briefing 5: impact of personal budgets on providers

Briefing paper 5: Impact of Personal Budgets on providers Findings from the third round of a three-year longitudinal study in Essex

September 2012

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Briefing paper 5: Impact of Personal Budgets on providers

Introduction

OPM and ecdp (formerly Essex Coalition of Disabled People) were commissioned by Essex County Council (ECC) in October 2008, at the time of introducing Personal Budgets for adult social care, to conduct a three-year, longitudinal study into the system of Personal Budgets. The study aimed to:

1. Capture the impact of self-managed Personal Budgets on the lives of people who use them, including evidence of how and why impact is being achieved over time;

2. Assess the effectiveness of practices and processes being used by ECC and its partners to support the delivery of Personal Budgets, including evidence of how the market is evolving over the study period.

This is one of a series of briefing papers containing findings from the third round of research with service users, frontline practitioners and providers in Essex. These brief papers have been produced to share key findings with audiences involved in personalising social care, including practitioners, managers, commissioners, service providers and policy makers.

Other papers in this series include:

Briefing paper 1: Positive impacts of Personal Budgets on service users

Briefing paper 2: Factors that enable Personal Budgets to have a positive impact

Briefing paper 3: Ways to improve the impact of Personal Budgets

Briefing paper 4: Family, friends and Personal Budgets


For copies of any of the above or for a copy of the full report, which contains details of our findings, please email Sanah Sheikh at OPM. ([email protected])

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mailto:[email protected]


Key points

Providers have been consistently positive about the introduction of Personal Budgets. Many are able to point examples of where the use of Personal Budgets is leading to positive outcomes and an improved quality of life for service users.

There was a view across provider types that Personal Budgets are adding weight to the concepts of choice and control because they give users greater flexibility to organise care when they need it; more choice over who comes into their home or delivers a service and the ability to create more tailored packages of support.

Personal Budgets are allowing service users to enter into a relationship with providers that are more direct and empowering. They are able to be more critical and discerning about whom they employ and this gives providers a greater incentive to raise the quality and responsiveness of their services and improve the value for money that they offer.

As the number of people using Personal Budgets increases many providers have been focussed on developing new services and tailoring existing ones. This includes providing new niche skills in order to meet the greater diversity of needs and interests; the ability to create more flexible packages of care; and in some instances the development of advice, brokerage and support services for new users coming into the system. There was also some evidence of some providers exploring how they can provide employment support services to freelance carers.

The shift towards Personal Budgets has also required providers to focus on a range of organisational and workforce development issues. This included

– Staff training and development

– New policies and procedures

– Recruiting staff with the right attitudes and values

– The ability of staff to building relationships and to play an enabling and facilitating role

– Marketing and branding

– Tracking insights and market trends

– Back office functions such as invoicing

Providers feel that the Council has an important role to play in supporting a ‘fully functioning market’ and they highlighted a number of priority issues:

– Improving the robustness of safe guarding and monitoring arrangements

– Supporting providers - particularly smaller ones - to develop the necessary skills and capacity to operate in a changing market

– Timely updates from ECC on progress and strategic aims towards implementing Personal Budgets as well as more spaces which support dialogue and collaboration

– Helping to create a more stratified market where providers work together to refer service users to specialist services where appropriate.

– Addressing shortfalls and variation in the skills and capacity of the social care workforce

– The need to assure payments for work delivered as well as considering the need to increases the hourly rates that are when contracting work to providers.

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Overview

In the current round of research, service users included in the sample had been receiving Personal Budgets for just over two years. During this time service providers have experienced a number of changes as they adapt to meet the changing needs of service users as the personalisation and independent living agendas gain traction. In the sections below, we will outline:

Provider support for Personal Budgets

Responding and adapting to the introduction of Personal Budgets

How local council’s can support further market development

Provider support for Personal Budgets

Over the three years providers, both in the private and voluntary and community sector have been consistently positive about the personalisation agenda and the introduction of Personal Budgets in Essex. The majority of providers are able to point to examples of where Personal Budgets are supporting people to make significant improvements to their quality of life and to the level of choice and control they have in their lives.

Providers feel strongly that Personal Budgets are adding weight to the concepts of choice, control and greater independence, because they offer service users:

Flexibility to arrange the care and support when they need it;

Choice over who comes in to their home or delivers a service; and

The ability to create a package of care and support that is more tailored to their needs and that they can scale up or down as their needs change.

As a result of the introduction of Personal Budgets, service users are starting to enter into a much more direct and empowering relationship with providers – as the customer or direct employer they can raise concerns about the quality of a service and are free to take their business elsewhere if they are not satisfied. For this reason the introduction of Personal Budgets was felt to be creating a more competitive market, where costs were being driven down, while the quality and responsiveness of services rises.

“We have eight service users in our unit, they changed from an agency they weren’t happy with and moved to us. As the first one moved over and gave us positive feedback, others decided to migrate too.”

In the current round of the research providers talked about how Personal Budgets were allowing service users to be more creative and strategic in how they use their resources, for example by planning activities and forms of support that are more focused on meeting their well being and psychological needs.

“As a provider we can play a role in encouraging greater independence of service users – helping to them to lever in the range of resources and support sources that could be available in their communities. It’s about adding value to our clients in a more creative way.”

There was a sense that in the best examples, Personal Budgets are supporting a relationship and dynamic between users and care givers that is more outcomes focused and rewarding.

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“People are realising that they can be flexible with their care calls – they may not need two carers at lunch and tea time, this gives them extra time for shopping – to use it more on what they actually need from week to week.”

Responding and adapting to the introduction of Personal Budgets

As greater numbers of Personal Budget users enter the social care market, providers highlighted the importance of responding to changing patterns of demand. As well as developing services and products providers highlighted the range of organisational and workforce changes that are required.

1. Developing services

There were some new initiatives that providers have been motivated to develop in response to the market of service users using Personal Budgets. These included:

New care services - providers talked about how they had updated their services in response to the health and well being agenda and the demands of Personal Budget users. This included a much greater emphasis on preventative services and re-ablement.

“Some people want housework but don’t want it done for them, the service user wants to clean with the carer, that takes more time, some have asked to do - perhaps they’ve had a stroke, they come out of hospital and want to build their skills and independence the Personal Budget allows a big push early on then a slow reduction.”

Providers, particularly those providing domiciliary care also talked about their focus on offering a greater range of ‘niche’ services and support, that wouldn’t normally be included in a managed service. This included nail cutting where there is a huge shortage of supply, as well as accompanying service users on outings and daily trips.

Development of flexible service models - In the current round of the research there were several examples of providers developing service models that could deliver more flexible and tailored packages of support and care. In their efforts to meet a range of user needs, several providers had shifted to a point where they no longer neatly occupied a single category of service provision. For example one provider has developed a one-stop-shop offer which begins with a free assessment that explores a range of options. This could include a combination of telecare, home modifications, information and advocacy as well as domiciliary care.

“We try to be flexible, we’re not a domiciliary service strictly speaking, what we deliver is very much driven by our users. The key decisions are just not about whether we make an AM or PM call.”

Support, brokerage and advocacy – In round 2 several providers, both private and voluntary and community sector, noted that they were in the process of developing employer support and brokerage services for service users on Personal Budgets. For example, they may be supporting service users to learn about payroll and employment law, or supporting them to think in detail about their care needs and aspirations. Voluntary and community sector organisations were also considering the contribution that they could make to service users’ support planning.

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Services to support freelance carers - A domiciliary and residential provider in round 2 was in the process of developing a payroll service for PAs who want to work freelance – the aim being to “take the pain out of being self employed” by allowing people to work flexibly while also being able to provide much needed evidence of income.

2. Recruitment and workforce development

Providers – particularly in the current round of the research - emphasised the way in which the introduction of Personal Budgets was requiring a number of changes to their recruitment and workforce development practices.

Training and development – Staff training and development continues to be vital to maintaining a competitive high quality service as Personal Budget users demand a greater range of services and types of support. This includes training in how to do a range of risk assessments; training related to meeting the needs of particular user groups e.g. Autism or Parkinson’s; the principles of person centred care.

Ethos and values – There appears to be a stronger emphasis in the current round on the fact that delivering quality care is becoming less about delivering a fixed set of traditional social care tasks to an agreed time, and more about working collaboratively with service users to achieve positive outcomes. This requires ‘values based recruitment’ in order to ensure that staff have the appropriate mindset and attitudes required to deliver a personalised service. An example included the need for staff to be prepared to vary their work patterns around service users’ changing needs and routines rather than expecting highly predictable shift patterns.

Building relationships – Providers described a market where it is common for users to expect to have a rapport and some shared interests with care staff, such as sports or cooking. This is requiring providers to take greater care to match service users with staff. Once users have built these more fulfilling relationships they are demanding a greater continuity of care rather than a ‘revolving door of strangers’ coming into their home.

“It doesn’t tend to be price that is most highly valued – it’s about the relationship they have with for example their home support worker and our local officers. So our support workers will do over and above what’s expected.”

An enabling and facilitating role – Alongside delivering traditional personal care tasks, in the current round of the research is appeared to be more common for carers are PAs to play an important role in helping service users to socialise and make connections in their local area and leverage new sources of support.

“A gentlemen client wanted to have a drink and socialise in a local labour club – our member of staff could only accompany him once a week so we ended up using informal support to help that individual… more and more it’s about thinking outside the box, we are limited in what we can provide but we can bring in other forms of support.”

3. Marketing and branding services

Providers across all three rounds of the research emphasised the growing importance of marketing and branding their services in order to build and sustain their business. With increasing numbers of Personal Budget users entering the market the key challenge is to ensure that one’s service is known about and has a good reputation. As the personalisation and the independent living agenda gathers pace particular sectors such as day care and

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residential care emphasised the need to effectively market and reposition their services so that they continue to be appealing and relevant.

Providers emphasised the importance of communicating the value and outcomes they are achieving to external audiences. There was also view that the third sector has had to become increasingly business savvy, and able to demonstrate outcomes to both commissioners and users.

“We’ve stopped saying ‘we do good work’, we’re better at defining what that means, in terms of quantitative and qualitative data.”

Providers of all types emphasised that marketing needs to use a range of channels, including online and paper based campaigns as well as organising events, open days and giving presentations. Providers also talked about the importance of different forms of local marketing and networking with groups and forums and the need to build awareness and reputation through word of mouth.

“The link between the home and their community becomes paramount, in most cases people come from the local area - this is what feeds the home.”

For this reason it was noted staff are increasingly being expected to have good links and knowledge of the areas that they serve so that they can tap into various formal and informal support networks available to their clients and attract new customers.

4. Tracking insights and trends

Alongside marketing, in round 3 of the research there appears to be a greater focus on the need to generate deep insights about the needs of customers and to track trends in demand in order to inform service development.

“For us it was about getting a real sense of people’s expectations, we commissioned research – a series of conduct focus groups – about what is important, what are the frustrations that people are experiencing how can our service challenge the problems and meet these expectation, what appeals to who and what do family members consider?”

It was also emphasised that in the current climate there can be no room for complacency and that providers need to be innovative and ready to revise and reassess what they are doing.

“We are reacting always to what comes are way – we are always trying to evolve our service to meet needs, not necessarily just individual budgets, we always try to evolve the service – if you’re not flexible and adaptable you won’t survive.”

Looking ahead there was a view that providers – particularly those in the third sector – should be making efforts to learn from innovative business practice to ensure that they can deliver responsive, customer focussed and flexible services.

“It’s about innovation and finding out what your customers want. The irony is that if you can find out what customers want and deliver that, you can do that on so many levels, for example, Tesco has a sophisticated way of monitoring what people want and they’ve also diversified what they provide, based on the needs of customers. This is exactly what you can do with Personal Budgets.”

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5. Back office functions

As in round 2 of the research, providers continue to highlight the need to redesign and invest in back office functions so that they can deal with higher volumes of transactions. In some instances the costs associated with these changes has meant that resources have had to be shifted away from the frontline.

Invoicing and credit control – As providers move away from delivering managed services, providers continue to talk about the need to invest and modernise their back office systems so that they have efficient invoicing and credit control systems. Providers also talked about the need to have invoicing systems in place which demonstrate and capture the full range of the services there staff are now delivering.

“We need to be evidencing every bit of support we’re providing so that we can justify the invoice. We have various types of documentation for staff to correctly record everything.”

Risk assessments and insurance and travel policies – Providers cited the need to create new policies and procedures associated with supporting service users to make leisure trips and engage in a wider range of activities.

Better information sharing - A residential care provider in round 2 described changes to their internal documentation – whereby client’s personal budget support plans are now online and will be accessible staff and to service users and can be updated as their needs and goals change.

How local councils can support market development

1. Support to providers

There was a view providers, particular the smaller ones, could benefit from greater support from ECC to help them succeed and adapt to the new market. There were felt to be shortfalls in skills and capacity, (for example e.g. marketing and communications) where ECC could play a valuable role by giving advice and guidance.

2. Communication between ECC and providers

Providers felt that more regular updates and feedback from ECC on their progress and plans relating to Personal Budgets would be helpful. There was a sense that roadshows and newsletters aren’t enough – with providers calling for more opportunities to have face to face meetings and for more of an ongoing dialogue about how the provider market could further support the roll out of Personal Budgets. Providers also welcomed ECC playing a facilitating role with several calling for them to re-introduce regional provider forums.

With the introduction of the Home Support Service contract some providers felt that the partnership relationship with ECC had been lost, and that communication had been reduced to largely online exchanges on ECC’s procurement website.

3. A more stratified market

Providers called for a more stratified market where providers work together – in the interests of service users - to ensure that they are referred to the specialist services that can best meet their needs.

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“The market would work better if it was more stratified – getting away from organisations saying they specialise in this that and the other, when actually they don’t. We would like to see care providers working in partnership – if we have referrals that we know we can’t support we can refer them over to somebody else.”

4. Pricing services and assuring payments

Providers across the rounds of the study had a cluster of financial concerns, such as the fact that the hourly rates used in Personal Budgets are failing to reflect and keep up with the real costs of the market. It was also felt that the system needs to be able to give providers more assurance that service users will have the necessary level of Personal Budget to be able purchase services.

5. Criteria for approving Personal Budgets

For older people in particular, it was felt that cash payments should be used to support much needed opportunities for them to socialise and get “out and about”. However, the concern was that most cash payments were solely addressing care needs, based on the criteria of “critical or substantial need”. Several providers drew attention to the use of “critical or substantial need” as the overarching criteria being used by ECC to approve cash payments. They warned that if this was interpreted “too conservatively” cash payments would fail to achieve what they have set out to do in terms of broader service user well-being.

It was also said to be extremely important that service users – particularly those with a learning disability and older people – have access to effective brokerage and support throughout the process in order to make the most from the funds available to them.

6. Social care workforce development

Finally several respondents drew attention to variability in terms of the time, motivation and knowledge of social workers which were felt to be key factors effecting the size and value of cash payments. Providers called for the importance of ECC creating a fair and equitable process and for the use of clear and consistent criteria when allocating resources. Around this point a respondent pointed out that “…it can be dispiriting for people when a neighbour’s personal budget is inexplicably larger, or is processed much more quickly than one’s own.”

7. Safeguarding and monitoring

As in round 2 of the research, many providers continue to have concerns that Personal Budgets are not monitored in enough depth to properly safeguard users and protect them against fraud. Providers emphasised the need to have stringent checks in place to ensure that staff delivering services have the required levels of training, qualifications and that CRB checks are well enforced.

Without robust arrangements in place providers noted that the negative impacts would be felt by service users, particularly those that are most vulnerable. Providers also noted that there would be a negative impact on reputable providers who might be undercut by competitors who lack their skills, commitment and values. For these reasons providers argued that regular reviews of Personal Budgets should be considered a top priority– as they fulfil a vital safeguarding function, as well as ensuring that the budgets continue to meet service user’s needs

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It is worth noting that in the majority of interviews where these issues were raised, providers talked about the potential for breaches in safeguarding and financial abuse as the usage of Personal Budgets increases, however it was not common for them to point to current examples of where this was happening.

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briefing 5: impact of personal budgets on providers

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