So, Should We Scrap Personal Budgets?

Peter Beresford, service user activist and co-Chair of ‘Changing our Lives’, wrote an on-line Guardian article titled ‘Personal Budgets don’t work – so why are we ignoring the evidence’ . In summary (as I read it), Peter is arguing that cuts in social care funding mean that PB recipients have insufficient money to purchase the support they need to get good outcomes. This is compounded by structural or delivery problems such as the up-front funding system element of PBs (RAS) failing through either incompetence or disingenuous Council behaviour. Hence, Peter concludes, the policy is discredited.

Neil Crowther, an activist and writer on equality, human rights and disability, responded with ‘Personal budgets can and do work: Why are some not prepared to let them?’ He argued that the problem is in delivery rather than the concept and the aim now should be to ‘hold the government’s feet to the fire’ around delivering on its personalisation policy (again, my reading of it).

From my perspective, some things are so incontrovertibly clear that they have to be accepted as facts. These include:

• The previous system was failing. Most social care users experienced poor quality services/support, little control over their lives, and poor outcomes.
• For a significant number of people, PBs have worked. They have been the route to greater control over their support, and thus their life, with demonstrably improved life outcomes – and they often (but certainly not always) involve less direct service cost.
• For a significant number of people, PBs have not worked. They have experienced additional burdens, limited access to alternative supports and insufficient assistance through the PB process.
• Many local authorities, and their staff, have never really bought into the personalisation concept and see delivery as a compliance requirement (and cost saving opportunity) – rather than an opportunity to empower people who use services and achieve fundamental change.

This last point is particularly important (and probable cause of the third). If we have learnt one thing from policy initiatives over the years it is that you cannot force people or organisations to do something well if they don’t believe in it. Radical change happens because people have a vision of better outcomes and commit to make that happen – not because they have been told to do it.

15 years ago, when the likes of Martin Routledge and others were arguing the case for what became known as personal budgets, I well recall my response of “it’s a great idea, it could really work, but think how it could be misused by a government that has no commitment to the rights and empowerment of excluded people and the main priority is to cut public spending”. Recognise this?

So I’d suggest that where we are is entirely predictable. Peter’s description of the problems is his article is basically accurate – but then he makes a conceptual leap to a conclusion with little evidence or logic to support that. If a government refusal to sufficiently fund a policy makes that policy flawed, then we should also be scrapping direct payments, which Peter appears to argue are positive, but which face exactly the same challenge. In fact, we should immediately scrap most policy expectations around advocacy, human rights and de-institutionalisation given insufficient money is being invested in their delivery.

Clearly that should not happen. Instead, I think we need to rediscover what personal budgets were supposed to entail. Here’s my six bullet-point summary:

• Direct payments (DPs) had helped people get better outcomes (and control) but not everyone could or wanted to take on that responsibility. Alternatives were needed – as otherwise DPs would remain the privilege of the few. Those personal budget alternatives would range from direct payments, through concepts such as trust systems to (if wanted) LA-managed funding that had to be used in the ways that the person wanted.
• Genuine person centred support planning was a non-negotiable starting point.
• Every local area should have a funded support system to help people navigate PBs/DPs – advocacy and family support, service brokers, PA employment agencies and so on.
• The local authority had a responsibility to shape and manage the ‘market’ so a range of new support options and staff roles would be available for people to buy into. Otherwise, PBs would just be used for the same old services.
• Community inclusion becomes the mind-set, thinking about mutuality, relationships and employment – not just what services are available.
• The measure of success would be the outcomes in people’s lives, not the number of personal budgets each authority had put in place.

Yet most of these things are missing. Scaling up a good idea is always a challenge, but in my mind, personal budgets started to go wrong when it became a policy requirement for every LA to hit a minimum level of PBs. These wider, system supports should also have been an absolute requirement as, without them, PBs and DPs risk being little more than a tick box requirement and mechanism that absolves the state of its responsibilities. This is one reason why I have some optimism around the latest NHSE Integrated Personalised Commissioning (IPC) initiative. It has explicit strands of delivery support around community, market development, support planning and people’s voice – and is, significantly, led by people who understand the personalisation concept. (Sorry, guys, if I’ve blown your cover).

Apologies Peter, but I think Neil’s got this one right. Should we scrap personal budgets – no. Should we make a renewed effort to implement them as originally conceived – yes.

We need to focus on winning the hearts and minds of politicians, managers and practitioners for radical change, not just put a new system in place or, just as bad, revert to the old one.