Personalisation: Who cares?
Who Pays?
Hilary Land
Sue Himmelweit
Unison, 2010
Personalisation
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“every person who receives support, whether
provided by statutory services or funded by themselves,
will have the choice and control over the shape of that
support in all care settings…
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…..Self-assessment will also be a cornerstone of
personalization. Giving service users the opportunity to
assess their own care and support needs and decide
how their individual budgets are spent are central parts
of the agenda.”
• (Department of Health, Expert Guide to Personalisation,
2009)
Culmination of changes set in train
twenty years ago
• Provision of residential and domiciliary care shifted from
public sector (LAs) to the market (private for profit and
voluntary)
• LAs funded and managed care, monitored standards
and ‘co-ordinated’ market
• Home helps redefined as home carers
• Support increasingly concentrated on those with greatest
needs living in own home to save costs of residential
care – thus heavily reliant on family care
• Social security system ceased funding care directly
• Personal, as opposed to medical, care means-tested
But important continuities
• Services still means-tested and underfunded
• Boundaries between social care and
health care shifting and problematic
• Cost-containment a key policy objective
• Care from family and friends far outweighs
formal care provision
Consequences of 1990s reforms
and increasingly tight budgets
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Interventions became task oriented-‘packages’ of care
Recipients of domiciliary care have more complex needs
those with lower levels of needs not supported
High turnover of providers of residential and domiciliary
care
high turnover of care staff
high vacancy rates
lack of investment in training, career structure
growing dependence on migrant workers
Access to services a ‘post-code lottery’
Personalisation
• Seen as a way of ameliorating negative
consequences of early 1990s reforms:
• by shifting choice of service and carer from LA to
individual needing care
• Consistent with Independent Living Movement’s demand
for choice and control over
• the timing and form of care received as well as who
provides it
• Direct Payments, introduced mid 1990s, most common
form of personalisation
• often spent on employing a Personal Assistant
• over half DP holders choose to employ relative or friend
Early adopters
• Both DP holders and their PAs often satisfied
• However:
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“Across government there are examples of policies accidentally
placing workers at risk in vulnerable employment, for example
through the introduction of Direct Payments without sufficient
support for social care service users to undertake their
responsibilities as employers.”
• (TUC Commission on Vulnerable Employment, 2009, p35)
• “many of the success stories in using personal budgets featured
new patterns of support often developed with the help of exceptional
caring families and of visionary and committed staff” (CSCI, 2009,
130).
• “I think the government is exploiting vulnerable parents and calling it
empowering. It is actually exhausting.”
A parent of a deaf blind child (Sense, 2008, p 17).
Care and the market
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The market is supposed to deliver:
Choice for purchasers
Market mechanisms to provide value for money
Competition between providers delivering high quality at
lowest possible cost
Personalisation should do this better than privatisation
Because purchaser is actual recipient
Thus better services can be provided and money saved
through personalisation because
people purchase only the services that they want
those services are provided most efficiently at lowest
possible cost
Argument relies on care being a
commodity like any other
• But care involves a relationship
• Care workers learn how to care for particular people: continuity of
care matters making it costly to change care providers
• Hard to know if better care would be available elsewhere or whether
current provider is providing good value for money
• because relational quality of care cannot entirely be assessed and
monitored and is often personal
• Care needs may give some care recipients difficulty in using the
market themselves
• In practice, choice is often constrained by funding policy
• Market mechanism therefore in practice costly to use effectively to
deliver good quality care
Quality and value for money in care
• Government recognises information on care quality
important for market to work:
• but such evaluation tends to miss the hard to assess
relational aspects of care
• To compete providers have to lower standards on
aspects that are not monitored - race to the bottom at
least by private for profit providers
• But these aspects may be what really matter in care
quality
• Even harder to enforce quality through the market when
purchasers are individuals and have little clout (or help
with evaluation)
So why might personalisation save
money?
• May not need to pay for some “unwanted” services
• Self-fulfilling prophecy in some cases e.g. collectively
provided services such as day centres
• These likely to become uneconomic if current users do
not all decide to spend their DPs this way
• Personalisation will:
• expand the care labour force by bringing in new carers
with low expectations, and skills rather than
qualifications
• use unorganised labour working in isolation
• Budgets can be cut (or fail to rise in line with costs) more
easily when allocated to individuals rather than local
authority departments
Using market to deliver “value for
money”
• Must therefore mean either:
• Care workers wages fall further behind
those in other sectors
• Care ratios deteriorate
• Either way: lower quality care
• Only way to avoid this is keeping spending
rising in line with earnings not prices (and
increased demand) i.e. must take a rising
proportion of GDP
Rising costs an important issue in
care
• Current budgets inadequate
• Costs will rise because of greater numbers needing care
• Units costs will rise unless care quality is allowed to
deteriorate further
• Sector in which productivity rises inherently impossible
without lowering quality
• productivity i.e. staffing ratios seen as measure of quality
• high productivity = low quality
• Relative cost of care rises because of productivity
increases in other sectors
Individual budgets likely to be
minimal
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So corporate providers will
have to compete on price
have no incentive to train their workers
DP recipients may not have sufficient
resources/knowledge to train their PAs
Care wages, both basic and increments for
qualifications, too low to enable/encourage care
workers to finance their own training
Market mechanism unlikely to work in ensuring
skill development, and career structure
and thus quality of care