My Budget My Choice. Implementing Self-Directed Support in the City of London, October Authors: Mark Peak and John Waters

Transcription

1 My Budget My Choice Implementing Self-Directed Support in the City of London, October 8 Authors: Mark Peak and John Waters

2 My Budget My Choice Implementing Self-Directed Support in the City of London Forward Recent Department of Health guidance has challenged Social Service Departments up and down the country to reform their Adult Social Care systems and offer people maximum choice, control and power over the support services that they receive. In response to this challenge and following the successful introduction of a direct payments scheme that, with over users boasts the highest number of direct payment users per head of population in London, it was decided that a pilot Personal Budgets scheme would be initiated in the City. The decision of whether or not to test out the feasibility of offering a personal budget to a crosssection of both current users of our services and new users to the service was an easy one to take. We are totally committed to any approach that will enable local people who need our support to be able to take greater control over their lives. Historically, the City has always stayed close to its resident community and local services have continuously been developed to reflect the changing requirements and expectations of its stakeholders. The rising expectations of those living in the City who are dependent on social care for enhancing their quality of life and maximising their capacity to lead full, purposeful lives has led to the adoption of this new and exciting way of delivering services. As explained later in this report, the City s pilot personal budget scheme was set up with the intention of exploring not only whether this approach could work for people with learning disabilities, as pilot schemes in other local authorities have tested, but also for people from other social care groups. In considering this report I think it is quite evident that, by offering users from all social care groups a personal budget, we have found a way of providing services to local people in the way that they would choose. The success of this pilot has only been possible through the efforts and dedicated work of our project manager, Mark Peak, and the professional support offered to him from both our colleague from in Control, John Waters and our independent broker, Laura Luckhurst. By sharing our experiences of this pilot project and learning from what we are told by service users and others about our personal budget scheme, we in Adult Social Care wish to take a leading role within the City and across public services to develop and deliver the highest quality, personalised support to our local community. Simon Temerlies Adult Services Director City of London Council in Control Partnerships

3 Introduction In March 7 the City of London embarked upon an ambitious endeavour. We wanted to explore whether we could reorganise our social care system and work in a way that was both affordable and sensitive to the individual needs and aspirations of local people. By reorganising our approach to social care we wanted to find out if local people who need support could really take more control over their lives. The work described in this report draws on learning from in Control, a National charity dedicated to reforming the social care system in the UK. in Control has developed and tested ways of placing individuals at the centre of the care management process. This new system has become known as Self-Directed Support. Self-Directed Support Self-Directed Support works very differently from the way we currently organise social care in the City of London. Our current system is similar to most local authorities, and follows a traditional care management approach. This professional-led process was established in the early 99s and is outlined below. Care Plan Assessment Service Price Allocation Traditional care management proces The individual needing support undergoes a professional assessment of their needs, a care manager then creates a care plan often from a menu of existing services. The care plan is then purchased, the cost of the care is not known until the end of the process. The individual often remains unaware of the actual costs involved. It has been argued strongly that this traditional care management approach has a number of inherent flaws: the system is overly reliant on professionals (making the process disempowering and costly to transact) there is little or no incentive for the individual or their family to contribute services tend to be pre-commissioned and people slotted into them meaning people end up with a service not designed to meet their individual needs social workers are forced into a gate keeping role which prevents creative planning the approach often leads to a low correlation between level of need and level of resources allocated to an individual people are prevented from taking control as they do not know the resources within which they can plan Self-Directed Support reshapes this process in a simple but radical way. The approach places control over an individual budget in the hands of the person needing support (where people lack capacity a representative, usually a close family member, is identified). This is achieved by allocating resources to people at the start of the support process and following the completion of a simple questionnaire. This change necessitates the introduction of a resource allocation system (RAS). The RAS takes the form of a simple self assessment questionnaire that lets people know early on in the process how much money is available to them from the local authority to fund their support. It also clearly states the intended outcomes of their support plan. This allows the person themselves to move from a position of passive recipient to that of active partner. The personal budget can be held by the person themselves, by their representative, by a social care provider or by the authority. The important thing is that the person and those close to them have control of the money. RAS Self-Directed Support process Support Plan Knowing how much money is available and what outcomes must be achieved the person and their family can then take control of their personal budget and plan how it is used. Once the person and their family (or those closest to them) have developed a plan the authority is then asked to approve the plan and arrange payment. This important check provides a mechanism through which the authority is able to meet its social and financial responsibilities. City of London Council in Control Partnerships

4 The effect of this innovative shift is that: People can draw on their natural family and community support People are able to plan flexibly and creatively within available resources People can develop plans that are truly personal to them The relationship between the local authority and the local citizen is made clear Background The City had previously developed a high quality and accessible Direct Payment Scheme that was person centred, flexible and available to all service users. The City was the leading authority for direct payments (DOH League Table 7). We wanted to build upon the knowledge, achievements and successes of the direct payment scheme to provide an innovative Self Direct Support Scheme. Implementing Self-Directed Support in the City of London Much of the early learning from in Control s work had been gained from working with people with learning disabilities and their families. In the City we wanted to build on this learning and explore if the approach could work with people from other social care groups. We also wanted to learn about Self-Directed Support when we worked both with people already known to us and with people approaching us for help for the first time. Some people receiving support from the City already use a type of personal budget in the form of a direct payment, for this group the traditional care management process had resulted in them being given money in lieu of services. We wanted to find out whether people currently receiving direct payments, would benefit from the greater freedoms and flexibilities of Self-Directed Support. For people already receiving a direct payment the move toward Self-Directed Support meant being clear the money available could be used in a range of different ways, and offering support to develop an individualised support plan. For the pilot study, we invited people ( with mental health needs, with learning disabilities and older people) to plan and direct their own support using a personal budget. Of the people offered this opportunity were already receiving direct payments. All people have now successfully transferred to the personal budget arrangements. Developing a RAS In order to offer people a personal budget we needed to develop a way of deciding who should be eligible for a payment under the scheme and the amount of money to which they are entitled in order to pay for their support. We then worked closely with our colleagues from in Control to develop a resource allocation system (RAS) that was adapted to the particular needs of the City. Aims for the RAS Be financially viable for the local authority Be financially viable for individuals Allocate available resources against a transparent framework of needs Indicate how much money each person should have available to them This meant If successful we could afford to roll out the approach People can produce plans that meet their needs People with similar levels of need would receive similar funding People can develop plans that work well for them The first task was to develop a user friendly self assessment form that people themselves could use to identify their personal budget. Using the in Control model self assessment questionnaire (SAQ) as our starting point, Adult Social Care, Home Care, Occupational Therapy and our key external partners agreed a self assessment questionnaire. The questionnaire measures needs and allocates a score for each of the following areas: Personal care Relationships Getting out and about Being part of the local community Work, leisure and learning Making decisions Staying safe from harm Complex needs and risks Support available from friends and family City of London Council in Control Partnerships

5 So that we could convert a person s total needs score to an individual allocation of money, we then undertook a desktop exercise to analyse current costs and needs of people we currently support. In this exercise the SAQ was completed by social workers who identified a needs score for each individual in a selected group of current service users. The group in this desktop exercise were receiving a range of services including people in residential placements and people with community packages. This process generated a score for each individual relative to their level of need. By looking at the existing care package costs for this group a financial value was awarded to each point in the SAQ. In this way it was possible to identify an amount of money for each person in the pilot that was a good indication of how much money it would cost to meet their needs. We found that our needs and cost analysis supported some of the criticism of the traditional care management system outlined earlier. The graph below shows level of need and costs associated with 6 existing service users, who had previously had support through the traditional care management system. As can be seen from this graph, there appeared to be a very poor correlation between the level of resources currently made available to people and their level of need. Current cost v s ras allocation,, 8, 6,,, Current Cost vs Ras Allocation Ras Allocation Current Cost per annum In the graph individual needs scores from the desktop exercise are ranked left to right, low to high. The suggested RAS allocation increases in relation to needs whereas the current allocations appear somewhat erratic. Planning for Personal Budgets Once we had developed the RAS the scheme manager identified the people to be included in the pilot scheme. He offered initial support to all people involved in the pilot, explaining the principles, the money available to them (calculated by the RAS) and gave advice on writing support plans. Further specialist advice and support was available either from an independent consultant employed by the City of London or other external agencies if required. Interestingly only one person required further specialist advice to produce a person centred support plan. This low need for professional support in planning may be related to the relatively high percentage of people in the pilot who had previously had a direct payment. However, it would seem to support the earlier assertion that the current system is overly professionalised, and that we currently underestimate the capacity of individuals and their families to take a lead role in designing and developing their own support. How people spent their money One of the benefits of Self-Directed Support is that people are free to choose support that makes sense to them, and are not restricted to a list of existing service options. Given the size of the sample we found a remarkable range of things that people spend their money on. This included: Support to older people to stay in their own homes. (Live in carer) Support to younger people to leave the parental home. Provide respite to carers to give them a break from their unpaid caring role. Self employment of individual support workers. Support and equipment to pursue academic studies. Learning new skills and obtaining qualifications to access work opportunities. Support to find work and employment opportunities. Securing work and leisure premises. Accessing social and leisure activities (keep fit & social clubs). Gaining life skills (support learning to drive). Providing a person to be a nominated key holder for a community alarm. Spending more time with other people. City of London Council in Control Partnerships

6 What were the outcomes? To understand if we had succeeded in making a difference to people s lives we undertook structured interviews with individuals or their representatives. Firstly prior to having a personal budget and then again once the support package had been developed and in place for some time. The interviews were conducted using in Control s recommended evaluation tool, this looked at people s satisfaction with their: General Health and well being Feeling of safety and security at home Money Choice and Control over important things in life Being with the people you want Life as a whole For each domain people were asked to rank their level of satisfaction on a descriptive scale. Data was collected for all people taking part at both points in time. The results are impressive, showing marked improvements across each of the domains measured. These early findings are drawn from a very small sample but never the less they seem to show a marked increase in satisfaction levels. Interestingly all the older people in the group said they felt safer at home. Every member of the group reported an increased satisfaction with the level of choice and control. Average satisfaction Average satisfaction scores scores and and Health & Well Being Feeling Safe at Home Money Choice and Control How much did it cost? Being With the People you want Life as a Whole As well as knowing how people spent their money and whether taking control of a personal budget made a difference to people s lives, we needed to make sure that the approach was affordable. Cost of personal Cost of Personal budgets Budgets and traditional Traditional Support support 7, 6,,,,,, Personal Budget Traditional support Of the people taking part 7 already had previously received a traditional service. The cost to support these 7 people was,6. The total cost of all personal budgets turned out to be,. The detail of how these totals break down is shown in the chart. How Peter used his money. Peter is a year old man with a learning disability. He currently lives at home with his parents and older sister who has a learning disability. Peter initially had a Direct Payment and was using this payment to fund his attendance at a day care project providing services to people with a learning disability. He had been attending this project since leaving school and had learnt lots of new skills. He had also increased his confidence and gained employment experience in a number of work based settings. Peter identified in his person centred plan that he wanted to leave home and to do something different during the day, with a focus on gaining paid employment. Peter identified that he would like to use a personal budget to achieve these outcomes. Peter knew that he would need support to achieve these outcomes and that he would need to initially gain more skills in looking himself and in managing his money living independently. He agreed to work with his allocated social worker and an independent specialist employment advisor to produce a support plan that would best meet his needs and achieve the outcomes City of London Council in Control Partnerships

7 On discharge from hospital he was placed in a supported housing project for people requiring support leaving hospital. He was also attending a specialist day care project for people with Mental Health issues for five days per week. At a review at his day care project he identified that he was interested in exploring Personal Budgets to try out alternative activities to his current day care with a focus on gaining paid employment and regaining his health. that were important to him. Due to the nature of Peter s identified needs he developed a two phase support plan to achieve all his outcomes. Phase one has resulted in Peter leaving the day care project for two days per week and having his own support worker that he employs directly using his personal budget. He is using this service to increase his skills in working towards living independently. Peter is now looking for paid work opportunities. He identified initially that he wanted to learn to drive and to look for possible driving work. Ahmed worked closely with Social Services to establish his Consultant s agreement to this and he was then able to apply to the DVLA for a provisional licence. This was successful and Ahmed was able to use his Personal Budget to fund driving lessons. Peter hopes that Phase two will result in him living independently in his own flat with the support that is required. He hopes to achieve this in a year s time with the use of his personal budget. He is also thinking about leaving his day centre and increasing his support worker hours. Peter has been able to share his experiences of personal budgets with other service users and this has encouraged them to explore the use of personal budgets to achieve change with positive outcomes. He has also attended our Supporting People forum and made them aware of his needs and has requested their financial support towards his future plans. He is awaiting their decision. How Ahmed used his money. Ahmed is a year old man recovering from mental ill health. About two years ago, when Ahmed was unwell, he attempted to take his own life; this resulted in the need for hospital admissions. Some months later he passed his driving test and now holds a full UK driving licence. Ahmed then identified a number of training courses as an alternative to his day care attendance that would utilise his driving skills so that he could gain paid employment. Ahmed attended a fork lift truck driving course and passed with flying colours. However, completing the course he did not think that this would be a job for him. He is now planning to attend a Heavy Goods Vehicle training course with the use of his Personal Budget. Ahmed also identified that he wanted to use his Personal Budget to improve his health. He was able to join a local gym and now takes regular exercise. He is now looking fit and trim and feeling much healthier. He was also able to work closely with Social Services and his Consultant 6 City of London Council in Control Partnerships

8 and is now able to manage his own medication with prescribed tablets, rather than the need for fortnightly injections that Ahmed disliked and wanted to stop. Ahmed continues to make positive progress towards his mental health recovery. Ahmed has now left the supported housing project and is living independently in his own flat. Ahmed has been able to share his creative use of his Personal Budget with other Service Users and other professionals. He has completed many presentations to internal and external agencies and has motivated them to explore the benefits of Personal Budgets. Ahmed has recently been offered a place on a training course to become a support planner and we hope to be using his skills and expert experience with other Service Users in the preparation of Support Plans. How Mary used her money. Mary is 7 years old who has a physical disability. She lives at home with her husband and primary carer James who is 7 years old. Mary has Parkinson s disease which affects her physical functioning and cognitive abilities. Mary uses a wheel chair and requires assistance with her moving around. Mary also has uncontrollable and unpredictable spasms that require immediate medication to prevent possible harm to her self and others. Her husband, James managed Mary s care without support for a number of years. However over time Mary s condition has become severe and he has been unable to manage her care without support. His caring role has also impacted on his own health as is often the problem for carers. Initially services were provided by morning and evening visit from carers. However it became evident that it was impossible to specify when Mary needed help it might be at any time in the day. Mary and her husband began to think that the only solution was residential care though as The only solution was residential care but as Mary said, I ve always dreaded it and I don t want to be parted from James Mary said I ve always dreaded it and I don t want to be parted from James. Mary and James requested a visit to discuss this and found out that there was the possibility of a Personal Budget to assist Mary in avoiding residential care by employing a live in carer who would provide services to support Mary in her own home and at the same time reduce the caring responsibilities of her husband, whose health was also being affected. Luckily Mary lives in a two bedroom property and used one of the bedrooms as a spare room for guests. With the The only solution was residential care but as Mary said, I ve always dreaded it and I don t want to be parted from James use of her Personal Budget, Mary has been able to employ a hr live in carer and this arrangement is now working extremely well. Mary has been able to receive the correct level of care that she requires and her husband has been able to reduce the level of care he previously provided. He is now able to have regular breaks and his good health is slowly returning he has even been able to do some charitable work, as he wanted to do his bit for the community. With the use of her Personal Budget Mary has been able to stay at home with her husband. She has remained independent and in control and has avoided the need for residential care As they say It s the perfect solution for us!. City of London Council in Control Partnerships 7

9 What happens next? Following the success of the pilot, the next challenge for our Adult Social Care service is to proceed towards a total transformation of our services and to consequently be able to offer Self-Directed Support to all our service users. By the end of we are aiming for % of our service users to be in receipt of a personal budget. To help us achieve this target and share information about the pilot, people already in receipt of a personal budget have been telling their success stories to other service users and local professionals. Some people who now have a personal budget have given a presentation about their experience to local politicians, Commission for Social Care Inspectors and neighbouring local authorities. Two existing Personal Budget holders are training to become support planners/brokers themselves and will be able to offer support planning assistance to others. In the longer term we are planning to provide a complete Self-Directed Support service that offers either Direct Payments or Personal Budgets to all users. To achieve this we plan to integrate additional funding from areas such as Supporting People and the Independent Living Fund. There are two other challenges that will need to be overcome if we are to succeed in our plans to expand the personal budget scheme. Currently the Fairer Charging Policy guidance dictates that state retirement pension is still treated as a source of income for Personal Budgets in contrast to earned income. This creates a disincentive for people to work and needs to be reviewed. It is not currently possible in the city to make personal budgets available where the health authority contributes funds to support a person. However NHS London is setting up a pilot project to review the situation. Whatever the obstacles we believe that the principle of Self-Directed Support is now established in the City and our future service provision will be based on this principle. Mark Peak Personal Budgets Pilot Scheme Manager. The City of London Corporation is an unusually diverse organisation with three main aims: to support and promote the Square Mile, the financial and business heart of the UK, by maintaining and enhancing its status as the world s leading international financial and business centre to provide the highest quality local government services within the Square Mile for the benefit of workers, residents and visitors alike to provide valued services to London and the nation as a whole, especially regeneration of the surrounding area in partnership with its neighbouring boroughs. The City pre-dates parliament and its experience and tradition underpins its modern and efficient services. It operates on a non-party political basis through its Lord Mayor, aldermen and elected council members. 8 City of London Council in Control Partnerships

10 Results of satisfaction survey People were asked they had a personal budget to judge their satisfaction with various aspects of their life, and were asked again having Being with people Being you with want people you want 6 Choice and Control Choice and Control Definitely Just Not Definitely Not had the personal budget for some time. The results of the survey are presented here. Health and Wellbeing Health and Wellbeing 7 6 Very Good Fairly Good Not Good Feeling Safe at Home Feeling Safe at Home Definitely Just Not Definitely Not Very Safe Fairly Safe Fairly Unsafe Very Unsafe Money Money Thinking of Thinking your life of as your a whole life as a whole Definitely Just Not Definitely Not Very Happy Fairly Happy Fairly Unhappy Unhappy City of London Council in Control Partnerships 9

11 This report is an account of our work and the things we believe we have learned by implementing Self-Directed Support in the City of London. The findings are not intended to represent the results of an academic study, rather they are a critical self evaluation of our progress to date. The findings represent our best attempt to understand and report the things people have said to us about their experience of taking control of a personal budget. City of London, Adult Social Care Department: Tel: social.services@cityoflondon.gov.uk Website: Address: City Of London, PO Box 7, Guildhall, London, ECP EJ in Control Partnerships Website: