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A new system for personal budgets

David Roe responds to Colin Slasberg’s Straight Talk feature from CMM June and argues that the approach to personal budget formulation needs to change significantly, to support personalisation, and to meet the new agenda to deliver and sustain better outcomes and well-being cost-effectively and dynamically.

In the light of the Care Act 2014, there is an urgent requirement for a new national system for personal budgets to be designed and introduced, as soon as possible. The challenge is to come up with an approach which promotes empowerment of the individual, to make their own support choices, whilst recognising that commissioner cash budgets are very limited and need to be spent optimally, over the medium term. From the research Colin refers to, it is clear that up-front allocations have not worked, as they do not take account of personal circumstances and goals, so always need to be personalised, and often substantially altered.

Individualised and flexible

Every situation can be different, so there is no substitute for developing personal budgets on an individualised, flexible basis. The imperatives to do this are increasing, in order to:

  1. Fully take into account the varying support resources every individual already has at their disposal, or could further draw on, including carer/family, friends and community support; this is partly dependent on living arrangements and home location accessibility; all options need to be considered, to make support as cost-effective as possible, whilst ensuring that the burden placed on personal carers is not excessive.
  2. Take account of the specific risks facing the individual, in their living environment, bearing in mind their support needs and resources, including their capabilities, behavioural challenges, possible loneliness and social isolation.
  3. Consider the need to invest in the individual’s support (rather than assuming continuing dependency), either to prevent needs escalating, or to help develop capabilities which can then lead to lower support needs for the future (building on existing personal ‘assets’/capabilities, given clear evidence of the payback, both for the individual and commissioner, against a background where most commissioners still admit to not investing for the future).
  4. Allow individuals to make their own decisions about the optimal combination of support resources they utilise at different levels of cost, between professional support from registered providers, where their specialist experience is key, throughto lower cost personal assistants, expenses for attendance at educational and activity centres, to free support from family and friends, and in the community.
  5. Revise budgets frequently and dynamically, to take account of variations in capabilities, needs, risks, support resource availability, as well as current/increasing levels of cost needing to be paid for.
  6. Respond to the ramifications of more widespread use of outcomes-based commissioning. None of this should undermine the opportunity for individuals to have their own personal budgets and to plan their own support. On the contrary, abandoning the entirely wasteful activity of preparing up-front budget allocations should remove a barrier to personalisation, and free up some commissioner/care manager resources to assist more directly in personal budget formulation and review.

Commissioner information support and choice for the individual

Commissioners/care managers will need to provide the information role envisaged in the new Care Act, by furnishing individuals with details of good quality providers, outlining their relative costs, and quality ratings, so that individuals can then exercise choice based on personal preferences and value for money. As part of this, it will be incumbent on commissioners to ascertain the true costs of care with providers, per hour of support.

Individuals should be able to make their own choice of support resources, although this may need to be from a list of those meeting minimum quality and guaranteed support level criteria. Commissioners will still need to be accountable for ensuring that limited financial resources are deployed wisely to meet agreed needs, so will need to monitor progress against goals and approve revisions, working in more effective partnership with individuals
and providers.

A standard personal budget formulation model

It is hoped that there will be improvement and standardisation in needs assessment approaches, including to focus more on prevention and investment. In conjunction with this, a standard framework can quite readily be developed to translate needs into levels of support required, in hours per day or week, and preferred associated resource support to be assigned, somewhat more systematically and consistently than currently. This can then, in turn, be used to apply relevant costs per hour, so that individuals can prepare their own proposed personal budget, with assistance as needed.

It is suggested that this be developed for each common area of support in turn, as relevant to each individual (ie personal care, domestic support, social activity support, education, work etc.), and then aggregated, adding in proposed expense costs to produce the total budget. Such a consistent analysis framework for support costs could be applied right across social care, and complemented with accommodation costs and living expenses for residential care settings, thereby facilitating support level and cost comparisons for similar levels of need, supported in different settings (eg to compare personal care costs at home or in a nursing home).

There has been much talk in recent years about the need to move away from talking about hours of support required, enabling individuals with personal budgets to spend the money allocated entirely as they wish. However, this misses the essential point that it is still necessary to use the hours-based approach as the best, only reliable way to calculate the level of personal budget required, coupled with expense estimates.

This approach has the added benefit (compared to existing resource allocation points systems) that the extent of free carer/family and other resource inputs are quantified, and can then be reviewed to ensure that these are not excessive. Changes in levels of support, resource mix and costs can all readily be made, flexibly, and the budget revised simply. Costing models are already available and in use which can probably be modified to achieve this by area.

It might be argued that the need to analyse support needs by area will prove too onerous, although it is already being done in home-based care, and through the care funding calculator, for learning disabilities. The suggested approach would not require anywhere near such detailed analysis, but can, nevertheless, be tested for practicability and refined, using tailored costing models. The benefits likely to be gained, in ensuring that all areas of need are addressed holistically, to ensure that all-round well-being is promoted, as well as in being able to compare different areas of outcome directly with relevant resource inputs, could be significant.

Making progress

It is widely recognised that social care budgets are currently insufficient to meet all eligible needs but at least the new system could address the needs better, and more flexibly, enabling personalisation to proceed as planned, whilst meeting commissioner aims to promote the ‘more for less’ agenda, where progress can be made now.

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