Why are personal budgets not working for older people?
T he recently announced extension of personal budgets is a clear sign that the government's ambition for self-directed support shows no sign of waning. Not content with overhauling the structures for funding and delivery in adult social care and elements of the NHS, advocates of personalisation now push for the holy grail: integration.
From 2015 opportunities for combined health and social care personal budgets will be available, as announced by NHS chief executive Simon Stevens. As if to add a further challenge to this Herculean endeavour, one of the earliest target groups will include frail older people with long-term conditions, whose meagre appetite for personal budgets has been a hallmark of implementation ever since direct payments were first made available.
Ben Goldacre's angry reaction on social media to this news was rooted in concern over the evidence base. Had he confined his attention to research with older budget-holders, his mood would scarcely have improved.
Large, independent evaluations of both social and healthcare variants have found that the positive outcomes for working age adults were not apparent for older people. This has been supported by subsequent research, albeit of limited scale. Analysis of POET (personal outcomes evaluation tool) data finds that older budget holders also typically report lower satisfaction than working-age adult client groups. This latter finding is worth dwelling on, since people in later life almost always report more positive views about care services than younger adults. Any study finding the reverse is probably performing well below par as far as older clients are concerned.
Possibly, personal budgets are the victim of their own success with younger adults. The story of the independent living movement is one of a gradual revolution, seeking to unlock shackles that prevent disabled people from achieving their full potential. Person-centred support planning is a powerful tool in this mould, enabling service users to reflect on where they wish to be, and designing the support needed to achieve their life ambitions. It doesn't take a feat of imagination to see how life affirming the support planning process can be: it is not simply a means to an end. This might go some way to explaining how research has found positive results for younger adults only a few months down the personal budget journey.
Yet older budget-holders are likely to frame their ambitions differently, often in terms of stability, maintenance and protection;
a language less familiar to those who cut their teeth in the support of younger people. What makes for a successful support planning experience among the oldest old will be different to other groups, and needs more research.
Person-centredness, broadly defined, has been 60 or more years in the making. However, the flag-waving of recent years towards choice and control over services, as a way to achieving personal autonomy, may have been at the expense of other important features. Not every choice is, or can be, articulated; not all control can be executed with precision. Service users are reliant on the skills of care and support workers to work with them to achieve their goals, through their understanding of the person they are supporting. Resource allocation systems, brokerage toolkits and risk facilitation panels form an enabling architecture, but will come to nothing if care workers are not person-centred themselves.
For older people, and the oldest old in particular, it is in the interaction with the practitioner that the magic of person-centred care happens, not in the support plan. Evidence suggests that older people often prioritise the affective characteristics of care relationships, built over time, where interpersonal exchanges maintain a person's sense of identity and value. While personal budgets are associated with the quest for independence, in some quarters interdependence is considered the best way to achieve the long-term care goals of older people. Specialist training for home care workers in these features of person-centredness is rare, and will continue to be so as long as they are not viewed as legitimate features of care quality.
As for the hope that personal budgets could solve the integration puzzle, it is easy to be cynical, given the skeletons of many previous policies that litter the road. Integrating multiple funding streams as part of the individual budget pilots proved enormously difficult. But for older people, often using the broadest range of health and care services, the potential is enticing. There are echoes of the care management pilots, which combined integrated care planning with devolved budgets, and proved successful with older people. Perhaps this is where personal budgets will find traction.
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