Partnerships and personalisation: the implications of direct payments and personal budgets

1. Partnerships and personalisation: the implications of direct payments and personal budgets Prof. Jon Glasby Co-Director, Health Services Management Centre

2. Outline • Background • Advantages/barriers • Personal budgets • Implications for social care • (Tentative) implications for health care

3. 1. Background “The potential for the most fundamental reorganisation of welfare for half a century” • Cash payments to service users aged 18-65 in lieu of direct service provision • Extended to include older people, younger people aged 16 and 17, carers and the parents of disabled children • Now mandatory rather than discretionary

4. 1. Background • Illegal under 1948 legislation • Indirect payments (pioneered by disabled people) • ILF • 1990 NHS and Community Care Act • Lobbying and research by disabled people • Disabled people involved in implementing direct payments

5. 1. Direct Payments are very simple – it’s not hard Direct Payments = a means to an end (of independent living) Choice and control are central

6. 2. Advantages • More responsive services and increased choice and control • Improved morale and mental/psychological wellbeing • A more creative use of resources which may sometimes reduce costs, but which certainly ensures better value for money • A blurring of the boundary between health and social care

7. 2. Barriers • Perceived focus on physical impairment • ‘Willing and able’ • Complexity of monitoring arrangements • Staff attitudes and knowledge • Political concerns in some authorities: ‘privatisation by the backdoor’? • Boundaries with NHS and housing

8. 3. Personal budgets • Rights-based approach (more like social security than traditional social care) • Links to PCP and circles of support • Sees DPs/PBs as a means to an end • Can use same resources much more effectively • Emphasised in the White Paper and being rolled out

9. 3. Seven steps to Self-directed Support • Set PB (using in Control’s RAS) • Plan support – with support as needed • Agree plan • Manage PB (currently 6 distinct degrees of control) • Organise support – complete flexibility • Live life - people use their PBs to achieve outcomes important to them • Review and learn

10. 4. Implications for social care “In the future, all individuals eligible for publicly-funded adult social care will have a personal budget (other than in circumstances where people require emergency access to provision): a clear, upfront allocation of funding to enable them to make informed choices about how best to meet their needs.” (Transforming social care 2008 circular)

11. 4. Implications for social care • Not a matter of ‘whether’ but of ‘how’ and ‘how quickly’ • Significant cultural challenges for whole of social care • Key test will be not regulating/scrutinising the new system to death • Focus shifts from assessment and from services to planning/review/outcomes • Holds out the potential for reforming the system as a whole – not just bolting on to the existing system

12. 5. (Tentative) implications for health • People do use DP/PB for health care • Separating health and social care rarely makes sense to the individual (or workers) • DP/PB for social care and not health flies in the face of the partnership agenda • DP/PB could help the NHS deliver key priorities • Growing sense of momentum

13. 5. What could the world be like? – HSMC’s expert seminar, 2004 • How can we make direct payments work better in integrated health and social care settings? • Could/should direct payments be extended to health care and in which areas of health care?  What implications might this have? • Could we learn from the choice and control of direct payments to improve health care?

14. 5. What could the world be like? – HSMC’s expert seminar, 2004 • Would fit well with long-term conditions agenda • Scope to extend to specific groups • Wide concerns about a broader roll out (equity, supply, cost etc) • Scope to learn DP lessons in health care • Need to repeat the 1990s battle for ‘hearts and minds’

15. 5. Key questions for health care? • When might it improve outcomes if people know upfront how much is available to meet their needs? • When could the person/those close to them/a worker achieve better outcomes by having the flexibility to be creative? • Where is it really important that support is truly personalised?

16. 5. Possible areas for an integrated PB? • LTC (admission avoidance)? • Mental health (recovery budget)? • Continuing care? • Maternity services? • Expensive out-of-area placements? • Learning difficulty services? • Disabled children? • End of life care? Etc etc

17. 5. How could this work for LTCs? • Scope for an admission avoidance scheme (with IB set at a % of the tariff)? • Scope to compare community matron v budget-holding professional v CIL/peer support model? • Scope to work with LA to make money available (similar to Pointon case)? • Scope to encourage Independent Living Trusts?

18. Further information • Alakeson, V. (2008) Let patients control the purse strings, BMJ, 12 April, 807-809 • Glasby, J. and Duffy, S. (2007) – policy paper on direct payments and health (www.bham.ac.uk/hsmc) • Glasby and Littlechild (2009) Direct payments and personal budgets. Policy Press • In Control (www.in-control.org.uk) • National Centre for Independent Living (www.ncil.org.uk) See also, the partnerships and personalisation section of the HSMC website