Micro-enterprise: care and support on a scale that’s “just right”?

This is a guest blog from researcher Catherine Needham of the University of Birmingham, who is launching the first research to look at whether size of provider organisation makes a difference to outcomes and cost-effectiveness. The summary is very readable and should be of interest to all care commissioners. Dr Needham writes:

It has long been evident that large-scale care provision on a time-and-task model has not been delivering care and support which is personalised and leads to valued outcomes. This week, a team from the University of Birmingham, of which I was a part, launched findings which solidify the evidence base about the benefits of micro-enterprise over larger providers.

Twenty-seven care organisations in England were included in the study, covering a range of sizes and functions, including day activities and support in the home. Interviews were done by academic researchers working alongside people with experience of local care services on a co-research model. Among the 143 people interviewed were owners, managers, members of staff, carers, and those receiving care services, including older and disabled people.

Findings show that micro-enterprises offer more personalised support than larger care services, and contribute to better outcomes (measured using ASCOT, the Adult Social Care Outcomes Toolkit). These benefits stem from micro-enterprises having greater continuity of staff, greater staff autonomy and greater accessibility of managers compared to larger organisations. The research also found that micro-enterprises offer good value for money: their hourly rates were on average lower than the larger comparator organisations, helped by low overheads.

The micro-enterprises in our sample talked about what had helped them to get started, and what barriers they faced in staying in business. Many had benefitted from local micro coordinators, part-funded by Community Catalysts, which helped them understand care sector regulation and funding.

To keep going the micro-enterprises had to market their services to potential users as they didn’t have a formal contract with the local authority in the way a large care companies did. Most people supported by micro-providers had a direct payment or were self-funding, and had found out about the provider through word-of-mouth or local advertising. The relatively low take-up of direct payments by older people highlights the need to provide alternative routes into micro-enterprise. Social workers, GPs and other care professionals need to be informed about micro-enterprises operating close-by so that they can match up people with support in their local communities.

Like most academic studies, the research answered many questions but generated others. In particular I was struck

Personal budgets: summit or nowt?

At the Personalisation Summit yesterday, chaired by the Minister, Norman Lamb MP, and hosted by Think Local Act Personal and the Dept Health, we had a useful recap on the findings from the second POET survey of people in 20 odd local authorities about their experience of personal budgets. As in previous surveys, the average result of a personal budget is improvement in outcomes and experience, which is encouraging. What was helpful about this survey was that the report also sets out the range of responses, which, even amongst the local authorities committed enough to take part in POET, was wide.

Another striking feature was that the positive outcomes of personal budgets, for both people using budgets and for family carers, tended to be around the quality and experience of support to live independently, with the findings on some less service-related areas of life, including friendships, volunteering and getting a job, showing smaller improvements. In the worst performing areas surveyed, the increase in people gaining employment was almost zero, for instance.

So, on average, having a personal budget is better than not having one. And having that budget as a Direct Payment continues to be associated with better outcomes still. But it is still possible of course to have a personal budget or a Direct Payment (or be deemed to have one) and to experience no improvements, particularly in areas of life where services are less relevant, however purchased or managed.

Personal budgets and Direct Payments are clearly just one – vital – part of achieving change. Helping people who use services to take on or sustain roles and responsibilities within their families, communities and as members of the workforce, needs a deeper change, which only a few areas are achieving. We all need to learn from them if we are going to genuinely Make it Real.

Why we need the government to act on the Choice Review

With some of our partner organisations, we wrote an open letter last week to Care Minister Norman Lamb MP, urging him to act on the recent Cabinet Office review of choice in public services, which recommended that people should be free to spend personal budgets as they see fit so long as they meet broad outcomes, with the removal of ‘preferred provider lists’ and other traditional commissioning approaches which hamper start-ups, micro-enterprises and other innovators from competing with bigger, more established providers. There’s no point in having control of the money if there’s nothing new or different to buy with it. As reported in Community Care, we warned that without these ‘supply side’ reforms, the risk of personalisation failing in its own terms is high.

A great illustration of the problem is in this Guardian article about how council procurement processes left one social entrepreneur literally starving (at least around lunchtime!) due to their inabiility to renew a contract in a timely fashion. When the basics are so wrong, having an impressive virtual online marketplace for providers and a marketing programme to encourage people to take personal budgets will fall flat.

Our report on Ten ways to stop bashing -and start boosting – micro-enterprise shows how councils can learn from the best work of their peers and get this right, so that we can ‘Make Personalisation Real’, not just another box-ticking exercise.

A patchwork quilt

Think Local, Act Personal, the sector-led partnership which is helping providers and councils to push forward with personalisation, has teamed up with SCIE to publish “Improving Personal Budgets for Older People: A Review” which you can find here: http://bit.ly/YyWRZR. Some of the findings are based on data from the ADASS personalisation survey (2012) of councils and the 2011 POET survey which is a large annual survey carried out by Think Local, Act Personal of people’s experiences of personal budgets.

It’s quite common to hear people say “personal budgets and Direct Payments don’t work for older people” so it’s useful to have some real evidence to look at in testing whether those doubts are based in reality, or in assumptions about older people and choice. The report finds that in some areas many more older people are using personal budgets, so the argument that older people aren’t interested or can’t use personal budgets does not seem to hold up. However, that picture is really patchy and the report finds lots of barriers to older people taking up personal budgets, including confusing processes and lack of support to make choices; lack of understanding about the things personal budgets and direct payments can be spent on (not just Personal Assistants) or little real choice of new provision; and reluctance on the part of older people or their families to take on responsibilities like being an employer. All of these factors are relevant to younger people as well as older people, but perhaps the most telling differences are that some of the powerful features of using a personal budget for younger people – such as taking that budget as a cash Direct Payment and having complete control over a care package or a team of staff – appear not to be so relevant or available for older people, who are often working with lower budget allocations and who may be looking for quality and consistency of service above control for its own sake (although the report cautions against the risk of these conclusions being influenced by ageist assumptions.

Of course, if the high numbers of older personal budget holders in some areas were present everywhere, we would be talking about how well they work for older people. The apparent success in some areas could mean that

Demand and supply

Here’s a third and final blog off the back of this week’s King’s Fund discussion about innovation in healthcare.

I’ve argued on a number of occasions that we have focused too much on trying to adjust demand within social care -by giving people personal budgets and Direct Payments with which they could, in theory, demand the service of their choice – at the expense of thinking about supply. Without developing diversity of supply, it turns out that people only have the same old choice of services to spend their personal budgets on, and that problem gets worse as supply organisations find it easier to compete on price than on personalisation of their offer and the market consolidates into fewer, larger organisations.

In conversation with colleagues in healthcare innovation, it was suggested that if social care’s innovation problem is that we focus too much on demand and not enough on supply, perhaps the main barrier to innovation in the NHS is focusing too much on supply – new contracts, payment by results, innovation in medicines and procedures – and not nearly enough about demand. We are all ‘patients’ and ‘consumers’ when we step into the realm of the NHS, which talks about things like increasing our level of ‘compliance’ with treatment regimes.

Could we bring together social care’s progress on thinking about demand, and the NHS’s progress on streamlining supply?

Some consensus on the problem, solutions prove harder…

There has been an interesting debate on the LinkedIn group called “The Personalisation Group to revolutionise social care” (http://www.linkedin.com) about my last blog entry. I’ve cut and pasted the contributions as comments at the bottom of the last entry.

Martin Routledge (ex DH, now In control and Think Local, Act Personal lead) warned against any suggestion that there was a golden age. I agree that there were of course good reasons for shaking up the system and the RAS was probably the only credible and widely understood approach to managing the money at the time.

Veteran disability rights activist, consultant and trainer, Simon Stevens outlines how his council effectively took a different approach, whilst the RAS is, in his view, ” just itemised billing on an old system”. In a recent comment he says, “A good assessment is a piece of art and not a work of science….It is important to remember, personal budgets were never what was intended, and it was born out of the failure of individualised budgets where the funding streams were supposed to come together……Life is complex and fairness is subjective so assessments must be reflective to individual circumstances. I have heard RAS described as an mechanism to keep social workers ‘on the straight and narrow’ rather than users.”

Colin Strasberg agrees that trying to get to even an estimated cash amount first, before interventions have been properly explored, is the wrong way round. He argues that Fair Access to Care (FACS) eligibility criteria, reviled by many, is actually sound, just poorly developed and applied; it needs developing in Colin’s view to move away from a black and white divide between needs which are eligible for support and those which are ineligible. Colin is working on that idea and it will be interesting to see if he can turn that into a workable route to a personalised system.

Jez Ashdown adds, “My experience of working with a number local authorities across the North of England is that the RAS process has never lived up to its intended purpose… In a system where the resources available fail to meet the need the primary function of that system will be to ration, or allocate resources to competing priorities. In the case of social care this tends to mean that nearly everyone gets less than they need.”

So what we’re all agreed upon is that there are still huge challenges in turning the ideal of choice and control into practical reality, but what we’re short of are detailed, workable alternatives to the RAS…. I’m still drafting my attempt at this – and fully expecting to be shot down in flames when I post it!

Please keep the comments coming…