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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