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Personalisation - give up or move on?

By Martin Routledge, Alex Fox, Miro Griffiths, Vidhya Alakeson

Introduction

There is lots of discussion at the moment about the state of personalisation in public services. This includes a "failure narrative" with some even suggesting that the delivery of the policy in social care has been largely unsuccessful and its extension into other areas - especially health, is really unwise. Some people have a sense of failure because they are passionate about people getting choice and control and are disappointed that things haven't moved faster or better or included everyone to date. Others believe that some of the mechanisms for delivery are not working or not the right approaches. Some see personalisation as primarily a government driven agenda or cover for cuts and oppose it for these reasons.

At a time of severe cuts, it's understandable how this failure narrative can take hold and starts to undermine support for personalisation. We have much sympathy with these concerns - especially those in the first group. But there is a risk that we forget even in the midst of the challenges, pretty much all outcomes evidence paints a picture of something potentially very positive to be built upon not rejected in favour of…. well we are not sure what. One problem is that no one seems to be coming up with any better ideas.

Asked recently to think about some ideas to drive improvements in personalisation, we did some initial thinking to try to come up with suggestions for policymakers and others. These are outline thoughts and we want to work them up and have them challenged so we can offer the best advice possible. So - here goes - we'd be very interested in people's responses:

Context

We believe that we need a personalised system of health, social care and other public services. For us though personalisation is not the end. Delivered well it can only be one (necessary but not sufficient) means to the ends of independent living, inclusion, and well-being.  Removal of disabling barriers and the establishment of important rights will be key to the change we want to see. For personalisation to make its necessary contribution we need a system which achieves/includes a number of things:

  • It explicitly supports the shift to independent living and inclusion and away from unnecessary and expensive institutional provision
  • It is joined up across health, social care and other public services for more efficiency and effectiveness
  • It is sustainable (in a political as well as economic sense)
  • It supports community and individual strength and resilience
  • Where possible it helps people avoid or delay the need for long term significant use of health and social care services
  • Where people do need long term support they have entitlements to this and can powerfully self-direct it with few hindrances
  • Integration operates not just at the system, service and professional levels but at the individual level in ways which allow the person to self-direct. Integration without personalisation will fail to deliver the shifts towards self-management and individual control which people will come to demand and resource realities require
  • It is delivered by a changing balance of "ordinary" community based support and more usefully focussed professional and provider capacity
  • Is not in the hands of a small number of organisations providing one size fits all solutions (state or independent) but rather a much larger, diverse and largely local market
  • For workers it is not a low value, low skilled experience
  • People using long term support are not dependent on the whims of charity or the uncaring market but neither are they subject to the controls of a bureaucratic state

There are some key barriers to these shifts:

  • Resources are currently allocated to organisations, services, groups and vested interests which silo and defend them in ways that do not start primarily from the interests of the people using them
  • There are powerful cultures and management of change challenges - conservative, bureaucratic and risk averse systems within which the people using services have low levels of power
  • Some real practical and technical challenges - legal, employment etc. -  how do you shift resources "upstream" when you are rationing acute support already etc.
  • People running the system are distracted and frozen by the current resource challenges (though we detect some "burning platform" effects)
  • The public have become used to a "professional gift" model of public services and need support to see the possibilities of a shift to greater self-direction

What kinds of things can help bring the shifts about? A few thoughts

Note: We have listed five areas specific to boosting personalisation. These changes would need to take place within wider system developments, especially including action on building community capacity and resilience and targeted support to help people avoid or delay the use of acute or long term support - there is real opportunity to use the mechanisms of personalisation within these areas but we are not focussing on that here. Additionally there are number of aspects of poor personalisation delivery that need to be urgently addressed - but again we do not discuss these here. The five areas are not in priority order and they inevitably overlap:

  1. Drive co-production into all areas of commissioning and delivery of key local services. Currently nearly all efforts to support public policy change involve investment and attention only on the "supply side". This would require investment in the "demand side" -people, families and communities - to provide them with the information, skills and images of possibility to require and support changes in public services. An expansion of local, interest and national networks of peer support - this includes local DPULOs and trusted sources of support, advocacy and advice from third sector organisations. Also includes investment in support for organisations to establish themselves as social enterprises etc. and be effective businesses/partners providing the things that people need - support planning etc. at an acceptable cost. There would need to be a resource transfer from councils and NHS where some of these functions are currently delivered in controlling and inefficient ways. Using this capacity we could make co-design a non-negotiable across all kinds of commissioning and provision. This implies all public services start with the question "what does a good life look like and how can public and other resources be used to achieve that" rather than "which of our services do you fit into"? (see below for more detail and mechanisms).
  2. Measure the things that are important to users of key public services and use the results to drive local developments. Currently local users of health and social care have only modest opportunity to shape local services to reflect what matters most to them. An example of how to do this is offered by the POET and Partners in Policymaking methods. POET checks the outcomes of personal budgets (or other supports) with people using them, carers, staff, then identifies areas that could be improved and the actions that could achieve this. The findings are taken into stakeholder sessions and put alongside other intelligence to agree impactful and "doable" improvements. Partners/All Together Better offers the possibility of bringing local people into close partnership with commissioners, providers and professionals to agree, own and jointly drive improvement over time.  Such mechanisms would need to be structurally incorporated into local systems (e.g. Heath and Wellbeing Board planning, council and clinical commissioning group strategy development).
  3. Lever and incentivise the development of a very different provider market. This would include the rapid expansion of support options which are currently marginal, combine affordability and offer attractive choices to significant numbers: including shared lives, flexible use of personal budgets to buy "non-service" solutions and activate community capacity. It could involve supporting the significant expansion of co-operatives and other models of not for profit ownership, provider collaborations etc. which limit/reverse the dominance of larger providers. It would require the levering of shifts to local systems of commissioning and provision which incentivise and maximise co-production in allocation and use of available resources and collaboration between a range of local providers of health, social care and housing support and support greater local diversification. It would be crucial that this is not just a commissioner/provider exchange that preserves existing interests - e.g. mechanisms such as community fund-holding which set out required outcomes while offering flexibility of activity/process to local collaboratives. Examples of ways of levering these changes might include a 'right to challenge' for commissioning functions, not just provision; Extension of the Public Services Act principle to give commercial advantage to providers which can demonstrate user ownership and/or employment
  4. Drive integrated personal budgets with a strong focus on those areas which would be of major benefit for people using them while helping to address significant system financial challenges or "wicked issues". There is a potential strong win around long-term conditions/mental health. An early step would be to extend the "right to have" a PHB beyond CHC to people with joint health and social care packages. It would probably be necessary to use strong system levers to avoid marginalisation of PHBs - for example requiring a % of local CCG budgets be used for PHBs targeted in the above areas
  5. Lever and support the re-targeted use of professional skills and capacity: includes linking people to non-professional forms of support, supporting people wherever possible to self-manage, targeting most direct professional support to people in complex and risky situations: Local Area Co-ordination, social work practices shift from care management etc. This would require the expansion of organisational forms and mechanisms which maximise the energy and innovation of key professional, worker and "service user" groups - e.g. social work practices, support for social enterprises of innovative providers, micro-enterprises, integrated professional offers, personal assistant groups etc. It would also need new approaches to professional and leadership training and development to re-orient professional priorities and behaviour

Help!

So what do you think? Are these the right or most important ideas - we'd love to hear your views - please post comments!



1 comment for “Personalisation - give up or move on?”

  1. Gravatar of Graig ForstGraig Forst
    posted 03 April 2016 at 16:20:06

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Last Updated : 31 January 2014. Page Author: Laura Bimpson.