Can personalisation be a reality for frail older
people?
John Woolham
Can personalisation be a reality for frail older people?
Structure
• Definition of terms
• Context of personalisation and personal budgets
• What evidence do we have about the impact of personal
budgets on the lives of older people
• Conclusions and challenges
Can personalisation be a reality for frail older people?
Definition of terms
Personalisation: nuanced definitions?
‘Personalisation means thinking about care and support services in an entirely
different way. This means starting with the person as an individual with
strengths, preferences and aspirations and putting them at the centre of the
process of identifying their needs and making choices about how and when
they are supported to live their lives’.
Carr (2011) p. 3.
‘Individuals not institutions take control of their care. Personal budgets,
preferably as direct payments are provided to all eligible people. Information
about care and support is available for all local people, regardless of whether
or not they fund their own care’
DH Vision for Social Care Nov. 2011 p. 8.
Can personalisation be a reality for frail older people?
Definition of terms
• Personalisation: an elusive policy aspiration over last quarter
of a century
–
–
–
–
–
–
Disability rights in USA
Case /Care Management
Social model of disability
Valuing people
Personhood & Kitwood’s work
Core social work values
• If personalisation is the ends, SDS, DP,PB, & IB are the means.
Can personalisation be a reality for frail older people?
Context
• Personal budgets & SDS another means of achieving:
o
o
o
o
o
personalisation
empowerment & control
Citizenship
choice
Also claimed it will save a lot of money
• Evidence base growing but key policy decisions e.g. Transformation
Grant (2008) were made without the benefit of much evidence
• Not just social care: now being introduced within the NHS for long
term conditions.
Can personalisation be a reality for frail older people?
Advocates of personal budgets
• Demos/Leadbeater
o
o
o
o
Critique of public services as disempowering and inefficient
Personal budgets a way of empowering and enfranchising people Choice and consumer control
Saving the public purse
• In Control: Waters, Duffy, Poll.
o
o
A coherent programme for change in social services through SDS and PB – emerged
from successful use of personal budgets for adults with learning disabilities
Highly influential amongst policy makers and in local government
Can personalisation be a reality for frail older people?
Critics and dissenters
• Clarke (2006, 2008)
–
–
choice not always a good thing
Proper role of public services isn’t necessarily about delivering choice
• Ferguson (2007)
–
transfer of responsibility/risk from state to individual
• Beresford (2009)
–
proper funding is a precondition for success.
• Barnes (2011)
–
‘‘Careandprotection’ is the booby prize if people can’t exercise ‘choiceandcontrol’’.
Can personalisation be a reality for frail older people?
Early evidence
• Local authority case studies e.g.
o
o
o
http://www.in-control.org.uk/resources/research-and-evaluation/your-support,-your-wayrichmond.aspx
http://www.incontrol.org.uk/media/3196/this%20time%20its%20personal%20northamptonshire.pdf
http://www.in-control.org.uk/media/3190/steering%20my%20own%20course%20report.pdf
• In Control evaluations (x3)
o
o
o
First two studies arguably more influential than deserved
Evangelists for SDS and personal budgets?
Model based on successful work with younger adults with learning disabilities
• Small numbers, no specific focus of impact on older
people.
Can personalisation be a reality for frail older people?
Later evidence
• IBSEN (2008)
o
o
o
the best study to date
Suggested negative impact of IB on older people
Speculated that this was because managing a budget caused stress
Can personalisation be a reality for frail older people?
Later evidence
• DH: Making personal budgets work for older people
o
o
o
o
Picked up on qualitative evidence from IBSEN that older people didn’t want the
additional burden of managing a personal budget
2008 guidance – upbeat reflections on what older people interviewed in IBSEN said
they wanted
Case study and anecdotal material from staff (not older people!) about ‘best
practice’ – e.g. Changing staff attitudes, developing flexible and individual solutions,
providing more choice over services and support and how money is managed.
2010 guidance – success criteria for personal budgets for older people – evidence
coming from local authorities seen to be ‘pathfinders’
• Newbronner et.al. Keeping personal budgets personal (SCIE 2011)
o
Qualitative study of best practice in implementing personal budgets – based on views
of older people and people with mental health problems. Reported on suggestions
older people were ‘steered away’ from getting their budget as a Direct Payment.
Can personalisation be a reality for frail older people?
Evidence from own research
• Design
• methods
• objectives (satisfaction, impact & outcomes)
Can personalisation be a reality for frail older people?
Evidence from own research: key findings
• Budget holders overall were more likely than traditional service users
to report improvements in
•
o
Their personal health,
o
feelings of personal safety inside and outside their home,
o
the level of control they had over their support,
o
the extent to which they felt they were treated with dignity,
o
their social life (they were more likely to say it had improved),
o
overall levels of satisfaction with services and support
But for older people, the story was not so positive....
Can personalisation be a reality for frail older people?
Evidence from own research: key findings
•Budget holders
received more
money than
traditional
service package
users (44% more
overall).
•Differences were
much greater for
some care
groups: (111% for
older people).
Care group
Older people
Learning disabilities
Mental health
Younger adults with physical
disabilities/sensory impairments
ALL
Mean package costs by care group
Mean package costs (£ p.w.)
‘traditional’
SDS users
service users
113.86 (n= 80) 243.41 (n= 53)
337.30 (n= 96) 412.06 (n= 59)
116.57 (n=
4) 383.51 (n= 4)
202.59 (n= 91) 298.84 (n= 61)
222.85 (n= 271) 321.90 (n=177)
Can personalisation be a reality for frail older people?
Evidence from own research: key findings
Older people
Health has got better
More safe at home
More safe when out
More control over support
Social life has got better
Treated with more dignity
Trad
7 (7%)
30 (29%)
8 (8%)
20 (21%)
9 (9%)
39 (39%)
SDS
3 (6%)
19 (35%)
8 (16%)
16 (31%)
5 (10%)
22 (42%)
Other care groups
<65 yrs
Trad
25 (9%)
70 (26%)
46 (18%)
68 (26%)
80 (30%)
102 (40%)
SDS
24 (19%)
57 (45%)
52 (41%)
88 (70%)
79 (63%)
60 48%)
Margin of
difference
(%)
65+
<65
-1%
10%
6%
19%
8%
23%
10%
44%
1%
33%
3%
8%
The difference between ‘traditional’ and budget holder groups was
slight amongst older people, and large amongst people aged under 65
years
Can personalisation be a reality for frail older people?
Evidence from own research: key findings
Bootstrapping was
used to plot
cost/benefit data on
a quadrant graph.
Data above the
horizontal line =
worse than average.
Data to the right of
the vertical line =
more expensive than
average.
Low cost, poor
outcome
High cost, poor
outcome
BAD
Low cost, good
outcome
GOOD
High cost, good
outcome
Can personalisation be a reality for frail older people?
Evidence from own research: comparing costs & benefits for younger and
older people: budget holders only
ADL and GHQ scales
were used to assess
outcomes.
Younger budget
holders (on left)
had better
outcomes than
older people (right)
on both ADL and
GHQ scales.
Costs were also
greater
People using personal budgets only: cost benefit for younger adults (left) and
older people (right) using ADL outcome scores.
People using personal budgets only: cost benefit for younger adults (left hand
graph) and older people (right hand graph) using GHQ outcome scores
Can personalisation be a reality for frail older people?
Evidence from own research: comparing costs & benefits budget holders
with ‘traditional’ package users: older people only:
IBSEN found no
benefit for older
people.
My study suggests
limited benefit
but greater cost.
ADL and cost scores for older respondents 65+ comparing bootstrapped
data for ‘traditional’ package users (left) and budget holders (right).
GHQ and cost scores for older respondents (65+ only) comparing
bootstrapped data for traditional package users (left) and budget holders
(right).
Can personalisation be a reality for frail older people?
What do these findings tell us about the use of personal budgets
for older people?
• Budget holders were more likely to report improvements in health,
feelings of personal safety, control over their support, being treated
with dignity that their social life had improved, and less likely to be
experiencing mental distress.
But
• Impact was differential – younger adults had better outcomes on the
measures used. For older people differences between traditional
service users and budget holders were much less marked.
Can personalisation be a reality for frail older people?
What do these findings tell us about the use of personal budgets
for older people?
• Costs were much greater for budget holders:
o
o
If budget holder costs were equivalent to ‘traditional’ packages, would
this lead to poorer outcomes for budget holders?
If costs of ‘traditional’ packages were increased commensurately with
budget holder costs, would this lead to better outcomes for ‘traditional’
package users?
Can personalisation be a reality for frail older people?
Summing up
•
•
•
•
•
•
Current evidence is mixed.
Larger quantitative studies suggest older people fare less well as
budget holders but aren’t clear why.
Smaller qualitative studies have focused on what needs to be done
to make budgets work for older people but findings are less reliable.
More spending power didn’t make much difference to outcome in my
study
Stress and levels of responsibility can probably be reduced with
support (Newbronner et.al)
Additional support will cost money. Local authorities are cutting
personal budgets because of the government’s austerity strategy
Can personalisation be a reality for frail older people?
The Community Care/Unison survey 2011
•
•
•
•
83% said cuts to adult care budgets in their areas would impede the operation
of personal budgets.
48% thought that personal budgets were not of sufficient value to help users
meet their needs.
33% said resources had been the greatest barrier in making progress with
implementing personalisation.
44% said people were generally buying the same kinds of support under
personal budgets as under traditionally commissioned packages of care.
ADASS has also reported that only 1/3 get a budget as a direct payment –
for others it’s managed on their behalf by the SSD. Where it’s managed
it may not always be ‘transformative’.
Can personalisation be a reality for frail older people?
Does the ‘model’ work for older people?
•
What it means to be a citizen – and rights, roles and responsibilities
may be different at age 85 to 35:
‘There is a risk that people in later life are being squeezed into a ‘one-size-fits-all’
model of personalisation designed with and for younger people with physical and or
learning disabilities’
‘In discussion of personal budgets, much has been made of the way in which control
over the resources available for their care enhances the ‘citizenship’ of disabled
people. But for older people, achieving full citizenship is not the ‘aim’ in the same way
that it may be for many younger disabled people. Most older people have already
experienced citizenship in the form of an active role in family, work and community
life: it is not an unrealised aspiration’.
Orellana 2010.
Can personalisation be a reality for frail older people?
Three challenges
• Are there better ways of achieving personalised services for some
people than offering personal budgets?
• If everyone has to have a personal budget, how can it be spent in
ways that lead to the personalisation of care and support: if it’s
managed by someone else does this always mean it’s less
personalised?
• Are the costs of providing some groups with the level of support they
are likely to need anywhere close to being realised?
Can personalisation be a reality for frail older people?
Selected references
Beresford, P., (2009) Whose Personalisation? Compass Think Piece No. 47.
Carr, S. (2011) Personalisation: A Rough Guide (2011) SCIE., London.
Carr, S. (2007) Choice, Control & Individual Budgets: Emerging themes (2007) SCIE., London
Clarke, J., Smith, N., & Vidler,E., (2006) The Indeterminacy of Choice: Political, Policy and Organisational Implications Social Policy &
Society 5.3. p 327-336 CUP.
Clarke, J., Newman, J. & Westmarland, L., (2008) The Antagonisms of Choice: New Labour and the Reform of Public Services Social
Policy & Society (7) p 245-253 CUP
Glendinning C., et. al (2008) IBSEN Evaluation of the Individual Budgets Pilot Programme SPRU, University of York.
Hatton, C., Waters, J. et al. (2008) A Report on In Control’s Second Phase Evaluation and Learning 2005-07 (2008) In Control
Publications, London.
Newbronner, E., et.al. (2011) Keeping personal budgets personal: learning from the experiences of older people, people with mental
health problems and their carers Adult Services Report 40. SCIE,
Orellana, K., (2010) Personalisation in practice: lessons from experience Making personal budgets, support Planning. Age UK, London.
and brokerage work for people in later life
Poll, C., Duffy, S., et al A report on In Control’s First Phase 2003-05 (2006) In Control Publications, London.
Woolham, J., & Benton, C., (2012) The Costs and Benefits of Personal Budgets for Older People: Evidence from a Single Local Authority
British Journal of Social Work Advance Access published July 20, 1–20 doi:10.1093/bjsw/bcs086.