Social Work History Network with Making Research Count
8 June 2009
“The Kent Community Care Project, mid-90’s care-managed care and the new world of Personal Budget models”
Some notes on the paper given by Bleddyn Davies on care management and the Transforming Social Care circular (Department of Health, 17 January 2008)
In the late 1980’s Bleddyn Davies, then at the Personal Social Services Research Unit at the University of Kent at Canterbury, led a team studying the introduction of a care management approach to the delivery of adult services by Kent Social Services Department. This preceded the more general adoption by local authorities of care management systems and separation of purchaser and provider functions under the 1990 NHS and Community Care Act. His paper compared this care management approach with the personalisation approach in the more recent Transforming Social Care circular. The following are among the points he made in a densely argued paper.
The introduction of care management required the construction of a political consensus which in turn required a convincing political narrative (Services must respond to individual assessed need, and if this is to be achieved, provider self-interest must be overcome.) The Transforming Social Care circular similarly attempted to build a consensus via a simple political narrative which uses three key concepts:
‘Personal Budget’ (a sum of money allocated to the individual service user which could either be handed over as a direct payment or retained as an individual budget or partly one and partly the other);
‘Personalisation’; and
‘User Control’.
The assertion was that personal budgets combined with user control will produce personalisation of services and will maximise service users’ welfare.
This narrative was similar to the earlier care management guidance (e.g. “Instead of users and carers being subordinate to the wishes of service providers … users and carers will be enabled to exercise the same power as consumers of other services”), but the process proposed was different. The biggest difference lay in the greater priority given in the 2008 circular to user control.
The Kent Community Care Project should be seen in the context of experience of delivering services in Social Services Departments. The Seebohm Report had
focussed on the bringing together of personal social services in one department without considering the processes within that department by which services would be delivered and welfare enhanced. Nicholas Stacey, Kent’s Director of Social Services, had wanted to introduce a voucher scheme for service users, but there was no statutory authority for this, and devolved budgeting was therefore introduced instead. Initially care managers were appointed for only a minority of service users, but it was intended that a care management approach would nevertheless be universal. The next Kent Director, Norman Warner, changed the system to one with care managers for all. This was in the context of government commitment to the idea of the enabling authority, which fragmented provision. Kent’s budget devolution to care managers was, however, supported by the White Paper which preceded the NHS and Community Care Act and by the Audit Commission, and also by the Social Service Inspectorate, although the SSI saw difficulties ahead and talked of transition periods.
The nature and performance of care management nationwide during the 1990s suffered because devices to ensure achievement were weak, with little investment in training for fieldworkers and managers (and what was provided was largely focussed on procedures), and also because of massive distractions, including preoccupation with moving to a mixed economy of care, pressure to hold down expenditure and growth in demand, including that caused by diversion of provision from the NHS to the personal social services.
It did not, however, follow that the system needed radical revision as implied by the “Transforming Social Care” 2008 Circular. To demonstrate such a need would involve showing that:
1. Older citizens value increased control more highly than other service benefits;
2. The post-1989 reforms did not substantially enhance users’ control;
3. Those reforms did not contribute to the support of carers and/or to their sense of influence over care plans;
4. What the reforms produced fitted worse with users’ wishes and interests than would maximising users’ sense of being in control.
The available research did not support these propositions.
In conclusion, it seemed that some apparently new models for service provision are more like their predecessors than their proponents believe. One should not approach proposed reforms as if they and what has gone before are necessarily rivals. Different approaches should be mixed, and matched to their contexts with the aid of evidence as to what works in which situations. And simple ideas, while important for constructing a winning political narrative, should not be allowed to distort the more complex policy and practice discussion which will always be necessary.
KWB
19.08.09