Personalised public services could revolutionise welfare

If self-directed support can simplify social care, could it be used as a new organising principle for the whole welfare state?

Alan has learning disabilities and “challenging behaviour”. He’s in an expensive private-sector care home miles away from where he lives, and wants to come home to be near his mum. Jane was sexually abused as child, has a drugs problem and is coming out of prison. She wants to be reunited with her children. Dave is disabled and trying to get by on a low income. He receives support from social services, the housing department, the NHS, social security and the job centre. Every day he’s confused by what he owes in tax and charges, what he receives in benefits and tax credits and who provides what.

Although these people are all different, they have five things in common. First, their needs are complex and the current system struggles to provide a joined-up response. The result is a mass of gaps and duplication and a system no one understands. Second, these services all cost a fortune and don’t often produce very good results. Third, they all want to make a go of their lives – but the system only focuses on what they can’t do. Fourth, they’re meant to feel grateful for the support they receive – even though they’re fully entitled to it. Above all, each of them use services based on a 1940s “professional gift” model. Under this system, people pay tax to the government, who distributes it to local welfare organisations, who use it to deliver services on our behalf. The task for front-line workers is essentially to slot people into the services they know they already have on the shelf. However, this 1940s model is now creaking at the seams – we can’t afford it, it is frequently self-defeating and it doesn’t fit the way we live other aspects of our lives. Add in the current economic situation and something has to give.

Faced with these dilemmas, various governments have talked about concepts such as “partnership”, “involvement”, “localism”, a “third way” and a “Big Society”. Strip this away, though, and the response has often boiled down to greater “choice” and use of market mechanisms – in social care, in schools, in healthcare. But choice without control doesn’t always feel very meaningful, and the “choice” policies of various governments often don’t look that different. Although it sounds like heresy to say it, the key danger even now may be that the current economic situation may not actually be quite bad enough to force a fundamental rethink. Instead we could end up carrying on with more of the same (just with less money), rather than recognising that it was “more of the same” that got us here in the first place.

Ironically, there are parallels with events in the 1940s when the welfare state was established. Then it was the second world war that had caused the crisis; now it’s the economic situation. Then as now, the country was nearly bankrupt, there was a coalition government and there were far-reaching decisions to be made about the future of welfare services. Arguably the key difference is that, with the 1942 Beveridge report, we had a plan of what to do – of how the future could and should be different from the past. In the runup to the emergency budget and the forthcoming spending review, current issues seem equally fundamental – but it’s less clear whether there is the same vision to guide us this time.

Somewhat unusually, the answer may lie in adult social care. Here, local people and workers have developed a system of self-directed support and personal budgets – putting people more in control of the funding that supports their services. By framing this as an entitlement and by being clear about the money upfront, this has unleashed the creativity of people using services, their families and frontline staff – with more innovative use of scarce resources and better outcomes for either the same, or sometimes less, money.

At the heart of this agenda is the notion of people not as passive recipients of pre-purchased services nor or of “consumers” taking their “custom” elsewhere – but of citizens, helping to co-design their own support and their own solutions. It’s hardly surprising, but the evidence suggests that helping people make the decisions that affect them can really work, and that people with the biggest interest in getting all they can from every pound tend to spend the money well. So far this approach is being rolled out throughout adult social care, and is now being piloted in children’s services and in healthcare. However, to really achieve a Beveridge report for the 21st century we need to do much more – if these approaches seem to work in adult social care, then could this form a new organising principle for the welfare state more generally?

If a personal budget may be a good way of helping someone come out of a mental-health hospital, then could it be a good way of helping someone leave prison and reintegrate into society? If it helps disabled people make desired changes in their lives then could it help to support people with substance misuse problems, the victims of domestic violence or people trapped in prostitution? If self-directed support can simplify social care and allocate equal resource to equal needs, then couldn’t it help to do the same for the tax and the benefits system?

In future, the world might be different if Alan, Jane, Dave and others like them could get a single assessment of their needs, have a single person to support them (if they need it) and know upfront how much money they are entitled to when trying to get their needs met. We may find a way of getting Alan home, helping Jane sort out her life and helping Dave work out how much he has to manage his life as best he can. If we did that we’d get better outcomes for less money – and that seems worth striving for right now.