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 Continue reading

Commissioning and control – where is the citizen?

A guest blog from Simon Taylor (simon@sharedlivesplus.org.uk), who supports our micro-enterprise members:

Another fascinating but frustrating blog just crossed my radar. It is from the Chief Executive of the British Association of Social Workers, Bridget Robb about how social workers feel frustrated with the commissioning of homecare and alienated from their own authorities’ commissioning systems.

It is a thought-provoking piece exploring how front line professionals can be excluded from decision-making and commissioning processes. She argues that many social workers are unhappy about the quality of much of the domiciliary care that they arrange, but “feel that they have little power and control over the services. Social workers need to be able to work with a small number of locally based suppliers of home care in small localities in order to build up relationships with the suppliers”.

The last line would hearten many micro-enterprise care providers who would relish such engagement. However, it is disheartening when even professionals do not feel as if they have any control, choice or power.

Alongside this, in my inbox, was news of a new Government attempt to drive up quality in local authority adult services. It is a new website launched to compare authorities’ adult social care performance via the Adult Social Care Outcome indicators. It hopes to help local people hold their council to account by making this, already available information, more accessible.

This seems laudable, but does raise the question of how local people will be able to use the information they can gather to hold their council to account, if BASW feels that even social workers can have no impact upon the support services they are able to purchase? Continue reading

Finding out more about micro-enterprise workers

A guest blog from Simon Taylor (simon@sharedlivesplus.org.uk), who supports our micro-enterprise members:

A reduction in the local authority workforce has not seen all these people disappear from the care and support workforce. Some join established agencies or providers but many have looked at their skills, considered their frustrations with former work and seen new opportunities to start their own micro-enterprise services.

Skills for Care’s report from last year’s “State of the Adult Social Care Sector and Workforce in England”, highlights some shifts in the workforce. The report shows the reduction of the local authority workforce (-9.3%) with a converse increase in Direct Payment employers (+15.8%) and the independent sector (+3.1%).

The report didn’t include statistics on micro-enterprise providers, but we know that some of the growth in micro-enterprises is through former local authority workers starting their own enterprises. Other enterprises are started by people entering social care for the first time, including some disabled and older people themselves starting their own micro-enterprises. These micro-entrepreneurs cover many areas, from residential support, services delivered in the home, help to access the community and many others which defy characterisation. Over 150 enterprises are now Shared Lives Plus members, benefitting from support, advice, insurance and a voice, whilst our sister organisation, Community Catalysts, supports areas to become micro-friendly and helps enterprises in the start-up phase.  

We are working closely with our very supportive colleagues at Skills for Care to look at how to include self-employed providers in national workforce information gathering. Getting more information about the people working in micro-enterprises will help us to ensure that their work is considered by policy makers and workforce planners.

Hence this very short survey: http://www.surveymonkey.com/s/SfC_SelfEmployment2013

If you know of any self-employed providers, please ask them to take part and ensure their voice is heard too. If you want to talk to us more about our micro enterprise services or our work informing policy do get in touch.

How to commission for a diverse range of providers

A guest blog from Simon Taylor (simon@sharedlivesplus.org.uk), who supports our micro-enterprise members:

When the Care Bill becomes law, commissioners will have a duty to promote a range of services that meet local people’s needs. This won’t be easy with tightening budgets and the drive to commission services ‘efficiently’, which many areas have seen in terms of having fewer contracts to manage. In addition, councils will have duties to support the development of preventative services and to help individuals to use Direct Payments and personal budgets to purchase support which is of their choosing.

Shared Lives Plus, supported by the Department of Health and endorsed by sector partnership Think Local Act Personal, has produced “Commissioning for Provider Diversity – A Guide”, which will help councils commission in a way which gets better value for money through having a wide range of local services, not just a few large contracts.

The report draws on the voices of the smallest of providers who deliver services at the ‘micro’ scale and on the work of our sister organisation, Community Catalysts, which supports local authorities to create the conditions in which micro as well as larger providers can thrive. The report explains the principles and then sets out the practical steps for commissioners to take, including identifying the met and unmet needs of personal budget holders and enabling citizens to have a say at every stage.

From our membership, we hear stories such as Continue reading

Saving money or seeking outcomes?

A guest blog from Simon Taylor (simon@sharedlivesplus.org.uk), who supports our micro-enterprise members:

Delegating decisions in care and support

Last week Think Local Act Personal launched its report on making the best use of the available resources when developing adult social care. It highlights options which could save councils money when other traditional costs saving methods are exhausted. This debate underlines the delicate balance councils must manage. Many unfortunately use remote senior managers or panels to maintain control over the money. All too few delegate decisions to front line workers to try and avoid costly red tape. The report identifies how councils can evidence the benefits of options like delegation to encourage them to use such approaches. www.thinklocalactpersonal.org.uk/Latest/Resource/?cid=9444

My initial reaction was astonishment that some local authorities struggle to release control to the professionals in their employment and are unable to understand the cost implications of their approaches.  The excellent report and toolkit developed by Think Local Act Personal working with the Towards Excellence in Adult Social Care Programme is a start for councils to consider and implement change.  

However, we need not only to hand power to front line workers, but also to people who use services so that they can be at the heart of decision making.

We need also to look beyond cost reductions. Delegation Continue reading

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 Continue reading

It’s better when it’s personal

I’m often asked about which kinds of social care services can be provided on a micro-scale. The answer, in my view, is all of them. As these two examples of micro-enterprises illustrate, services for younger and older people can all benefit from feeling much more personal.

After spending many years in further education and social care and seeing the limited opportunities that young people leaving post-19 education have to experience adventurous activities, Helen and Terry decided to set up The Adventure Service. Their services include environmental studies, mountain biking, bushcraft and hill walking offered on a day service basis for up to 12 people. They also offer outreach services working with people who need more direct one-to-one input to become more confident in accessing mainstream services.

They support people in Nottinghamshire and Derbyshire with a range of support needs including learning disabilities, autism and mental illness. All the services are paid for either by individuals’ own money or their personal budgets. They also provide services to schools to enable students who have support needs of some kind or are vulnerable to access adventurous activities. www.theadventureservice.com

Izabela, following on from her many years of experience as a qualified nurse, has set up her own small care and nursing agency for people in the Thames Valley area. Henley Care Ltd. specialises in providing nurses and carers for 24 hour live in care, as well as offering a daily visit service.

Izabela believes that care at home is not a universal panacea and may not suit everyone, however it is possible and can allow people to remain in the comfort of their own home, surrounded by friends and familiar objects for as long as they wish. She offers community health services, care in people’s homes and supported living with specialisms in dementia, diagnostic and/or screening services, mental health conditions and physical disabilities.

The business is run on the principal that everything comes down to the quality of the individual providing the day to day support and whether they actually care by treating people with respect and taking a real interest in all their needs. www.henleycare.com

Micro solutions to huge NHS problems

I spoke at the NHS Confederation conference yesterday about micro-scale and community-based approaches to health care, which was the subject of a paper I wrote for NHS Confed recently (“Working locally: micro-enterprises and building community assets“). The session was chaired by NHS Confed CEO Mike Farrar and packed with NHS professionals who, from their questions, were deeply engaged with community development and ‘assets’ approaches to healthcare. It felt like this agenda is finally getting some momentum in the NHS, which is very good news indeed. Here’s my bit from the session:

When faced with huge challenges like providing healthcare to an ageing population, it’s reasonable to assume that only huge solutions will do.

The problem with that way of thinking is that, whilst some healthcare activities need to take place on a large scale, achieving health itself happens, or fails to happen, on an individual level. Big buildings are sometimes the best place to treat illness, but achieving health generally happens in our own homes, workplaces and communities.

The only way to make sense of that conundrum (big challenges with as many different solutions as there are people) is to push as much of the power to design, control and deliver solutions into the hands of individuals, families and communities as possible.

Social care has gone a little way down this road, at least in its aspirations, if not always in its implementation. Healthcare has, in my view, barely started on this journey and the difference between the health and social care visions is striking in this respect:

The vision for healthcare is that patients will become informed consumers of the choices designed and commissioned for them by GPs and other professionals.

The emerging vision for social care is that citizens will not only be able to choose from the offers of providers and professionals, but also to take charge of commissioning and to pool their resources to design and own new services and enterprises when there is not an existing solution available to them.

Mix in healthcare circles and you will hear “clinical leadership” rather than “citizen leadership” and “patients” rather than “people”.

The comparisons I’m making are not entirely fair on the healthcare sector. If I ever need emergency brain surgery Continue reading

Bashing and boosting micro-enterprise

We launched a new report today on the top ten ways in which councils are boosting – and bashing – micro-enterprises in their area. Whilst some areas limit ways of spending personal budgets or access to ‘approved provider’ lists to tried and tested large providers, others actively encourage creativity and have thought through the environment needed for successful start-ups. Some councils throw a bit of money at budding micro-entrepreneurs in the hope that some great ideas will stick, whilst others have used the learning from successful micro-enterprise programmes (eg 125 jobs and 40 volunteering opportunities created in three years by Oldham’s Community Catalysts programme) to create a really thoughtful support programme which gives entrepreneurs a fighting chance of success.

The variation in micro-enterprise support is huge. Even areas with expensive brokerage systems are often only able to offer people the option of a Personal Assistant or traditional services. The report suggests that most areas have some way to go to unlock local people’s creativity and to raise aspirations. But the rewards are huge, as Angela Catley of our sister organisation, Community Catalysts, points out in an interesting article about micro-enterprise, which includes a picture of the Green Team in Dudley, which was set up by three support workers to provide people with learning disabilities with an alternative to day services in the shape of meaningful work as part of a gardening team.