Going through the levels

Yesterday I sat in on a conversation about social care involving about twenty people, mainly practitioners from Leicester. They were an impressive group; committed, thoughtful, optimistic about what could be achieved but very aware of the limitations of existing provision.

Personalisation was a recurrent theme of the conversation. Speaker after speaker described the importance of fully understanding someone’s needs. A typical story involved a person with severe learning difficulties who started continually hitting his head against a wall. The behaviour was treated as a regrettable but inexplicable symptom of mental incapacity until a nurse noticed that the person always hit the same side of his head. It was only then that a quick examination revealed a severe but treatable ear infection.

Government strategy on personalisation has for several years revolved around the development of individual budgets. Currently, about a third of eligible social care clients have taken up individualised funding (either through direct payments or managed personal budgets) but take-up has been by far highest amongst those with physical disabilities. Extending individual budgets to people with learning difficulties, mental illness or dementia is much more challenging, though it will often be the carer who is the budget holder. Evaluation of individual budgets is limited but positive. But just because more people have individual budgets doesn’t mean services will necessarily be better, even from the perspective of the service user. The quality of care will depend enormously on the amount of money allocated and what services are available to be purchased.

A key question is how individual budgets might develop to facilitate a reframing of social care. As I listened to the conversation I could distinguish four levels of ambition for publicly funded interventions. Level one – the traditional system - simply involves the bureaucratic allocation of available services to the identified client group. Level two is what is conventionally meant by personalisation: allowing individuals to use allocated resources to choose their own care packages. This is fine for individuals, but many clients need support in making choices, and unless clients and carers come together to commission services, their choices may be very limited. So level three involves working with clients and carers to identify a set of interventions, which in the context of people’s wider personal resources and needs, will offer them the greatest empowerment and wellbeing. An example here is a group of people with physical disabilities and learning difficulties who collectively commissioned fitness classes which are not only tailored to their needs but also offer the opportunity for sociability for both clients and carers.

Level four is the most challenging but arguably the most necessary. This involves exploring the latent resources of care, altruism and ingenuity which exist within a client’s family, friends and wider community and then asking what interventions might best release these resources. This is the kind of thing being explored by a variety of RSA projects ranging from work on social networks and wellbeing to a whole person recovery approach to people in rehabilitation from drug and alcohol dependency.

There is no inherent reason why this social asset approach can’t be pursued within the context of individual budgets. The fact that individuals have to buy into services is a useful discipline to ensure those services are effective and relevant. But without co-ordination and collaboration the danger is that individual budgets end up buying tiny parcels of care from large impersonal providers while local public agencies retreat into a focus on resource allocation and risk management.

As resources are squeezed and needs grow the ambition should be that individual budgets are seen not simply as a way of paying for services but as a means to leveraging collective action and civic commitment. A new deal for social care rests on reframing the relationship at its core from professional and client to community and citizen.