Assessment, resource allocation and culture change
Dr Tim Gollins Y&H ADASS Regional Coordinator and the Think Local Act Personal Partnership (TLAP); Dr Celia Harbottle Independent Training Consultant working with Doncaster Council, Martin Walker Team Manager, Modernisation & Engagement, Adults and Communities Directorateand Doncaster Council’s Social Care Rescript Project Team.
June 2014
Introduction
There are some key strategic drivers for adult social care at the beginning of 2014-15: the Better Care Fund (BCF) and integration, the Care Act, localism and sector led improvement, and of course austerity cuts. Personalisation in this complex context has been squeezed – its key concepts developed over a decade ago reviewed and revised amid the practicalities and the politics of change at national, regional and local levels. Through all of this change personalisation remains a key strategic priority for councils, but what its scope is, or has become, is much less clear. This paper considers these contextual factors as they impact on assessment and resource allocation. Practical solutions are offered for doing things differently, focussing on the workforce and culture change, which are seen as critical to delivering personalisation.
Since the introduction of self-directed support, which, for the sake of argument, we take to be when In Control introduced the ‘7-steps of self-directed support’ in about 2003, personal budgets have grown to become the norm. The majority of social care customers receiving a community-based service across England now have a personal budget, and the use of direct payments has become a mainstream activity[1]. Whether all of the people who have a personal budget know this fact is an important question, but generally, the principles of self-directed support are well established in councils systems: once eligibility is established for a service user there is an up-front allocation, and a care plan is developed, signed off and there is then a subsequent review.
Personalisation, however, is a much broader concept than self-directed support. It is a programme of change that links health and social care policy and practice back to the experiences of service users. It emphasises the need for better outcomes and the need for choice and control, across both the health and social care systems. In a self-assessment document developed by ADASS and TLAP in 2014, 18 separate areas of the health and social care system are identified as relevant to personalisation. These vary from workforce development and commissioning, to re-ablement, channel –shift and active citizenship.
Beyond the strategic policy areas, the detailed elements of self-directed support are also under pressure. Recent work considers the customer pathway and how councils can ‘slim down’ systems (Think Local Act Personal, TLAP), and councils continue to modernize their operating systems, especially in light of integration. Then there are public critiques of current systems and practice fromactivists and academics[2] and service users themselves. This paper addresses many of these concerns. Much of the content is provided by Doncaster Council’s adult social services modernisation team, with contributions from various other councils, networks and individuals in Yorkshire and Humber (Y&H). Specifically, the Y&H personalisation network for ADASS has worked closely with Think Local Act Personal (TLAP) nationally, and all of this collective knowledge is used in the development of this paper. Some key aspects of culture change are developed by Dr Celia Harbottle, and work on the resource allocation process has been supported by OLM, and Dr Simon Duffy worked with Doncaster Council early in 2013 to identify key issues and strategic direction. This paper is therefore, a collaborative piece, borrowing elements of good practice from various places. Derived from this collective knowledge network is a focus in this paper on three key areas of social care activity:
- Assessment, taking an asset-based approach
- Resource allocation, reliant on practitioner competency
- Culture change, a major challenge
The hope is that providing this analysis will help continue and re-invigorate the delivery of personalised health and social care policy and practice that is informed by the enduring principles of personalisation – choice, control and better outcomes for the service user.
1.Asset-based assessment
The concept of asset-based social care has its origins in three inter-related fields, the first community-based social work, the second community development, and the third is personalisation. Its basic tenet is to view individuals as people who have strengths, skills and abilities. The approach also considers that individuals operate within the context of the family and a friendship network. This social interaction takes place within a community of universal services, voluntary and community sector organisations, pubs, clubs and work. It is in these spheres of the personal, the family, and the community that social care intrinsically operates.
Adopting this asset-based approach to need assessment means balancing deficits with the strengths people have. People may have skills, abilities and are involved in communities in ways which help to reduce need or risk. Alternatively, people could be easily and quickly supported to develop these assets. Therefore, rather than formulating a straight forward idea about what someone’s needs are based on a list of categories in an assessment document, a social care worker must work with the individual concerned to understand whether and how assets can be developed. For example, perhaps professional support for a short period to engage with appropriate community groups, and to develop family relationships or friendships, might be enough to address issues of isolation or loneliness. These activities can be done before any formal assessment of eligibility is made. However, it can only be achieved by co-producing the assessment with a service user.
Taking an asset-based approach prior to establishing eligibility may reduce the overall cost of some care packages, and it might also reduce someone’s eligibility to below the unmet need threshold, but the main reason for doing it is that it makes assessments more meaningful to everyone being assessed, even those who are ineligible for services. For example, people who have to pay for their care themselves get the benefit of having an assessment which provides information and advice about the things they can do to maximise their personal resilience, reduce need and prevent the onset of new needs, and even some professional advice and informal support to help them achieve it, even if they are not eligible for public money via a personal budget[3].
Fundamentally, taking an asset-based perspective the job of social work is conceptualised as helping people (whether eligible or not) to make the most of these elements of their lives, - to become resilient. Only when an individual’s needs cannot be contained by developing resilience is the state asked to intervene. In this context the assessment of unmet eligible need is key to social work, or rather more precisely, doing everything possible to create resilience and to prevent the escalation of need is paramount.
Community-care assessments and The Care Act
The problem that asset-based assessments address is one created by community care assessments. Community care assessments, introduced following the community care act in 1990, responded largely to the need to move people out of large scale institutions into more community-based settings. Achieving this desired outcome required the identification of the problems that individuals would have in living a more independent life less prescribed by an institutions rules and regulations. The focus of assessment became the identification of the extent of absences of independent living skills, and the necessary knowledge and ability to live outside an institution.
The Caring for People White Paper 1989 set out six National Objectives, the first of which was the provision of domiciliary, day and respite services so that people could remain in the community wherever feasible and sensible. This objective largely set out the commissioned landscape of service provision we see today with a limited menu of social care options resulting in a prescription approach to meeting need with outputs rather than responses which reflected the desired outcomes of prospective service users.
The Care Act changes the duties on councils. Clause 1 of the Act places duties on the council to take a holistic view of the individual and promote general wellbeing, whilst Clause 25(6) (a) & (b) requires the local authority to have regard to the outcomes the social care customer wishes to achieve. Clause 2 of the Act places a duty on councils to seek to act to prevent or reduce the development of need, and guidance suggests that social care service users should be helped to consider ways of meeting some needs without recourse to long term state support, and where targeted Interventions are needed, they should be proportionate and responsive to the specific circumstances of each individual case.
Current deficit-based community-care assessments are still relevant post Care Act because Fair Access to Care Criteria (FACs) is still going to be used to establish a customer’s eligibility for public money. However, the Care Act demands that assessments have a broader perspective, namely, to address wellbeing and prevention. Therefore, assessments will need to be holistic and support the development of resilient individuals. Effectively, social care workers will need to maximise a person’s self-management capabilities before assessing the extent of unmet needs, and then whether or not that need is eligible for public money. With government austerity policies only half way through their planned duration and in contrast to the assessments needed after the community care act 1990, the assessments we need post Care Act will need to be about promoting self-care.
Awareness of this stimulated Doncaster Council to develop an asset-based assessment which is provided in appendix 1. It has been produced by them as part of their adult services modernisation programme and is currently being trialled by a small team of social work practitioners to ensure it is fit for purpose.
The assessment
The assessment and review of care and support needs document in appendix 1 is designed to replace the community care assessment in Doncaster and has been designed specifically to work with the RAS grid in appendix 2. The document is self-explanatory but differs from the previous community care assessment in a number of important ways. Firstly it is less prescriptive, allowing the service user to tell their story from their own perspective. Secondly, it draws out a picture of need and the context of that need from what the customer is saying, and thirdly it filters needs into met and unmet needs, and where unmet needs are identified it allows the social worker to discuss informal options prior to establishing the need for statutory services being delivered. It takes into account carer's contributions to the situation and only then identifies the eligible unmet need which enables a FACs decision. The overall purpose of the assessment is different to the previous one Doncaster Council used. Whilst the previous one was focused on identifying eligibility and the services needed, this assessment is about supporting independence and wellbeing, only resorting to filling the deficits with services as the last resort.
The assessment works with a RAS grid resource allocation tool (see below). Only if social care workers are rigorously pursuing an asset-based coproduced assessment approach, can a RAS grid resource allocation tool work. The current community care assessment aims to assess eligibility as its primary function and results in what could be described as a service prescription which is then costed by a common RAS based system or ‘black box’ (see below). This new assessment does not. It results in an agreement with the customer about how they are going to maximize their wellbeing and health, and it describes the arrangements that are needed or are already in place to help the service user achieve this. Its purpose is broader to reflect the requirement of the Care Act. However, it must also address eligibility, but it does so at the end of the process, at which point the RAS grid allocates a starter budget on the basis of unmet eligible need, not on the basis of services.
Completing the assessment with a starter budget if there are eligible unmet needs breaks the link between cash and services. It leaves room for the agreement of outcomes with the service user. Doncaster has, as part of their assessment, designed an ‘outcomes statement’ which follows on from the assessment. Further work has resulted in this being developed into a care and support plan that complies with the Care Act (see appendix 4). It is a simple tool which allows the social care worker to agree with the service user what their cash sum is for, not what services it must buy, but what the purchasing must achieve. This care and support plan is then intended to be used with independent brokers, or informal family and friends to guide the purchasing independently of the council. A starter budget will be agreed and made available to spend immediately with a review shortly following (6 weeksis envisaged) of whether the RAS grid allocation is sufficient to enable services to be purchased that address the outcomes statement. A significant step forward is made slimming down systems and process, a primary determinant, alongside involving service users in decision making, which influences positive outcomes[4].
2.Resource allocation
Criticisms about resource allocation systems (RAS) are not difficult to find. Two have already been referenced in this paper, but there are many more – there are users and carers (not all of course) from many councils in England who are likely to have experienced some kind of a problem as a result of resource allocation systems that have disempowered them. All too often resource allocation systems lack transparency, do not provide sufficient resources or alternatively they result in major shift between indicative and actual allocated amounts. On top of which, exactly how the RAS itself operates is poorly understood. Indeed, the complex algorithms in use to determine the money people need to meet their needs constitute a ‘black box’ within the council whose workings few but the most IT literate actually understand.
The black box problem is neatly summarised by Dr Simon Duffy (Centre for Welfare Reform) in 2012, where he explains that:
•It disempowers social workers and service providers
•It keeps breaking (the allocation is wrong)
•It can be used to disguise unfair cuts and cap budgets
•The calculations are unclear
•It doesn’t empower service users
A fundamental premise of self-directed support, at its inception, was the notion that councils and service users need an ‘up-front’ financial allocation. This is because an early allocation of resources promotes control, independence, responsibility and creativity. Up-front allocation is essentially premised on the notion that no one can plan effectively if they don’t know what their budget is, whether disabled or not disabled. The alternative to up-front allocation seems to be to go back to post care-planning resource allocation where the customer gets what the professional wants / says they can have. Both models have issues. The former entails the problem of how to identify an amount of money that is sufficient to meet needs on an individual basis when you don’t know what services the user wants, and the latter simply ignores the fact that when people control their own lives they achieve better outcomes and live more healthily and happily.
The solution seems straight forwards conceptually - ditch the black box and keep the up-front allocation. However, this may be more easily said than done as any number of councils and their IT providers can probably testify. However, some significant progress has been made in recent years both on making resource allocation systems more transparent and simpler to understand. Some councils, having spent time re-calibrating and explaining their RAS, now report that they are happy with how it is operating. Other councils continue to have problems. Below, is an account of the work Doncaster Councilhas done to address the long-standing problems they have had with their Common RAS based resource allocation system.
Doncaster council’s approach
There were a number of problems Doncaster’s modernisation team wanted to address:
- The current Self Assessment form was far too long
- The way the RAS worked was not understood by either social care workers or service users
- Social care workers were seen as ‘gaming’ the assessment process so that the RAS would produce the result they wanted. Social care workers knew that if they did not do this, and instead limited allocations to what the common RAS would deliver, the allocations would be insufficient for the customer to meet their needs.
The obvious solution was to re-calibrate the RAS. However, at the same time new thoughts about slimmed down systems and processes were being published by TLAP. A new more radical solution became plausible – rather than re-calibrating a flawed resource allocation system, create a new system that did what service users needed, and which used the skills and abilities of professionals. This fundamentally meant creating processes that support social work, not ones that disempower it. A co-produced competence-based resource allocation system was defined.