Written evidence from Shaping Our Lives
1.1 My name is Professor Peter Beresford OBE. I was interviewed by the National Audit Office as part of their field work. The auditors also referred to three articles I co-authored on the subject of personal budgets and personalisation in social care which were published in peer reviewed academic journals. I am Professor of Citizen Participation at the University of Essex and Emeritus Professor of Social Policy at Brunel University London. I am also Co-chair of Shaping our Lives, a national service user and disabled people’s organisation.
1.2 I am making this submission because I do not believe the auditors have appropriately absorbed and reflected the evidence I put before them, which reflects wider evidence and experience on personal budgets. The implications are too important for the service and appropriate use of public resources for me not to act.
1.3 The NAO accepted the prevailing narrative that the failure of the personal budget strategy to deliver its promises is due to councils not delivering it properly. However, examination of all the evidence shows that it is more likely to be failing because the strategy is fundamentally flawed and therefore unlikely to succeed.
1.4 The consequences of not heeding the evidence and changing direction are serious;
1.5 The following will set out;
It is based on evidence and analysis published in peer reviewed journals. They are listed at the end.
2.1 Personal budgets are defined as an allocation of money ‘up-front’ to allow the person choice in how the money is spent. The thinking is that people with similar needs require similar amounts of resource. The architects of the personal budget theory looked at the very wide variations in the levels of support different service users received. They took this as evidence that professional largesse was the decisive factor. They coined the phrase ‘the professional gift’ to describe the power they believed practitioners wielded. The ‘up-front’ allocation would be calculated using a Resource Allocation System (RAS).
2.2 It was an idea that had instant appeal. However, this overlooked the alternative explanation for the wide variation in the cost of packages, which is that it reflected wide variation in levels of need. Social care needs arise from the complex interplay of a range of factors each of which are themselves highly variable. The nature of the person’s impairment, its severity, the impact on physical or intellectual functioning, how long they have lived with it; the attitudes and personal resources they bring to bear; the attitudes and resources family and friends bring to bear; the attitudes and resources of the local community; attitudes and resources of other services; the person’s physical living environment. The almost infinite variety of ways these factors can interact means that each person is unique.
2.3 The architects of the strategy originally believed that the up-front allocation should be an entitlement. This was to ensure the service user is empowered as a consumer. However, prior to implementation the ‘up-front’ allocation ceased to be an entitlement and was reduced to being ‘indicative’ only. This was said to allow a final check following the choice of services that the amount was sufficient to meet needs that were a legal duty. It was envisaged it would only involve an ‘adjustment’ of the indicative amount.
2.4 The reality is that the actual allocation has not been a mere adjustment. In order to decide if the allocation is sufficient councils have to carry out an assessment of their needs as they would have anyway. Thus a parallel process had been created.
2.5 The evidence is that there is no meaningful relationship between the two processes;
‘Most authorities we spoke with were struggling to develop resource allocation systems’
and
‘Most staff we spoke with found indicative budgets to be inaccurate and unhelpful, and said they were often ignored’
The University of Kent made a similar finding in work for the Department of Health to research the impact of the Care Act.
2.6 The implications of this evidence are profound;
2.7 Herein lies the true reason for why the NAO found ‘no association’ between levels of take up and better outcomes. Councils have created the bureaucracy to deliver up-front allocations in order to claim they have reached their targets, but they have not changed the way needs are assessed and resources allocated. It could be described a phantom policy.
2.8 The Care Act does not change the situation. Although introducing the term ‘personal budget’, it makes no mention of up-front allocations. A ‘personal budget’ is no more than the financial value of the services required to meet needs. This is only known after decisions have been made about needs and services.
3.1 The NAO authors noted that there remains a widely held view that personal budgets deliver better outcomes, and all that is required is better delivery by councils. How can this perception be created and sustained in the face of the evidence set out above? It has been achieved by the following methods;
3.2 Conflating personal budgets and direct payments.
Supporters of personal budgets conflate personal budgets and direct payments as if they were variations of a similar theme. However, they are quite different concepts;
3.3 There is clear and persistent evidence over their twenty years of existence that when people take a direct payment to employ their own Personal Assistants (rather than use regulated services), and their payments are large enough to meet leisure and social needs as well as personal care needs, they consistently enjoy much better outcomes. Their support is fully personalised given that they are clear what quality of life they want, and so are clear about their needs and the resources required to meet them. Up-front allocations have never been a requirement or a component of their success.
3.4 However, the numbers of service users who fall into this category has never risen much above 5%. It demands high levels of skills, confidence and time to manage one’s own support system. This is most likely to be found amongst working age disabled people, and also occasionally relatives of older people or learning disabled people. Although, under pressure of targets from central government to increase numbers with a direct payment since 2010, the number has increased some three-fold, Skills for Care estimate that only a third of them employ a PA. The other two thirds simply pay the invoices for the regulated services they would have received anyway. There is no evidence that this latter group of direct payments recipients achieve any better outcomes than any other recipient of regulated services. Indeed, there is evidence that they do not.
3.5 In Control, the organisation that created the idea of personal budgets, and Think Local Act Personal (TLAP) who are carrying the strategy forward for Government, have carried out three national surveys of ‘personal budget’ holders (the ‘POET’ surveys). They have been very influential, not least with Ministers. Norman Lamb as Minister for Care wrote the introduction to the third survey and warmly welcomed its positive findings. However, they are seriously misleading.
3.6 In the first two, some 90% of survey respondents were direct payment recipients. As would be expected, they reported high level of satisfaction. Calling them ‘personal budget holders’ gave the impression it was the personal budget strategy that was responsible. However, the 10% who were not direct payments recipients but who were still called ‘personal budget holders’ and who received regulated services did not enjoy better outcomes. Thus the success of the 1996 provision was used to convey a misleading impression that the personal budget strategy was working well.
3.7 In the third survey – in 2015 - they chose not to reveal the percentage of survey respondents who were direct payment recipients. As for the first two surveys, the findings were overwhelmingly positive, once again leading to confidence that personal budgets were working well. However, embedded in the report was a finding that the people who achieved the better outcomes were those who used Personal Assistants and who had enough resource to meet leisure and social needs. These are, of course, the exact characteristics of people who have been using a direct payment to manage their own support system since 1996. Again those who relied on regulated services did not achieve better outcomes.
3.8 The third POET survey found that having a direct payment was no longer in itself related to better outcomes. This is further evidence of the changing characteristics of the direct payments group. Those who simply use them to buy regulated services outnumber those who use them to by two to one. POET showed they do not enjoy better outcomes.
3.9 It is estimated there are about 70,000 direct payment recipients who manage their own support system by employing a PA. Whilst a small percentage of service users it provides a large pool from which to use individual success stories to over-sell a mass policy. Even though the size of their payment is likely to owe nothing to the up-front allocation, they are perfectly happy to describe their package as their ‘personal budget.
3.10 Creating the impression that some councils are delivering the process well.
This is key to ensuring the perception that the strategy is sound, with failure to deliver better outcomes due to councils failing to deliver it well.
3.11 The second POET survey noted a strong variation between councils in the percentage of respondents who reported better outcomes. This was taken as evidence of some councils getting it right. However, the variation in the percentage of respondents who reported better outcomes in each council almost exactly mirrored the variation in percentage of respondents who had a direct payment within each council’s sample. The variation in outcomes was most likely related to how many people in the sample had a direct payment, not to any differences in how councils operate.
3.12 POET also note that the better outcomes are associated with respondents who report that they believe the process is a good one, such as their views being influential. However, this too is likely to be associated with the minority who are able to use a direct payment to manage their own support system. People are likely to approve a process that has given them what they need. Further, this group tend to be articulate and determined people who are able to empower themselves within a complex bureaucracy.
3.13 Conveying the message that the Personal Health Budget pilot evaluation showed up-front allocations work
Most people in these pilots achieved better outcomes. This was taken as the headline message, and that therefore the process of allowing choice through an up-front allocation worked in health. However, this misrepresents what the evaluation actually found.
3.14 The participating Clinical Commissioning Groups were divided into four groups. Three delivered an up-front allocation and one did not. Three of the four groups achieved better outcomes and one did not. However, the group that did not deliver better outcomes was not the one that did not use an up-front allocation. It was one of the three that did. This led the evaluation team to suggest that;
‘…….it is the greater choice and flexibility that is more important than
knowing the budget level’
The pilots were supported by substantial sums of money.
The word personalisation has come to be defined in social care by the process designed to deliver it. If, however, the word is restored to its ordinary English meaning of designing services to meet individual requirements it remains the key objective of policy. It will deliver obvious benefits to service users whilst making best use of public resources.
4.1 The fundamental cause of depersonalisation is the way ‘need’ is understood. There is a long tradition of councils defining ‘need’ in the light of available resources. This cuts across individual need and leads to the ‘one size fits all’ culture. The original pioneers of direct payments recognised this and saw direct payments as the way to wrest control from councils of the way their needs are seen and then addressed. The architects of the personal budget strategy who followed them saw up-front allocations as the way to eradicate the problem. While direct payments provided an escape route for the minority, neither strategy has changed the system.
4.2 Its persistence is perhaps owed to it addressing concern about the potential cost of social care. In 2012, the then Minister for Care was asked by the Health Select Committee about the ‘funding gap’, which the Committee said had been estimated to be as much as £7BN. He replied that there was no funding gap as all ‘eligible’ needs were met. This was true given the circular way of defining ‘eligible need’ according to resource availability. It will always be true no matter the size of the budget.
4.3 A personalised system of assessment of need must allow for the full individuality of the lived experience of need for the individual to have a level of well-being that is right for them. This cannot happen under conditions where ‘need’ has to be fashioned to match resources.
4.4 However, social care is delivered within a cash limit. Once all needs that can appropriately be met through natural resources are identified, there has to be an ability to acknowledge if there is not sufficient public funding to meet all assessed needs.
4.5 There will be three major benefits to such an approach;
4.6 We have explored how the Care Act has created the legal basis to make such an approach possible, but that Government guidance to the Act eschews this opportunity and instead encourages perpetuation of the status quo. (http://www.tandfonline.com/doi/full/10.1080/09687599.2014.954785#.Vvjx7I-cEhc).
4.7 I urge the Committee to make representations to Government to bring about the change in direction that is required.
Peter Beresford, Co-Chair
30 March 2016
Background papers
Further lessons from the continuing failure of personal budgets to deliver personalization; Research in Policy and Practice: Colin Slasberg, Peter Beresford, Peter Schofield http://ssrg.org.uk/wp-content/uploads/2012/01/Slasberg-et-al3.pdf
The Standards We Expect, Joseph Rowntree Trust Peter Beresford et al, https://www.jrf.org.uk/report/transforming-social-care-sustaining-person-centred-support
Have the wrong lessons been drawn from the Personal Health Budget pilots; Journal of Health Services Policy and Research: Colin Slasberg, Nicolas Watson, Peter Beresford, Peter Schofield https://www.researchgate.net/publication/261374080_%27Personalization_of_Health_Care_in_England_Have_the_Wrong_Lessons_Been_Drawn_from_the_Personal_Health_Budget_Pilots
Building on the original strengths of direct payments to create a better future for social care; Disability and Society: Colin Slasberg, Peter Beresford http://www.tandfonline.com/doi/full/10.1080/09687599.2015.1007672
Government Guidance for the Care Act – undermining ambitions for change: Disability and Society: Colin Slasberg and Peter Beresford http://www.tandfonline.com/doi/full/10.1080/09687599.2014.954785#.Vvjx7I-cEhc
Putting the cart before the horse; Journal of Social Welfare and Family Law: Lucy Series and Luke Clements
http://www.lukeclements.co.uk/wp-content/uploads/2013/08/RAS-Article-JSWFL-Authors%E2%80%99-Original-Manuscript.pdf