Social Care - Health Committee Contents


Examination of Witnesses (Question Numbers 780-798)

PROFESSOR CAROLINE GLENDINNING, PROFESSOR PETER BERESFORD AND MR JOHN WATERS

3 DECEMBER 2009

  Q780  Stephen Hesford: If there was a quick, for our benefit, definitional relationship between individual budgets and personal budgets, what is it?

  Professor Glendinning: Individual budgets were intended to bring together multiple funding streams—resources from Social Care, Access to Work, Disabled Facilities Grants, Supporting People, Independent Living Fund—so resources from DWP funding streams and DCLG funding streams. The personal budgets that are now being implemented under Putting People First are social care resources only, and I do want to emphasise that this was probably the most disappointing element of the pilots. The proposal that individual budgets should include these different funding streams came from the Prime Minister's Strategy Unit report in 2005, and it was an attempt to try and reduce the complex set of multiple assessments, multiple eligibility criteria that disabled people and older people have to go through. The pilot sites were very excited at the prospect of being able to try and bring together funding streams, but they found it very, very difficult, largely because of restrictions at central government level on what the different funding streams could be used for and accountability for how they were used. That was one of the really difficult areas. Of course, the other really difficult area was the fact that although all these funding streams were included in individual budgets NHS resources were not. So there were major problems at the NHS/social care boundaries, particularly around continuing healthcare and mental health services, where people very often used both health and social care resources. So, individual budgets, multiple funding streams, personal budgets and social care resources only.

  Q781  Stephen Hesford: I think you have probably answered this, but was there anything that came out of the pilots which still seems to be hanging in the air?

  Professor Glendinning: I think the funding stream issue is one, and, of course, since the IBSEN evaluation has been completed, the Department of Health is now piloting personal health budgets. We are still very unclear about how they will interface with social care personal budgets and the Department for Work and Pensions is discussing the piloting of right-to-control projects, which will include some of those IB funding streams—it will include Access to Work and the Independent Living Fund. I think the whole issue of cross-departmental working to try and simplify all the different resource streams and the assessment processes that go with them is a major issue that remains to be addressed and it links to the Improving Life Chances strategy. I think there are some other issues we have touched on already about what it is legitimate to spend public resources on. What are the boundaries on what people can use their personal budgets for? I think we need a much bigger debate around that, and I think it is something that government needs to lead on, because the uncertainty about what people could spend their money on really restricts creativity both in terms of frontline staff and personal budget holders and I think we also need a bigger debate on how we actually allocate resources to people. The resource allocation process that In Control pioneered and was very, very influential with many of the pilot sites, in a sense, by-passed a bigger question about what criteria we should use, what levels of resources we should allocate to which groups of people, and, of course, it revealed big inequities. It revealed very clearly that older people get far lower levels of resources than other groups of service users. I think those are some big debates that still remain.

  Professor Beresford: Can I add something to that. I think it is very helpful to hear set out in a very clear way things are that are not always set out very clearly at all, but we need to remind ourselves that the Government made a commitment 18 months ago to transforming social care services, and one of the findings from the preliminary work we have completed in the national project supported by the Joseph Rowntree Foundation is just how many things need to change and be got right systemically at local and central level if you are being serious about actually transforming—and I think that comes across very strongly also from what Caroline has said—and, therefore, it is a worry to service users who have been long-term service users, who have experienced wave after wave of policy change which has not been reflected in positive change in their day-to-day experience, but the same might happen now, because we are using very large words like "transformation" but not necessarily recognising that if we are talking transformation it actually does mean that, and it is an enormous thing to be aiming for. On the ground, service users and, of course, practitioners are concerned.

  Q782  Stephen Hesford: Can I come back to you, Professor Glendinning. The Government have moved towards personal budgets. Am I right in thinking that what you are saying is they were driven to that because of the complexity of operating individual budgets, or is there some other explanation?

  Professor Glendinning: I do not know. I do not know the reason for the decision. The decision to roll out personal budgets across English adult social care was, of course, made before the findings of the IBSEN evaluation were available. I do not know. My own personal view is that it was a political decision. I am not aware of any clear evidence underpinning that decision.

  Q783  Stephen Hesford: Is it a done deal, or is there a way back, or should we move on?

  Professor Glendinning: I think certainly the experience of the individual budget pilots (and I am sure John would reinforce this) the processes of developing different ways of allocating resources, different ways of agreeing with people what they might use those resources for and accounting for them, the issues about risk and safeguarding that are related to it, and there are some very big issues as well around service commissioning that we have not touched on—I think the changes that are involved in all of those things would make it very difficult to go back because I think it is a total transformation. It is a transformation in culture and in operating systems throughout adult social care.

  Mr Waters: Can I take a quick opportunity to add to what Caroline has said in terms of clarifying the issues in terms of a resource allocation system. Quite clearly, it was the work around the resource allocation system. It caused a lot of folk to realise some of the differentials across different social care groups; it was not the innate cause of those. The system had been operating and older people had got, on average, significantly less than other groups, but it was not the shift towards personalisation or personal budgets that caused that, that was already part of the system, and I think our work has demonstrated some very practical and simple solutions to some of these key problems and a much greater focus on outcomes around a fair deal. Added into that a capacity to begin to begin to define how much support is it reasonable to draw from those people around you, from your family; how do you define that? There were some very practical problems that needed to be solved to move on. In terms of the funding integration, a lot of the difficulties and issues there were very predictable and were predicted. A colleague of mine, Simon Duffy, and I prepared a paper predicting some of these difficulties and there were attempts to solve or to ask local people to solve problems that should have been solved centrally. Where there needed to be an alignment around the means-testing arrangements or the charging arrangements, the restrictions, these were set in statute or in trust deeds that quite clearly needed to be removed and flexibility given to local authorities and to local people. So these things were predictable. They are not massively complicated. You can quite clearly say, if you begin to set out a way of measuring need, if you begin to set out what a fair deal looks like, if you begin to set out some clear outcomes for people, they can then bring on and draw from their own resources and their own creativity. If you help people plan and focus, not just on the money, we begin to see some better outcomes, and a lot of the feedback that I have when I talk to folk nationally is the emphasis often is in the wrong place around personal budgets and ignoring that actually it takes a lot of effort and a lot of time to sit down with somebody and figure out a decent plan that will work for them and their life. The focus often goes on to how we manage the budget, and that is only part of a bigger system.

  Professor Beresford: I would like to get back to some basics because I think it is very helpful. I think there has been a problem with this debate more generally in that there has been a tendency to focus on means, not ends. There has been an enormous focus on individual budgets and personal budgets, and we know that they offer good things and they also have serious and continuing problems. I think what we need to remember is that if there is not enough money in the system, as there does not seem to be (and, do not forget, what you get is ultimately bound by your role and your place in the eligibility criteria system) it means that what it is, apart from being top-sliced for its own administration, is points for prizes, as people call it, which ultimately is a rationing system, and what distinguished the newness of the idea of direct payments was that there was an independent criterion, which was how would this make it possible to live your life independently, and I do not think that is strongly there. I think the issue was never that moving to cash should simply be a financial transaction. We know that the group of people who do that routinely—self-funders—is the group most vulnerable, often unnecessarily, to institutionalisation, to moving into residential services. It was intended as a shift in power, and I think a lot needs to be in place, not least some of those things which have been talked about by Caroline: the idea of a system of infrastructural support, advice, guidance, of local organisations of service users, neither of which is truly in place, both of which have financial implications.

  Q784  Dr Taylor: This is your cue, Caroline, to come back on the older people and why they do feel so much less comfortable. Is it just because they are not confident, they do not get the advice and the guidance that has been said, and what can be done about it?

  Professor Glendinning: I will come back to that, but what I want to do, first of all, is to spell out that you can use personal budgets in different ways, and I think this is important to my part of the answer. In a personal budget you do not necessarily have to take the cash option. A personal budget: you can hand it back to your care manager and say, "Please commission the purchase of services on my behalf." You can give it to a service provider and, in a sense, call off packages of care as and when you need them. You could ask a third party, a carer or a trust to manage it for you. Those deployment options are very important because what all the research on direct payments has shown is that older people are not necessarily comfortable with the cash and being an employer, and I think that is an important issue. Certainly looking at the individual budget pilots and the evaluation and the evidence from that, older people were often very frail by the time they became eligible for social care, perhaps had fluctuating and deteriorating health problems, even if they were already receiving services, as Peter said. You have picked up the issue of the relationship with the people who provide your care, and, I think, certainly with the individual budget pilots, some older people may have experienced the pilot as a threat to that stability and the trusted relationship—it did not have to be, but that is how they perceived it—and, of course, they received lower level of resources, the bulk of their personal individual budgets were used for personal care because that was an absolute priority, and they had less scope within the resources they were given for those more creative things, using the money for social activities and improving other areas of their lives. This picks up the question about service commissioning because, for older people in particular, they may well want to hand the budget back to the local authority to say, "Please purchase services on my behalf", and what some local authorities are now beginning to do is to commission, for example, home care services with a greater degree of flexibility, and I think it is absolutely vitally important that older people who want the care manager to manage their personal budget, nevertheless, have opportunities for choice and control, because the contract with the provider allows some flexibility—for example half an hour a week that is unallocated and the older person can say, "Okay, I would like to go shopping this week. Next week I would like to go to the garden centre"—that kind of choice—but that involves changes in commissioning practices as well.

  Professor Beresford: One of my other roles is to be a trustee of the newly established National Skills Academy for Social Care, which has a role in trying to advance the quality of practice and provision in social care. One of the strands of work that we have been undertaking since we were set up has been around personal employers and personal assistants, and we commissioned some research, and what is interesting is the very low level of knowledge and understanding that there is across all user groups about having a personal assistant and also personal assistants not knowing a great deal about it themselves, often being quite isolated. I think there is a broader issue here. If you have had a life as a service user, or if you enter as an older person needing social care, where was the guidance, the tutelage, to be a very active person in the relationship? Historically, you have been expected to do what you were told, take the service that was offered, and, suddenly, we are saying the opposite to people. People need support to get to the starting point to be able to make choices and decide what they want. I think that helps explain what Caroline is saying. Older people are not one homogeneous group, they are incredibly diverse. There will be some older people, as some people of working age, who really would not want to do it—either take on a personal assistant or not have the money—but there might be many more that would. In Hampshire, where they carried out a national commission on personalisation, but they have got one pilot site where they have been taking forward the insights they gained from their activities around personalisation, they have told me that they have actually had a higher number of older people opting to go on personal budgets than of other age groups, but I think they put in place strong systems of support, and that is the bottom line of everything that I have got to say. If you want all this to work, you have got to help people be able to do it, and I say that speaking as someone who used mental health services for 12 years and I look back and I think: when this started to happen to me all the obvious things that you do to do the right thing to cope go out the window. When you have difficult times, when there is a crisis, if your condition is bad or gets worse, you do not know all the right things to do; you need lots of help to do it.

  Q785  Dr Taylor: One of your big criticisms is lack of training and instruction and how to access and decide upon the services?

  Professor Beresford: It is not a criticism; it is a statement of one of the essentials we need to have in place to make this transformation really work. People need to have help—whether they are someone with learning difficulties or an older person—and we cannot assume that the family can do it. Lots of people are old and do not have that family, some people are isolated, some people do not want to turn to their family. There needs to be some option of exterior support. One of the recommendations of the Hampshire Commission was that there did need to be this infrastructure of information, advice, advocacy and support for it to work well.

  Q786  Dr Taylor: Caroline, turning to the Netherlands, I think it was the Netherlands, you say, where people can employ their own family. With personal budgets, if you take a cash option in this country, why could you not employ your family?

  Professor Glendinning: At the moment you are not usually able to employ a close co-resident relative. That is the current regulation. Obviously, exceptions may be made for people, for example, in very rural areas where there is nobody else, but it particularly prevents older people paying a spouse. I think we need to bear in mind that as the population as a whole ages, carers age as well, and there are increasing numbers of elderly spouse carers. So that is probably the main restriction. Having said that, it is not the answer for everybody. Certainly I have come across anecdotes where real problems have arisen through the employment of family members. So it is not an answer for everybody, but it does seem to be popular with older people in the Netherlands. Having said that, one other big difference is that for carers who are employed above a certain number of hours per week in the Netherlands, that employment has to be properly regulated and it has to comply with minimum labour regulations about contracts, terms of employment, holiday pay, sick pay—all of those kinds of contractual things. I have not come across anybody who has objected to it. Older people do say, "It is strange having this contract with my wife", but I have not come across any evidence that it is a problem.

  Q787  Dr Taylor: I think that is great. Should it be one of our recommendations that there is flexibility for the use of personal budgets? If it is right for a certain person to employ their spouse, they should be able to do that?

  Professor Glendinning: I think that could be a useful recommendation, so it is about being more flexible in who you can employ and how you can use the personal budget, but I do want to emphasis the other options as well—giving your budget over to the care manager who can purchase a flexible range of services on your behalf, giving the money to a service provider and calling off packages as and when you need them—and local authorities are beginning to work with their local service providers to support the providers in delivering these more flexible options, and I think that is essential as well.

  Q788  Mr Syms: Should people have the right to choose not to choose and just keep the services they have got if they are happy with them?

  Professor Glendinning: I will say very quickly that at the Social Policy Research Unit we are doing a major study into how people experience and respond to choice over time. It is very clear that different people want different choices about different things. Choice may be very important in relation to housing options but much less important in relation to health treatment. I think it is a very individual choice.

  Professor Beresford: I have noticed that government does talk a lot about choice, service users talk a lot about control, and they are different, and there are tensions. For example, in relation to day services (and I can speak particularly in relation to mental health service users) mental health service users are seriously concerned about the disinvestment/closure of day services. There have been day services, day centres for mental health service users and people with learning difficulties that have not been good, which have just been, as it were, waiting rooms, but what they can be (and some are) is places where people can feel safe, have relationships, get support and have a springboard to other things. If you talk to mental health service users—I have heard this so many times—people say, "It is not often safe outside. If I behave in a way or am seen to be different or weird, people may not be nice to me. I like to be somewhere where it is not like that. I would love to go to a café, but it is £2 for a cappuccino. I would like to go somewhere where I can feel reassured." The worry is, of course—and I think Caroline referred to this—how do you sustain two different systems at the same time, but the bottom line is, if we are talking about personalisation, we must be offering the kind of choice that is implied in your comment.

  Q789  Mr Syms: Should day services for a centre be ringfenced?

  Professor Beresford: I do not see how you can ringfence one service and not another. I think, assuming, in simplistic terms, that the move now has to be to pushing people into employment and disinvesting from services that seek to enable people to have a chance for that and for other things is crude and does not recognise the complexity of mental health issues, the capacity for people to be able to move on but the needs that some have at any time to be somewhere safe.

  Mr Waters: It is important to recognise that choice operates at both ends and that just by identifying a particular service model to say, well, if some folk choose to take their personal budget and spend it on other things that will destabilise what is there and, effectively, not be a choice for some of the existing service users—that is very much an issue that needs to be borne in mind by commissioners. Equally, though, the opposite is true. I have managed many, many services over many years and known that the large numbers of people who go there, given a genuine choice, would not be there and have, with increasing choice, seen people vote with their feet. You need to say that this is a double-edged element and it is not a simple thing. Clearly, there are some things that you would say should be ring-fenced. You do want an infrastructure—and those would be the things that Peter and Caroline have talked about—and you need to make sure that there are good advice, support, planning and advocacy systems available to people.

  Professor Beresford: User-controlled services, user-controlled organisations.

  Mr Waters: There is an infrastructure that works for a new system that enables people to make informed choices and to take control, and those would be the sorts of areas that you would say that, if you want to protect something—the protection of vulnerable adults—you would need to have a system in place to see that there is an independent, most probably, local authority led body that takes that forward. You would not want to let that disappear. So there are clearly things in the system where you would say a helpful infrastructure is helpful. When you start getting into direct service provision, you need to bear in mind that choice is not an all or nothing for the folk who end up in systems. If the local authority has pre-purchased a bed in a home, they are going to use that and somebody is going to end up in there, so if that is committed, then that person's choices are restricted.

  Q790  Mr Syms: Do you think it would be practical for individual service users to collectively commission services, whether it is a day centre or a dance class? Do you think that would be practical or do you think that would be local authority led?

  Mr Waters: There are examples in the traditional system for many years where local families of people with learning disabilities potentially will have gathered together and set up a service. There is nothing to say that that cannot happen. There are some pilots under way exploring this issue more formally, in terms of personal budgets, with a housing association piloting some work in this area, but it is fairly early in terms of the idea of personal budgets and collaboration.

  Professor Beresford: Coming from the other end, for at least 20 years there have been efforts by service user organisations to establish collective services run by service users, and a major piece of research by the National Centre for Independent Living and the Centre for Disability Studies at Leeds University reported an evaluation of that and those services were particularly valued. What worries me, though, is that we have a Government, and I am sure an Opposition, which is committed to a plurality of supply, yet we know that so far enough attention has not been given to supporting service users and their organisations to establish the kinds of different and valued services that they have been able to initiate but not develop far enough.

  Professor Glendinning: I just want to add a reminder that older people are the biggest group of social care service users and reiterate my earlier point that people, by the time they become eligible for social care, are often fairly frail, may well have health problems, and the notion of organising your own services is, I think, not always realistic, nor should it be assumed that carers will do that for them.

  Q791  Mr Scott: It seems widely acknowledged that brokerage, advocacy and advice are an essential part of putting people's own care packages together. Who do you think should provide it and how should it be paid for? Could I perhaps start with John?

  Mr Waters: In terms of the total transformation that we have been talking about, there is clearly an issue. Large sums of money go on the transaction of the system already, and one of the dangers is that if you suddenly invent a new profession of brokerage, you end up saying, "Well, how do we fund that?" and you take money out of the hands of disabled and older people. Clearly, in terms of funding, one constraint will be you do not want to add to the transaction costs here. In terms of the idea of brokerage, we found it very helpful to think of it as a series of tasks and functions that need to be carried out rather than a role that any one individual can carry out and, also, to make the systems as straightforward as possible. Often it serves people's interests to create an industry around brokerage. There is a danger that you could make the whole process so complicated and planning so difficult: "That is something that I can do and needs to be paid for". One of the things in terms of opening out control needs to be where people themselves or their family members want to help people sit down and figure out, "How do I use a personal budget to achieve the outcomes that I want to in my life?" that there are systems there in terms of information and there are things there that people can draw on and can use. Rather than thinking of brokerage as something that has to be done by paid professionals, there are questions to be asked around how do we make the whole process as easy to navigate as possible, and then, when people themselves (and we see lots of examples of this) have sat down and developed a support plan, they often think, "I want to help somebody else", and the idea of peer support and enabling people and organisations to support each other around some of these aspects of brokerage.

  Professor Beresford: I would want to add to that. I think that John is right to caution us against the over-professionalisation of the role of service broker, but if we go back to comments that have come from several of us, being able to make meaningful choices, being able to give informed consent can be very difficult when you have no track record and experience of doing that in relation perhaps to a crisis, a changed circumstance in your life and the need to turn to social care. I would refer people to the work that has been undertaken by the National Development Team for Inclusion, who have given a lot of very careful thought to the role of service brokerage, for example; and I think what they and I would agree with is that we need to have service brokers who are not over-professionalised but who are skilled and qualified—we need some form of qualification—and who are independent, and that needs to be accommodated in costings. One of the points that they have made is that the management of such independent service brokers should very much be including people who come from service user perspectives and service user organisations. I think that would offer a real corrective to over-professionalisation, but, whatever we call it, people will need some kind of help in getting the best out of new arrangements for choice and control.

  Professor Glendinning: I would add two points to that. First, I think it is important not just to think about the initial sets of choices around services but it is about ongoing support, ongoing support as your condition changes. As your needs change, you may want to make changes in the services and kinds of support arrangements that you have. So I think people need ongoing support; it is not just that initial thing. The second point is your point about the expertise that brokers have. I think that achieving good professional brokerage or advice services requires financial stability, and I think it does require investment by local authorities.

  Q792  Dr Taylor: Peter in "What Service Users Want"[1] you say that direct payments should not be "framed in narrow consumerist terms of individualised purchase of care." You are just getting at the flexibility that we need with that, are you not?

  Professor Beresford: Partly, but I think we need to accept that having help when things are difficult to be able to live your life under what may be changed circumstances is not the same as buying a fridge or going on holiday. It really is not. Of course when you do go on holiday and you do buy a fridge, there are set up quite a few systems and organisations to safeguard and protect you. The whole crux of this is about enabling empowerment in a meaningful way, so that you could take back control over your life. One of the wonderful things about good social care, whether we are talking about people at end of life or when they have sustained through onset of impairment, mental or physical, some major change, is the way that it can enable people to make the very most of their life and have a positive life, and that is not, again, like buying a fridge or buying a holiday. You need help, you need support, as well as the flexibility you have just mentioned.

  Q793  Dr Taylor: But empowerment is vital.

  Professor Beresford: In a meaningful way, yes.

  Q794  Dr Taylor: Steve Cohen wrote an article in Community Care magazine: "Personal budgets remove choice. " What do you make of that?

  Professor Beresford: I wonder where Steve Cohen is coming from. I think the Government is getting it right. The Government started off with a bit of a preoccupation with means, and now, because it is talking much more not only about individual personal budgets but about personalisation, it is talking about goals and desired ends, and that is what it has to be. It is a weird word "personalisation." As I heard someone say the other day, it has taken us until the 21st century for social care to realise it is about human beings and enabling it to be in accordance with their unique rights and needs, but the truth of the matter is that we do have the potential for more change if we see this as a whole spectrum—Caroline has emphasised that—of different ways that you can get what will work best for you to maintain your unique aims in your life but your shared rights in our society.

  Q795  Dr Taylor: And goals and ends are the crucial, important things.

  Professor Beresford: Get the goals right, get the outcomes in your head, and let us spend a little less time just looking at technicalities.

  Q796  Stephen Hesford: Should the Vetting and Barring system apply to personal assistants? Should PAs be regulated? If they should, how would it work?

  Mr Waters: As Peter says, if you are taking control, you are making decisions in your life, there is a range of systems, are there not, that we can put in place to regulate the service we are getting? The key thing here would be in terms of access to that information and how you make it feasible that an individual who chooses to invite somebody into their life—because effectively that is what you are doing when you are acquiring a personal assistant—has appropriate and ready access to relevant information. It is a relevant safeguard.

  Professor Beresford: I was interested in the comments that I think Caroline made about the Dutch experience, about making sure that there are in place the usual sorts of control and regulatory arrangements that there would be for any kind of employment. I know that service users have big qualms, and have long had, about simplistic assumptions that regulating and registering of personal assistants will sort it all out. They worry that it will be registered and regulated in accordance with old-style approaches to supporting people rather than regulated and registered in accordance with what they want out of personal assistants. But something sticks in my mind from being a member of the Commission in Hampshire: one service user who gave evidence, who also supported many other people in relation to PAs, said, "I have to say the fact that someone has been CRB checked and had all sorts of other kinds of formal acknowledgement never convinces me and has never worked. What really works for me is my gut feeling about them as a human being." We are talking about very complicated judgments here. If we make sure that we have an occupation that is better understood, better valued and better rewarded, we are more likely to get a better quality of person doing it and then we might want to review, in association with service users, what kind of regulation and what kind of registration.

  Q797  Stephen Hesford: You are arguing, in some ways, for a sort of free-for-all kind of anarchy, because there would be potentially no control over people's exercise of whim. It would all be down to some personal whim of a user, and the system on each and every occasion would have to respond to that and would have no defence to it. That seems to be to be the logic of what you are saying, Peter. We have heard about councils running banks of PAs and having lists of preferred providers for people with personal budgets. Logically, from what you say, that would be just rubbish, because people's gut reaction could completely cut across that, even if it was some kind of attempt to make the system work.

  Professor Beresford: When it comes down to who we would want to have involved in our life, undertaking personal and intimate tasks, it will be down to the most sensitive kinds of choice, and I am not suggesting that. I have heard people say who use personal assistants that they are concerned about systems of regulation and registration giving people a false sense of security. I also know of service user organisations who operate and support direct payment schemes which have developed the equivalent of banks of PAs because there can be problems when people are having holidays or people get ill. You need more systemic arrangements which we do not have yet. We are at early days still for personal assistants. It is a massively expanding occupation. We need to put in place—and I think the National Skills Academy is doing work just along those lines—standards for quality, principles for practice. One of the really good things about the work that the Skills Academy is doing is that it is concerning itself with both the concerns and interests of the employer (the individual service user) and the employee. It is no good—and I think it would fall into the trap you are highlighting—to be concerned only with the rights of one. There must be rights for personal assistants, just as there must be right for personal employers, but we are not there yet. That is the point. Just thinking that if you have people on a list, if you have some sort of GSCC registration, people are saying that is not going to be enough.

  Professor Glendinning: We also need to think that personal assistants are only a part of the social care workforce even under personalisation. There are still, and will continue to be, very large numbers of care workers who work for agencies as well. We have to be careful that we do not concentrate on the personal assistant end and allow some of the provider agencies to become destabilised. They are having to respond to very different kinds of market situations, and some people will prefer an agency because they will see that as offering greater protection than being an individual employer. We also need to think about the other areas, ways in which people seek and obtain social care support.

  Mr Waters: Very practically, that range of options can increase choice. As Peter says, if you take the role as an employer directly, you have responsibilities. This is not all about rights; it is about responsibilities and you are tied into that. As an employer, if you choose to draw your support from an agency, then you have potentially greater flexibility in saying, "We didn't quite get on, I would like my support from another person, please," so that keeps that choice open. In terms of the idea of preferred provider lists, an interesting question arises, to which I think Peter was alluding, in terms of saying, "Whose preferences are these?" in the measures that local authority commissioners use to assess the quality of those providers and how we listen to the experiences and voices of people who need support in that process and then share that out appropriately. One of the areas of innovation that we are taking forward with a number of local authorities is exploring a form of eBay for social care, where there is a reporting system where people can vend a rate and people can draw down and offer comments back. A range of options here give different levels of choice to people, but at the end of the day we really need to figure how we listen to people and how we share that information and make use of some of the developments in technology that open up those opportunities to us.

  Q798  Charlotte Atkins: Thank you very much for that. That ends the session. Thank you very much for coming along. It has been a very interesting session this morning. Thank you very much for helping us with our inquiry.


1   Guardian, 23 March 2005 Back


 
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