A significant component of the personalisation agenda fundamentally challenges and changes where money goes as a result of the different choices people make about achieving what they want. This is rightly so, for “if you always do what you’ve always done, you’ll always get what you’ve always got.”
We know some pretty good numbers about how much money is spent in the social care system through Direct Payments. They show that the scale of spend through Direct Payments against all social care expenditure is growing, but small.
Does this mean that personalisation has failed? No. But what does it mean?
There have undoubtedly been compromises and manifestations of what was originally intended, meaning personalisation hasn’t always translated into what it was hoped and intended it would. For example, resource allocation systems and panel processes have become unwelcome norms. (We should remember that money was only ever one aspect of personalisation.)
But in any change that fundamentally disrupts, or has the potential to disrupt the status quo, other forces – invisible or not – will always play their role. These include organisations who benefit most from the status quo and have literally vested interests in maintaining it. This is, I think, one of the more powerful reasons why personalisation in mental health is still taking hold rather than taken hold, as seen through the Direct Payment numbers.
In mental health the status quo is a particular challenge because the overwhelming destination of money is in the health system. For health organisations dealing with mental health it tends to be more a question of how much money they’ll get rather than whether they’ll get it.
Organisations generally exist in order to protect what they are currently doing. The personalisation agenda in mental health is thus a fundamental challenge to health organisations and the status quo. How do we therefore bridge the chasm of effecting the change personalisation seeks to achieve by working with and through health organisations?
Rather than just mechanisms and processes, we need to think explicitly and tactically. We need to speak in a language that others will understand, and recognise their existing, actual starting point and create a path from that point to where we want things to be in the future.
Start where you are. Use what you have. Do what you can – Arthur Ashe (via @areynolds67)
To change the status quo you need a variety of approaches. Policy and legislation through government have their role. So does compulsion through regulation. Peer or public pressure is another, as is the drive to maintain existing levels of business.
A useful tactical way to change the status quo is to align agendas.
I’ve often talked about the public policy idea of the Advocacy Coalition Framework. Here, people with often very different perspectives share a common goal and form a coalition through which they advocate for particular outcomes. They align their agendas. Changes in the treatment of domestic violence are a good example of a successful Advocacy Coalition approach, bringing together feminists and the police as unlikely allies.
Another way of thinking of this is by imagining being George Clooney’s character in Up In The Air. He specialises in making people redundant, but how he frames it is not as an opportunity to carry on doing what’s always been done, but to take the opportunity to do something different. Despite it being painful, and a process that doesn’t always work for everyone, what Clooney’s character does is align one set of objectives – the company’s, wishing to make people redundant – with another – the person’s, wanting to make a different future.
What if we apply this to personalisation in, say, the area of mental health? I think it can be strongly argued that personalisation is a solution to two existing problems that health organisations (and others) are grappling with: Section 117 aftercare and out-of-area placements.
Without going into the details here, key elements of the personalisation agenda, if done properly, would directly address causes or effects of problems related to S117 aftercare or out-of-area placements. Personalised funding, integrated at the level of the individual, with a clear plan that matches assessed need with outcomes and choice over how best to achieve those outcomes, helps to address a myriad of S117 aftercare problems. Good market development in an area, that enables supporting people at the right level at the right time, with good information and a focus on maintaining meaningful networks important to the person, directly addresses many of the problems of out-of-area placements.
By tactically aligning agendas through choosing to address issues around S117 aftercare and out-of-area placements using personalisation, there is an opportunity to normalise personalisation. This approach takes account of where health organisations currently are, but gives them a different set of tools for addressing the problems they face which has the added benefit of showing them personalisation works. It is undoubtedly tactical, and may well involve an element of compromise, but I’d strongly suggest it would help with where we want to get when it comes to personalisation.
 – See Figure 3.2 in HSCIC’s 2013/14 Personal Social Services Expenditure and Unit costs release (pdf)
 – Remember when NHS England imposed a 1.8% deflator on non-acute health services, including mental health, compared to a 1.5% deflator for acute services? The equivalent cut to local authority social care services – also covering mental health – has been 26% to date since 2010/11. For more details see LGA’s Adult social care funding: 2014 state of the nation report
 – I can’t recommend highly enough Paul Cairney’s 1,000-word summary of the Advocacy Coalition Framework
 – (Spoiler) We should note that Clooney’s character is a bit of a schmuck for most of the film, but he comes good in the end.