1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and the Department for Communities and Local Government. We also took evidence from four representatives of the adult social care sector: the Executive Chairman of the National Care Association which represents provider organisations; the interim Group Head of Public Affairs of the charity Scope; the Corporate Director of Adult Social Care, Health and Public Protection, Nottingham County Council; and the Programme Director Community and Partnerships, NHS Bristol Clinical Commissioning Group.
2.The Department is responsible for setting national policy and the legal framework for adult social care. Social care comprises personal care and practical support for adults who cannot perform the activities of typical daily living, and support for their carers. Social care paid for by English local authorities makes up a minority of the total amount of care; most care is provided unpaid by family and friends (informal care), while many adults pay for some or all of their formal care. The overall need for social care is rising as people live longer with long-term and complex health conditions. Through the Care Act 2014, the Department aims to reduce adults’ reliance on formal care, to promote their independence and wellbeing, and give them more control over their own care and support.
3.Local authorities started to personalise the commissioning of community care services in the 1990s through giving adults with physical disabilities ‘direct payments’: money to buy their own care services. In 2007, the government introduced the broader concept of a ‘personal budget’: a sum of money allocated to an adult to meet their assessed social care needs, which can be given to the user as a direct payment or managed on behalf of the user by the local authority or a third party. The Care Act embedded personalisation into the legal framework for social care. It mandated adults’ involvement in planning their care, and required local authorities to give all eligible users a personal budget.
4.At the time of our evidence session, the Care Act requirement for all users to receive a personal budget had been in place for one year. Available data from 2014–15 show a broad spread in the level of take-up of personal budgets and direct payments across local authorities, reflecting differences in the priority that authorities have historically given to personalised commissioning. Data on the impact of personal budgets show that they benefit most users who receive them. The proportion of users who report that they are satisfied with their social care has remained high at around 90% of users.
5.We heard from the representatives of the care sector that giving users more choice and control over how they meet their care needs can involve them trying out different and untested ways to meet those needs. People with care needs should be supported to live as independently as possible but, as is the case for everyone, that can involve taking risks. We heard that personal budgets, and direct payments in particular, work very well for younger adults with disabilities who are keen to live full and independent lives, and have the capacity to take control of their lives. When users choose to have more control over the way they live, and try out new ways to meet their care needs, they must be adequately supported to do so and helped to manage any risks. Local authorities and care providers cannot be risk averse if personalisation is to take hold and lead to benefits and improved quality of life for users.
6.We were pleased to hear that there is no evidence to date that the increase in take-up of personal budgets has coincided with an increase in safeguarding incidents. However, more vulnerable users, and those who lack mental capacity, will find it more difficult to take control of their care. They are less likely to be able to make the good decisions on their own about how best to meet their care needs. When assessing users’ needs and planning their care, local authorities and providers, in conjunction with the user and their family, should be satisfied that the form of personal budget is appropriate to the user’s circumstances. Direct payments will not be appropriate for all users; for some users, a personal budget will need to be managed on their behalf. For all users, the care assessment and planning process should be used to identify any risks and plan how to manage and mitigate those risks.
7.Users with direct payments generally use them to employ personal assistants. They therefore need support to be an employer, to manage aspects such as salaries, pensions, sick pay and even the possibility of having to take disciplinary action against their employees. We heard that without support to do this, some users are reluctant to take on the responsibilities of a direct payment. In 2012, Skills for Care, the body funded by the Department of Health to provide practical tools and support to help develop the adult social care workforce, published good practice guidance for people employing personal assistants. Skills for Care conducted research in 2014 that found that not all local authorities are providing adequate support to users who employ personal assistants.
8.In 2013–14, local authorities reported a wide range in the proportions of users who were receiving personal budgets. At the lowest end, one authority reported that only 10% of long-term community care users had a personal budget, while at the other end, 12 authorities reported that 100% had a personal budget. The Department told us it did not necessarily believe that such values were true reflections of the proportions of users who were genuinely able to exercise choice and control over their care. The Department believes that authorities that report 100% may have simply gone through an administrative process to move users onto personal budgets, while authorities that report low values may have been more rigorous in reporting the proportions of users with genuine choice and control over their care. Choice and control can also be limited by local authorities’ responses to financial pressures.
9.The Department told us that research shows that direct payments (where the personal budget is given to the user for them to buy their own care) and individual service funds (where the personal budget is managed by a provider or other third party, allowing users to vary their care according to their needs) lead to a higher quality experience for appropriate users. The Department told us it wants to understand whether users are realising the benefits from receiving their personal budgets in these particular ways. The NAO reported that in 2013–14, only 4% of users received an individual service fund.
10.We heard from the representatives of the care sector that personal budgets have transformed the lives of many users for the better. Eighty percent of 4,000 users responding to a survey in 2014 reported that personal budgets made a significant difference to the quality of their care and the quality of their lives. Research by the charity Scope found that the mechanism of a personal budget was the biggest factor enabling users to have more choice and control over their care services. We heard that England is ahead of the rest of the world in personalising social care for users. However, the Department’s monitoring regime does not enable it to understand how personal budgets improve outcomes. The Department confirmed that it is starting to make better use of existing data on outcomes for users, and informed us of six relevant studies carried out by the National Institute for Health Research, but accepts that there is a need for deeper research into how the different ways in which users can receive personal budgets lead to improved outcomes.
11.We heard how two existing surveys of users—the Adult Social Care Outcomes Framework survey, and the POET survey—could usefully be enhanced to ask users more granular questions about how they spend their personal budgets and the impact on their quality of life. From that, the Department could derive more information on what works and what does not work for users. The NAO suggested that the POET survey could be improved by increasing the number of local authorities that take part, and more consistency in their participation over time. We heard from the sector representatives that more research and evidence of what works would be very welcome.
2 , paras 1–2
5 , paras 8, 9
14 , para 3.18
15 ; , para 1.22
16 , para 18, 2.19; see also Part 2 of this report.
17 ; , para 1.2
18 para 3.10
21 para 11
22 ; Department of Health
2 June 2016