Personalisation for older people and direct payments

1

• Personalisation for older people and direct
  payments time to re-discover person-centred
  care?
• John Woolham, Guy Daly, Nicole Steils, Katrina
  Ritters
• Faculty of Health and Life Sciences
• John.woolham_at_coventry.ac.uk

2
Structure

• From person centred care to personalisation
• Personal budgets and direct payments
• Perspectives
• Policy analysis of issues arising from PBs DPs
• Policy analysis of issues arising from PB and DPs
  specifically to older people
• Research evidence
• Conclusions

3
From person centred care to personalisation

• Person-centred support easy to describe
• .but hard to achieve
• Case /care management for older people
• IPPs shared action planning for people with
  learning disabilities
• Person-hood for people with dementia
• Transference of learning from project to service
  always difficult
• The term personalised has replaced person
  centred
• Often seen as the same by practitioners but
• Greater emphasis on some values
  self-direction, user empowerment, personal
  choice,
• Support is now used alongside or instead of
  care
• User rather than professional definitions of need
  
• Adult Social Care staff refer to people with
  social care needs as customers not clients or
  service users

4
1. From person centred care to personalisation

• Definitions vary.
• Personalisation means thinking about care and
  support services in an entirely different way.
  This means starting with the person as an
  individual with strengths, preferences and
  aspirations and putting them at the centre of the
  process of identifying their needs and making
  choices about how and when they are supported to
  live their lives.
• Carr (2011) p. 3.
• Individuals not institutions take control of
  their care. Personal budgets, preferably as
  direct payments are provided to all eligible
  people. Information about care and support is
  available for all local people, regardless of
  whether or not they fund their own care
• Department of Health Vision for Social Care.
  Nov. 2011 p. 8.

5
2. Personal budgets and direct payments

• Direct payments and personal budgets seen as the
  means by which personalised care and support will
  be delivered.
• A (very) short history of personal budgets and
  direct payments
• Independent living fund, cash for care
• Campaigns by younger disabled people for more
  control over care
• Direct Payments Act 1997
• In Control and campaigning for self-directed
  support
• Attracted local authority support
• Led to plethora of small scale local studies from
  local authorities
• In Control Evaluations 1 2.
• DH endorsement
• Commissioned IBSEN
• 500m Transformation Grant

6
2. Personal budgets and direct payments

• Transformation Grant was announced without
  reference to research evidence (so much for what
  works!)
• Some important findings from IBSEN ignored.
• Subsequent research policy guidance largely
  about how to make PBs and Direct Payments work -
  not whether it was the right approach.

• .older people did not find the individual
  budget system used in the pilot as easy to use as
  the other groups, and they did not appear to like
  the idea of managing their own support.
•  Extract of IBSEN team summary
•  Since this research was undertaken more support
  has been put in place for older people and early
  indicators have shown that this has transformed
  their experiences of using individual budgets. We
  will conduct further research to investigate the
  impacts further.
• Phil Hope M.P., Minister of State for Care
  Services

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3. Views a. Policy analysis of issues arising
from PBs DPs

• Advocates
• Better outcomes for social care users
• Greater empowerment of recipients, thereby
  conferring more dignity and personal
  responsibility
• fuller citizenship and greater inclusion
• more contestability/competition (aimed at using
  market mechanisms to improve quality) and
  diversity in local care economies leading to
• greater choice and more effective use of public
  money through
• greater efficiency in targeting of care and
• reduced CASSR care management input
• Response to failures of care management

• Sceptics
• Agendas of disabled people subverted by
  government
• Public services should not be about delivering
  choice
• Citizenship and universality undermined by
  consumerism and choice
• Downsides to choice
• Transfer of responsibility from state to
  individuals privatisation of risk
• links to wider disquiet about public sector
  reform
• shrinking the state,
• replacement of universal social rights with
  (increasingly rationed) consumer choice,
• the dominance of managerial not professional
  cultural values in CASSRs,
• potential fragmentation of care provision
  following marketisation.

8
3. Views b. Policy analysis of issues arising
from PBs DPs specifically relating to older
people

• Older people are the largest consumers of social
  care services.
• Values underpinning key policy documents (e.g.
  PPF 2007, Shaping the Future of Care 2009) are
  problematic for older people
• People who can exercise independence and
  self-determination those who cant
  choiceandcontrol vs careandprotection
• (Barnes 2011)
• Re-defining of care as a way to restore people to
  play a role as active citizens reshaping a
  fundamental human need to something instrumental
  and narrowly defined.
• (Lloyd 2010)

• Older people personal budget and citizenship
• For many older people, achieving full
  citizenship is not an aim in the same way
  asfor many younger disabled people. Most older
  people have already experienced citizenship in
  the form of an active role in family, work and
  community life it is not an unrealised
  aspiration.
• (Orellana 2012)
• Are older people being squeezed into a
  one-size-fits-all model of personalisation?

9
3. Viewsc. Research evidence

• Glasby (2012)
• both sides appealing to evidence (advocates any
  evidence will do, sceptics not enough,
  evidence, evidence not good enough)
• Calls for a move away from formal and
  quantitative research towards a more inclusive
  approach, combining research with practice
  wisdom.
• But not all findings created equal
• Not many quantitative but many qualitative too
  little attention to quantitative not too much
• Tendency to generalise too much from qualitative
  studies

10
3. Viewsc. Research evidence

• Reviews
• Manthorpe et al (2011) 161 studies.
• Many studies small scale
• Some were commentaries not empirical studies
• Some reported on experiences of people most
  likely to be offered /take up a budget so bias to
  positive findings
• Zamfir (2013) 68 studies specifically focused on
  older people
• Little evidence PBs had improved lives of older
  people
• Where improvements had occurred this was because
  support was adequate

11
3. Viewsc. Research evidence

• Empirical studies
• In Control (x 3)
• First two studies low numbers, sampled from
  people likely to be favourably disposed to PBs
• Third study (POET) found older people less likely
  to respond positively to budget ownership but a
  precondition was effective support.
• IBSEN
• Best study to date
• Evidence that PBs can work for younger adults
• No evidence they work for older people

12
3. Viewsc. Research evidence

• Own work
• No evidence of benefit to older people compared
  to younger adults
• Much larger budget size did not translate into
  much better outcomes for older direct payment
  users compared to traditional users (Woolham
  Benton 2012)
• Outcomes not significantly different for older DP
  and MPB users (2014, unpublished)

13
Conclusions

• Do Direct payments and personal budgets work for
  older people?
• Campaigns for direct payments and self directed
  support led by younger adults -not older people
• Older people do not achieve such good outcomes as
  younger adults when given a Direct Payment.
• The model of personalisation and use of direct
  payments as the means of achieving personalised
  support doesnt suit many older people

• The size of the direct payment doesnt enable
  people to have much more than their basic care
  needs met
• Self direction and choice and the organisation of
  the direct payment is often mediated by a
  relative

14
Conclusions

• Restoration of lost abilities to enable full
  community participation isnt always realistic
• Independence isnt always what older people
  people want.
• Empowerment may mean the ability to ask others to
  do things for or with them rather than them
  having to do it themselves.
• Control may be more effectively exercised through
  opportunities for older people to develop
  relationships of trust and friendship.

• To achieve this we may need to think less about
  choice and much more about what good care looks
  like.
• Good care depends on the quality of the care
  relationship.
• Commissioning on the basis of time and task
  has excluded the costs of the emotional labour
  needed to build a relationship with the user
• Lewis West 2014 p.5.
• This has been largely overlooked by English
  policymakers.

15
Conclusions

• The effective use of direct payments and user
  control reinforces a view of care-as-commodity in
  which customer-is-king.
• Our research suggests that though older people
  want choice and control, they want to exercise it
  in a different way.

• Person-centred care may offer a better approach
  than personalised support to the kinds of issues
  facing older people but would require
• Skilled staff
• Matching carer with person with care needs to
  enable relationship building
• Adequate remuneration

16
Selected references

• Barnes, M., (2011) Abandoning Care? A Critical
  Perspective on Personalisation from an Ethic of
  Care. Ethics and Social Welfare 5(2). p.
  153-167.
• Beresford, P. (2009b) Whose Personalisation?
  Compass Direction for the Democratic Left Think
  Pieces, No. 47 p. 1-5.
• Boyle (2013) The Barriers to Choice Review. How
  are people using choice in public services .
  London, Ipsos MORI.
• Carr, S., (2013) Improving personal budgets for
  older people a research overview. Adult Services
  Report 63London, Social Care Institute for
  Excellence.
• Clarke, J., Smith, N., and Vidler, E. (2006) The
  Indeterminacy of Choice Political, Policy and
  Organisational Implications, Social Policy and
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• Clarke, J., Newman, J, and Westmarland, L, (2008)
  The Antagonisms of Choice New Labour and the
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• Daly, G., (2012) Citizenship, choice and care an
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  provision of adult social care. Research Policy
  and Planning Vol. 29 (3) p. 179-190.
• Department of Health (2003) The Governments
  Expenditure Plans 2003 Local Authority Personal
  Social Services Gross Expenditure by Client
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• Department of Health (2008) Making personal
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• Department of Health (2008) Local Authority
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• Department of Health (2010) A Vision for Adult
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• Duffy, S., (2006) Keys to citizenship a guide to
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• Duffy, S., (2008) Personalisation in social care
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• Duffy, S, and Waters, J. (2008) The Economics of
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17
Selected references

• Ferguson, I. (2007) Increasing User Choice or
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18
Selected references

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• Manthorpe, J, Hindes, J, Martineau, S, Cornes, M,
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