Before the inaugural ‘Social Work Journal Club Chat’ tonight at 8pm (BST), I’m going to run through a summary/my thoughts of the article chosen completely undemocratically by me.
Anyone who wants to suggest an open access social work/social care related article for the next chat on 1/8/13, I’d really welcome it in the comments.
The article starts by explaining that ‘market forces’ are increasingly ubiquitous in all aspects of our lives but there are some areas which are recognised as needing some ‘assistance’ in order for a true ‘market’ to grow. In social care the market seamless. Some people enter social care ‘market’ through coercion (examples given are people who might be offenders) and some have less capacity to make choices about the kinds of support which they receive (people with dementia for example). So while the ‘market’ for social care provision is not free – there are elements that could be replicated and adapted to allow for greater choice than would otherwise be the case.
Interesting that Spicker says
‘Personalised’ services, in the sense of responsive, individualised treatment, are supposed to extend to the needs of elderly people, psychiatric patients, learning disability, people with addiction, offenders, school pupils, homeless people and the unemployed’
Moving away from some of my discomfort at his differential labelling (psychiatric patients yet people with addiction and no further explanation of addictions to what – elderly people rather than older people – but maybe I’m too sensitive about this!).
I’m curious by his use of ‘supposed’ to. It, to me, gives me a glimmer of hope of a realistic appraisal of where we are now as ‘supposed’ has a lot to do with the chasm between policy and practice.
Spicker offers us definitions of ‘personalisation’ which will be a useful starting point for a further discussion of the article itself.
These definitions are
1. Personalisation as a needs-led rather than a service-led provision (professional assessment and decisions about what is ‘needed’ though)
2 Personalisation as meeting wishes rather than assessed needs of users. (choice as an alternative to ‘assessment’)
3. Personalisation where professionals facilitate and inform user choice (hybrid between 1 and 2)
First thing to consider is whether these models ‘work’ in the context of the work we do/PBs we receive?
And what IS the role of the professional? Is there a role for a professional to ‘assess’ and how does this reconcile with duties or discharge of duties under NHS and Community Care Act (1990).?
Spicker then looks at whether ‘personalisation’ has over-promised. Personalisation should offer people who use services a ‘stake’ in the system that they are buying into and this is the change in attitude in services as being ‘given’. Co-production is the goal to move towards and it is a key stepping stone on the way.
Fundamentally, person-centred approach (which is the heart of personalisation) should lead to better outcomes for individuals as these outcomes are based on what is highlighted by the individual as being important to them.
Spicker quotes a govt document (Changing Lives Service Development Group 2008) saying ‘Personalisation is about prevention, maintenance or intensive support – whatever is needed’ which is a very broad brush statement.
So is personalisation preventative? We have to look at the funding streams and FACS and my response would be ‘unlikely’ but maybe that’s too harsh. Spicker claims that there is no reason prevention would feature more highly necessarily in a preventative agenda than in a professional-led service – which isn’t to say choice shouldn’t happen/isn’t better but that it doesn’t necessarily tackle this issue more robustly.
Then there is the issue that services delivered through personalisation can be more flexible and change more easily. Here the key difficulty, Spicker relates, is the link, in some services between accommodation and service provision, for example in supported living or residential care.
Then there is the hope that personalised services will be better ‘linked’ but while this is a hope, personalisation doesn’t inherently guarantee it.
Spicker moves to argue in favour of personalisation and it’s benefits.
It should be more effective, theoretically, and tailor services to individuals and put choice at the heart of the provision of services. There are different models of emphasis between professional and user but at its heart it is about shifting power and allowing more personal input and preference in delivery
Then, he says, personalisation can be more cost-effective. This is controversial. A lot of cuts came in through the personalisation agenda but in theory, the same outcomes could be achieved with less money and preferred results. I would dispute this but perhaps, its an area that can be discussed.
It can be more efficient. Assessments of need can be costly and take time. By taking into account individual needs/preferences – more dynamic choices can be made about where services can be directly. This is controversial in terms of cynical decisions about where money can best be spent.
People manage their own budgets better than the State does. Spicker comments that some of the criticism of ‘state-imposed’ systems of care as ‘one size fits all’ has been unfair in the models of care management which were more flexible and he refers to some of the services which have been provided as a ‘group’ – like day centre provision/respite provision and meals on wheels – which did limit choice but reduced costs. There may be some situations where personalised and individualised is not always the ‘answer’.
Spicker looks at the marketisation of social care from the roots in the Griffiths report in 1988 which looked towards the market to provide ‘answers’ however possibly the systems which grew through the 1990 NHS and Community Care Act possibly became less responsive to individuals.
Spicker challenges the ‘In Control’ claim to have ‘pioneered’ personal budgets in 2003 but by looking back at the ideas which had been in operation since the 1970s – the Family Fund and later ILF (Individual Living Fund) which pre-date direct payments.
Individual budgets, then, move in the direction of the market but it’s a wave of movement which has been happening for decades. Spicker refers to the fluidity of the market and some of the challenges that pushing social care into the market have presented. You can give someone a budget, all you like, but there have to be things – and reasonable, decent, affordable things – to spend that budget on.
The market has to deliver a range of viable options on the supply-side while on the demand-side people have to be able to decide on alternate provisions. This is not always the case and the ‘market’ is very much stunted. This doesn’t mean some choice is better than no choice – there’s no doubt it is and can be.
Spicker notes that the principle of personalisation depends on making it possible to match provision to need. Who makes this choice may differ from professional to user (or may not in respect to LA controlled ‘personal budgets) but there need to be a variety of options to choose from in order for that provision to be ‘person-centred’. As he says
“There has to be enough excess provision for a choice to be possible. That rarely happens”
There is always going to have to be compromise to the ideal in terms of supply. Spicker uses the example of accommodation where there are always constraints in terms of provision.
“if the problems are problems of scarcity, lack of resource and lack of choice, it is difficult to see what there is in the process of personalisation that could overcome them”
He refers to the difficulties of taking professionals wholly out of the process of choice which may mean (not necessarily and this may be an interesting point to debate) people may have less information about the options available to them.
He is very clear that “The process of personalisation was intended, at least in part, to save money and there are certainly indications that the desire to make savings has driven reforms” I think that is undeniable for anyone who has working in or has experience of using social care services.
Evaluations of personalised services.
Direct payments were opened up in 1997 and Spicker refers to guidance at the time
“A local authority should not make direct payments unless they are as cost-effective as the services they would otherwise arrange”
So DP (direct payments) reduced average costs. The Audit commission confirmed in 2006 report that more effective services could be delivered at a lower cost.
Spicker raises some of the difficulties with evaluations to date and I recognise some of his criticisms
“Arksey and Kemp (2008) point to some of the difficulties of evaluation: studies do not compare alternative approaches, agencies select clients who are most likely to benefit.. “
“Pilots are often undertaken by committed professionals who are active innovators. Positive results are liable to be generated not by the character of the programme so much as the energy and enthusiasm that go into them”
This has been very much my concern so I’m glad to see it raised. A lot of effort has gone in to telling us what we know works. Spicker notes “We are liable to be offered uncritical evangelism and case studies of enthusiastic professionals doing a wonderful job – some of them difficult to relate to personalisation at all” so where does the evaluation leave us.
There is little evidence of cost-effectiveness although it differs between user groups – particulatrly positive in mental health service users for example but is cost-effectiveness the main measure? It depends what we are looking for.
Spicker says, unsurprisingly but less helpfully for those of us looking for answers for a system which has been embedded for many years now
“It (personalisation) seems to work in some circumstances and not in others. The benefits are mixed, and contingent on application of the principles in context’ Thanks. That’s helpful”
Spicker concludes that the Dept of Health is claiming ‘personalisation’ is something new but it has its roots firmly in the processes started in the Griffiths Report. While it is supposed to match services to needs there is little entirely unequivocal evidence of that.
He says in conclusion
“Neither the theory nor the practice offers adequate justification for developing a programme of personalisation for all groups, all of the time”
Personalisation doesn’t ‘fail’ – but it isn’t necessarily universally appropriate and there is a danger that over-reliance on a model which doesn’t match all user groups may discriminate against some groups.
Spicker concludes that personalisation isn’t a failure but it does ‘fall short’ significantly and the model requires more critical examination.
So where now?
There’s the paper to discuss. Do read it and join me – I think there’s a lot to discuss about the evidence that Spicker looks at? What the relevance is of the groups where it fails and where it succeeds and whether the market can provide an answer?
I hope users of direct payments and individual budgets will join us as the experts in this field as well but of course, anyone and everyone is welcome!
There’s a lot there and I think we can come up with a solution to government policy gaps between us – on Twitter – I’m nothing if not hopeful!
See you tonight at 8pm @swjcchat and hashtag #swjcchat
And I hope to publish a summary afterwards here – unless it is just me talking to myself!