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During the last two decades social care for older adults in England has witnessed many significant changes. Implementation of the community care reform, privatisation of the social care and Direct Payments have had an impact on the social work as a profession to date. In the first part of the literature review I would like to give an overview how all of these initiatives shaped present social work practice for older adults and then focus strictly on personal budgets and recent research of the practice.
‘Traditional’ social work characterises working closely with the service user, building very much needed relationship, assessing problems, making a judgment about coping abilities, looking on range of resources and at the end making an informed professional judgment about the best way to support service user (Lymbery, 1998). Dustin (2006) presents ‘traditional’ set of skills such as communication and interpersonal skills, use of self, negotiation and mediation skills as well as appreciation of organisations and procedures as a core of the practice. In the 1980s government’s concerns about increasing number of older people as well as running very expensive residential care have been a driver for transformation delivery of social care (McDonald, 2010). Furthermore, and most significantly, a new Conservative political view included:
“a belief in the greater economy, efficiency and effectiveness of private sector management; consumerism; the virtues of competition and the benefits of a social care market; and a deep mistrust of public service professions and their claims to special knowledge and expertise” (Lymbery, 1998, p. 870)
had its reflection in implemented legislations and community care reforms. The White Paper Caring for People: Community Care in the Next Decade and Beyond and The NHS and Community Care Act 1990, implemented in 1993, introduced care management and changed the role of the social worker in statutory sector. Hugman (1994, p.30) argues that “the care management is a move away from professionally defined responses to need to managerialist responses dominated by resource priorities”. McDonald (2010, p. 28) also states that “professional discretion has to a large extend been replaced by formulaic approaches to assessment and service eligibility”. Community care reform imposed on practitioners to focus more on the processes and on more complex bureaucracy what affected other aspects of care managers/social workers practice such as limited and formal contact with the service user and therefore difficulties in building up relationships with the client, reduced emotional support, counselling role, advocacy role, group work, less attention to monitoring and reviewing (Lymbery, 1998; Postle, 2002; Weinberg et al. 2003; Carey, 2008). Carey (2008, p. 930) states that:
“the quasi-market system has also helped to create a complex administrative system based around the management of contracts, assessments, care plans and a seemingly infinite variety of bureaucratic regulations and procedures. Most such tasks are relentlessly processed by often perplexed care/case managers, many of whom quickly begin to question any initial motivations to enter social work”.
Lymbery (1998) points out that more administrative system and budgetary constraints took away from practitioners a sense of traditional role and increased monitoring of social workers’ decisions. It has been argued, that key community care reform objectives such as a wider range of choice of services, reducing unnecessary paperwork, meeting individual needs in a more flexible and innovative way have not been achieved (Scourfield, 2006; Carey, 2008).
The next important step for the shape of present social care has been introduction of direct payment schemes. The British Council of Disabled People (BCODP) presented findings of their research in publication Cash in on independence with evidence that directly provided services were inflexible, unresponsive, unreliable and take away service users’ control over the support (Zarb and Nadash, 1994). The BCODP also proved that direct payments can be cheaper and at the same time can provide a higher quality of support (Glasby and Littlechild, 2009). Under the pressure of sustained and strong campaign for reform from the BCODP and other bodies, the government finally implemented The 1996 Community Care (Direct Payment) Act (Glasby and Littlechild, 2009). The Act allowed making cash payments by local authorities to individuals to arrange their own support (McDonald, 2010). In 2000, direct payments were extended to other service user groups and from now on older adults could also benefit from it (Glasby and Littlechild, 2009).
Following direct payments, in 2003, the charity organisation in Control, focused on people with learning disabilities, developed the new way of organising care called self-directed support (Glasby and Littlechild, 2009). Browning (2007, p. 3) states that “the introduction of self-directed support is potentially the biggest change to the provision of social care in England in 60 years”. The terminology has developed during the process of implementation of this concept. By 2004 in Control started using the term ‘individual budget’ which describes budget from several different streams such as the Access to Work; the Independent Living Fund; Supporting People and the Disabled Facilities Grant; local Integrated Community Equipment Services, adult social care and NHS resources. In the pilots where funding streams were not integrated and projects relied on social care funds the term personal budgets was being used (Glasby and Littlechild, 2009). The in Control Partnership desire was to have their concept to be fitted to the existing social care arrangements, to free up available resources, which were “tied up in existing buildings and pre-paid services” and to allow people to use them flexibly and creatively (Glasby and Littlechild, 2009, p. 77). The aim of personal budgets was to shift power to service users by adaptation to the way of allocating resources, controlling and using the support (Routledge and Porter, 2008).
At the same time the government was facing challenges such as aging population, care within the family becoming less an option, more diverse communities, higher expectation form the service as well as continuing desire to retain by people control over their lives as much as possible, including risk management (DH, 2005; HM Government, 2007). Older adults are the largest group of recipients of social care with more than a one million in 2006 (Leadbeater et al., 2008). The number of people of state pensionable age is gradually increasing with twelve million in mid-2009 (ONS, 2010). Some of the above factors have been a drive for government’s increasing interest in a personalised system as a way of saving cost in already constrained budget (Glasby and Littlechild, 2009). From 2005, numerous documents such as Independence, Well-Being and Choice, Our Health, Our Care, Our Say: A New Direction for Community Services, Opportunity Age and Improving the Life Chances of Disabled People, Transforming Social Care stated government’s support and shift towards personalisation (Routledge and Porter, 2008). In 2007, The Putting People First concordat informs about reforms to transform the system, based on £522 million Social Care Reform Grant, to include service users and carers at every step of organising care (HM Government, 2007). Although the government states the way forward, it gives little explanation what it will mean for the front-line practitioners, for their roles and tasks required under new arrangements (Lymbery and Postle, 2010). It states
“the time has now come to build on best practice and replace paternalistic, reactive care of variable quality with a mainstream system focussed on prevention, early intervention, enablement, and high quality personally tailored services” (HM Government, 2007, p 2).
The Putting People First concordat (2007, p. 3) also says about more active role of agencies, emphasises greater role of self-assessment, therefore giving social workers more time for support, providing information, brokerage and advocacy. It also underlines importance of person centred planning, self directed support as well as personal budgets being for everyone. Glasby and Littlechild (2009, p. 75) define personal budget as:
“being clear with the person at the start how much money is available to meet their needs, then allowing them maximum choice over how this money is spent on their behalf and over how much control they want over the money itself”.
The recently published, in 2009, Working to Put People First: The Strategy for the Adult Social Care Workforce in England states a bit clearer roles and tasks of front-line staff under new arrangements and recognises social worker’s role as a central in delivering personalised service.
“Social workers play a key role in early intervention, promoting inclusion and developing social capital as well as safeguarding adults in vulnerable circumstances. They are skilled at identifying models of intervention, some therapeutic, some task centred and working through with people the outcomes to be achieved. They also undertake navigator and brokerage roles as well as supporting self-assessment” (DH, 2009, p. 34).
However, Lymbery and Postle (2010) points out that the strategy does not explain who will be undertaking specified roles and tasks, “we have the right people doing the right roles and not using highly skilled workers for lower skilled tasks” (DH, 2009, p. 33), and therefore the situation from community care reforms replicates where introduction of care manager denied the unique position of social worker. On the other hand, Glasby and Littlechild (2009) point out that the change of the social workers’ role from focusing on assessment to support planning and review will give more chances to work in partnership with service users to support them, what was the reason for many to come to the social care profession.
There is an agreement that social workers’ motivation and support are crucial for the success of personalisation and based on their education and experience they are best-placed to fulfil roles and tasks in the new arrangements (Tyson et al. 2010; Samuel, 2010). Results from Community Care and Unison this year survey regarding impact of personalisation on social workers reviled that 88% of respondents had recognised some impact on their job, with 40% saying it had been positive and 29% negative (Samuel, 2010). Two years ago in similar survey, negative impact of personalisation claimed only 18% of respondents (Samuel, 2010). One of the most important evaluation of personalised budgets undertaken by IBSEN (2008) indicates that practitioners attitude towards the new system was based on the positive experiences of service users, strong leadership from managers or implementation team. On the other hand, hindrance for positive experience included “high workloads, poor information and training about IBs, and the lack of clarity about detailed processes as new systems were put into place” (Glendinning et at., 2008, p.22). The IBSEN study also indicates that inclusion of front-line practitioners in developing documentation and processes was key factor for successful implementation. The limitations of the IBSEN study are that it have been conducted in very tight timescales and with continues policy changes and delays, however it is a crucial research on the early impact of individual budgets (Glasby and Littlechild, 2009). My research study will examine in depth the experiences of front-line practitioners of implementation of the personalisation and will also look at their positive and negative drivers.
The Community Care survey has found that two-thirds of respondents experience increase in bureaucracy as a result of transformation (Samuel, 2010). There has been an indication in the IBSEN study, two years earlier, that completing assessment and other office based duties was time consuming, however this increase was not significant. Although increased bureaucracy was an effect of more administrative approach of care management after community care reforms (Weinberg et al., 2003), it has been pointed out by Richard Jones, president of the ADASS, that some councils had over-complicated processes such as self-assessment and support planning (Samuel, 2010a). My research will provide in depth insight of the administrative role of the front-line practitioner in current system.
The social workers’ experiences varied significantly regarding assessment process based on self-assessment, with some seeing it as a complete transformation, where for others it was a move towards further development of practice (Glendinning et al., 2008). At the beginning working in dual assessment systems has been recognised as a major challenge (Glendinning et al., 2008). Moreover, the view of social workers from Community Care survey match with opinion form IBSEN study that self-assessment was not giving complete picture of a person’s needs, with no focus on risk, issues regarding carers and their needs, and putting at risk social workers skills and professionalism (Glendinning et al., 2008; Samuel, 2010). The in Control report of the Second Phase (Hatton et al., 2008) sees self-assessment approach as the way to reduce the process and at the same time social workers’ time on this task. On the other hand, Lymbery and Postle (2010, p. 11) point out that assessment is “at the heart of what social workers do” and that not all service users have a ability and knowledge to recognise their needs and then to find appropriate ways to address these needs. Front-line practitioners reported that self-assessment usually has been undertaken with support from a family member or a friend, which has been seen as essential support (Glendinning et al., 2008). It can be seen as a potential ground for conflict of interest between service users and carers with examples such as need for respite care or risk within home setting (Lymbery and Postle, 2010). On the positive side, some front-line practitioners indicated that self-assessment shows that “peoples’ views were taken seriously and as having the potential to generate positive discussions about needs and outcomes” (Glendinning et al., 2008, p. 147). The IBSEN study recognises that social workers’ involvement in this process in work with older adults may be of more importance. Older people become more isolated, have less available support from family, they tend to under-assess their own needs as well as do not perceive their behaviour as creating risk (Glendinning et al., 2008, p. 147). CSCI (2009, p. 137) back up above points regarding assessment stating that “In practice, and particularly for people with complex needs, self-assessment entailed intensive support from care managers, more demanding of staff time and skills than traditional professional assessment”. However, Community Care survey (2010) showed that two-third of social workers did not have enough time with service user to support self-assessment.
In support planning process, exploring options, co-ordination, building confidence and empowering service users and carers were the main roles and tasks mentioned by care co-ordinators (Glendinning et al., 2008, p. 147). Many co-ordinators taking part in IBSEN study admitted that the focus on outcomes had an important impact on their practice. Some participants said that one of their roles was to translate the information given by service user in order to produce a meaningful plan. One of the key issues, raised by practitioners, was confusion whether allocated monies based on for example personal care needs could be used flexibly to purchase other services. Further source of confusion and frustration for front-line staff as well as service users and carers, reported in the IBSEN study, was regarding the material good allowed to be purchased and whether family member could be paid for provided support. Specifically regarding older adults, the issue has been raised that their “needs tend to change much faster, therefore a support plan may be out of date within a couple of months” (CSCI, 2009, p. 140). In relation to support planning, the Resource Allocation System (RAS) has been perceived by front-line staff as purely mathematical, easy to use tool, on the other hand, some practitioners said that such mechanical approach to allocation of resources cannot fairly and accurately distribute resources due to complexity of service users’ needs and circumstances (Glendinning et al., 2008). This research will look at the experiences of front-line staff regarding assessment process, support planning as well as resource allocation in new arrangements.
In CSCI report (2008) there is indication that the new arrangements for social care might increase the level of risk for service users. This issue arise especially where service user with complex needs is involved, as he/she might not be able to show distress (CSCI, 2008). Lymbery and Postle (2010) state that critical in terms of safeguarding in new arrangements is to retain professional engagement with service user. The IBSEN study states that giving service users more responsibilities and therefore more risk was in personalisation philosophy from the very beginning and also recognises that it is a difficult shift for care co-ordinators (Glendinning et al., 2008). Front-line staff had concerns that money could be spend inappropriately by service users, that they might not have appropriate skills and experience to employ PAs, that PAs had proper training to provide for example personal care tasks in safe and effective way (Glendinning et al., 2008). Contrary to that, in Control Third Phase evaluation (2010, p. 73) evidence suggests “that people feel and are safer when they are In Control of their support and their money and they can determine what happens around them on a day-to-day basis”. In in Control study 60% of professionals said that there was no change in risk management from the start of Personal Budgets (Tyson et al., 2010). On the other hand, Community Care survey (Lombard, 2010) found that 37% of social workers do not know what to do when care arranged by service user puts him/her at risk. My research project will examine in depth the view of front-line staff regarding risk assessment and implication, if any, of shifting more responsibilities to service users.
Training, knowledge and skills
The IBSEN study found out that most of the care co-ordinators had training provided before implementation of the individual budgets, however there was some who did not have any before undertaking first IB case (Glendinning et al., 2008). The participants in the IBSEN study said that training was focused more on the idea and philosophy behind individual budgets, and did not concentrate enough on processes (Glendinning et al., 2008). Successful in terms of informal training were recognised interactive activities such as team meetings, meeting with IB team workers and development officers and peer support development groups (Glendinning et al., 2008; Lombard, 2010). The Community Care survey on personalisation shows that there are significant knowledge gaps amongst social workers (Lombard, 2010). 63% of respondents admitted the need for brokerage skills, with only 31% stating that they have them. An understanding of the key terms and overall knowledge about personalisation has improved (57%), however 14% of social workers still understand little or nothing about individual and personal budgets (Lombard, 2010). Only 49% of practitioners said that they feel they have enough knowledge about employing personal assistant (Lombard, 2010). My research will examine the experiences of front-line practitioners regarding received training as well as subjective opinion about skill gaps in their practice.
The need for cultural shift and change of mindset of service users and practitioners has been recognised in several publications as one of the most important issues (Glendinning et al., 2008; CSCI, 2009; DH, 2010). The CSCI report (2009) shows that it was not expected from older adults that they will appreciate additional responsibilities in managing individual/personal budgets, however in some sites more older people decided to have Direct Payment and to manage the money by themselves. In addition, in Control report (2010, p. 135 – 136) shows that by the end of 2009 30.000 people were having Personal Budgets across 75 local authorities with older people being the largest group of receivers (53%). The in Control evaluation was based on online data voluntarily shared by local authorities, however there was no requirement on authorities to share data as well as not all authorities included breakdown by social care group, therefore the information from this report does not show an accurate national picture (Tyson et al., 2010). The Personal Budgets for older people – making it happen guidance (2010) emphasises importance of sharing successful stories and cases in order to challenge front-line practitioners’ stereotypes and increase positive attitude towards older people as a recipients of personal budgets.
In this year Community Care survey 36% of respondents said that resources have been the biggest barrier for successful implementation of personalisation. Moreover, based on the information about planned cuts in public sector by the current government, 82% of respondents said that this will slow down the progress of personalisation (Samuel, 2010). It has been pointed out in several publications (Glendinning, 2008; Carr and Robbins, 2009; Samuel, 2010) that front-line practitioners using only public resources face significant challenges in exercising choice, control and independence of service user and his/her own creativity. It is well pictured in this quote “this is more difficult when a budget is strictly for personal care that is essential – the equivalent of 30 minutes’ washing and dressing a day is not going to allow much creativity” (Fighting Monsters, 2010). Social workers under new arrangements will still be responsible for control expenditure with “funding targeted at those most in need” (HM Government, 2008, p.9) what clashes with one of the key principle Putting People First which is prevention and early intervention (Lymbery and Postle, 2010). This research project will examine in depth the view of front-line staff about using of existing social care resources in order to fulfil policies principles and meet older adults’ needs.
In the CSCI report (2009) it has been emphasised that to allow people to exercise choice and control and to feel independent, together with transformation of the system, the existing services need reconfiguration. At the moment “services are limited and insufficiently flexible, where day services are traditional and predominantly based in buildings, and where block contracting arrangements limit the range of services on offer” (CSCI, 2009, p. 148). The Community Care survey (2010) found out that 56% social workers have noticed that services such as day centres are being closed down on the assumption that using personal budgets will mean reduced use of such services. Services, especially from local authority, will have to by attractive, flexible to needs, affordable, price competitive, sustainable, well structured and managed to meet service users’ needs (Tyson et al., 2010). My research will examine social workers experiences of changes in structure of services for older adults with the emphasise on increasing their choice, control and independence.
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