Personalisation of adult social care – do we have to decide between choice or quality?

Martin Stevens, Research Fellow at the Social Care Workforce Research Unit at King’s, discusses personalisation and the risks associated with an exaggerated concentration on choice in the context of adult social care.

Personalisation of adult social care (and other publicly funded services) is still an important goal of government policy and local practice. The claims about the benefits of personalisation are well known—choice and control produces better outcomes and is achieved primarily through an up-front allocation of resources to individuals to make decisions about what to purchase and from whom. ‘Think Local Act Personal’ is a sector partnership of voluntary and statutory organisations, which offers advice and information to councils and professionals in implementing personalisation and is a leading proponent of personalisation, particularly in relation to personal budgets.

The roots of personalisation lie in two strands of philosophical and political thought. First is a view that markets are the best way (if not the only way) of providing services. Second is an emancipatory perspective that identified professionally organised services as oppressive and restrictive, leading to a campaign for greater control. This was led by young disabled people.

John Clarke and his colleagues (2008) have raised three concerns over the value of emphasising choice in this context. First, they argued that focusing on increasing choice favours those with the best ability to exercise it (or with the most supportive networks), thus increasing inequality. Second, they maintained that a focus on choice ignores the complexities of power relationships and fails to recognise the public interest in decisions about public services, such as social care. Findings from the IBSEN study (evaluating the pilot individual budget sites) also supported this critique (see Stevens et al. 2011). While there has been great emphasis on increasing choice of provider within a market, this has possibly been at the expense of exploring the best ways to support people to exercise choice and control over their lives. Similarly, less attention has been paid to ensuring the quality of the support provided. Some commentators have therefore questioned the extent to which personalised funding should be the sole means of arranging services, arguing for the need for maintaining some collective provision (see Needham 2012).

This is not to argue against choice, but to caution against the adoption of choice as a goal in itself, separate from other aims of improving outcomes. It can be argued that personalisation policy has become focused on the means of choosing services, and how money is spent, rather than the kinds of support that is valued, although Think Local Act Personal has produced some guidance for people using direct payments to employ personal assistants.

The financial recession has led to several years of public sector spending restraint, which has coincided with a strengthening political will towards marketisation. This has become a dominant driver of personalisation. It has exacerbated the emphasis of choice over quality. In practice terms, this presents difficulties for social workers and others working to support people making choices about the use of public money allocated for their support, as there are fewer ‘levers’ to pull in terms of ensuring quality of service and outcomes. Where abuse is suspected, a safeguarding team can investigate and attempt to improve the quality of support if necessary, but this is a safety net approach. It is interesting that two recent evaluations have not emphasised the value of choice in contributing to outcomes, but have highlighted the importance of quality of support (these evaluations were launched at a joint King’s College London and Ipsos MORI event on 25 September (Personalised support services for disabled people: What can we learn?).

Great emphasis has also been placed on the support that disabled people and carers may need to use direct payments. User-led organisations can provide this support and are valued where this happens—see Think Local Act Personal’s guidance document: Best practice in direct payments support – a guide for commissioners. However, there is also a case to be made for professional support for this kind of decision making. Good relationships with individual disabled or older people may be one way of ensuring the availability of advice about the best kinds of support and how to assess the quality of care. Similarly, engagement with organisations of disabled or older people may help to identify concerns and lead to policy and practice questions being addressed. While this support does not necessarily need to be provided by social workers, their value as people trained in understanding the significance of major psycho-social decisions and (hopefully) a good knowledge of the different kinds of support, should not be dismissed.

Dr Stevens is Research Fellow at the Social Care Workforce Research Unit at King’s College London. Recent work includes the Jobs First Evaluation (launched at the 25 September event mentioned in this post). Current work includes Models of safeguarding: a study comparing specialist and non-specialist safeguarding teams for adults.

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Clarke, J., Newman, J. and Westmarland, L. (2008) The antagonisms of choice: New Labour and the reform of public services, Social Policy and Society, 7: 2, 245–53.

Needham, C. (2013) Personalized commissioning, public spaces: the limits of the market in English social care services, BMC Health Services Research 13 (Suppl 1): S5 9 pages.

Stevens, M., Glendinning, C., Jacobs, S., Moran, N., Challis, D., Manthorpe, J., Fernández, J-L., Jones, K., Knapp, M., Netten, A., Wilberforce, M. (2011) Assessing the role of increasing choice in English social care services, Journal of Social Policy. 40(2), 257–274.