Managed personal budgets for older people: what are English local authorities doing to facilitate personalised and flexible care?

Transcription

1 Managed personal budgets for older people: what are English local authorities doing to facilitate personalised and flexible care? Kate Baxter, Parvaneh Rabiee, Caroline Glendinning Kate Baxter is Research Fellow in the Social Policy Research Unit at the University of York, UK. Parvaneh Rabiee is Research Fellow in the Social Policy Research Unit at the University of York, UK. Caroline Glendinning is Professor of Social Policy, Social Policy Research Unit at the University of York, UK. This is an Author's Accepted Manuscript of an article published Baxter, K., Rabiee, P. and Glendinning, C. (2013) Managed personal budgets for older people: what are English local authorities doing to facilitate personalized and flexible care?, Public Money & Management, 33, 6, /9/2013 copyright Taylor & Francis, available online at: Summary: This paper explores how three local authorities in England have tried to facilitate personalised home care for older people through changes in commissioning and market development activities; and how these changes have been experienced by support planners and home care agency managers. Overall, it appears that changes are well intended but the practicalities of implementing them raise some challenges that mean desired objectives may not always be achieved. Keywords: commissioning; home care; managed personal budgets; market shaping; older people 1

2 Managed personal budgets for older people: what are English local authorities doing to facilitate personalised and flexible care? This paper uses research undertaken in three local authorities in England to explore changes aimed at facilitating personalised home care for older people, and how these changes have been experienced by support planners and home care agency managers. Specifically, our interest is in how changes in commissioning practices and market development activities are impacting on competition, choice and diversity. Personalisation and personal budgets Personalisation in social care aims to make social care support more tailored to their individual needs and preferences. One mechanism for facilitating personalisation is through a personal budget (PB). A PB is an amount of money allocated to an individual, based on an assessment of needs. Underpinning PBs are the principles that individuals should know the amount of the budget and plan its use to optimise outcomes. PBs can be taken as cash direct payments (DPs); held by a local authority or another third party account; or as a mixture of the two. The original target of 100% of eligible people having a PB by April 2013, preferably as a DP (Department of Health, 2012, p.54), was reduced to 70% by Minister Norman Lamb in October Evidence suggests that many people do not want to manage a DP and arrange services themselves. Take up of DPs by older people has been particularly low (Davey et al., 2007) and is currently around five per cent (The NHS Information Centre, 2012, Figure 4.10). One reason for this may be that older people do not want what they perceive to be the burden of managing their own support (Glendinning et al., 2008, Moran et al., 2012). It may also reflect the attitudes of social workers and others who assume that older people neither want nor would be able to manage DPs (Ellis, 2007). Instead, the majority of older people s PBs are held in local authority or third party accounts, known as managed personal budgets (Association of Directors of Adult Social Services, 2010). Across England as a whole, 89% of service users aged 65-plus have managed PBs and a further five per cent a combination of DPs and managed PBs (The NHS 2

3 Information Centre, 2012, Figure 4.10). Service providers such as home care agencies can also hold managed PBs; these are known as Individual Service Funds (ISFs) (Bennett and Miller, 2009). Here there is a contract between the local authority and provider, with the day-to-day arrangements agreed between the service user and provider (Bennett and Miller, 2009; Association of Directors of Adult Social Services, 2010). The question is whether the perceived benefits of personalisation, such as enhanced choice, control and flexibility, are available to older people using managed PBs. The home care market in England Most publicly funded support received by older people living in their own homes comprises personal care and other home care services. The home care market in England has seen huge changes in the last two decades, firstly on the supply side and latterly on the demand side. On the supply side, the NHS and Community Care Act 1990 introduced competition and thus broke up the monopoly provision of local authority in-house services. The independent sector now provides 87% of care compared to only five per cent in 1993 (Francis, 2012). Providers vary from small family-run businesses to national organisations and franchises and include for-profit and not-for-profit enterprises. The demand side of the home care market has hitherto been dominated by monopsony local authority purchasing. Through their purchasing power, local authorities have driven down prices and strongly shaped the type of care provided, in particular increasingly funding only personal care. However, the current focus on personal budgets, and increasing numbers of people using direct payments or self-funding their care, suggests a third era of procurement arrangements where the emphasis moves from who provides to who purchases (National Market Development Forum, 2010, p.4). Local authorities are still the major purchasers of home care services, increasingly funded through the personal budgets they manage on behalf of older people, and thus retain the power to influence the market directly. However, over time, their role is intended to become a more subtle one of shaping the market (Lyons, 2007; Boland and Coleman, 2008). This will be facilitated 3

4 through Market Position Statements setting out, amongst other things, current and future local demand (Department of Health, 2012), and by the Department of Health s Developing Care Markets for Quality and Choice programme (see health/2012/09/dcmqc-launch/) which aims to help local authorities create a diverse, vibrant and high quality market for social care services. Hitherto, local authorities have influenced the home care market through their contracts with providers, typically using block or cost and volume contracts to purchase services in bulk, at pre-arranged prices and quantities, from a small number of providers. Providers have thus needed capacity to deliver substantial numbers of hours of care within a specific geographical area. There is evidence that a significant minority of third sector organisations did not bid for such contracts because they lacked, amongst other things, necessary capacity or expertise in bidding; they were also uncomfortable with what they perceived to be excessive monitoring (Murray, 2011). Spot contracts, where service specifications and prices are agreed on an individual basis, were used less frequently but did offer some flexibility, often when block contract providers were unable to deliver additional or highly specialised packages of care. Spot contracts tended to have higher transaction costs than block or cost and volume contracts, both ex-ante (from negotiating and drafting agreements) and ex-post (from administering invoices and monitoring quality) (Bartlett and Le Grand, 1993). As the use of PBs increases, local authorities are changing these contracts to framework agreements. Framework agreements set out the terms (including price and quality) on which the authority will purchase services. Providers tender to be on the framework. Local authorities purchase care only from providers on the framework but, unlike block or cost and volume contracts, do not guarantee business to any provider. When packages of care are needed, all the framework providers can bid to deliver it. If more than one provider bids, that preferred by the service user is chosen. Framework agreements may reduce contract management time and also increase competition and therefore choice for service users, although tendering processes may still disadvantage smaller providers (National Market Development Forum, 2010). 4

5 Against this background we explore the activities of three local authorities to facilitate personalised home care through changes in purchasing and market shaping activities. Methods and sample The study took place in three English councils with social service responsibilities. We aimed to recruit councils that were known to be pro-active in facilitating personalisation for people using managed PBs or ISFs; had large proportions of older people within their populations; and large proportions of people using managed PBs. Eligible councils were identified through informal enquiries to PB implementation and service improvement networks; discussions with other researchers investigating implementation of PBs; recently published research; and routinely collected data from the Information Centre for Health and Social Care. A long list of possible councils was identified; short telephone interviews were conducted with senior officers in each about managed PBs and related developments, to scope current developments. The final selection, of two boroughs and one county council, reflected both our interests in what appeared to be innovative developments and councils willingness to host research activities. One council offered ISFs and one offered virtual budgets which we understood to be the equivalent of ISFs. Two had ethnically diverse populations. Table 1 gives the main characteristics of the three councils. Table 2 shows the population aged 65-plus using different forms of PBs. Table 1. Characteristics of study local authorities Local Authority A Local Authority B Local Authority C Type of authority Shire County London Borough Metropolitan Borough Geography Rural Urban Sub-urban Type of managed PB LA-managed PBs ISFs for all new clients LA-managed PBs Some virtual budgets Year framework introduced

6 Number of providers on framework 45 9 (including 4 with block contracts) Originally 13 Increased to 37 Table 2. Number of people aged 65 and over using personal budgets, by local authority Local Authority A Local Authority B Local Authority C Personal budgets DP only 125 (3%) 20 (2%) 95 (4%) Directly-provided services 3630 (84%) 300 (24%) 2390 (90%) only (i.e. managed PBs) Both DP and directlyprovided 300 (7%) 640 (51%) 110 (4%) services DP (not self-directed 300 (7%) 295 (24%) 60 (2%) support)* Total 4355 (100%) 1255 (100%) 2655 (100%) * Defined as 'the number of qualifying individuals who are in receipt of a direct payment, but who have not been through the Self Directed Support process (i.e. they do not have a personal budget)'. (The NHS Information Centre Adult Social Care, 2011, p92) Source: Adapted from Community Care Statistics England , Annex A, Provisional National Tables, Table SD2, The Information Centre for Health and Social Care. (see ) Data collection took place between August 2011 and October Stage one comprised interviews with senior managers from each council; job titles varied but interviews were sought with the person most knowledgeable about commissioning, contracting and market development activities. The interviews explored steps introduced to facilitate personalisation for managed PB users, including changes to contracts with home care agencies, and initiatives to develop local home care markets. Stage two involved focus group discussions with care managers/support planners in each authority. In each site, a key research contact was asked to recruit care managers/ support planners with most 6

7 experience of helping older people plan how to use managed PBs; within this parameter, focus group participants were self-selecting. The focus groups explored support planners experiences of encouraging choice and shaping the demands that managed PB holders made on providers. Stage three involved interviews with managers of home care agencies (five in authority A, six in B and four in C), about their experiences of changes introduced by the council and of providing support to people using managed PBs. Stage 4 involved interviews with 18 older people using managed PBs. This paper uses data from Stages 1 to 3. All interviews and focus group discussions were digitally recorded and transcribed. Data analysis used the Framework approach (Ritchie and Spencer, 1994). This involved writing summaries of data in cells on a spreadsheet to facilitate comparisons across themes and respondents. The analysis for this paper concentrated specifically on changes in ways of working and market shaping initiatives discussed by the commissioning managers; and how support planners and managers of home care agencies experienced these changes. Findings Changes in commissioning arrangements All three councils had begun to use framework agreements to procure services from home care providers, but were at different stages in the transition from block or cost and volume contracts. Although apparently at odds with the principles underpinning framework agreements, in one authority around half the framework providers still had block contracts and therefore had guaranteed work and income until these expired (within a year). Commissioning managers cited being able to offer a choice of provider to managed PB holders as the reason for introducing framework agreements. Previously, many authorities (not just those in this study) had contracted with home care providers to deliver services to people living in specific geographical zones. This meant providers could build staff capacity in particular areas, although they could not deliver care to clients in neighbouring streets that fell into different zones (Baxter et al., 2011). Framework agreements instead freed providers to take clients from any locality and thus facilitate choice of provider for managed PB holders. 7

8 Two of the councils initially had relatively few providers (around 10) on their frameworks, to ensure market stability. Both commissioning managers were concerned that spreading packages of care across more providers and thus reducing the number of clients each supported could endanger their financial viability. One manager thought it particularly important to begin with a small but stable foundation and then increase the number of providers. This local authority had recently increased the number of providers on the framework to 37. The manager recognised that this could be perceived as working against the authority s longer-term plan to reduce the volume of directly contracted services; however, the reason for increasing the number of providers on the framework was to encourage greater use of direct payments (rather than offering more choice to people using managed PBs). In this authority, framework providers had agreed to provide services to DP users at the same price that services were provided to those with local authority-managed budgets. The belief was that more people would start to use DPs if they could spend these with framework providers who had undergone rigorous local authority quality assurance checks and if they could choose between many providers. The third, rural, authority had over 40 framework providers. Most of these offered conventional personal care, but some also offered services such as domestic help or live-in carers; the council s intention was that people with local authority-managed PBs would begin to use a range of services from a number of providers. Alongside framework agreements, each local authority had introduced brokers. Brokers were local authority employees acting as intermediaries between support planners and home care providers. Their role was to source framework providers on behalf of managed PB holders. They did this by sending basic details about clients and their support plans to all providers on the framework, asking if they were able to provide that care. Details of providers who responded were then given to support planners, so that service users could select a preferred provider. Support planners and managers of home care agencies had mixed views of the new framework and brokerage systems. Support planners thought that brokerage helped to drive up and maintain quality: 8

9 It s probably generated an element of competitiveness, [ ] they [providers] have to be constantly proving themselves and proving their worth and being prepared to sign up to what our requirements are. In this respect, framework agreements were seen as positive. In the site that had recently increased the number of framework providers framework to 37, support planners felt it created more choice and increased capacity, whereas support planners in the authority with only nine agencies on the framework (half with block contracts) had concerns about quality and choice. These latter support planners believed the block contracted agencies were prioritised by the brokers, which meant very limited choice of provider to service users. These support planners would have preferred to be able to arrange more care through what they called the spot contracted providers on the framework, which were considered to offer better quality care because they were not as stretched. They felt strongly that block contracted providers had no incentive to improve quality as they were guaranteed a certain number of hours of care. Providers with spot contracts in this authority agreed with the support planners that the market was distorted by brokers not offering work fairly or giving clients full knowledge of all framework providers and services. The spot providers themselves thought they were approached by brokers about possible new clients only if block contracted providers lacked capacity. This meant that spot providers received relatively few requests for new clients. One agency manager believed local authority support planners (rather than brokers) actively discouraged clients from choosing spot providers: they do the assessment and they say These are the four block, these, these are the, the choices that you ve got, and in the big writing is the four blocks and everybody else may or may not be in the small writing or even on the list In the other two study authorities, agency managers had mixed views about framework agreements. One positive view (which concurred with that of commissioning managers) was that framework agreements gave agencies more freedom to select clients from any 9

10 geographical area, not just a specific zone. Providers noted that, under previous block contracts, they had not been able to turn down new clients if they were below their contracted minimum volume and hence had not had complete control over their workload; frameworks offered more control. However, while framework agreements may have opened opportunities for agencies to work in new areas, some providers were concerned that larger numbers of agencies on the frameworks meant competition was too high; they could also no longer group clients geographically. This had knock-on effects on employment of local care staff and travel costs, especially in rural areas. Such concerns were precisely why two of the authorities had begun with fewer providers on their framework. Even so, support planners from the council with over 40 providers on its framework thought that in rural areas choice of provider was still inadequate; there was often only one provider available. Occasionally, managed PB holders had their care delivered by two providers, but support planners stressed this was from necessity, not choice for example, one provider may have capacity to deliver morning visits and the other evening visits. This suggests that having large numbers of providers on a framework agreement does not necessarily indicate spare capacity, competition between providers or choice for users, particularly in rural areas where labour supply is low and travel costs are high. Views of brokerage systems were also mixed. One concern of both support planners and agency managers was that although brokers acted as market intermediaries they were less knowledgeable about clients than social workers or agency staff. This generated a lot of toing and froing between support planers and agencies, to ensure identified needs would be met. In two sites, support planners thought brokers were very good at taking on board their recommendations, derived from users preferences, for certain framework agencies and at getting back to them to negotiate, for example, start dates. In the other authority, support planners reported that delays in the brokerage system, combined with support planners preference for negotiating directly with agency managers, meant most support planners only contacted brokers to finalise arrangements once they had been made informally with agencies. Agency managers also preferred to negotiate directly with support planners over new clients; for example, they reported offers to take new clients who lived 10

11 close to existing clients being turned down by brokers who were unaware of their geographical proximity. Individual Service Funds Two councils had been selected for inclusion in the study because they were using ISFs or an equivalent. The commissioning manager in one explained that all older people who opted for a managed PB were automatically given an ISF; these remained as indicative allocations, held by the authority on behalf of framework providers. The difference between an ISF and a directly commissioned service, as explained by the commissioning manager, was that once a care package was in place, the provider had greater responsibility for reviewing a person s needs and making sure they were met, and there was more scope for flexibility in how funded hours were actually used. The other council had created virtual budgets. These were explained by the commissioning manager as similar to ISFs but for use with providers outside the framework. They were created when a small number of good quality providers failed to win places on the framework; their council-funded clients wished to continue receiving services from them but did not want DPs. These service users contracted directly with the providers, but the local authority managed the finances. In neither authority, therefore, were budgets held by agencies; agencies invoiced the council monthly for the services they provided. Support planners had little to say about ISFs. Significantly, in the authority where all older people were given ISFs, support planners felt their role was no different to pre-isf care management, suggesting there may have been little increase in opportunities for user choice. In the authority with virtual budgets, there was confusion amongst support planners (and, indeed, commissioning managers) about whether the virtual budget option could be offered to new PB holders or was a temporary offer at the time the providers failed to gain a place on the framework agreement. Agency managers whose clients had ISFs or virtual budgets felt they were neither working as expected, nor offered the levels of flexibility anticipated: 11

12 the local authorities are still going to want to hold the purse strings, so ISFs, yes it still can work and I think it can work in a fantastic way, but as I say unless the local authorities are prepared to let go of that funding and trust the.. service provider. One of the potential benefits of ISFs or other forms of managed PB anticipated by agency managers was that clients would have more freedom to discuss their support needs with agencies and make changes, as long as the costs remained within the PB limit. However, although four of the six agency managers interviewed in the local authority with ISFs knew the amount of the ISF, one agency using virtual budgets did not know the budget amount. Some agency managers felt there was flexibility in how the budget could be used and that they were trusted by their respective councils to adjust support plans in agreement with service users without seeking permission from the authority. Many, however, felt restricted to performing personal care tasks only and had to seek council permission to make even minor changes. Market development initiatives Two study authorities had introduced initiatives to encourage providers to widen their range of services. One authority had created two Market Development Officer posts with the aim of encouraging the development of a more diverse range of services. The Officers remit, according to the commissioning manager, was to provide a two-way information flow, gathering information about demands for new services by looking at support plans and talking to support planners and disseminating this to providers. Non-traditional providers, such as takeaways that might deliver meals, would be included. However, none of the six agency managers interviewed in this authority had heard of the Market Development Officers, although they had been in post for around six months at the time. Another authority had created an Innovation Fund of around 100,000 aimed at encouraging providers to create new services that people using PBs could buy. The Fund awarded grants of between 500 and 20,000 through open competition; existing and new providers from the voluntary, user-led and for-profit sectors could apply. The Fund shared 12

13 with providers the financial risks of developing new services; this was considered by the commissioning manager to be particularly important when providers established customer bases were being eroded through increased use of DPs and corresponding reductions in local authority-purchased packages of care. Two of four agency managers interviewed in this authority had heard of the Innovation Fund but neither had applied; one had not had time to do so and the other explained: I can never come up with an innovation that requires the fund or, if we re already doing one, then I m not good at, I don t.. it s a funny thing, innovation fund, because what s innovation? We re already doing stuff that nobody else in the borough is doing, so is that innovation? And then how do you cost it? I don t know. In general, agency managers across all three authorities though both types of initiative were great ideas; in fact, an agency manager from the council with neither scheme expressed a desire for designated funding to help develop new services aimed at increasing personalisation, which is exactly what the Innovation Fund aimed to do. None of the agency managers interviewed knew whether their local authority had a market position statement, or what these were. Discussion This paper reports early commissioning and market shaping activities aimed at increasing personalisation of home care support for people using council-managed PBs. We have examined how these developments were experienced in practice by support planners and home care agency managers, in order to learn which appear to work best, why and in what circumstances. However, the study is based on only three councils. Although we strived to select councils that had introduced changes aimed at encouraging personalised home care for people with managed PBs, those taking part were neither necessarily the most innovative nor representative. Instead, they offer insights into the types of developments under way and how these have been experienced. Similarly, the number of support planners and agency managers interviewed was quite small, although the views they 13

14 expressed were consistent enough within each local authority for us to be confident that additional interviews would not have resulted in different opinions. In summary, we found councils were at different stages in introducing framework agreements and associated brokerage arrangements. These arrangements aimed to increase both competition between providers and choice of provider for managed budgetholders. However, commissioning managers had to balance greater competition and choice with the need to maintain a strong and stable provider base. Support planners would have liked more competition between providers whereas agency managers felt that too much competition could undermine efficiency and flexibility. Challenges around the efficiency of brokerage systems in each council were also reported. Whilst ISFs existed, these were not functioning as anticipated. Finally, innovative ways of developing the supply-side of the market had been introduced but knowledge of them and their impacts to date were not widespread. Whereas framework agreements and brokerage systems aimed to increase competition and choice, market development activities aimed to increase the diversity of services available and thus, ultimately, opportunities for personalisation of services.. Overall, it appears that, in the study councils, these changes were well intended, but the practicalities of implementing them raised challenges so that desired objectives were not always achieved. For example, communication appeared as a recurring issue, especially in relation to brokerage. In one site support planners felt that brokers limited competition by not approaching all the providers on the framework, whereas at least one agency manager felt it was the support planners who limited choice by encouraging users to choose some agencies in preference to others. We did not interview brokers to obtain their perspectives; however, as some providers in this site still had block contracts and this issue was not raised in other sites, it is likely that both brokers and support planners prioritised agencies with outstanding block contracts. This issue may resolve itself once the block contracts expire. However, other communication issues are likely to remain. In all sites, both support planners and agency managers felt better able to communicate with each other directly than through brokers. While brokers may have improved market functioning, dealing through a third party, especially one without direct contact with service users, created 14

15 challenges. The toing and froing reported by support planners suggests it also increased their workloads. These issues highlight the challenges of successfully separating processes of arranging care (from needs assessment to sourcing appropriate providers) into individual tasks undertaken by different people. It suggests councils may benefit from bringing together brokers, support planners and agency managers to clarify their respective roles and regularly review the effectiveness of brokerage systems. Consistent with other research (Dowding and John, 2009; Wilberforce et al., 2012), the findings suggest that large number of providers on a framework does not necessarily guarantee choice. This was especially evident in the rural county, with over 40 providers on the framework but little choice in some localities; it suggests that in rural areas particular efforts may be needed to increase the numbers and capacity of providers. However, choice of provider is only one aspect of personalisation; choice over what services are provided, when, how and by whom are also important (National Market Development Forum, 2010). This raises the question of how best to shape local markets. Two councils had taken different pro-active approaches through Market Development Officers and innovation funds respectively. The Market Development Officers remit was to find out and inform providers where there were gaps in the market, what new services would fill these and what levels of demand were. This local authority-led approach appears similar to the new market position statements. In contrast, innovation funds were provider-focused, aimed at encouraging existing or new businesses to spot potential gaps and develop services to fill them. It was too early to assess which approach might be more successful in encouraging new service developments for older people using managed PBs. Both approaches to some extent depend on opportunities for managed PB users to voice their preferences. Combining both approaches so that local authorities research and disseminate information on gaps and also offer financial support for new services, may be necessary. A final issue is that of trust. It was clear that ISFs (or their local equivalents) were not being used as anticipated because of intensive monitoring by local authorities of providers daily activities with service users. Agency managers did not feel that they were trusted to make minor changes to individuals care without council authorisation. Whilst some monitoring is 15

16 necessary, given councils accountability for spending on social care and the quality of care that people receive, excessive monitoring may undermine opportunities to promote personalisation. This study offers a snapshot of council activities aiming to improve personalisation for older people using managed PBs for home care. The policy environment is changing rapidly, and will continue to do so as proposals in the 2012 Care and Support White Paper come on stream. However, these changes are being introduced in an extremely difficult financial context. Consequently, constraints on opportunities for choice and control by older PBholders are likely to continue, because of the relatively small size of their budgets and their high levels of need for essential personal care these factors will inevitably shape how their PBs can be used. While these constraints remain, both opportunities and demand for greater flexibility and personalisation are likely to be limited. Acknowledgements We would like to thank the local authorities, home care agencies and older people who took part in this research; the project advisory group; and Teresa Frank for administrative support. Disclaimer This article presents independent research funded by the NIHR School for Social Care Research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health, NIHR or NHS. References Association of Directors of Adult Social Services (2010), Personal Budgets: Council Commissioned Services. Advice Note (Putting People First). Bartlett, W. and Le Grand, J. (1993), The theory of quasi-markets, in Quasi-markets and Social Policy (The Macmillan Press Ltd, London pp ). 16

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