added bureaucracy. There is actually more gatekeeping than ever in some areas.
- The process focuses everyone on the money, which makes it harder to focus on outcomes and being creative.
I promised to think up some solutions to those problems, and asked you for yours.
The comments you were kind enough to post were very interesting. There was some consensus around the problems. No one believes that giving people the chance to control the money that is spent on them is the wrong aim, but lots of people would like it to be simpler, quicker and fairer to get to that amount of money, with fewer restrictions on what it is spent on. Several people feel that there is no way round the need for a RAS type system, and we should accept that reality and focus on making it work. If you put identifying the service first, you’ve returned to the old system; if you put identifying the budget first, you need to base that budget on costings based on a range of likely services. Few contributors, I felt, could articulate a practical third way.
Resource allocation systems build in two opportunities for professionals to exert control: first in setting an indicative amount, then in signing off (or not) the final budget. If it is never going to be possible for the state to relinquish budget sign-off completely, how could that control at least be eroded or tempered, without leading to bankrupt councils?
At a corporate level, council finance directors cannot relinquish overall control of budgets: it’s their job not to overspend. There is a tension between this need to exert control at a population level and the desire to relinquish budgetary control at the individual level. We could reduce that tension in a couple of ways:
First, and least likely, we could give council finance directors a breathing space where, if they can produce balanced budgets over five years, their budgets can be guaranteed for that period. This would allow councils to invest in prevention and to look more kindly on individuals who need to invest in non-traditional interventions which might prevent greater need later on. It’s hard to imagine this happening. The evidence base for many preventative services is weak and the government would need to find money up front and underwrite the losses if council’s plans didn’t work out.
Secondly, we could help people who use services act a little more like finance directors, through devolving spending power not only down to individuals (which puts me in the role of consumer, rather than commissioner), but also to groups and communities who would have the ability to invest to save on a smaller scale, taking risks such as investment in prevention, which are perhaps more manageable than the risks associated with council-wide investment. People who chose to take part would agree to spend their budgets collaboratively, aiming to meet their own needs but also to achieve outcomes for others. In return they would have access to the support of the group, which could include a shared emergency fund and the contributions from volunteers and families which a health community group can often bring in. Groups which were successful in bringing down costs whilst achieving outcomes could be given greater freedom and the opportunity invite more personal budget holding members. This is, of course, localism/ Big Society thinking and brings its own risks, not to mention public scepticism, but community budgeting ideas such as those espoused by the Stamford Forum are well worth exploring.
The suggestions above would not address the first and more fundamental problem I outlined at the start of this entry, which is that you have to wait until things are bad enough, and then prove it, before accessing new support. I believe the solution to this problem is to assess the individual’s direction of travel, not just a snapshot of their current problems. How about an assessment which looked at the next 12 months of someone’s life, for instance? Where are they now, but also, where are they expected to be? If the answer is, “okayish now, but likely to be in critical need of services in a year’s time”, then the person is entitled to a service now, even if, under the current system, s/he would be miles away from meeting the “critical need” eligibility criteria. The bad news is that councils would suddenly need to fund services for people who wouldn’t currently be entitled to a share of their pitifully small budgets. And no one has a crystal ball, so assessments would have to take an educated guess at someone’s future wellbeing, by analysing the risk factors in their lives. This would require new assessment tools, drawing on recent work on predictive risk analysis and the use of psychometric approaches which can draw robust data about wellbeing from fairly short self-assessment questionaires.
The good news for councils would be that people newly entitled to support, would be in need of cheaper, preventative services, not expensive crisis services. They would be encouraged to think in terms of investing to save and preventing future dependency. Providing that preventative services were effective, savings would be realised on crisis services within a fairly short period of time. Most social workers will tell you that, in reality, many bend the eligibility rules in favour of their clients all the time; this system would reduce the need to do so.
I’ll end with two possible ways of increasing the likelihood that the approach I’ve just outlined could achieve better outcomes, leading to people needing less expensive support.
First, we need to shift resources and expertise away from the processes designed to calculate a personal budget and towards support to plan. In a typical area, the process starts with an assessment of need, then a panel is involved in generating an indicative amount, then there is a planning process, then another panel approves or rejects the final amount. Then there is an appeals process. Instead, let’s start with a questionnaire about your needs and direction of travel (with the option to self-assess) which will suggest where you are within broad bands of eligibility, which give you a broad range of figures for your twelve month budget. Then an independent social worker is on hand to help you create a spending plan for the year. That person can advise on your eligibility and has a duty to verify that your self-assessment of need is accurate, but it is not their job to sign-off your budget. They help you draft a proposed budget which goes to an in-house team whose job is either to sign it off, or to suggest changes. If you can’t agree, that team can impose a lower overall budget, but it will have to show how that lower amount will meet all of your predicted needs over the next twelve months, making it hard to justify self-defeating short termism.
The current system is far too quick to reduce support (sometimes sending people crashing back into an expensive crisis) and far too slow to increase support to head off a crisis. Giving people the ability to spend money on preventative services could result in targeted, needs-led investment in the kinds of services which have often been shown to be effective, but which councils currently find hard to fund at the expense of reactive crisis services. You could reward people with greater freedom to spend with less need for reassessment, if they were able to make savings on their predicted budget. Individuals could have the right to bank a portion of any savings they made as an emergency fund, or as a capital investment in a home adaptation or to start up a new micro-enterprise.
I’m looking forward (kind of) to hearing all the new problems and perverse incentives you will, I’m sure, be able to spot in these ideas! We have a new social care statute on the way. If all it achieves is a more streamlined, clearer version of the current/ emerging system, that will be no bad thing. But let’s not confine our ambitions to that. What would your new blueprint for social care be?
hi Alex I was in the process of writing a post on my blog about the danger oft working from snapshots of our clients lives when i spotted your post – i hope you dont mind but i have referenced your comments and given out your link as they resonated so with me and were very relevent. See http://www.afteralice.wordpress.com .
I think you make a very pertinant point when you suggest a forward assessment of 12months allowing preventative care to be put in place.
I always like what I read here
Good approach and you have rightly recognised that ‘crisis management’ is not the answer anymore.
If reablement monies (both for functional and instrumental activities) are factored as the person moves from an early intervention service to a personal budget, (the reason for saying that is then we can have a qualitative account of spend on reablement types of services (When we talk about reablement we are not just talking about personal care reablement, we are talking about equipment as a solution, use of voluntary sector contracts etc) which may not be captured particularly well by authorities currently. If we could do this effectively and efficiently, we will know the costs and the outcomes it produces. Without complicating, if the service user is informed of the amount of money spent (which they do not pay but costs the LAs) for them for Reablement then this also increases confidence, trust and transparency and may perhaps increase responsibility on both sides.
My only other suggestion will be to have a small recording part of the support plan which the user can use to say what they would have liked to do but was not available in the LA – this could easily inform commissioning in market shaping.
Again, with greater integration with health, commissioning of contracts becomes another big challenge but a promising solution for the future
Colin Slasberg is happy for me to share his comments, sent via email:
I think its great you are putting forward thoughts. I believe there has to be an open debate about these issues.
In agreeing with you that it is time to ditch the RAS, I actually go much further and believe it is time to ditch the concept of allocating resources before support planning. I think it is ideologically based – part of the wider consumerist approach to reform of public services – and a red herring. Also, given the wide acceptance that you have to have two decision points – prior to and then after support planning – surely it can only increase bureaucracy. I think the really important issue is that the right services are chosen to meet the person’s needs and outcomes and in the most cost effective way. The important change is from selecting services from a menu of pre-purchased services. All that requires is for Councils to ensure their resource base is not tied up in pre-purchased services, and secondly to have the policy framework that supports (indeed requires) best practice at the front line. This contrasts with the ideological position that a choice of service is right simply by virtue of having been chosen by the service user. I think that’s just not true – with lots of evidence of people making really bad choices. This brings into focus Simon Stevens emphasis on co-production – I agree with him 100% about that.
I really like the idea of pooling resources amongst service users. I did something similar in my last full time post, albeit perhaps more limited as it was in relation to a group of home care users within a local patch. But it worked very well – and a small community of service users grew up who cared about one another and saw one another over difficult patches.
I think it’s the preventive agenda that is the most taxing. I think the underlying issue we are all grappling with is the severe underfunding of Social Care. Dilnot will only address the issue of loss of wealth for end of life care. I think the current under-funding that is managed by restricting service levels could cost as much £5BN. There is also the funding needed to address the under-pricing of services. I don’t think there is any system of resource allocation that will address this problem in the short term. It is inevitable that money will be spent first on those with most pressing needs, especially when it is so hard to confidently predict the future. I have never been persuaded by the “little bit of help” now approach to prevention. It can just as easily be the thin end of the dependency wedge and authentically preventive. The evidence is that those Councils who give more help at home also provide more residential care.
I think the very best that can happen in the short term is to free up the system through a fit for purpose policy and practice framework so that there can be honesty about what can and what cant be done. This will mean a). that practitioners who currently, as you point out, manipulate the system no longer have to do so but can get the resource openly b). Practitioners wont have to lie to service users about their needs not being needs, and so can be authentically holistic, but acknowledge some of their needs cannot be afforded and c). Most crucial of all, the system can be made fully aware of the extent and cost of unmet need and the pain being experienced as a result. This can create the political pressure for change.
I have to say I also recoil at the idea of assessment tools. I do think that the best tools are the service user and a practitioner with the ability to listen, make sense with the person of their lives, and bring a bit of relevant knowledge about needs and services to the conversation.
John Waters, of In Control, is happy for me to share his comments. His last reference, to ‘community fund holding’ refers to an approach still in development at In Control. He says:
I think your really against poor implementation and attacking the wrong beast :
“The assessment of your needs is based on you proving how bad things are. You might even have to wait for things to get worse before you become eligible for expensive support, when making cheaper, preventative support available would have been much more cost-effective.”
Your merely point out a perverse incentive inherent to rationing/targeting not constructing an argument against RAS ? RAS has capacity if implemented appropriately to begin to address many of the perverse incentives .. particularly around social capital …
“The addition of extra assessment and planning stages to the existing system, in order to convert your needs into an appropriate cash personal budget, has added bureaucracy. There is actually more gatekeeping than ever in some areas”
Who said anything about ras meaning extra ? This is about poor implementation not an argument against RAS It can should and has in places have the opposite effect to the one you describe here, again argument against poor implementation
“The process focuses everyone on the money, which makes it harder to focus on outcomes and being creative.”
The corollary of your argument is to not tell people how much money they have to plan as a way of freeing them from the rationing that exist. An odd basis for a rationale mature social care system
“give council finance directors a breathing space where, if they can produce balanced budgets over five years,”
sensible proposal in many ways helpful, but not one linked to the merits or other wise of RAS and personalisation per se. If you’re seeking radical financial environmental change of this scale that would be helpful you would be better exploring balance across time and public bodies around a community .. balance across time within one silo will have very little impact..
but also to groups and communities
yes but not at the expense of individual control and here’s how: community fund holding.