Using direct payments to transform the quality of social care

We have been discussing the social care problem for decades. Understandably, the focus has been on how to pay for it but that misses an essential point, how to make social care better, how to make it a service that people want to pay for.

The provision of social services has remained largely untouched by the modernisation which has improved other services. Technology which could transform lives is only used at the margins. The quality of care is often low and takes no account of individual needs and preferences. The very vulnerability of the people receiving the services has made providers and funders highly risk averse. As Atul Gawande, the surgeon and writer, points out in his book Being Mortal, care home residents suffer the three plagues of “boredom, loneliness and helplessness,” unable to make choices about what they eat, how they spend their days, unable to live life on their own terms.

There are no easy answers. Confronting the truth that you can no longer look after yourself is uncomfortable and unpleasant. However, there is a way to make the provision a bit better. That is by giving the recipient of the service the cash to buy their own care. There is a lot of money potentially available, with spending in England by local authorities on personal social services amounting to more than £17 billion a year.

Handing that over to individuals would empower them in a dramatic way, giving them the kind of choice and control that could make a difference to the services they receive. It would not even need major legislative change to achieve this. Direct payments for social care have been an option since 1997 and in 2007, the government introduced the broader concept of a ‘personal budget,’ followed by the 2014 Care Act which put a further emphasis on the personalisation of care.

However, direct payments are only chosen by about 130,000 of the two million people who receive publicly funded care. As long as the cash option is only taken up by a few then a full transformation of the way social care is delivered will not be achieved. Giving everyone a direct payment could drive innovation and encourage new providers.

There are examples from other countries around the world, where more imaginative approaches are helping to improve the quality of life of the people in care homes. These include the Eden alternative in the US which provides small scale care homes for up to ten residents which offer a much wider range of activities that can be tailored to individual needs. Other examples are found in the Netherlands where the Buurtzoorg model, focuses on providing individualised care, an approach which has brought improvements in satisfaction and cost reductions.

A system which puts the spending power in the hands of individuals will make it more likely that these kinds of new approaches and new providers will emerge. There is similar scope for real improvements in service in the provision of home care. This is the support provided to people in their own home to help them with activities like washing, dressing and meals. Even if this care is of high quality, it is likely to be unsatisfactory because it will not meet the person’s individual needs but those of the provider.

In the UK 873,000 people receive home care, amounting to 318 million hours, and a total market of £4.6 billion a year, of which £3.9 billion is spent by the public sector. Again this adds up to a significant amount of money potentially available to individuals to employ carers directly and so make their own choices about what hours they want them to come and what tasks they want them to carry out.

While there has been little recent research on the effect of direct payments on the quality of life of the recipients that which has been carried out shows significant benefits. Research by the charity, In Control, in 2006 found that 98% of people said they were quite or really happy with services once they had individualised budgets, compared with 48% receiving local authority provided care.

Those sceptical about direct payments tend to suggest that the reason they have not taken off is that they place unmanageable burdens on the person or their carers but systems of support could be put in place relatively easily. That could range from voluntary sector advice or comparison websites to the provision of agents or brokers. These agents could be in the private sector or voluntary organisations perhaps working on similar lines to independent financial advisers.

While more research needs to be done there is some evidence that because the individual is spending their own money they spend it more effectively and so reduce overall costs. Those using services will know the costs of what they are buying or want to buy and so are more likely to be willing to make trade-offs in a way that council employees never can. The limited analysis to date shows that average costs for local authorities are 12% lower with direct payments than traditional funding approaches.

There are also lessons from abroad. In Germany, which has a private care insurance system, social services clients are offered the choice between cash and benefits in kind, where care is provided by an agency. Only about two thirds choose to take the benefits, even though the cash option is worth only 50% of the costs of providing the benefits. To make this happen all that would be needed is a simple adjustment of regulations to require councils make a direct payment the default option offered to those entitled to social care.

By giving people real choice and control over the kind of service they receive they will get better care and it will become easier to persuade them to make provision for that care and open up a way through the problem of social care funding.




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