Personalisation and older people – better outcomes?

John Woolham is Senior Research Fellow at the Social Care Workforce Research Unit, King’s College London. (455 words)

On Friday 14 September I met with a small international delegation of Occupational Therapists who work in two hospitals in Hong Kong: Pamela Youde Nethersole Eastern Hospital, an Acute District General Hospital, and Kowloon Hospital, a slightly smaller institution which offers general care to people who have chronic health conditions. They were accompanied by Denise Forte, who works as a senior lecturer in gerontology at Kingston University and who had organised the itinerary of the group. I had been invited to talk to them about two topics about which they were keen to know more: personalisation for older people in England, and the role of social workers and social services in supporting older people. Though the group was small, which enabled the seminar to be very informal, I did prepare some slides which I used where necessary.

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Personalisation: towards evidence that counts

Dr Martin StevensMartin Stevens is Senior Research Fellow at the Social Care Workforce Research Unit at King’s. (811 words)

Personalisation has been a dominant theme in social care policy for 25 years and has also been a strong theme for the Social Care Workforce Research Unit. In addition to our involvement in the Evaluation of the Individual Budgets pilots in 2008 (Glendinning et al 2008), the Unit has completed studies on Risk, Safeguarding and Personal Budgets; personalised employment support: Jobs First; and, on Personal Assistants and Personal Budgets. The Unit has published extensively on this topic, which has also been identified as a context in many other studies. Continue reading

Personal budgets in Finland

John WoolhamJohn Woolham is Senior Research Fellow at the Social Care Workforce Research Unit in the Policy Institute at King’s. He recently returned from a trip to Helsinki where he discussed the English experience of implementing personal budgets. (1,141 words)

On 31 May of this year, the Social Care Workforce Research Unit at King’s was asked to organise a seminar on the topic of Personal Budgets and Direct Payments for a group of social care practitioners, project managers, academics and civil servants from Finland. They were over here on a ‘fact-finding’ mission. The Finnish Government is proposing to introduce a form of Personal Budgets and Direct Payments in their social care and welfare services, and the group were here to find out what they could about how they had been, and were being, implemented in England. This was a very rapid tour round the landscape. In two hours, Professor Jill Manthorpe, Dr Martin Stevens, Dr Nicole Steils and I told them about the impact of personalisation, personal budgets and direct payments on social care providers, unpaid carers and older people as well as a rapid overview of the research evidence and key issues. Surviving half-baked but well-meaning attempts by me to add Finnish subtitles to my own slides using ‘Google translate’—just don’t, OK?—we even managed to squeeze in a short discussion with questions and answers. Amazingly, after such an intense burst of information sharing, we got some extremely interesting and thoughtful questions. Although Finland was, and remains, at an early stage in the process of transforming part of its welfare services, it was clear that a great deal of thinking was being devoted to how to do this smoothly, and without the ideological rigidity that has characterised some debates around the topic in this country. Continue reading

Risk, Safeguarding and Personal Budgets: exploring relationships and identifying good practice

Martin StevensDr Martin Stevens is Senior Research Fellow at the Social Care Workforce Research Unit in the Policy Institute at King’s. (900 words)

Published today are our findings from this timely NIHR-SSCR funded study, which aimed to provide evidence about the impact of using different forms of Personal Budgets on risks of abuse, to explore practice responses to the increased emphasis on using Personal Budgets and the experiences of Personal Budget holders who had been the subject of a safeguarding referral (suspected abuse or neglect). This collaborative research (undertaken by researchers from King’s, the University of York and Coventry University) was driven by our awareness of contradictory perceptions held by practitioners and other researchers. We had heard views that people on Direct Payments (one main form of Personal Budgets) were more at risk of abuse than other social care users, but on the other hand that the increased control offered by Direct Payments was a protective factor. In order to provide some evidence to address these contradictions, we re-analysed national and local data on safeguarding referrals and take-up of the different forms of Personal Budget. Continue reading

Is a Personal Budget right for you?

Sarah Hamilton, Research Manager at The McPin Foundation, introduces new guides available for practitioners, service users and families getting to grips with Personal Budgets and Direct Payments for people with severe mental illness.

The transformation of social care services and the shift towards personalisation over the last few years has presented many, well discussed challenges for local authorities, social care professionals and service users and their families. In mental health, however, there are specific challenges that need to be addressed. Take up of personal budgets in mental health lags behind other disability groups. In 2012-13, 8.6% of people with mental health problems received self-directed support compared to 27.3% of people with a physical disability and 28.4% of people with a learning disability (HSCIC, 2013).

Is a Personal Budget right for youOur three year research project explored the challenges of introducing personal budgets for severe mental illness in four local authorities. We identified barriers to implementing personalisation that meant that some areas were still struggling to offer personal budgets at all. Chief among these is the difficulty posed by the integration of health and social care, such that personal budgets became the responsibility of both – or sometimes seemingly of neither (Larsen et al, 2013).

Where personal budgets are available, however, other difficulties arise in practice. In the PEOPLE Study we interviewed over 50 people who received, or were applying for, a personal budget to support their mental health, as well as care co-ordinators and families. We found, even among these service users, that there was little awareness of personal budgets, what they are for and how they can be used. The shifting policies and budget cuts of local authorities made it hard for practitioners and service users to get to grips with what was possible. Among many practitioners, patience with these problems had already run out, and we heard how many no longer saw any value in starting a process that was liable to disappoint.

Despite the challenges, however, we also saw how personal budgets and direct payments, when used creatively, could transform lives and give people the determination and the control to manage their lives in the way they wanted. The learning from this research showed how the experience of getting and using personal budgets could be improved, and how practitioners, service users and families can, between them, secure the type of support that makes the biggest difference.

Reaching goals and moving onFrom this research we have produced a series of guides for people with a mental illness, their families, and mental health staff. The guides tell it as it was for the people who shared their stories with us. They point out challenges and offer solutions, and provide examples of what can change for people when it works. They include recorded stories using people’s own words to describe what getting a personal budget was like for them. The guides are freely available to download, use and distribute from Rethink Mental Illness.


The research project which led to the guides was delivered in a partnership between The McPin Foundation and Rethink Mental Illness, with support from Jill Manthorpe of the Social Care Workforce Research Unit (SCWRU), King’s College London, and Jerry Tew of the University of Birmingham. It was funded by the Big Lottery.

Sarah Hamilton is based at The McPin Foundation in London. You can contact her on, or visit the Foundation’s website to see more of its work.

@McPinFoundation | @Rethink_ | @scwru


Adult Social Care Statistics team, Health & Social Care Information Centre, Measures from the Adult Social Care Outcomes Framework, England 2012-13, Provisional Release, 10 July, 2013.

Larsen, J., Ainsworth, E., Harrop, C., Patterson, S., Hamilton, S., Szymczynska, P. Tew, J., Manthorpe, J. & Pinfold, V. (2013). Implementing personalisation for people with mental health problems: A comparative case study of four local authorities in England. Journal of Mental Health, 22(2): 174-182.

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.


Are direct payments a form of activation policy?

Martin Stevens

by Martin Stevens

It was Jo Moriarty, a colleague here at SCWRU, who introduced me to the idea of labour activation, pointing out its relevance to Jobs First, the evaluation report of which I am just now drafting.

Is it right to see the Jobs First initiative as a labour activation policy in relation to people with learning disabilities? More than that, might the policy drive toward personalisation bear the imprint of an ‘activation ethos’?

Labour Activation Policies have a long history, at least back to the 16th Century, when those overseeing the poor were involved in ‘sending vagrants to work’ (Patrick, 2012:6). These days, we can talk about four key facets: increasing market involvement in providing services; individualisation or personalisation of response to each individual; integration of different forms of support (e.g. the merging of welfare benefit organisations and Job Centres into Jobcentre Plus); and an uneasy balance between coercion and support. This last is illustrated in the varying degree to which policies support people to get jobs that fit their qualifications and previous experience or apply pressure for people to take any job, to get off welfare benefits.

These topics were the focus of the Workshop on integrated employment and activation policies in a multilevel welfare system, in Milan at the end of August, where Jobs First had its first academic outing. The workshop aimed to explore facets of European Activation Policies, involving academic speakers from across Europe. One message from the Workshop was that some form of labour market activation had been almost universally accepted in Europe. Consequently, there are many kinds of interventions to support or coerce young people and unemployed people to get paid jobs.

Jobs First shares the first three elements of activation: an increased emphasis on using personal budgets to purchase supported employment services from independent sector organisations; an individualistic approach; and increased links between adult social care and Jobcentre Plus. However, there are no directly coercive elements, in relation to loss of benefits. Having said that, some participants referred to the reduction of public spending on support for leisure as creating pressure to get jobs.

Of perhaps wider interest in relation to social care is the application of activation to personalisation. Direct Payments can also be said to share three elements of activation policies. First, they create more reliance on markets and individualisation of service. Second, they put more responsibility on individuals and their families to manage their own support. Third, there are ongoing efforts at integration with health (e.g. the Personal Health Budgets project) or through combining funding streams (as is being trialled in the Right to Control, trailblazer sites). There is no direct analogue for coercion, although the government’s strong preference for direct payments, puts pressure on local agencies to increase their use. The key link is perhaps the focus on individuals to bear responsibility to be active co-producers of welfare. So is this a useful way to think about personalisation?

Patrick, R. (2012) ‘Work as the primary ‘duty’ of the responsible citizen: a critique of this work-centric approach’ People, Place and Policy Online 6(1), 5-15.

Dr Martin Stevens is Research Fellow at the Social Care Workforce Research Unit at King’s College London. With Jess Harris he is currently writing the final report for the evaluation of Jobs First (an initiative encouraging the employment of people with learning disabilities) for the Department of Health.