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Let's get personal
25 October 2010
Three years on from the birth of the public sector
personalisation agenda, and six months prior to the local authority
target of having 30% of social care users on personal budgets, it
is clear that there are many unanswered questions and obstacles for
private providers of health and social care services adapting to
the increased autonomy of service users and the widening choice of
potential providers available to them.
What is personalisation?
Personalisation allows service users to shape their local
services according to their needs and priorities, giving them
greater choice and control over their care. The idea is not new and
variations have been trialled from as far back as the 1980s,
however, it was the “Putting People First” agenda, published by the
Department of Health in conjunction with six Government
departments, the Local Government Association, the Association of
Directors of Adult Services, representatives of independent sector
providers and the Commission for Social Care Inspection (now the
Care Quality Commission) amongst others, in 2007, which placed
personalisation firmly at the heart of the delivery of health and
social care services.
“Putting People First” built on the conclusions of the
consultation White Paper, “Our health, our care, our say: a new
direction for community services” which confirmed that the public
wanted services which were accessible, and made provision for a
range of needs with a focus on enabling independence.
Since then, the direction has been clear: the transformation of
health and social care services involves all organisations working
across traditional boundaries to make personalisation the
‘cornerstone’ of the services offered.
Personal budgets for social care users have been implemented
gradually throughout the local authorities that are required to get
30% of their users onto such personal budgets by April 2011.
However, Lord Darzi’s ‘Next Stage Review’ (2008) indicated the
Department of Health’s intention to pilot personal health budgets,
which were subsequently introduced in 2009, and will be trialled
until 2012.
The implementation of personal budgets for health and social
care service users represents a massive change for private sector
providers in the way that they have traditionally done business.
Their introduction fundamentally impacts on the manner in which
these services are commissioned and paid for. Seemingly, service
users will be able to access the marketplace for services that they
require, with choice being at the heart of that process.
The pilots have required local authorities and NHS organisations
to adapt their services and operations to accommodate their
respective pilots; however, it is the separation of these two
organisations, as a result of the separate pilots, which has posed
the most significant obstacles. It is inevitable that a significant
proportion of service users require a combined package of health
and social care with the result being that providers must be able
to flex their own service provision, not only to secure combined
packages of care, but also to manage the inherent tension between
meeting the needs and expectations of service users – it is after
all their ‘personal budget’ – whilst recognising the need for
commissioners to manage down cost. How this tension will be played
out in the current economic climate remains to be seen.
This trend reflects a policy imperative – the inevitable
integration of health and social care for individuals in receipt of
community services so that they receive a co-ordinated, tailored
package whilst at the same time reducing duplication and
administrative and back office costs. Competition for these
services will be multi-layered – private provider, social
enterprise, to mixed provider models incorporating council and
community health provider arms. Equally, combined packages raise a
number of issues which potential providers of these services should
be aware of.
Important considerations for providers
The first obstacle relates to payments, a combined care package
means that a provider will potentially need to seek payment from
two organisations. It is more cost effective for the relevant NHS
organisation and local authority to appoint a lead commissioner to
act on behalf of the other party in order to ensure coordinated and
regular payments without one party being temporarily out of pocket
or making payments late. However, the historic separation of these
services would require the two organisations to develop
synchronised financial frameworks which cover budget setting,
governance, financial planning, financial timetables and risk share
and these are often prohibitive factors.
Added to this, is the difference in basic funding principles and
the difficulties in reconciling financial systems which acknowledge
the fact that NHS services are free at the point of use, whereas
social care is often the subject of charges. Providers must ensure
that there is clarity as to which organisation is responsible for
which services so that the risks of any later disputes, either with
the service user or the local authority or NHS organisation, are
avoided.
Giving service users control over the services they receive
poses further problems in terms of who the provider is then
accountable to in terms of regulation and reporting. Whilst the
service user is effectively the commissioner, it is unlikely they
will have the requisite skill and knowledge to be able to do this
themselves. Even where the service user appoints an advocate to
represent them in any decisions regarding their care package, there
must be a central record check to ensure that where there are any
issues such as poor quality of service or performance and/or a
failure to respond to reported issues; these are addressed,
monitored and recorded so that local authorities and NHS
organisations remain accountable and transparent for the
personalisation agenda. Effective co-ordination from the centre
will also assist providers in establishing effective relationships
with all of the contracting parties and enable any risks to be
appropriately balanced and managed between the same.
With an increased emphasis on providers being able to identify
and demonstrate specific outcomes for services being delivered, the
same problem applies when trying to determine who should be
responsible for monitoring outcomes. The NHS White Paper announced
that the coalition Government would be developing a national NHS
outcomes framework to set consistent outcome indicators but, as the
consultation has only recently closed, it is as yet unclear how the
policy of personalisation will fit with “transparency in
outcomes”.
When the outcome is deemed poor, it is even more unclear as to
who should be able to take action. NHS organisations and local
authorities are best placed to manage underperformance but the
level of involvement which they are required to enter into with the
service user is unclear, and this is an issue which providers
should seek to resolve at the initial stages in order to ensure
that there are effective lines of communication prior to any issues
arising as this will enable all parties to address any
underperformance issues together and will also grant the provider
greater certainty as to the likely implications in this event.
What next?
The pilots have been allocated funding and set targets to get a
certain amount of service users onto self-directed support. Future
funding will no doubt be dependent on satisfaction of these targets
and, as the pilots come to an end, 2011/12 will undoubtedly be a
key year.
The issues raised by combined health and social care packages in
particular demonstrate that there is much more work to be done
before the future form of the personalisation agenda can be
finalised. However, this means that there are plenty of
opportunities to get involved and the most important thing for
providers to note is that personal budgets are not yet set in
stone. For the more innovative providers there is huge scope to
play a significant role in shaping the policy regarding personal
budgets going forward. It presents an opportunity to the emerging
provider marketplace to shape its provider structure so that it is
best placed to be responsive to the personalised needs of the
service users, whilst demonstrating value for money for
commissioners going forward.
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