There is broad agreement that the thrust of the reforms to make social care services more person-centred is the right one. However, there’s widespread disagreement about whether or not reforms in the last decade have worked. Catherine Needham and Jon Glasby sit on different sides of the argument and together they have edited a book to draw together these different perspectives and identify five different areas of contestation.
In the midst of relentless bad news about the perilous financial position of social care services it is hard to remember that recent years have been a time of relative optimism in English social care provision. For almost a decade there has been widespread consensus that services should become more person-centred and lots of political capital around (and even some real capital) to make it happen.
As 2015 draws to a close, the capital is long gone and so is the optimism. Care homes teeter on the brink of bankrupty, propelled there all the more resolutely by the Comprehensive Spending Review. Thousands of people are excluded from care services which they desperately need as tightening eligibility is the only approach that can deal with the scale of the funding cuts.
But if we look at what kind of social care services we want, it remains hard to find anyone who disagrees that these should be person-centred, shaped by and responsive to the people who use them and their families. The policy that aimed to pursue this approach is usually referred to as personalisation. It became a formal policy commitment following the signing of the Putting People First Concordat between the then New Labour government and the social care sector in 2007 – although its genesis lies in much older campaigns to increase choice and independence for people with disabilities.
Personalisation has largely been focused on financial devolution, making people who are eligible for state funding aware of how much money is available and then giving them as much control as possible over how that money is spent. Personal Health Budgets (PHBs) are now available for people using Continuing Health Care within the NHS. Integrated personal commissioning pilots are ongoing for a range of people defined as having ‘high needs’, highlighting the potential for personalisation to be a key strand of the integration agenda.
Whilst there is broad agreement that the thrust of the reforms – to make social care services more person-centred – is the right one, there has been widespread disagreement about whether or not a decade of such reforms have worked. As researchers we come from different perspectives on the debate (Jon is more positive, Catherine more sceptical) and so we decided to edit a book drawing together these different perspectives, because we felt that they tended to argue past each other rather than engaging in debate. Contributors to the book included someone who holds a person budget, a family carer, a social worker, as well as campaigners, policy makers and academics (with some contributors of course performing more than one role).
In the book we identified five reasons why personalisation is so contested.
|1: Different historical reference points||For some people personalisation, and personal budgets in particular, stem from attempts to correct the failings of the post-war welfare state’s treatment of disabled people; for others they threaten to undermine the benign principles on which it was based.|
|2: Different vantage points||Different perspectives also stem from the extent to which people are writing about their own personal perspective of personal budgets or are reflecting on concerns about the potential marginalisation of other people. Contributors who have had their own personal or family experiences of using personal budgets and personal health budgets are largely positive. For others it is the potential exclusion of other people from these benefits that is of concern.|
|3: Different views of the workforce||Some chapters frame the worker as a key source of support for people who want to move towards more personalised approaches. However, there are other accounts of the professional-care user relationship which highlight tensions. Personalisation can be framed as a ‘zero sum’ game, in which individual care users gain power by taking it from care workers, who themselves are already a marginalised and vulnerable workforce.|
|4: Different interpretations of the evidence||Perhaps the most intriguing example of different perspectives is how the same piece of evidence is interpreted in different chapters. Julian Forder and Karen Jones report the findings of a three year evaluation of the PHB pilots, funded by the Department of Health. Key findings were that the use of personal health budgets was associated with a significant improvement in care-related quality of life and psychological wellbeing of patients over the 12-month follow-up period, relative to those receiving conventional services. There was no significant impact on health-related quality of life. For some contributors these findings are clear evidence of the need to push ahead with PHBs. But others point out that participants in the intervention sites were better funded than the control sites, and it is the higher individual budget allocations that have made a difference to outcomes rather than the choice and control associated with a personal health budget.|
|5: Engagement with the broader political context||A final difference is about how to move forward in the future, linking personalisation into the broader political context. Some contributors are optimistic about the scope for reconfiguration and individualised budgets to trigger innovation and improvement. For Peter Beresford there is no more urgent a priority than to tackle the underfunding of social care. Simon Duffy argues that nothing less than a new constitutional settlement, underpinned by a theory of citizenship and human rights, will be sufficient to bring about more fundamental reform.|
Whilst these five points of disagreement highlight the fissures in personalisation debates, it is also possible to find some common ground. The authors in the book may be writing from very different perspectives and taking different approaches to different aspects of the personalisation agenda – but it is possible to identify some shared underlying principles. Most people writing about personalisation are critical of aspects of the traditional system which they see as doing things to people (or even for them) rather than with them, arguing in favour of more person-centred and self-directed approaches. Often, there is a shared commitment to a common citizenship and civil rights, with a fundamental belief that disabled and older people should have the same choices and the same degree of control over the lives as non-disabled people.
We tried to maintain a balance of perspectives in the book, partly reflecting our own different perspectives as editors – indeed one of the reviewers praised the book for being fair and balanced. But the deep and relentless cuts to social care services in recent years have made optimism about personalisation harder to sustain. The gap between the promise of personalisation and the reality of state-funded care was large enough before the Comprehensive Spending Review. Afterwards, the gap looks set to become a yawning and unbridgeable gulf.
Note: A longer version of this article appeared in the Journal of Integrated Care and the book Debates in personalisation is available from Policy Press. The article represents the views of the authors and not those of the British Politics and Policy blog nor the LSE. Please read our comments policy before posting.
Jon Glasby is Professor of Health and Social Care and Head of School of Social Policy at the University of Birmingham.
(Featured image credit: Steve Harwood CC BY NC 2.0)