An ownership revolution for public services?

Prof Peter Beresford of Brunel University chairs the user led network, Shaping our Lives. We sometimes find ourselves debating the practicalities of personal budgets and resource allocation systems, but also share lots of common ground when it comes to the values of personalisation. We co-authored an article published in the Local Government Chronicle website on May 14th and on the TLAP blog which argues for an ownership revolution in public services.

Time to ditch the RAS? Part 2.

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:

  1. 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.
  2. 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.
  3. 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, Continue reading

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…

Time to ditch the RAS?

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:

  1.  The individual is assessed to see if they are eligible for state support.
  2.  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.
  3.  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.
  4.  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. Continue reading