Why care needs to go way beyond personal budgets

Tough financial times and increasing demographic pressures call for innovation and transformation in social care – and personal budgets may not be part of that mix, writes NLGN’s Daria Kuznetsova

The quality and sustainability of social care provision is going to be largely dependent on the way these services will be commissioned.

Although there is a common conception that the social care challenge is confined to the elderly, services for people with learning disabilities account for more than 23 per cent of the adult social care budget and face rapidly rising demand. As social care is becoming more ‘consumerised’ – with an increasing number of purchasers and providers – a new approach to commissioning will be needed.

New NLGN research, produced in collaboration with the Adults with Learning Disabilities Services Forum (ALDS) and Learning Disability Coalition (LDC), explores how commissioning practices must develop – so that they achieve more with less – to protect the interests of people with learning disabilities.

As personal budgets dominate the headlines as the panacea of social care provision, there is justifiable concern within the social care sector that personal budgets are being rolled out too fast, and that the 2013 target could have unintended consequences, both in terms of cost and quality. New NLGN analysis shows that from 2001/02 to 2009/10, each new direct payment added an average of £17,000 to the cost of caring for someone with a learning disability. Similar inflationary pressures help to explain why the Netherlands – once a pioneer of “Cash for Care” – is now dramatically scaling back their availability.

This does not mean personal budgets should not be rolled out but points to potential inefficiencies in a switch to a micro-commissioning model alongside a traditional commissioning model. The rush to sign up service users up to personal budgets without ensuring the readiness of the market to accompany them is a real danger for the 2013 goal of 100 per cent personal budgets. This raises an important question: if personal budgets are not, on their own, the solution, then what is?

New ways to maintain quality provision and widely available services with tight budgets will therefore need to be found. This would need a broader shift in the way commissioning is done. The first priority is for commissioners to make a decisive shift away from managing outputs and instead develop new metrics and commissioning approaches based on outcomes. This will drive a focus on value for money, rather than simply cost, and it will help commissioners identify the most effective forms of intervention for those with learning disabilities. At the moment areas with higher social care spend per user are not accompanied by increased quality of life reported by users, raising doubts about the cost effectiveness of current service provision.

While outcome measurement is complex, the social care sector has started designing and implementing sophisticated mechanisms for integrating this approach into the delivery of individual services. The challenge is to create a standardised system of outcome measurement and value for money assessment that can be used to compare different services and support commissioners in deciding where to invest their limited resources. A promising tool for achieving such a system is the Adult Social Care Outcomes Toolkit (ASCOT) developed by Personal Social Services Research Unit (PSSRU). The outcomes toolkit allows for a comparison of a Social Care Related Quality of Life (SCRQoL) along a person’s care pathway and across different services. Benchmarking investments against outcomes will help shift resource allocation towards services achieving greater well-being improvements with less resource.

To achieve value for money, commissioners will need to be involved in developing a competitive market of service providers delivering against improved outcome measures. By maintaining or improving quality, councils will be better positioned to contain costs. In developing a vibrant and mixed market, a commissioner’s role is to correct the information gap that occurs. The current market will need clear projections of future demand and publicised plans to address any gaps through market development. Secondly encouraging transparency in cost and quality will ensure that services are directly accountable to users as consumers of provider services.

Sophisticated systems for outcome measurement could also give way to a number of commissioning strategies such as payment by results and social impact bonds within the social care sector. Although it is often stated that payment by results excludes smaller providers from entering the market, a similar approach to the Work Choice Program (70 per cent of fees paid without strings and 30 per cent of fees paid on achievement of outcomes) could be adopted.

Tough financial times and increasing demographic pressures call for innovation and transformation – which needs to go beyond personal budgets. This is the right time for commissioners to move away from purchasing set services for users to working with users and providers in creating an environment in which a range of services can be developed to meet the needs of people with learning disabilities and achieve improved outcomes.