Q
16Mr.
Lilley: A point which may be as much, if not more, related
to Ms Sayce as to you, is that we are all familiar with the
difficulties different institutions have in co-operating with each
other. I used to say that it was more difficult to get one Government
Department to co-operate with another than it was to get the United
States and the USSR to co-operate at the height of the cold war. I
think that that is true not just in central or local government and in
other institutions, and it is clearly a
problem. I
wonder to what extent the difficulty that institutions have in
co-operating is that they find that the current rules and the current
control that they have are a way of rationing resources, and that if
they move to personalised budgets, they believe it will lead to an
explosion of demand. The presumption in what both of you have said is
that within a given budget you can get much more well-being, and that
is why you want to move there. Is the reluctance to move towards
creating more well-being due to Departments seeing the existing rules
as enabling them to live within their
budgets? Paul
Davies: I think that that is entirely true. There is
a school of thought that feels that going down this route will unlock
everything and then there will be no limit to what people will want. I
think that that is a naïve and hugely mistaken view. The
evidence is that, when you co-ordinate funding streams with an element
of each relevant funding stream, you get more than the sum of the
parts.
In the case
of adult social care, there is something called a resource allocation
system, which calculates the amount of money available to the
individual according need, on a points-based system. It is very
straightforward. It sounds remarkably simple, but it is something we
have essentially not done since 1945 until about 2000. The previous
system was like many other systems, in that need was assessed but no
resource was set against that need, while some mechanism went on in the
background that ultimately resulted in somebody receiving a
service.
This is
important, because a transparent resource allocation system that is
able to integrate the different funding streams at whatever level and
according to need deals with a lot of those objections, because the
budget is the budget—it is finite. I am no different from any
other local authority service director, in that my budget is limited
too, and I have to live within that budget.
However, there is a better mechanism in this arrangement for dealing
with that conundrum. When there is a properly integrated, transparent
system for allocating the money—and it is resource-limited,
because that is the amount of money you have got to spend and you have
to make the best of it—it brings together much more than one
budget alone. To me, that is the means of dealing with what we deal
with now, which are resource-limited capped budgets, and of making
better use of the money than we do at present. I am not sure if that
answers your
question. Q
17John
Mason (Glasgow, East) (SNP): My question is about how we
deal with the fact that, as you said, every individual is different; if
I understood you correctly, something like 50 per cent. of your folk
prefer not to take control of the resources, 25 per cent. take full
control and 25 per cent. are somewhere in between.
Paul
Davies: That is our experience in
Oldham.
Q
18John
Mason: Is that an ideal position or is the ideal to move
to 100 per cent. control? What do you foresee? I assume that for some
people choice is quite stressful and they do not want it. There is also
the thing about the individual against the community. The example was
of driving lessons against a day centre, and for some people getting
the driving lessons would be right, but others might want the driving
lessons, yet be better off in a day centre. Is that the case?
Paul
Davies: That is a good question. I do not have an
optimal position on the number of people we should end up with who
choose to take the money and control their own services—if it is
100 per cent. then it is 100 per cent. The trick is demand management,
which is perfectly possible. There is sufficient experience around now
to judge who would prefer a more traditional service, such as a day
centre; many elderly people in my area still choose that, but others
prefer to take the money and do something different. If the experience
is applied properly, it is sufficient to judge how the money works
itself out and to ensure that one allocates the money and carries out
the calculation accordingly.
You are right
that choice is stressful for some people, which is why
“choice” is the operative word. People are able to say,
“Thank you very much, but I do not want to deal with that. I
will tell you what my wishes are but please can you deal with
it?” and we happily do that. One live example is that very early
on in Oldham, somebody, who I think was taking the mickey, asked me
whether people with substance misuse problems could have an
individualised budget. The answer was yes, in principle, and, sure
enough, eight weeks later somebody with a substance misuse problem came
along and started managing her own money. She did that very well until
her ex-partner came back on the scene and she said, “If my
partner knows that I have money, he will make me spend it on drugs.
Will you take control of the money and administer it on my behalf
according to my wishes?” We did that.
On the stress
and challenge issue, looking at mental health services across the
country, it is no secret that they have—I would not say
connived—co-operated in a system that is aimed at keeping people
unwell, with no sense of “well-being,” which is a very
important word. There is no expectation that people will come through
their illness, to a greater or lesser extent, and find
themselves back in employment and living the same lives as the rest of
us enjoy, as far as they are able. It seems to me that a system that
does not take a view that we should be ensuring that everybody can
maximise their potential does not work for
folks. On
the physical delivery, everyone that I deal with needs support, by
definition; the question is how much. That is what we are arguing over
and what we need to put in to ensure that they can maximise their
potential. These are the key elements. First, there is a need for
traditional supply. Even in Oldham we have some traditional supply that
some people choose, but it is more limited than it was and the services
are completely different in complexion and character from those that we
had four years ago. Secondly, as much as anything else it is about a
will to win—a will to deliver and succeed and about putting that
person at the centre to ensure that they are able to maximise their
potential. I keep banging on about more direction rather than
permissiveness because I think that a permissive arrangement for the
agencies involved does not, on present evidence, seem to be delivering
that aspiration in the way that I would like it to be
delivered. Liz
Sayce: On the question whether it might be better for
some people to be in a day centre, I do not think we can be confident
that the one-size-fits-all supply models have been effective, either in
terms of people’s satisfaction and quality of life, or in terms
of other outcomes, such as the likelihood of people moving towards
employment. On the latter, the evidence is variable, but there is no
real evidence that attending a day centre or a sheltered workshop will
help you on the path back to employment. It is often the reverse,
actually—you get stuck there. Similarly, for the person who
chose to go fishing rather than to a day centre, that was about
preserving the activities that mattered to him with the people that
mattered to him, given that he had developed dementia.
Although I
agree that there is a role for traditional supply, I think it unlikely
that it will be better for people. The evidence shows that, in terms of
what enables people to get back into work, motivation is a key thing,
so if you pursue something that really interests you, rather than going
to a day centre and having whatever happens to be on offer, you are
more likely to be motivated and encouraged. It is not rocket science
that you are more likely to succeed in a job that you want to do, or
that you are more likely to get a qualification for something in which
you are interested. The evidence tends towards the suggestion that
personalisation will deliver better outcomes, and that we do not need
to be too worried about people choosing things that might not be as
good for them as what went
before.
Q
19John
Mason: I take your point that personalisation is generally
better, but clearly some people will make the wrong decisions at times.
On the example of substance abuse, it is tremendous that somebody
actually recognised that there would be a problem if they had cash. I
suspect that other people would not have recognised that. Are you
therefore saying that people should not be proactive, or would you just
allow them to make
mistakes? Paul
Davies: All this comes into the
issue of risk and whether we are able to proactively manage the risk
associated with particular individuals, their own view of
choice and control, and what it is they want to deliver, as well as the
risks to public money, safety and so on. There is in existence a
perfectly well developed risk enabling tool that enables agencies to
work with individuals—it is not a big, bureaucratic
process—to assess what the risks are and what the outcomes will
be for them, because as I said earlier, in adult social care it is
conditional on delivering the outcomes. It is not a gift in that sense;
there are outcomes to be
had. In
Oldham, for example, we have a risk enablement panel. The panel has
that title because its purpose is to enable risk rather than to avoid
it in a bureaucratic sense. The panel ensures that the individual can
have a discussion with the agency about the levels of risk, how the
money is managed and how that is tied to their outcomes. As my
colleague rightly said, if the outcome as far as an agency is concerned
is that somebody should sit in a day centre, as has been the case,
smoking their head off for the next 20 years, I am afraid that is not
much of an outcome.
But if I may
take the Oldham example again—it is the one with which I am most
familiar—the risk enablement panel meets on a regular, if ad
hoc, basis to discuss issues of risk that emerge from particular cases.
The panel has three options: it can refuse the risk because it cannot
live with it, it can agree the risk and state that it is absolutely
fine, or it can agree the risk with certain changes. To my knowledge,
in over 2,000-odd people, I think we have only ever refused about two
plans. The individual—their carer or supporter can also be
there—is part of a conversation with professionals on what that
risk means to them, how it is managed and how they deliver the outcomes
and aspiration in the conditional offer of money from the local
authority. That is a way of developing the self-efficacy argument about
people being part of taking control of their own lives as far as they
are able and encouraged to do so. Having seen the alternative,
particularly in the field of mental health services and vulnerable
adults, which is statutory organisations trying to take a view on what
is best for folks, we have ended up with an awful lot of people on
incapacity benefit and not a lot of movement on
that.
Q
20Mr.
Harper: I have two linked questions for both of you.
First, the Government’s analysis states that the right to
control for these funding streams will be tested in a small number of
authorities from 2010. It seems from what both of you were saying that
the right to control individual budget process has been well tested in
adult social care. You know what works in your authority and there are
examples from across the country of what works. Does the Department
need to pilot this stuff or should it be braver about trying to move
faster?
The linked
part of the question is this: clearly the Department and the Government
will be nervous about going fast and having things not work, but there
is a cost on the other side of going too slowly. If you get better
outcomes for the people themselves and you spend public money better,
particularly in the current climate where that money is very limited,
there seems to be an incredible cost in going slowly: you are forcing
people to get worse outcomes and you are spending public money more
inefficiently. Given that the Bill gives the Secretary of State quite
wide-ranging powers to make regulations, should he be brave and make
regulations that apply to everyone straight away? Then authorities that
want to go faster can, and we can put
pressure on. Or should the Department do what it plans to
do—pilot this in a few authorities, potentially for up to three
years? So another three years will pass before we see a great deal of
progress. Liz
Sayce: Clearly it is very important that evaluation
and learning take place throughout the implementation. In that sense
the trailblazer notion makes sense. There will be learning as this
develops about what works in putting these different funding streams
together. We need to understand the outcomes. We need to understand the
cost-effectiveness and so on. It is important that there should be an
evaluative element. There is a question about pace and cost. One of the
issues that has been raised with us is that it can be more costly to
double-run different systems within a local authority or another public
body. There is a risk that, out of a concern for affordability, we
create an additional cost through the double running of different
systems rather than moving as quickly as possible to the system that we
want and learning as we go.
Disabled
people want to ensure that the resources available are spent on choice
and control and in the most effective way possible. It would be worth
considering whether there is another option, such as making it clear
that developments have to happen within a constrained budget. It is not
about implementing programmes that will not be cost-effective, but
without the in-built delay from the piloting. Pace will be important
and we will look for pace. So yes, there are some questions about
it. Paul
Davies: I can well understand why people would want
to feel the comfort of a pilot and see how that worked; I just do not
agree with it. There is more than sufficient evidence to justify going
straight ahead.
I had a wry
smile when I saw that there was provision for an exit strategy. If I
were to go back to any of the people in Oldham who have an
individualised budget and tell them that there was an exit strategy and
that I would take it off them and put them back into the old system, I
probably would not survive very long. There is very strong evidence
that once people get control over their own services and choices, they
value it incredibly and it makes a big difference to them.
Secondly—this is significant in the context of public
services—even where the outcomes are not quite as good as they
thought they might be in the beginning, the sheer fact of having choice
and control makes a big difference and increases enormously the level
of what in another context is described as customer
satisfaction.
I will be
strong about this. If the intention is to give control to some of those
people whose lives are currently being wasted because the system is not
supporting them to get back into employment and they are not playing
their full part as citizens and doing all the other things they need to
do, the period that is being suggested is far too long. We need to make
a start on this today. We have the experience and the background
knowledge. There is no reason why there could not be some
conditionality, as was implied, in terms of budgets and so on. I see no
problem with that at all because that is not an unreasonable thing to
say. It seems that the vision is fantastic but the route being
suggested to deliver will not be fit for purpose, for the simple reason
I have already suggested.
I come back
to direct payments legislation. It was perfectly possible for a local
authority to run two competing systems, a direct payment system and a
traditionally
delivered system in adult social care, as long as the authority had the
money to do so. When the spare money came to an end, people either
could not continue to make those choices or had to wait a year until
the money became available, because the existing money was already tied
up in a system that was not delivering what was required. For some
people it was delivering what was required; I am not knocking all
traditional services and I would never say that the system is broken in
that sense. If the money
is tied up in delivering one set of arrangements it stands to reason
that you cannot then just unpick small parts of it on a piecemeal basis
and take it away and do something different. There is a massive
opportunity cost as well as a financial cost in running two different
systems. Oldham mainstreamed its processes very early on, simply
because it is impossible to get away from the logic of having to extend
the system across all services. A pilot, and possibly a subsequent
pilot, is being suggested. I hope everything I have said makes it clear
that I do not think that fits the
bill.
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