Natalie Tarry, Research Manager, NLGN
The modernisation of social care services has recently received a boost through the Adult Social Care Green paper. With a focus on individualised budgets, the extension of direct payments, more emphasis on prevention, new technologies, local partnership working and new roles for care staff, the choice agenda in social care is really taking off. A slightly overused buzzword in recent years, choice has become to mean many things for those involved in the public policy debate. What it means for those in need of care is clear: greater independence and autonomy over vital life choices.
But do people really care about choice, asks the cynic. Aren’t they overwhelmed by what’s on offer? Don’t they just want good services?
It is exactly those well-meaning but patronising assumptions that need to be challenged within the social care profession and the wider public. Of course, people want good services more than anything, but we know from our research that many users also want a greater say and decision-making power over the services provided for them and that what they receive is often not adequate.1 Users are also mostly far more capable in assessing their level of need, but too often this is done on their behalf. The Green Paper’s proposals for more self-assessment are thankfully addressing this imbalance.
The social care profession has witnessed significant changes over the last decade and the new proposals will hopefully keep what they so boldly promise: Independence, Well-being and Choice. Instead of being locked into an inflexible system of provision, many social care recipients can now live more independent lives by choosing to employ personal assistance through a direct payment. No longer do they have to put up with a service that is often provided according to the local authorities’ time table that prevented many from employment or autonomy over their daily activities. Now service users can make fundamental choices about who is allowed to enter their house, touch their body, and wash and dress them.
A mother, whose disabled daughter receives a package of care supported by direct payments, which allow her to live independently with a friend said:
“I believe the difference in Gemma and Katy’s lives is that it really is their own home. We have designed the service around them, based on their chosen lives and needs, not fitted them into an already existing situation or filled two empty beds! It has been about shifting the emphasis from control by professionals to partnerships with families and taking responsibility together to make sure it continues to reflect their choices”.2
Of course the system is not without flaws and we know that the most common criticism of direct payments is the relatively low take up, with most recent figures somewhere around 18,000 (even though this is an 80% rise on the previous annual figure). Many adopt this as the main argument against direct payments. Yet the figures are misleading as they don’t include the many children now receiving direct payments. Nor do they tell us anything about lives that have been changed for the better. We need to therefore think much harder about how we can ensure higher take up across all user groups and how we can improve implementation. In places where implementation is handled well take up is high, e.g. in Essex County Council, who have over 1,000 direct payment users.3
Research evidence reveals that the main barrier to success is generally due to care staff’s reluctance to offer direct payments to the user in their care assessment. The main reason for this being that they are either making the judgement that many users will be overwhelmed with the task of being an employer or that staff has difficulty understanding how the scheme works. Too many times assumptions are made about people’s ability to manage. Both reasons highlight the need for more and better social care staff training if we are determined to make direct payments a success. However, we have to be careful when attributing blame. Social workers are dedicated, hard working, caring people who sincerely want to improve people’s life outcomes and they need all the support they can get to get to grips with constant changes and new systems.
The introduction of individualised budgets in the recent Adult Social Care Green paper is of course a further step in the right direction of greater choice and independence and might counter some people’s genuine fears about being employers through direct payments. Individualised budgets would leave as much risk or budget management with the local authority as the service user prefers. However, we have to be careful that they will not be used as a compromise and will in fact curtail people’s choices again. They should not replace direct payments, which might have more transformational potential as they give those users that want it even greater freedom and independence. Individualised budgets might limit the risk factor for users, but they might also mean less empowerment. And again some users might find themselves in positions where professionals give well-meant but biased advice because of their lack of faith in disabled users’ ability to manage.
Not all challenges have to do with new structures; there continues to be an issue around capacity. In many parts of the country, there are nowhere near as many personal assistants available as are necessary. The sheer existence of direct payments and the ensuing demand have done little in themselves to stimulate greater supply and tempt more people into the caring profession. The position of a personal assistant remains underpaid and insecure with little long-term career prospects. Local authorities need to play a more pro-active role in creating healthy local supply markets if take up is meant to grow, but most have so far failed to demonstrate any leadership in this area. The paper’s recommendation of an increased role for the voluntary and community sector (VCS) to provide social care and advocacy is an important one, but it remains to be seen whether this will be successfully implemented, as many local authorities continue to struggle to accept the VCS as equal “partner”. The fragmented nature of the sector further adds to the challenges to increase their clout.4
New Localism, the devolution of power away from the centre to a more local level, is another of the recent agendas that is likely to have an impact of the future of social care provision. However, so far there has been little evidence in this field. A recent NLGN research project that evaluated three councils’ differing approaches of devolving power in some service areas to sub-authority level found that none of the three councils had attempted to devolve social care. Although all planned to devolve some aspects at some point, they all had begun with comparatively ‘easier’ services like environmental services and street scene.5 Another project that examined Lancashire County Council’s locality programme found some limited outcomes where some aspects of its social care service had been devolved.6 However, the council is doing so from the perspective of an excellent local authority with two stars (and improving) for its social care service. It almost works as an add-on to the existing service and the council does not use devolution to improve service delivery per se. The overall evidence currently remains very thin and there will continue to be a need for centralised social care delivery at local authority level. There are also obviously CPA implications if social care is devolved as this is likely to have an effect of the council’s social care star rating.
And than there is the Government’s efficiency agenda that might be at odds with the modernisation plans for social care. Greater personalisation and choice through enhanced direct payments and individualised budgets conflict with the drive for more efficiency and savings and the common route of block contracts to deliver social care services. The mixed messages from government in this area need to be resolved.
However, the fact remains that personalised and tailored services are definitely the future and the Government’s Green Paper gives us hope that the tide has turned. No longer can we get away by offering a ‘one-size-fits-all’ social care service. If we want the unprecedented investment in public services to have an effect on the perceptions of users, we need to rethink and truly put them at the heart of the service. We need to pay more than just lip-service to “voice” and give people a real say over social care provision. No longer can professionals assume that they know what is best for individual users. If we want people to live independent lives, we have to let them choose.
1 Lent, A. and Arend, N. (2004) Making Choices: How can choice improve local public services?, NLGN: London
2 Quoted in “Green paper on adult social care”, eGov monitor, 21 March 2005
4 National Audit Office (2005) Working with the Third Sector, NAO: London
5 Randle, A. (2005) Councils Embracing Localism, NLGN: London
6 Randle, A. and E. Robinson (2005, forthcoming) Evaluating the Locality Focus Programme, NLGN: London