Partnerships and personalisation: the implications of direct payments and personal budgets Prof. Jon Glasby Co-Director, Health Services Management Centre

Outline  Background  Advantages/barriers  Personal budgets  Implications for social care  (Tentative) implications for health care

1. Background “ The potential for the most fundamental reorganisation of welfare for half a century”  Cash payments to service users aged in lieu of direct service provision  Extended to include older people, younger people aged 16 and 17, carers and the parents of disabled children  Now mandatory rather than discretionary

1. Background  Illegal under 1948 legislation  Indirect payments (pioneered by disabled people)  ILF  1990 NHS and Community Care Act  Lobbying and research by disabled people  Disabled people involved in implementing direct payments

1. Direct Payments are very simple – it’s not hard Direct Payments = a means to an end (of independent living) Choice and control are central

2. Advantages  More responsive services and increased choice and control  Improved morale and mental/psychological wellbeing  A more creative use of resources which may sometimes reduce costs, but which certainly ensures better value for money  A blurring of the boundary between health and social care

2. Barriers  Perceived focus on physical impairment  ‘Willing and able’  Complexity of monitoring arrangements  Staff attitudes and knowledge  Political concerns in some authorities: ‘privatisation by the backdoor’?  Boundaries with NHS and housing

3. Personal budgets  Rights-based approach (more like social security than traditional social care)  Links to PCP and circles of support  Sees DPs/PBs as a means to an end  Can use same resources much more effectively  Emphasised in the White Paper and being rolled out

3. Seven steps to Self-directed Support  Set PB (using in Control’s RAS)  Plan support – with support as needed  Agree plan  Manage PB (currently 6 distinct degrees of control)  Organise support – complete flexibility  Live life - people use their PBs to achieve outcomes important to them  Review and learn

4. Implications for social care “In the future, all individuals eligible for publicly- funded adult social care will have a personal budget (other than in circumstances where people require emergency access to provision): a clear, upfront allocation of funding to enable them to make informed choices about how best to meet their needs.” (Transforming social care 2008 circular)

4. Implications for social care  Not a matter of ‘whether’ but of ‘how’ and ‘how quickly’  Significant cultural challenges for whole of social care  Key test will be not regulating/scrutinising the new system to death  Focus shifts from assessment and from services to planning/review/outcomes  Holds out the potential for reforming the system as a whole – not just bolting on to the existing system

5. (Tentative) implications for health  People do use DP/PB for health care  Separating health and social care rarely makes sense to the individual (or workers)  DP/PB for social care and not health flies in the face of the partnership agenda  DP/PB could help the NHS deliver key priorities  Growing sense of momentum

5. What could the world be like? – HSMC’s expert seminar, 2004  How can we make direct payments work better in integrated health and social care settings?  Could/should direct payments be extended to health care and in which areas of health care? What implications might this have?  Could we learn from the choice and control of direct payments to improve health care?

5. What could the world be like? – HSMC’s expert seminar, 2004  Would fit well with long-term conditions agenda  Scope to extend to specific groups  Wide concerns about a broader roll out (equity, supply, cost etc)  Scope to learn DP lessons in health care  Need to repeat the 1990s battle for ‘hearts and minds’

5. Key questions for health care?  When might it improve outcomes if people know upfront how much is available to meet their needs?  When could the person/those close to them/a worker achieve better outcomes by having the flexibility to be creative?  Where is it really important that support is truly personalised?

5. Possible areas for an integrated PB?  LTC (admission avoidance)?  Mental health (recovery budget)?  Continuing care?  Maternity services?  Expensive out-of-area placements?  Learning difficulty services?  Disabled children?  End of life care?Etc etc

5. How could this work for LTCs?  Scope for an admission avoidance scheme (with IB set at a % of the tariff)?  Scope to compare community matron v budget-holding professional v CIL/peer support model?  Scope to work with LA to make money available (similar to Pointon case)?  Scope to encourage Independent Living Trusts?

Further information  Alakeson, V. (2008) Let patients control the purse strings, BMJ, 12 April,  Glasby, J. and Duffy, S. (2007) – policy paper on direct payments and health (  Glasby and Littlechild (2009) Direct payments and personal budgets. Policy Press  In Control (  National Centre for Independent Living ( See also, the partnerships and personalisation section of the HSMC website