What are the hopes and frustrations in the everyday practice of person-centred support, or 'personalisation'?
This study is the most user-centred and authoritative commentary to date on current policies and practice. The Standards We Expect project team (service users, practitioners and researchers) worked with service users, carers, front-line practitioners and managers in eight very diverse settings. They found:
- Good practice is possible, even in the hardest of times.
- Funding and organisational culture need frank discussion.
- Power imbalances, outdated attitudes and doubtful practice are still too common.
A comprehensive book, Supporting people: Towards a person-centred approach by Peter Beresford and others, is published for JRF by The Policy Press, price £19.99 rrp (plus £2.75 p&p).
The four-year Standards We Expect project forms the major part of the JRF Independent Living programme. The team has also produced various guides and studies (see the ZIP file). These include:
- Person-centred support: A service users' guide (available soon)
- Person-centred support: A guide to person-centred working for practitioners (available soon)
- Person-centred support – Choices for end of life care (available soon)
- Making changes: A guide to running successful and accessible workshops and training (available soon)
- Working towards person-centred support: A local case study (available soon)
- Supporting people: Summary in easy words and pictures (available soon)
- Person-centred support: the big issues (available soon)
PDF version Councils are taking steps towards adult social care efficiency but need to pick up the pace
Councils are changing their approach to providing adult social care to make services more efficient, the Audit Commission briefing Improving value for money in adult social care has found.
As demographic change and financial pressures combine to create tough times for adult social care, councils have looked at many aspects of the service in order to provide better, more efficient services. Not only is the population ageing, but the pressure on services from people with learning disabilities is increasing as those people live longer.
Better procurement, improved back office arrangements, and a preference for community based rather than residential care where possible, are just some of the changes that local authorities have implemented to help them meet the challenges they face.
But the briefing finds that the pace and scale of change need to increase if councils want to release material savings, as well as improve care for people.
Andy McKeon, Managing Director Health, said:
‘Social care services have seen an increase in demand because of an ageing population and because people with learning disabilities are living longer. We are pleased to see that councils have reacted to these pressures and started to change the way they operate, by giving more people personal budgets and spending more on prevention.
‘But the pressures on councils are growing. They have many competing demands on their finances and, over time, more and more people will need their help. Small, tried and tested improvements will help to make savings in the short term and there are opportunities to do this. But councils also need to look more widely to deliver greater savings and make a real difference to peoples’ lives in the longer term.’
The briefing identifies nine areas in which councils can make changes to deliver efficiency savings. They are procurement; staffing; back office; assessment and care management; prevention; personalisation; changing the balance of care; partnership and charging. Most councils have addressed a combination of these factors, but no one council has made changes to all nine.
The briefing highlights examples of councils who have made substantial savings in these areas. The West London Alliance, made up of six London boroughs, predicted a combined saving of £4 million by jointly procuring personal home care. Hertfordshire County Council has reviewed its care packages for people with learning disabilities. By introducing individual budgets and negotiating cuts in fees for high-cost placements, it expects to make substantial savings while improving outcomes for service users.
All of the positive examples in the briefing bring savings and improvements for service users, but they are mostly transactional. Councils are seeking to redesign services and develop different approaches to care to provide a better quality of life - so called ‘transformational’ change. However, the briefing points out that although transforming services will help to deliver better quality support, it is a long and challenging process, and may not deliver savings.
One big opportunity for councils to do things differently in the coming years will be working more closely with the NHS. Working together they can make savings by commissioning or delivering services jointly, cutting duplication and avoiding simply transferring costs from one organisation to another.
Andy McKeon continues:
‘Social care is undergoing a radical change and we cannot predict what the service will look like in years to come. But we do know that like all public services, savings will need to be found in social care. This briefing presents a starting point for local authority decisions on adult social care spending over the next three years.’
This briefing is the first in a series from the Audit Commission, looking at value for money in social care.
Notes to editors
- The Audit Commission is a public corporation set up in 1983 to protect the public purse.
- The Commission appoints auditors to councils, NHS bodies (excluding NHS Foundation trusts), police authorities and other local public services in England, and oversees their work. The auditors we appoint are either Audit Commission employees (our in-house Audit Practice) or one of the private audit firms. Our Audit Practice also audits NHS foundation trusts under separate arrangements.
- We also help public bodies manage the financial challenges they face by providing authoritative, unbiased, evidence-based analysis and advice.
- The government has announced plans to disband the Audit Commission and put in place new arrangements for auditing England's local public bodies. It is consulting on proposals for the new regime. It is also considering with us the options for transferring the in-house work to the private sector, including the in-house audit practice becoming an employee-owned company.
http://www.audit-commission.gov.uk/pressoffice/pressreleases/Pages/adult...
Plans to make it easier for people with disabilities to employ Personal Assistants to help them to live as full a life as possible were revealed today by Care Services Minister Paul Burstow.
A Framework for Personal Assistants helps offer universal support for people with care needs as well as the PAs they employ. It maintains the flexibility of the role, which makes them so vital in helping people with disabilities to live their lives and aims to increase the number of PAs available.
Research shows that those receiving payments can be nervous about becoming an employer and the lack of a clear, universal job description can be a barrier to those considering joining the profession.
The publication is part of the personalisation agenda at the heart of the Government’s Vision for Adult Social Care to deliver services chosen by people to meet their individual needs. By 2013, everyone eligible should be offered a personal budget to spend on the best care package for them. It is estimated that by 2025 this could create nearly 1.2 million Personal Assistant jobs - there are currently less than 200,000 people working as Personal Assistants in England.
Care Services Minister Paul Burstow said:
"Many company executives would describe their PA as a life-saver, but for those who employ a personal assistant for their social care needs, they really do give them back their life. Being able to set the job description spelling out exactly what support you need and when, can be liberating. It's much better than trying to fit your life around Local Authority-commissioned services."
"I've seen today in Essex what can be achieved when social services work together with people who need personal assistants to make sure both they and their PA are fully supported. The difference it has made to these peoples' lives is a clear reminder of why personalisation is so important and is at the heart of our plans for social care."
The new framework will:
- Provide employers with an up to date toolkit to make the practical side of employment easier to understand including job descriptions and interviewing.
- Develop an induction framework so all PAs have the same basic introduction to the role based on the Common Induction Standards developed by Skills for Care.
- Create a clear, national toolkit including templates for contracts and other legal aspects of employment. This will be regularly reviewed and updated.
- Use Local Authorities to assist in background and reference checking where requested.
- Work with Job Centre Plus to make all staff aware of PAs as a career option for job seekers.
In some areas employers and PAs already receive all this support and more - but it isn't the norm. This Framework will also look to help share best practice so everyone has access to the same information and support.
Paul Burstow, this morning, visited ecdp (formerly Essex Coalition of Disabled People), a disabled person’s user-led organisation which offers a high level of support to people employing Personal Assistants including a full payroll service and access to training and development opportunities for Personal Assistants. They currently support nearly 4,000 people to employ personal assistants.
Anyone looking for information or support on hiring or becoming a Personal Assistant should visit www.skillsforcare.org.
Notes to editors
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For media enquiries only contact the Department of Health Press Office on 020 7210 5221 - The Personal Assistants Framework can be found here: www.dh.gov.uk/publications
- The Vision for Adult Social Care can be found here: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121508
http://nds.coi.gov.uk/content/detail.aspx?NewsAreaId=2&ReleaseID=420595&...
Social care and clinical commissioning for people with long-term conditions
Key messages
- In caring for an ageing population, with rising numbers of people living with long-term conditions (LTCs), more integrated working between the NHS and social care is crucial to achieve good outcomes and make best use of resources.
- Working collaboratively with local services, clinical commissioners can redesign services to ensure patients and their families get the care that will improve their health outcomes, will be more efficient and effective and may save money.
- Divisions between health and social care make little sense to people using services. They expect joined-up services that give them choice and control.
- Users of social care services increasingly plan, purchase and control their own care and support through personal budgets. Personal health budgets are currently being piloted.
- A tough spending settlement for local government means that many authorities are having to raise eligibility criteria for publicly funded social care services. It is important for health and social care to work closely with people needing support and their families, to get the most out of all the available resources.
Introduction
How can clinical commissioners secure best use of social care to maximise outcomes and improve patient experience, while ensuring efficient, affordable care into the future? With an ageing population and rising numbers of adults with long-term conditions (LTCs), more integrated working is vital to achieving good outcomes for people and making best use of scarce resources.
This At a glance briefing is a summary of some of the ways in which working with adult social care can help clinical commissioning groups manage their new responsibilities. Following the NHS Future Forum report, the Health and Social Care Bill will (subject to parliamentary approval) place stronger duties on the NHS Commissioning Board, clinical commissioning groups, Health and Wellbeing boards and Monitor to encourage integrated working at all levels (Hansard 2011). Integrated care is also one of the strands of a second phase of the NHS Future Forum’s work, launched in August 2011.
By 2015, the NHS is expected to find £20bn of efficiency savings to maintain quality and service levels and absorb demographic pressures. It is reported that 20 per cent must come from ‘deep service change’ for which commissioning groups will be responsible (Ireland 2011). This figure is partly based on the assumed benefits from clinical commissioners working collaboratively with social care.
The workstream on LTCs within the NHS Quality, Innovation, Productivity and Prevention (QIPP) programme is explicit that ‘providing joined up and personal services particularly in community and primary care and working closely and effectively with social care’ is key to improving outcomes for patients and their families (DH 2010). An independent inquiry into the quality of general practice underlined the importance of better co-ordination and engagement with social care (Goodwin et al. 2011).
Long-term conditions
There are around 15 million people in England with at least one LTC. Their treatment makes up 50 per cent of GP appointments and 70 per cent of the primary and acute care budget in England. GPs, not hospitals, deal with the majority of LTCs, and in future, will have to manage the growing demand arising from the ageing population. LTCs increase with age, with the Department of Health (DH) predicting a 252 per cent increase in people aged over 65 with one or more conditions by 2050. It is here that social care can help most in the ongoing support of people with LTCs affecting their physical, mental and psychological health.
How social care works
Social care covers a range of services and support designed to help people maintain their health and wellbeing. The use of social care by people with LTCs varies widely by diagnosis: people with mental health problems, falls and injury, stroke symptoms, diabetes and asthma tend to use more social care services, while those with cancer appear to use less (Humphries 2011). Adult social care services include the commissioning and provision of home care, meals, equipment and adaptations, day services, residential and nursing home care. It also includes the mechanisms for delivering these services, such as individual and carer assessments, personal budgets and direct payments, and adult protection procedures (Law Commission 2011).
Adult social care services include the commissioning and provision of home care, meals, equipment and adaptations, day services, residential and nursing home care.
Personalisation involves putting the individual at the centre of the process of identifying their needs, and helping them make choices about how they are supported to live their lives.
Personalisation
In recent years, social care policy and delivery has focused on personalisation, emphasising greater choice and control for people who use services and carers over the services and support that are provided. This policy involves putting the individual at the centre of the process of identifying their needs, and helping them make choices about how they are supported to live their lives (TLAP 2010). Personal budgets offer people who use services flexibility in identifying outcomes and purchasing their own care and support. In March 2011, ADASS reported there were around 338,000 personal budget holders across the country, twice the total of the previous year and representing one third of eligible people (ADASS 2011).
A personal budget is a clear allocation of funding which service users and carers are able to control. They can use the budget to buy support which meets their outcomes. These are agreed as part of an assessment and self-directed support planning process. Personal budgets can be taken as direct cash payments.
Personal health budgets (PHBs) for people with LTCs are now being piloted across 61 sites in England. Evidence from countries that have introduced PHBs suggests they can be a powerful tool in improving patient satisfaction and helping to increase available treatment choices (Alakeson 2007). In future, it may be possible to combine personal care budgets with PHBs. Importantly, personalisation has the potential to achieve greater efficiency, while giving people who use services greater control (Carr 2010).
Example: Older people and dementia
Personalisation for people with dementia means getting to know the person, finding ways of connecting with them and identifying what behaviours and reactions might mean, as well as assessing risks. Social care support can include assessment (of abilities, family and neighbourhood networks, care needs, and risks), care planning, review and ongoing support services, access to occupational therapy services and assessment and support for carer needs. Service provision can include home care (personal care, meals, laundry, shopping), day services, respite care (at home or in a care home), extra care housing and residential/nursing home care where necessary. Social care also has a safeguarding role, given the increased vulnerability of people with dementia. With appropriate support, people with dementia and their relatives can use personal budgets to plan their own support package, including wider opportunities for carers. Crucially, assessment and support of carers, for example access to short breaks, can make the difference between keeping someone at home and carers breaking down. This holistic approach is valued by people with dementia and their families and can help avoid unnecessary hospital admissions and/or inappropriate placement within care homes (see SCIE’s Dementia Gateway).
Seventy eight per cent of local authorities (LAs) will fund care only for those assessed as having ‘critical’ and ‘substantial’ needs.
Social care funding
Social care is funded very differently from the NHS, although both are currently under real pressure. While the NHS is a national service, largely free at the point of use, personal social services are the responsibility of local councils and subject to both assessment of need and means-testing of the person’s capacity to pay. Seventy eight per cent of local authorities (LAs) will fund care only for those assessed as having ‘critical’ and ‘substantial’ needs. This means that LA-funded social care services are largely delivered to people with the highest needs and the lowest financial means, many of whom are already ill and/or disabled (Humphries 2011).
Social care service users
In 2009-10:
- approximately 1.7 million adults received one or more social care services following a local authority assessment of needs (this is a decrease of five per cent on 2008-09)
- of these, 1.46 million received community-based services whilst living in their own homes.
A substantial number of these would also have received informal care from a relative or friend. In 2009/10 it was estimated that there were around five million informal carers, with 1.1 million providing more than 50 hours of care per week. 387,000 carers received services after a LA carer’s assessment. (NHS Information Centre 2011: 4-6)
Local government spending cuts have led some councils to raise eligibility criteria, restricting access to LA-funded social care services. This means more people will have to fund their own care and/or rely on support from family and friends, potentially resulting in increased pressure on primary and secondary health services. It is here that joint working with social care services by clinical commissioners could pay dividends, by preventing unnecessary hospital admissions and increasing services to patients in their own homes.
Working with social care
People with LTCs and their carers require services that are straightforward and accessible. A key concern of GPs and social care professionals has been the inaccessibility of each other’s services and expertise. From the social care perspective, this can result in inappropriate referrals from GPs, while GPs are not clear about the services and skills that social care can offer (Kharicha et al. 2005). More integrated health and social care support offers a way forward by building relationships, resolving misunderstandings, simplifying care pathways and minimising organisational barriers between different agencies.
GPs report concerns about the disappearance of previous multidisciplinary team arrangements, whereby social care practitioners have been removed from primary care (along with district nurses, palliative care nurses and community psychiatric nurses). Clinical commissioners have the opportunity to reinstate these much missed links, as well as potentially save money (McKeown 2011).
Most councils already have systems in place for joint working with health.
Most councils already have systems in place for joint working with health. Good local relationships are key to determining successful partnership arrangements. More integrated working brings the chance to reduce bureaucracy and overlaps, to ensure patients and their families get the care that will improve their health outcomes as well as deliver efficiency savings. Clinical commissioners will need to work with councils to understand and, if appropriate, protect existing joint arrangements, as well as building new ones. Councils are the lead commissioners now for learning disability funding, while many PCTs are the lead for integrated mental health services, with pooled budgets amounting to £1.4 billion annually (Audit Commission 2009; Turning Point 2010).
Examples: Integrated working
A GP practice in Norfolk holds weekly multidisciplinary meetings with allocated social work and community staff, to plan the care and support of adults and older people with complex health care needs. The team has redesigned care management arrangements and provides a prevention and monitoring service, as well as support to patients with urgent, long-term and high care needs. This approach has been shown to reduce admissions to hospital, with no increase in the use of residential or nursing homes. It also highlights the importance of social care input into case management. Thirty three other GP practices are now adopting similar arrangements and a commissioning specification is being developed to support this way of integrated working (Tucker 2010).
Torbay Care Trust established five integrated health and social care teams that are organised in localities aligned with general practices. The teams target their efforts at the very highest-risk individuals who require intensive support from community matrons and integrated teams (Imison et al. 2011: 7).
What next for clinical commissioners?
Developing new relationships to improve the health and wellbeing of patients as well as achieve efficiencies will be one of key tasks of commissioning groups. There are many ways in which groups can work with social care to achieve this. Local authorities’ experience of commissioning social care may hold lessons that will ease the transition to becoming clinical commissioners and to developing strategies to meet the health needs of the practice population as well as the individual patient.
These are some key questions to consider asking locally:
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Relationship building |
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Planning and |
What opportunities do the changes present to better co-ordinate the health and social care of people with LTC and particular groups such as frail older people and people with dementia? Examples might include:
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Funding and |
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Further information
- SCIE Social care TV films: ‘What is social work?’
- SCIE resources on personalisation and dementia
- SCIE Research briefing 33: The contribution of social care to reducing health inequalities
- King’s Fund: Transforming our health care system: ten priorities for commissioning
- King’s Fund: Improving the quality of care in general practice: Report of an independent inquiry
- King’s Fund: Routes for social and health care
References
- Alakeson, V. (2007) Putting service users in control: The case for extending self-direction into the NHS. London: Social Market Foundation.
- Audit Commission (2009) Means to an end: Joint financing across health and social care. London: Audit Commission.
- Carr, S. (2010) SCIE Report 37: Personalisation, productivity and efficiency. London: SCIE.
- Association of Directors of Adults Services (2011) Personal budget survey March 2011. London: ADASS.
- Department of Health (2010) Long-term conditions.[accessed 2011 06.04.11]
- Department of Health (2011) Millions of patients set to benefit from a modern NHS. (press release) [cited 2011 12.05.11]
- Goodwin, N., Dixon, A., Poole, T., Raleigh, V. (2011) Improving the quality of care in general practice: Report of an independent inquiry commissioned by The King’s Fund. London: King’s Fund.
- Hansard (2011) Written parliamentary answer 13 July 2011 Col 421W.
- Humphries, R. (2011) Social care funding and the NHS: An impending crisis? London: Kings Fund.
- Ireland, T. (2011) Consortia must save £4bn by 2014. [cited 2011 22.0311]
- Imison, C., Naylor, C., Goodwin, N., Buck, D., Curry, N., Addicott, R., Zollinger-Read, P. (2010) Transforming our health care system: Ten priorities for commissioning. London: King’s Fund.
- Kharicha, K., Iliffe, S., Levin, E., Davey, B., Fleming, C. (2005) ‘Tearing down the Berlin wall: Social workers' perspectives on joint working with general practice’ in Family practitioner 22(4): 399-405.
- McKeown, H. (2011) Personal email communication in capacity as Chair BMA community care committee 10.08.11.
- NHS Information centre (2011) Community care statistics: Social services activity, England 2010-11. London: NHS Information Centre.
- Think Local, Act Personal: (2010) Think Local, Act Personal: Next steps for transforming adult social care, Putting people first.
- The Law Commission, Adult social care: Final report no. 326. 2011, London: Law Commission.
- Tucker, H. (2010). ‘Integrating care in Norfolk: progress of a national pilot.’ in Journal of integrated care 18(1): 32-37.
- Turning Point (2010) Benefits realisation: Assessing the evidence for the cost benefit and cost effectiveness of integrated health and social care. London: Turning Point.
Acknowledgements
Written by Dr Lisa Bostock and Richard Humphries.
SCIE is also grateful to Dr Helena McKeown, Chairman of the BMA's Committee on Community Care, and other medical colleagues for their advice on the development of this At-a-glance briefing.
http://www.scie.org.uk/publications/ataglance/ataglance45.asp
Local Healthwatch: A strong voice for people – the policy explained
https://www.wp.dh.gov.uk/healthandcare/files/2012/03/Local-Healthwatch-p...
http://healthandcare.dh.gov.uk/how-will-local-healthwatch-work/
Improving the social care system: money does matter... but it’s not the only problem
Today we launched findings from a major JRF project about person-centred support. Whether we’re talking about social care, independent living, personalisation, self-directed support or individual budgets, what 'person-centred support' really means is organising services around the person rather than trying to make the person fit the services.
An investigation has been under way for over four years looking at what has been happening to service users in practice. Working with eight services (and a wider network of 12 others), 'The Standards We Expect' consortium has tried to get under the rhetoric. Those involved are from diverse backgrounds across the UK. They have not claimed excellence, merely a willingness to explore what it might take to be ‘person-centred’. The consortium (with a user-led organisation at its hub) has tried to be clear and constructive – pointing out poorer practice, supporting the development of better practice, and working with face-to-face workers, service users and managers.
Co-incidentally, this work has taken place both at a time of the expansion of personalisation and cuts threatened by the deficit. Surely, you ask, with such societal changes, today’s lessons will be very different. In fact, the arguments for change have remained remarkably similar throughout this period, and are reflected in the sometimes hopeful, sometimes sombre, evidence from 'The Standards We Expect' investigation:
Cash and culture change are fundamental to a system that is, at its best, crucial to so many people’s lives. The evidence from this report is that, unless you address both, hand in hand, change will not succeed.
http://www.jrf.org.uk/blog/2011/05/improving-social-care-system?utm_medi...