Social Work History Network with Making Research Count
8 June 2009
“The Kent Community Care Project, mid-90’s care-managed care
and the new world of Personal Budget models”
Some notes on the paper given by Bleddyn Davies on care management and the
Transforming Social Care circular (Department of Health, 17 January 2008)
In the late 1980’s Bleddyn Davies, then at the Personal Social Services Research Unit
at the University of Kent at Canterbury, led a team studying the introduction of a care
management approach to the delivery of adult services by Kent Social Services
Department. This preceded the more general adoption by local authorities of care
management systems and separation of purchaser and provider functions under the
1990 NHS and Community Care Act. His paper compared this care management
approach with the personalisation approach in the more recent Transforming Social
Care circular. The following are among the points he made in a densely argued paper.
The introduction of care management required the construction of a political
consensus which in turn required a convincing political narrative (Services must
respond to individual assessed need, and if this is to be achieved, provider self-interest
must be overcome.) The Transforming Social Care circular similarly attempted to
build a consensus via a simple political narrative which uses three key concepts:
‘Personal Budget’ (a sum of money allocated to the individual service user which
could either be handed over as a direct payment or retained as an individual budget
or partly one and partly the other);
‘Personalisation’; and
‘User Control’.
The assertion was that personal budgets combined with user control will produce
personalisation of services and will maximise service users’ welfare.
This narrative was similar to the earlier care management guidance (e.g. “Instead of
users and carers being subordinate to the wishes of service providers … users and
carers will be enabled to exercise the same power as consumers of other services”),
but the process proposed was different. The biggest difference lay in the greater
priority given in the 2008 circular to user control.
The Kent Community Care Project should be seen in the context of experience of
delivering services in Social Services Departments. The Seebohm Report had
focussed on the bringing together of personal social services in one department
without considering the processes within that department by which services would be
delivered and welfare enhanced. Nicholas Stacey, Kent’s Director of Social Services,
had wanted to introduce a voucher scheme for service users, but there was no
statutory authority for this, and devolved budgeting was therefore introduced instead.
Initially care managers were appointed for only a minority of service users, but it was
intended that a care management approach would nevertheless be universal. The next
Kent Director, Norman Warner, changed the system to one with care managers for all.
This was in the context of government commitment to the idea of the enabling
authority, which fragmented provision. Kent’s budget devolution to care managers
was, however, supported by the White Paper which preceded the NHS and
Community Care Act and by the Audit Commission, and also by the Social Service
Inspectorate, although the SSI saw difficulties ahead and talked of transition periods.
The nature and performance of care management nationwide during the 1990s
suffered because devices to ensure achievement were weak, with little investment in
training for fieldworkers and managers (and what was provided was largely focussed
on procedures), and also because of massive distractions, including preoccupation
with moving to a mixed economy of care, pressure to hold down expenditure and
growth in demand, including that caused by diversion of provision from the NHS to
the personal social services.
It did not, however, follow that the system needed radical revision as implied by the
“Transforming Social Care” 2008 Circular. To demonstrate such a need would
involve showing that:
1. Older citizens value increased control more highly than other service benefits;
2. The post-1989 reforms did not substantially enhance users’ control;
3. Those reforms did not contribute to the support of carers and/or to their sense of
influence over care plans;
4. What the reforms produced fitted worse with users’ wishes and interests than
would maximising users’ sense of being in control.
The available research did not support these propositions.
In conclusion, it seemed that some apparently new models for service provision are
more like their predecessors than their proponents believe. One should not approach
proposed reforms as if they and what has gone before are necessarily rivals. Different
approaches should be mixed, and matched to their contexts with the aid of evidence as
to what works in which situations. And simple ideas, while important for constructing
a winning political narrative, should not be allowed to distort the more complex
policy and practice discussion which will always be necessary.
KWB
19.08.09