“Personalisation is just a cover for cuts” – debunked

If there was a pound for every time someone has said that personalisation is just a cover for cuts in adult social care, then we could pay off the national debt.

For a moment, though, let’s assume that personalisation is just a cover for cuts. What would this actually involve? I think there are three things:

1. Personalisation would have been introduced deliberately to achieve/deliver cuts to social care services
2. Further, personalisation would have to have been introduced at the time the need for cuts was identified
3. We wouldn’t see cuts in services that aren’t personalised or have the option of Personal Budgets.

Let’s look at each of these in reverse order.

No cuts elsewhere

Is it true to say that there haven’t been cuts in services that aren’t personalised?

Below is a table that captures social care expenditure over the last 9 years [1], including for different types of services – “personalised” (incorporating Direct Payments and homecare services) and “non-personalised” (Nursing care, residential care, supported/other accommodation, equipment and adaptations, meals, “other”) [2].

Figure 1 below charts gross levels of adult social care expenditure for all personalised and non-personalised services.

Figure 2 charts year-on-year changes in levels of adult social care expenditure for the same.

What the table and figures 1 and 2 show that little distinguishes levels of spend or year-on-year changes for personalised and non-personalised services. Or, put another way, the data doesn’t show that personalised services are more likely to be cut that non-personalised services.

Timing

If personalisation was a cover for cuts, it would have to have been introduced at the time the need for cuts was identified.

It is agreed the financial crisis hit in 2007/08, though public sector spending increased from 2007/08 to 2009/10. Since the General Election in 2010 we know that public sector spending as a proportion of GDP has decreased, and that there have been real-terms cuts in local authority budgets.

Personalisation would therefore need to have been introduced in at least 2008, and certainly by 2010, were it a mechanism for delivering cuts.

However, Putting People First – the key policy document that heralded the formal introduction of Personalisation – was published at the end of 2007. Before this, there had been the Individual Budgets pilots which ran from 2005 to 2007, as well as the Personal Health Budgets pilot that ran after, from 2009.

More pertinently, personalisation has a long history. Quite aside from campaigning efforts, Direct Payments legislation was first introduced in 1996 through the Community Care and Direct Payments Act 1996 and 2001’s Health and Social Care Act made it mandatory rather than discretionary to offer direct payments to those with an assessed need.  (See both the King’s Fund and SCIE’s excellent timelines of adult social care.)

What these timings therefore show is that personalisation, as enacted in legislation, pre-dates the financial crisis by at least 10 years, and that the introduction of the existing policy framework, Putting People First, pre-dates public sector spending cuts by 3 years.

A deliberate plan?

The final piece of ensuring personalisation is a cover for cuts would be for it to have been introduced deliberately to achieve/deliver cuts to social care services.

Anyone who has worked in government, in local government or in provider organisations – actually, anyone who has worked for any large-ish organisation at all – knows that the gap between what’s asked for and what’s delivered can be large. This is especially so if what’s asked for challenges existing behavior / culture.

In the case of personalisation we know the benefits of it haven’t flowed as far and as fast as people would like, mainly demonstrated by ongoing debates about how well it has been implemented and how true it is to any original vision.

Such a debate highlights to me there is simply not the level of command and control through the adult social care system – with its national policy from DH, distributed through 152 local authorities with their own local policies, decision makers and workforces, and 1000s of provider organisations supporting people on the ground – that can deliberately do anything very easily, quite aside from use personalisation as a means of achieving cuts.

Conclusion

I can understand why people think personalisation is just a cover for cuts in adult social care. This is especially the case for anyone who doesn’t have a more detailed, perhaps professional interest in the issue.

But, as demonstrated by this post, anything more than superficial thinking on the topic shows that saying personalisation is just a cover for cuts is wrong.

I close with the best observation I’ve seen on this topic:

Although the implementation of Self-Directed Support will be affected by funding cuts, personalisation brings challenges regardless of the financial context; cuts bring challenges regardless of the model of social care.

[1] – Gross social care expenditure, excluding Supporting People. Since SP couldn’t be personalised (see [2] below), these figures possibly favour non-personalised services

[2] – These are categorised according to what, in theory, can or can’t be personalised through a Personal Budget or Direct Payment.

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Spending in mental health: 80% in and out

In 2011/12, the total spend on Direct Payments for Mental Health was £30.5m. This was 0.56% of all mental health spend.

Of the total mental health spend, over 80% (83.3%, in fact) is spent in the NHS. However, when someone with a mental health condition is given money to spend to meet their mental health outcomes, over 80% (84.5%, in fact) is spent on non-statutory providers.

That is, when there is no choice for mental health services users, over 80% of mental health spend is in the NHS. When there is choice, over 80% of mental health spend is outside the NHS.

What does this tell you?

Comparing #socialcare hourly pay across the sectors

Following on from my post comparing in-house and external costs in social care (and do please read the caveats in that post), here are some more interesting comparisons, this time on the pay per hour for social care workers. (Data from the Adult Social Care Workforce Strategy)

Pay per hour: Social Care Workers:

• Local government: £7.19
• Voluntary Sector: £7.00
• Private Sector: £6.54

Of course, we should always remember 6.4m people also provide unpaid care worth approximately £119bn per year – the equivalent of a salary of approx. £18.5k per unpaid carer per year (from Carers UK)

In-house and external costs in #socialcare: a comparison

I have to confess that the words “Return on Investment” often make me want to roll my eyes.

This is not to say that I don’t think service delivery or innovation shouldn’t have some form of financial attractiveness attached to it in terms of better value for money or more for less.

It’s more that my eye-rolling is an outward expression of a feeling it’s quite easy to hide behind ROI as something that is very hard to robustly prove, either as a way of saying “no” or just to put off for a bit doing something someone may not necessarily want to do.

(There’s also a point here that it shouldn’t just be financial measures we consider in terms of value, but that’s a post for another day.)

Shifting on slightly from ROI, figures published by the English Community Care Association (via Community Care) on the costs of residential and home care provision both by one particular council and by external providers operating in that council’s area make for fascinating comparisons.

In older people’s residential care:

• Gross total cost per week for external providers = £433.62
• Gross total cost per week for in-house services = £839.20

For domiciliary care:

• Gross hourly cost for external providers = £13.49
• Gross hourly cost for in-house services = £34.19

Obviously, we should treat these figures with some caution, and remember that they arise only from one local authority (which could have a particular history which skews these figures).

But the gap between in-house and external provider costs suggests that, even for adjustments because of the methodology used, there’s an argument that external providers (most likely private and voluntary sectors, don’t forget) are considerably cheaper than in-house.

If anyone knows if there is similar data across a wider set, I’d love to know about it. In particular, if there is anything out there regarding voluntary sector costs compare to public and private sector costs, please let me know.

Revisiting the National Care Service White and Green Papers ahead of #Dilnot

At the end of March 2010, a White Paper on adult social care was published called “Building the National Care Service”. This was the result of the Big Care Debate and a Green Paper published in July 2009.

Ahead of the publication of the Dilnot Commission’s report on the funding of care and support, I thought it would be useful to revisit the key pledges made in the White Paper, concentrating mainly on the financial proposals it contained.

(Please note: I’m not making reference to the free personal care to people in their own homes part of the White Paper, since this was a bit of political opportunism just before the general election.)

Potential costs of social care

The average expected lifetime cost of care for a female 65-year-old is £40,400. Average expected lifetime cost of care for a male 65-year-old is £22,300. Average expected lifetime cost of care for all is therefore £31,700 (p125).

Around 20% of people will need care costing less than £1,000 during their retirement. Conversely, around 20% of people will need care costing more than £50,000 during their retirement. Some 5% of people will need care costing more than £100,000 (p45).

The Green Paper contains more detail on the potential cost profile (p98) as follows:

• 22% of people will need care costing £0-£1,000
• 26% costing £1,001-£25,000
• 30% costing £25,001-£50,000
• 16% costing £50,001-£100,000
• 6% costing £100,001 or more.

Potential funding models

The pay-for-yourself option of funding care was ruled out on the basis it was unfair that individuals who could not afford to pay for care would go without. Similarly, funding care from general taxation was ruled out on the basis it would put too high a financial burden on the decreasing proportion of the working-age population (p126).

The Partnership option meant that everyone who qualified for care and support would be entitled to a set proportion (for example, a quarter or a third) of their assessed care and support costs paid for by the state. People who were less well-off would have more care paid for (for example, two thirds) while the least well-off would have continued to have all their care paid for free (p126). The rest would be paid for by the individual. This option received 35% support in the consultation process (p127). According to the prior Green Paper, a 65-year-old may need to pay on average between £20,000-£22,500 under the partnership option. The system would work for people of all ages (p17 of Green Paper).

The Insurance option would have built on the partnership option, offering everyone the opportunity for people to cover the additional costs of their care and support through insurance, if they wanted to do so (p126).  This option received 22% support in the consultation process (p127). According to the prior Green Paper, a 65-year-old may need to pay on average between £20,000-£25,000 under the insurance option. The system would work for people over retirement age (p17 of Green Paper).

The Comprehensive option would provide free care when people needed it for those who qualified for care and support, with everyone paying a compulsory contribution (p127). This option received 41% support in the consultation process (ibid). According to the prior Green Paper, a 65-year-old may need to pay on average between £17,000-£20,000 under the insurance option (p17 of Green Paper).

Preferred option and its implications

The White Paper rejected the Partnership and Insurance options, and opted for the Comprehensive option (p128). Partnership was rejected because it still left people exposed to “catastrophic” care costs (p128). Insurance was rejected because evidence from other countries suggested voluntary insurance schemes had low take-up (p129).

Accommodation costs were not considered in these recommendations (p137). A proposal was put forward for a “universal  deferred payment” system for accommodation costs in care.  This built on the fact many Councils already offer deferred payment schemes, but that this wasn’t universally available (p137). Its purpose was to stop the requirement for people to sell their homes to meet their accommodation costs, meaning that people with high incomes or savings would not necessarily have been eligible for the deferred payment scheme (p137).

Everyone would have been required to make a fair contribution to the social care system. The best method for achieving this would have been determined by a commission established to help reach consensus on the right ways of funding the system. The recommendations, if accepted by Ministers, would have been implemented in the Parliament from 2015 onwards (p10).

Disability benefits and eligibility

Any changes to Disability Living Allowance and Attendance Allowance were ruled out (p123).

Eligibility for the National Care Service will have been consistent across the country and enshrined in law. Assessments would have been portable across different areas and would have moved to be joined up across social care and disability assessments (pp88-89).

Reflections

Looking back at the Green and White papers it’s interesting to see that, though the way in which social care would be funded was set (i.e. the Comprehensive option), the exact limits for individual contributions were not given. Only a broad range – of £17,000-£20,000 under the Comprehensive option – was given, and the rest left to a commission to sort out.

It will be interesting to compare and contrast the recommendations of the Dilnot Commission with those broadly outlined by the Green and White Papers published during 2009-10.

It’s also intriguing to hypothesize if Andrew Dilnot would have been asked to convene his eponymous Commission come what may, irrespective of the result of the General Election in 2010.

Dilnot commission report due on 4 July

The Commission on Funding of Care and Support today stated that it would publish its final report on 4 July.

It wouldn’t be an understatement to say that this will be one of the most significant developments in policy in general, let alone in social care, of this year or many more to come.

We’ll have to wait until 4 July for the details (Community Care has done a bit on keeping track of what we know so far). But the announcement of the publication date for the report is encouraging.

Here are three reasons why:

1. They’ve published a specific date the report will be available. They’ve not been vague. They’re serious about this report and so will hold firm to what it says in it – not dilly dally and go round the houses with it.
2. The report will be on an “affordable and sustainable funding system for care and support for all adults in England”. That is, not just older people, but people of working age as well. That’s a focus that hasn’t always been there in previous social care publications.
3. The report will be for care and support “both in the home and other settings”. Note it isn’t just about residential care – there is an implied focus here on independent living and not “traditional” forms of social care.

I’m hopeful about Dilnot, and today’s release reaffirms that hope.

Redistributing my rebate: Hello to CiFers

As part of the Comment is Free’s People’s Panel, I’ve made a small contribution to their feature today on giving to charity. Anyone visiting there from there: hello!

The first full post with details of the tax rebate and my plan is here. The follow-up of suggestions so far is here.

On Monday I’ll post the shortlist of 5 organisations and details of how to vote.

Feel free to say hi in the comments, or get in touch via Twitter: @rich_w.

In it for a biscuit

I don’t normally follow the ins and outs of rugby, but if it’s normally this funny, I may have to start:

A row has broken out between the Rugby Football Union and Saracens over a disputed disciplinary case. Sarries criticised the way boss Brendan Venter was handed a misconduct charge following an incident at Leicester… The RFU released an 11-page statement on Thursday, in which it observed Venter’s “arrogant behaviour” during the hearing, citing his eating of biscuits and sweets as examples.

As the Saracens’ Chief Exec rightly asks:

Why did the RFU provide biscuits if they were not to be eaten?

(In related news, it should be noted that Salford Council were ahead of the RFU in their thinking, because they removed biscuits from their meetings. They obviously knew what trouble they could cause and decided not to run the risk.)

Disagreeing with the TPA’s budget cut analysis

I more than disagree with the analysis proffered by the Tax Payers’ Alliance on how to implement budget cuts in the public sector. Stef uses the euphemism ‘thought provoking’ to capture his thoughts on the article; I prefer to call it a load of crap, for the following reasons:

1. Mark Wallace has it precisely the wrong way around: Councillors may be elected, but (in my experience) they are generally poor quality. It’s the managers, particularly senior leadership within local authorities, who run councils. So the idea of Councillors sitting down and figuring out where they want cuts made is ridiculous.

2. The idea of the council officers, by default, opposing spending cuts. I fear this view is informed more by Wallace’s ideological persuasion than evidence. Ask practically anyone working within local government, but particularly middle and senior managers, whether or not 10% savings are possible and they’ll laugh: that could be done easily. Paradoxically, Wallace acknowledges this when he says:

Councils should introduce reward schemes to encourage staff to propose successful ways of making savings. Today’s grumbles at lunchtime about this or that pointless form, or the absurdity of having to make two trips in the van instead of one, could be transformed into tomorrow’s practical spending cuts.

3. And therein lies the third problem with Wallace’s suggestions: incentivising staff to reward their ideas for successful savings. Wallace has clearly never worked in the public sector, particularly not as a senior manager (as his profile attests), and so has no direct experience of the complexities of introducing such a scheme. Such complexities would include the question of attribution (how do you know whose idea it specifically was? what if it was a team idea? how do you then share equally any benefits accrued from the idea?) and the issue of how much management time it would take to manage and address the inevitable conflicts. Complexities would also involve the question of knowing just how much has been saved: the direct and indirect costs of identifying savings arising from one idea would be disproportionately larger than the savings themselves in the vast majority of cases.

There’s a great irony here. By rubbishing his scheme, Wallace will accuse me of being precisely the kind of manager who stands in the way of Councillors (or whoever) driving through the change he perceives is needed within local government.

What his superficial analysis won’t have noted is that it’s more likely those managers are precisely the people who recognise the change needed, and are most likely to be driven by a public duty to deliver the best services and outcomes for local residents than some ideological perversion that places less public sector spending above any other consideration.