Social Care - Health Committee Contents


Examination ofWitnesses (Question Numbers 100-119)

MR DAVID BEHAN, MR JOHN BOLTON, MS ALEXANDRA NORRISH AND MR JEFF JEROME

29 OCTOBER 2009

  Q100  Dr Taylor: Those are fairly easy to grasp, I think. "Individual budgets" and "personal budgets"? We have been given a diagram from the Department of Health and it describes individual budgets as "a clear up-front allocation of money that can combine several funding sources that you can use to design and purchase support from the public, private or voluntary sector" and the personal budget "like individual but solely made up of social care funding". It appears that the Department of Health is moving away from individual to personal. Is that right and why are they doing that?

  Mr Jerome: We put something out last week to help councils and others clarify that. The main issue is individual budgets was a pilot looking at a number of public sector funding streams. In fact, that has now been picked up by something from the Office for Disability Issues through the Right to Control Trailblazers which Members here might know about which is going forward into legislation. There will be some further piloting of public sector funding streams under something called "right to control". Individual budgets was just something that happened in councils some 18 months ago which were looking at that. We are trying to make it clear to people that that is something that has gone and moved into right to control, but the term we are trying to get everybody to use is "personal budgets" which is at the moment about the social care money only and of course links to the term "personal health budgets" and makes it easier for people to understand in terms of what is going to happen on the health side.

  Q101  Dr Taylor: Did the pilots not work then?

  Mr Jerome: It might be best if you ask colleagues in DH about that because that was a Department of Health set of pilots.

  Mr Behan: Can I help, Chairman. I think one of the issues about the session is that Jeff is being asked questions which are really about the accountability of DH officials and I would regard myself as being the senior official responsible for this. In straight answer to Dr Taylor's question, the individual budgets that were piloted, which in effect brought funding streams from DWP and from social care together, were evaluated by a group of academics linked to LSE and the University of York as well as the University of Kent. They carried out a classic research study including randomized controlled trials and they published that research at the beginning of this year. What that research showed is compared with the randomized controlled trials the degree of satisfaction and improvement in outcomes and improvements in the quality of experience as reported by the individuals—to go back to Dr Stoate's earlier question about outcomes—showed that those people who used an individual budget had higher outcomes than those who used more traditional forms of service. That was a published report and that was particularly noticeable for people with learning disabilities, people with mental health problems and people with physical disabilities. The evidence was less conclusive for older people but the sample for older people was much smaller.

  Q102  Dr Taylor: When you said higher outcomes did you mean better outcomes or more expensive outcomes?

  Mr Behan: No, the evidence was, although this was not statistically significant, that the individual budgets were cheaper than the more traditional forms of service, but the outcomes as reported by individuals in terms of their confidence and feelings of being in control were better. That is hardly surprising if you think about it; people with mental health problems who might think that control is taken away from them in a hospital setting when given control over their budgets feel in control of them. The evidence was statistically significant and that is now a peer-reviewed published piece of research carried out by independent evaluators of the success of that and that was individual budgets.

  Q103  Dr Taylor: Where is that published?

  Mr Behan: That was published at the end of last year.

  Mr Bolton: About a year ago.

  Q104  Dr Taylor: Moving on to direct payments, and I do not know if this is Jeff or David. They have been available for some time, take-up have not been particularly high; is personalisation going to lead to a higher take-up?

  Mr Jerome: We think personal budgets will enhance that. Direct payments have been low but in fact they have gone up significantly. The last published numbers were about 90,000. Personal budgets can be taken either as a cash payment or direct budget, and you heard that earlier, or as a managed service which is effectively a variation of what happens now and which is managed by the council or offering a provider organisation to do that but in a personalised way. That is quite a big change for local authorities. Direct payments is not a big change, it has been around quite a while. There have been some slight changes to the guidance but in fact numbers have been going up increasingly on that side.

  Q105  Dr Taylor: So they are going up and this will probably increase them?

  Mr Jerome: Increase them.

  Q106  Dr Taylor: Will there be any limit on what they can use it on if people take it in cash?

  Mr Jerome: There is guidance that defines that but effectively it is fairly liberal. The main issue in terms of the law is that there has to be some connection between assessment of need and how that is being met. You can set that out, and that discussion on outcomes earlier was quite interesting, as a set of outcomes providing the amount of money that is allocated ultimately, either taken as a direct payment or personal budget, is reasonable to meet the set of needs. That is really what the law requires.

  Q107  Dr Taylor: If their needs are just to get out and meet people?

  Mr Jerome: If that is the identified need and it is a valid and eligible need, money could be provided for that.

  Q108  Dr Taylor: So they could be used for anything that was moral or legal?

  Mr Jerome: Yes, moral or legal.

  Chairman: I am tempted to ask where the morality is but we will leave that for the time being! Doug?

  Q109  Dr Naysmith: Following up what you have just said, Mr Jerome, I think part of the personalisation policy seems to have been to turn service users into micro employers and a number of concerns have been raised in different areas about this, including whether people can choose to opt out of doing so if they do not want to be an employer and whether the funding will be adequate for the service being sought, and the protection of both service users and employees from exploitation. Is each of these concerns legitimate and is there evidence that they are occurring? If so, how are they being addressed?

  Mr Jerome: People can opt in or out of being an employer. They can take a managed service through the council or ask a provider to manage it on their behalf or employ people on their behalf. In fact, there are arrangements springing up where providers will employ people specifically or recruit people specifically for individuals or they can decide to take the cash and handle that themselves. What we are saying is that it needs to be legal, we are not saying anything more than that. There are all sorts of issues, I know and I have discussed that with the trade unions and with users, about the best way to approach some of the complexities about employment. A number of local authorities have set up umbrella-type support that will allow either payroll to be done or advice on national insurance, criminal records checks, et cetera, to be made available to people that will take some of the pressure off them as employers, but there is not anything explicitly saying you have to go down a certain route of employment. It just has to be legal.

  Mr Bolton: Can I add something that might just help here. There are about 40 councils who now offer personal budgets as a matter of course, particularly to new customers, and the evidence we have from them is about 50% of customers are still taking the service as a managed service so they are still wanting the council or a third party to organise that. About a third of people are taking a mix-and-match approach so they want some services managed by the council but they want some of the money for them to manage themselves. That is rarely to employ somebody; often it is to do something they want to do with that money. Then about 17% are much closer to the direct payment where they are taking the money and that is the group that is likely to be employing somebody. That is holding up fairly consistently when I go round and visit councils.

  Q110  Dr Naysmith: Is there any evidence of exploitation by firms coming in and exploiting individuals or of people being exploited?

  Mr Bolton: There are always cases you should worry about in any system and there certainly have been examples in direct payments before this policy came in of some risks and obviously we hope councils are carefully monitoring those people who they deem to be at risk and ensuring they have the right protection and safeguarding plans in place.

  Q111  Dr Naysmith: Is there an adequacy of funding for what is expected to be purchased for particular sums?

  Mr Bolton: At this point in time the evidence seems to support that there are certainly no additional costs arising from this. Councils are reporting that they are able to deliver these services within the budgets available given the budgets have been stretched for the reasons we described because of demography, et cetera. It is not personalisation that is causing additional problems, as reported to us.

  Q112  Sandra Gidley: Another question for Mr Jerome. Local authorities are going to be expected to shift their commissioning role towards stimulating and managing local markets of a number of competing providers, from which the service users will choose directly. You can make a parallel with the NHS where primary care trusts do that to a certain extent. We are also doing a separate inquiry into commissioning and there is a lot of evidence to show that commissioning in the Health Service is very, very poor. How can we be reassured that councils will do better?

  Mr Jerome: Than the NHS?

  Q113  Sandra Gidley: That would be a starting point.

  Mr Jerome: Commissioning is a complicated term. The council responsibility in Putting People First is to make sure there is the range of care and support services there that individuals might want, so the immediate issue really is the broadening of choice because unfortunately just giving people a personal budget or cash does not broaden choice if the market response is not there. At the moment most of the evidence will be if you are not employing a personal assistant you are going to be taking a relatively traditional domiciliary care or even a residential care option, so what we are trying to do is encourage commissioning that broadens that choice and that is one of the milestone areas. The complicated bit really is that councils are going to need to stop thinking about themselves as the major holder of money in this and that is the balance that is there in personalisation and in personal budgets. A decision needs to be made about what councils need to collectively commission and how much people will draw off in a collective way from that even as a managed service and what they might be passing over to individuals for them to access the market. The council role therefore is to make sure in discussion with suppliers—and there is a big issue for suppliers here—that those services that people want are there. Going back to your earlier question about unmet need and want, some of the work that has been going on in the Department of Health around contracting has started to look in about half a dozen local authorities at what is known from what is not there, if you like, what is wanted, and to start to try and shape the market response by gathering that information and feeding it back to suppliers. The suppliers themselves of course have that information and that is an area we are trying to develop.

  Q114  Sandra Gidley: The NHS has been quite directive towards PCTs. How much help are councils getting to make sure this is not a complete shambles like the original commissioning from PCTs was?

  Mr Jerome: We have a national work programme on which there is a major strand on commissioning and market development and market shaping. Some of John's team at the Department of Health working with people on the local government side and in the regions are working particularly with suppliers and we are trying to have that interaction.

  Q115  Sandra Gidley: How much liaison has there been with the people responsible for implementing World Class Commissioning? Are you learning any lessons from that?

  Mr Jerome: We are certainly having those conversations. The Department of Health has quite tight links. They are slightly different approaches though because we are starting from a completely different position and a lot of what happens in the NHS is procurement-based; this is a different concept.

  Q116  Sandra Gidley: Is there any work being done to make sure that what is happening in social care and the changes to commissioning there do not clash in any way but rather complement what is happening in the NHS? Has any thought been given to that?

  Mr Behan: Again, Chairman, I feel that questions are being directed at Jeff that really should be coming to me and my team because we are in the Department of Health and to go on to the theme from some of the earlier questions about accountability—

  Q117  Sandra Gidley: To be fair this was about joint working.

  Mr Behan: With respect, if I can just go back to the original questions about the concordat. This is the Government's policy document Putting People First. It was a statement of direction of travel for the reform of the system. This is where the £520 million in three chunks of money is going into the system to reform the system. The delivery of this policy was built on a new model of delivery and we were trying to move away from a top-down model of implementing change of "government knows best". Consequently the back of this document is signed by over 16 organisations, of which ADASS is one and the Local Government Association is another, and in delivering this strategy we had to reflect on how does change occur at a local level, particularly going back to your question, Chairman, about how is social care different from the NHS where there is not a command and control structure. There is not a Chief Executive of Social Care. It is a largely distributed and pluralist system where each of the 152 local authorities is a separate legal autonomous body in its own right. Arguably, the Department of Health's job in relation to local government is to set out the direction of travel, the vision for care, and the signatures on this particular strategy are from the Local Government Association and from organisations such as the Association of Directors of Social Services, where they said we think this is the right vision, we think this is the right direction to reform social care services, and we sign up to working with you to change the system to deliver that vision. Going back to your question, Chairman, the Department is accountable to the Secretary of State for the delivery of that vision. The way that we have chosen to take that vision forward is by a consortium which brings together the Local Government Association and the Association of Directors. John chairs that programme board and the money which pays Jeff's salary goes to the consortium so Jeff can be employed to work locally alongside local authorities to introduce those changes. So we are trying to move away a top-down approach and we are trying to build the capacity at a local and at a regional level to introduce these changes. This is less about "government knows best; please do what we tell you to do" and more about how can we grow the capacity at a local level. The accountable questions, Chairman, I think are rightfully pointed at the Department and the work about delivery and implementation are taken forward by John, accountable to me, accountable to the Minister and the Secretary of State, but with Jeff working alongside local government colleagues, the voluntary sector and the private sector at a local level on how we take these changes forward. It is largely about innovation that will take place in local authorities, in local partnerships and in local systems, and what we need to do is draw on those, but the accountability is through me to the Secretary of State.

  Q118  Sandra Gidley: I think the problem is it is all very well saying we do not want a top-down approach and many of us would applaud that, but parallels in the NHS have shown that some help and guidance and assistance is needed. It is not necessarily didactic, I have heard the word "tool kit" sitting here more times than I care to think about. My question is really about what help is being given or is there any help being given to help councils do this or are they just expected to be imaginative?

  Mr Jerome: The answer to that is there is a lot of help from the central programme. In fact, every single joint improvement partnership in all the regions has a commissioning programme. We are trying to link that to the national programme and we are trying to make sure there is no duplication and repetition. I was really throwing it across to the Department of Health side, particularly around the World Class Commissioning work which I know also has a central stream to it and I was inviting John whether he wanted to come in around that.

  Q119  Dr Stoate: Mine is a fairly straightforward question and that is obviously local authorities can be bulk purchasers of services and therefore presumably get much better prices. What can we do to protect individual purchasers to make sure they are not disadvantaged?

  Mr Jerome: A number of local authorities are saying to providers that they would like them through the different agreements they have—although this is a very tricky area—to offer, and in fact sometimes requiring it in a contract, and I have some difficulty with that I have so say, that they should sell privately in the same way that they are selling to the local authority. I say I have some difficulty because the providers do not like that at all.



 
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