The Argument For Cost Effectiveness

Published Date: 02 Nov 2017

Introduction:

The focus of this literature review is to gain a better understanding of Personalisation and Direct Payments for the elderly. I also feel this is important as we have an ageing population and people are living longer. If the government is struggling at the moment to provide the money for services what will happen in the future as the population grows and budgets are reduced.

NCIL (National Centre for Independent Living) reports that the evidence showing direct payments to be cost-effective seems to have led some authorities to assume direct payments must always save them money. This is despite all the advice from good practice authorities, stressing that direct payments represent an effective, targeted use of resources, whether or not they actually save money … Budget issues also have an effect on individual assessments, and thus on the design of viable direct payment packages.

The argument for cost effectiveness was tested again by Dawson in 2000. It

concluded that: "A direct payment scheme that involves disabled people from its inception and throughout its operation can provide a very positive alternative to direct service provision and one which empowers disabled people to live their lives as they choose with no additional cost to the Social Services Department". (Dawson (2000))

Under the umbrella of personalization is Direct Payments which under the Health and Social care act 2001 empowers local authority social services departments to make a direct cash payment, this is for those clients that meet the eligibility criteria after an assessment has been done and it states that the client needs care. At present I am not convinced that all people will be better off with a Direct Payment and that personalization is actually working for those who need the care. I base this on anecdotal evidence within the area I work, adult assessment team, which has often expressed by work colleagues, so what could be done to make sure that direct payments really work well for people.

Before a client can have a direct payment they first have to have an assessment and go through the eligibility criteria. It is here that some clients are being excluded as they do not necessarily meet the eligibility criteria for services, to be eligible for services the client would have to be at substantial risk and in need of the services.

Crawford and Walker (2009) argue, the eligibility criteria which are applied to all who come into contact with social services "could be seen to restrict options available to older people"(Crawford, walker 2009:51). They state, the legislation Community Care (Direct Payments) Act 1996 set out to address the issues of choice and control over services giving authorities power to provide cash payments to certain individuals, initially this legislation excluded people over 65 from direct payments unless they received this before their 65th birthday. Golightley states the "HSCA 2001 made it a duty from April 2003; Direct Payments should be extended to cover and include people of any age" (Golightley 2009:107).

Evaluations have been made of a number of other direct payments schemes. Most have not been published. Similar themes emerge in them all – for instance, that payments are cost-effective. (Hasler (2003)

Direct payments and personal budgets are a central part of the personalisation agenda, the drive to give clients choice and control over the care services they receive. The aim of a direct payment is to give clients more flexibility in how those services are provided.

Direct Payments are cash payments given to service users in lieu of community care services they have been assessed as needing, and are intended to give users greater choice in their care. The payment must be sufficient to enable the service user to purchase services to meet their needs, and must be spent on services that meet eligible needs.

Direct payments were introduced in the Community Care (Direct Payments) Act in 1996/1997. It wasn’t until 2000 that people over 65 could access a direct payment. (Glasby and Littlechild 2009 2nd edition).

Methodology

A literature review is a critical look at what has been said regarding specific topic by researchers and scholars.

The aim of this research is to identify and systematically describe factors that lead to success with direct payments and personal budgets for people within the past ten years. This approach uses the analysis of data to establish if a variable has an effect and therefore a possible causality for the hypotheses. This method type is associated with literature reviews of existing studies to identify similarities or differences in outcomes (Bryman, 2008). Meta analysis may be a more effective way of establishing links between certain phenomena due to the ability to base conclusions on generalisations made from the various studies associated with the subject material and use the similarities and results as evidence to either agree or disagree with the chosen hypothesis (Vail & Cavanaugh, 2010).

All information and data used for the literature review relates to analysis of secondary data of various forms and is based on the review of the current knowledge base available on the chosen subject used to inform conclusions (Novick & Mays, 2005). An Empirical methodology is used that uses the latest publications on a particular subject matter that works backwards to establish the routes of theory associated with concepts that current thinking has built on (Grinnell & Unrau, 2011).

Firstly I checked the internet for past papers and or researches regarding direct payments/personal budgets/personalisation to see if there were any relevant information, from there I used the Solar system at Salford Universities Library department which was an informative source to use to retrieve data bases and search for relevant articles. I only used papers from the past ten years to show if things had progressed or not, to see where if there were any gap that would require more research doing.

Once I had collected the information I read the information I made some notes. Once this had been done I again read the information I made a plan of the relevant information using a three columned layout process as discussed with my training department with in social services as an easy way to evaluate a lot of information. From this I reviewed the information and made lists of all commonalities and anything that seemed to be a common issue. Once this had been done a list of recommendations from all three was made. By doing this it helped me to look at all three articles in the same way and to plan what I was doing so that it was focused and relevant.

Published Literature

I used the Salford University Solar system to retrieve databases to search for relevant Journals and articles. I also used the internet to search for other literature and books that may be relevant. I used some of the books that I have already purchased for the course as a means of reference.

I have listed below the databases that I have used and also any grey literature found.

Database

Articles

Relevant Articles

1

Academic Search Premier

4

2

2

Ovid

15

3

3

Social Care On Line

7

1

4

Science Direct

400

2

5

NHS Evidence

200

5

6

Applied Social Science Index and Abstract

2

0

7

Taylor Francis on Line

2

1

8

Alzheimer’s Research Trust

9

Alzheimer’s Society

10

Community Care

11

Dementia UK

12

General Social Care Council (GSCC)

13

Department of Health

Parameters

The search did not incorporate many parameters due to the need to broaden out the search criteria and to understand the historical perspective of the proposed theme (Cottrell & McKenzie, 2011). Due to the precise nature of the hypotheses and the view that the study is the first in the field (Norton et al, 2010) the criteria was broadened out to include the related wording of individual budgets/budgets/direct payments/ self directed support/support.

Inclusion/exclusion criteria

Inclusion criteria were broad and included studies and research related to:

English language

Published grey articles relevant to the review

An exclusion criterion was limited due to the need to expand on the theme and incorporate relevant associated material. The exclusion criteria include:

Unpublished articles

Not English language

Blogs

Limitations

There are limitations to the study due to a lack of direct comparisons. It is essential that certain issues within the study are broken down and compared with similar studies to discuss the various aspects of the hypothesis that offers scope for further research to draw conclusions that provides an evidence base.

Key Words

Personalisation, individual budgets, direct payments, carer support, employment, census, personal assistant, personal services, care, carer stress, residential care,

Critical Analysis and Discussion

Personalisation can be seen to go back as far as the 19th century with charitable social work alleviating poverty, homelessness as social work became involved in case management and the assessment of individuals having a clear distinction between ‘worthy’ and ‘unworthy’ cases.

It wasn’t until 2001 when the Health and Social Care Act 2001 Valuing People White Paper 2001 came to fruition. Giving Direct Payments to those with an assessed need also making direct payment available to more client with learning disabilities, which in turn introduced Person Centred Planning as part of the Social Work practice

In 2005 Individual Budgets were introduced to improve choice and control for client. In 2006 Our Health Our Care Our Say (Department of Health White Paper 2006) giving clients more choice and control achieving a more personalised care, this was agreed by Manthorpe and Stevens 2010:1454

Personalisation is a social care approach which is described by the Department of Health as being "every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings". (Department Of Health Cited in Community Care 25/07/12) Again this was agreed by Manthorpe & Stevens 2010:1454. Personalisation is also associated with Direct Payments and Personal Budgets to include services that are tailored to the needs of those who use services, rather than a one size fits all approach.

The Department of Health stated in 2008 that "personalisation has been identified as the modernisation of public services". (Department of Health 2008:4) Personalisation was also supposed to encompass improved information and advice on care services, the aim was to reduce delays in implementation of care services for clients to maintain dignity, healthy life style, to prevent people becoming dependant on care services as clients could see this as being a lack of independence and be more dependent on services as a loss of control and autonomy as a study by ECDP stated (2011:2), however the study found positives to personalisation, personal budgets and direct payments that clients , after being on a direct payment or personal budget for one year or more that the quality of care had improved and that the clients felt a sense of interaction.

The government introduced a White Paper in 2012 which has a central idea that the current system transforms the care system from being of one based in a crisis response to one that promotes well being and most if all independence (UK Government paper 2012 white paper). Manthorpe and Stevens agree with this as they said that personalisation does promote greater independence and well being for older clients. The governments draft Care Support Bill 2012 places a direct duty on councils to make sure clients can access the essential care providers/markets giving greater choice. The ECDP study 2012 showed many clients that stated their cash payments they received aided them to access more tailored services from local providers/markets (ECDP paper 3:3) giving the client a more independent life and being able to promote greater inclusion and control as found in the research by Manthorpe and Stevens (2010)

Direct payment and or Individual Budget cannot be used to pay for health care or day to day living expenses that are covered by other income, e.g. food, alcohol, bills or fines. It must not be used for anything which is illegal or will put the client or others at risk of harm or abuse. They will also need to show that how they plan to spend their direct payment and if it is best value for money.

A Direct Payment is a means tested cash payment made in place of regular social service provision to an individual who has been assessed as needing support. Following a financial assessment those eligible can choose to take a direct payment and arrange for their own support instead of a personal budget. A Direct Payment is just one way of taking a Personal Budget. Recently Waters J (2008) from the think local act personal blog stated that "giving choice and control of their own personal budget it is seen as better use of public money". (Waters 2012)

The legislation Community Care (Direct Payments) Act 1996 set out to address the issues of choice and control over services giving authorities power to provide cash payments to certain individuals, initially this legislation excluded people over 65 from direct payments unless they received this before their 65th birthday. Golightley states the "HSCA 2001 made it a duty from April 2003; Direct Payments should be extended to cover and include people of any age" (Golightley 2009:107).

There are approximately 56.1 million people in England and Wales. This being broken down equates to 53.0 million in England and 3.1 million in Wales. The population has grown in England and Wales by 3.7 million over the past 10 years giving a 7.1 % increase since 2001. The percentage of people over 65 is 16.4% which equates in 1 in every 6 people in the population is over 65 and that there are 430,000 people of ages 90 and over which was highlighted in the 2011 Census. (Office of National Statistics 2011)

Lloyd (2010) discussed that the projection for the next few years up to 2026 at least that the amount of people needing social care would rise to more than1.7 million, this surely must be of concern to local government with budgets to control that are decreasing by the government yearly this could jeopardise the choice and control that clients have at present.

The statistics show that the ageing population is rising and will continue to rise in the future. This is turn is putting a strain on services that are provided for older people and people age so the public budgets reduce this in turn is making current services increasingly unsustainable.

Manthorpe & Stevens state that due to the ageing population that those in rural areas experience the effects of an ageing population sooner than other part of the country. The reason for this is that people retire and move to more rural, secluded areas, not taking into account what services they may need in the future.

If the government keep making changes and cutting budgets it is therefore more difficult to attain services in urban areas but those in rural areas will feel the effects greatly (Manthorpe & Stevens 2010:1455/56). Hence the criteria for those services changes as and when the government policy/legislation and budgets change making the level of needs assessed change only being able to provide services for those clients who are at critical risk/need only, they also stated that those in rural areas and especially those that are remote would have problems with recruiting carers and also services that are provided and become more difficult to engage. (Brown Etal 2006 cited in Manthorpe & Stevens 2010:1456.)

The community care publication by Tickle (2011) stated that "there are problems with direct payments/personal budgets where the PA’s have little rights as potential employees, hence the relationship could turn sour and the cared for can feel as though they don’t have a choice". (Community Care 2011:32)

Within Direct Payments and all users groups there are some elements of power relations. It can be easy for the social worker and for the care coordinator to become the more powerful one within the relationship rather than empowering the client. It must remain that the client has the power to make their own decisions and be at the centre of the assessment and or services empowering them to make informed choices/decisions. Fook (2009) states that "every person, despite their social status and or location, exercises and has the potential to create some form of power". (Fook 2009:53) She also stated that both less and more powerful people can work together to create situations in which all experience empowerment, and more power can be created through collaboration (Fook 2009:52). Rummery (2010) agrees with this she states that a "reconciliation between a feminist demand for an ethic of care on one hand and a disability rights demand for empowerment on the other". (Rummery K 2010)

Manthorpe and Stevens (2010) say that empowerment of all could be a positive one there could be a power struggle between client, family and worker (pa) bringing disharmony and personality clashes in turn could mean possible neglect and mistreatment giving a second rate service that would not meet individual needs. (Manthorpe &Stevens 2010:1460)

The ECDP commenced a three year longitudinal study in 2009. It showed that clients who were receiving cash payments for a few months were showing signs of positive results. After a year of these cash payments there were more evidence of positive outcomes. The study grouped the results into five areas.

Improving quality of care

Increased sense of control

Improved emotional well being

Increased opportunities for social interaction

Improved family relationships

Clients reported having access to higher quality of care through cash payments receiving better levels of care, as providers giving better levels of services to maintain good relationships between all those involved and to keep their custom, as agreed in the study by Manthorpe and Stevens (2010) as well as that by Lloyd (2010) and Rummery (2011)

Another positive all researchers agreed on was improved family relationship[s as family carers have more control over their life and time, they find that they can go back to work without worrying about their family and that they can continue the care at the times that carers are not there hence preventing carer stress and the care breaking down.

However the study by ECDP found that there were issues around risk and clients being aware of these risks. The study found that some front line social worker/practioners made decisions around direct payments for clients who were based on generalised views about the capacity of certain groups such as those clients with mental health issues, which was carried out without adequate engagement with those individuals and an understanding of their circumstances. The study by Manthorpe and Stevens showed that some clients have a risk of unrealistic expectations that the support will always be provided when in theory they can not be.

Research has identified a number of barriers to Direct Payments across all groups, including Mental Health. The barriers include lack of awareness regarding Direct Payments among social workers and care coordinators, conflict between risk taking and safeguarding within vulnerable groups, lack of resources and lack of access to transport, assessments that are led by services and not by needs and concerns over the concept of being ‘willing and able’ to consent to and manage a Direct Payments. Research in relation to young adults with mental health difficulties has also identified some specific barriers. Manthorpe and Stevens agree with the above where they also state that the lack of or limited access to transport can be problematic in itself. (Manthorpe and Stevens 2010:1455)

Conclusion

Studies have showed that the take up of a direct payment by people is still slow. It showed that this could be due to the lack of awareness from professionals and the client and their carer. Therefore it would be suggestible that there should be more information for people and for professionals.

The studies showed that work still needs to be done to eliminate the barriers that people are having and are still facing such as professionals, GP’s need to be fully aware of what is available for their client and that residential care is not always the best option and that a direct payment/personal budget may be more suitable and in line with the personalisation agenda.

There needs to be more robust assessments risk assessment and inclusions of all parties involved that the process could be effective and lead to positive outcomes for all. This is especially so for those with mental health issues to make sure that a direct payment is suitable making sure that the client is not disappointed or disadvantaged/discriminated against in anyway. (Goodchild 2011, Lightfoot 2010) It has also indicated many areas for improvement such as training of staff who deal with clients on a daily basis. They also indicate many areas for improvement such as relationships between all, good communication and most of all confidentiality.

The study shows that there are many barriers for those people with a mental health problem such as dementia that there some barriers are around risk and capacity. Other barriers and concerns are that the client is able to make informed decisions about their care and are able to manage a direct payment effectively. To make sure that no one is unnecessarily excluded or disadvantaged when considering a direct payment for services. (Lightfoot (2010)). Other risks are around capacity, he concerns by professional sis that are they able to make a decisions and take positive risks, and are they able to manage a direct payment and workers?

There are however some gaps that was quite apparent within the studies this was around capacity and the lack of and in whose best interest is the direct payment/personal budget really. They also stated that there was an increase in bureaucracy in the social work role.

However it is clear personalisation in the form of direct payment or personal budget does give the client’s independence, choice and control, positive risk taking, engaging with all services and those involved, shows positive improvement and most of all it prevents the client from becoming dependant on services and being more positive and independent for themselves. They all agreed that Personalisation is the way forward for service delivery as services and budgets are constantly changing.

Abstract 301 words

Word Count 3800 words