Transcript Individual budgets: evaluation

Housing LIN
17 February 2015
What price care?
Research reflections
Martin Knapp
PSSRU, Social Policy Department
London School of Economics and Political Science
NIHR School for Social Care Research
What price care? Research reflections
A. Mixed economy of care
B. Personalisation &
choice
C. Neighbourhoods
D. Design & technology
E. Concluding comments
NIHR School for Social Care Research
Mission: to develop the evidence base for adult social care
practice in England by commissioning and conducting
world-class research
• LSE, KCL, Universities of Kent, Manchester, York
• £30 million funding over 10 years (since May 2009)
• Both ‘intramural’ and ‘extramural’ commissioned research
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Conduct and commission high-quality research
Provide focus for social care research within NIHR; strategic leadership
Develop methodological rigour and broaden repertoire
Consult widely on research priorities
Help to build social care research capacity & awareness
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Support knowledge exchange and impact
SSCR: activity since 2009
70+ commissioned projects
completed or underway.
The research questions
follow wide consultation.
Active engagement with all
stakeholders
40+ methods & scoping
reviews commissioned –
promoting understanding
and research skills and
capacity.
Annual conference
Aim to span today’s (and
tomorrow’s) leading social
care practice issues.
Full programme of seminars
& workshops on leading
practice topics.
Findings available on many
topics
We are very keen to engage
as widely as possible
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Personal Social Services Research Unit @
LSE (February 2015)
Research areas
• Social care service evaluation
• Dementia
• Systems / policy analysis
• Outcome / performance meas’t
• Modelling needs, funding & LTC
• Children & young people
• Mental health economics & policy
• Unpaid care
Overarching emphases
• Policy engagement
• Improving user, carer involvement
• Practice relevance
• Supporting staff development
• Academic contributions
• Impact & knowledge exchange
• International collaboration
All work/staff externally funded: 40+ staff; 0.2 HEFCE
Project lengths range from 2 weeks to 4 years
The Social Care Elf (launched 26 Nov 2014)
Aim: to get the best available evidence to
those who need it
• Scanning >70 journals, databases &
websites
• Identifying relevant & reliable evidence
• Blogs on days that start with T
• Short summaries (<1,000 words)
• Critical appraisal and commentary
• Written by researchers, social care workers,
others
Mixed economy
of care
Provider types
• Public sector: the state - national, regional
or local
• Voluntary (Third) sector: organisations
independent of the state which cannot
distribute any surpluses (profits) to owners
• Private (for-profit) sector: also
independent of the state, but surpluses
(profits) can be distributed
• Informal sector: individuals, families and
groups without formal rules / structure /
governance
Purchasing routes
• Public sector: ‘coerced’, collective. Public sector
acts on behalf of citizens, mandated by
democratic processes, funded mainly by taxation.
• Charitable: uncoerced, collective. Voluntary
organisations use voluntarily-donated funds to
finance their own or other services
• Corporate: private-sector companies funding
services or insurance for employees or families.
• Individual (own use): payment for goods or
services by the individual using them
• Individual transfers: payment for goods or
services by one person for use by another person
The mixed economy of care matrix
Public
Voluntary
Private
Public
sector
Charitable
Corporate
Individual –
own use
Individual
transfers
Martin Knapp, The Economics of Social Care, 1984
Informal
Policy options in the mixed economy
Public
Public
sector
Hierarchy
& quasimarkets
Charitable
Voluntary
‘Out-sourcing’ or
contracting out
Foundation
support
Corporate
Individual –
User
own use
charges
Individual Donations
transfers
to the
state
Private
User
charges
Informal
Services
for carers
Community
grants
Paid leave
for carers
‘Textbook’ Self-care
markets
Support for
neighbours
Martin Knapp, The Economics of Social Care, 1984
Personalisation
and choice
Why this policy/practice emphasis? (1)
• Long-standing social work commitment to selfdetermination for (under-privileged) individuals and
families – i.e. empowerment …
• (Also to encourage personal responsibility for
health e.g. for lifestyle, diet, exercise, alcohol…)
• Empowerment could encourage services to be more
responsive to individual needs & preferences.
• Social care, public health (and health care?)
emphases on the roles of families & communities
• … particularly benefits of social capital (trust etc.)
• And over-arching belief that individual, family & social
outcomes will be better; and/or costs will be lower
Why this policy/practice emphasis? (2)
• Citizenship agenda – ground-level politics,
participation
• Rights-based advocacy by / for service users
• Flexibility: personalisation potentially offers different
levels of independence & control
• ‘Collectivization of welfare’ – encourages informal
pooling of budgets.
• Political support:
– from Right – encourages personal responsibility;
accountability; market-like allocations (e.g. PBs)
– from Centre Left – encourages public confidence,
social inclusion, personal rights
Personalisation in practice in social care
• Services tailored to the needs of the individual,
rather than ‘one size fits all’
• Services tailored to the preferences of the individual
Hence actions could include:
• Better information & advice on care & support
• Promotion of independence & self-reliance among
individuals & communities (includes social capital)
• Prevention / risk-reduction strategies that
emphasise personal strengths & responsibilities
• Direct payments and personal budgets (with
appropriate brokerage & support)
Evaluating personal budgets (IBSEN)
CORE QUESTION  Do individual (personal) budgets
offer a better way to support disabled adults and
older people than conventional methods of resource
allocation and service delivery?
If so, which models work best and for whom?
Evaluation dimensions
User experience
Carer impact
Workforce
Care management
Provider impact
Risk & protection
Commissioning
Outcomes
Costs
Cost-effectiveness
Glendinning et al (2008) Evaluation of the Individual Budget Pilots + numerous journal
Outcomes and costs (IBSEN evaluation)
Domain
Pooled sample
of all users
Subgroup
differences?
Quality of life
No difference
IBs better for mental
health subgroup
Psychological well-being
No difference
IBs worse for older
people
Social care outcomes
No difference*
No difference*
Satisfaction
IB better
IBs better for
physical/sensory
disability group
Costs
IB lower (small
diff)
No difference
* IBs offered more ‘felt control’ when analysed for the overall sample
and the learning disability group
Overall conclusions from IBSEN
 Positive effects of Personal Budgets (IBs)
- Quality of life, social care outcomes and
satisfaction
- Outcomes linked to level of support
- Overall - cost-effective use of public resources
 But much less positive for older people
- Concerns about managing budgets
- Concerns about employing PAs and similar
- Individuals needed more preparation & support
- Carers much more positive, however
Adult Social Care Environments & Settings
• The ASSET study explored views and experiences of people
commissioning, delivering and receiving adult social care services
in extra care housing and retirement villages.
• For some older people a move to housing with care improved
quality of life compared with living in mainstream housing.
• Local authority commissioning approaches vary considerably
• Urgent need to provide better financial information to current
and prospective residents and their families - including
information on personal budgets, direct payments and
charging arrangements.
• The housing with care model can support residents who are very
diverse in terms of abilities, needs and care packages.
Simon Evans (Univ of Worcester) et al. Funding NIHR School for Social Care Research
Neighbourhoods
Neighbourhood effects
Social capital  socially cohesive  better health and
wellbeing, reduced level of (perceived) crime, higher
educational achievement, economic growth
Volunteering  intrinsic motivation and benefits, health
and wellbeing, pathway to employment
Social support  reduced social isolation, loneliness and
depression, and risk of death
Community capacity-building  can be effective and
cost-effective
Age-friendly  involve older people as participants,
respond to local conditions, including (e.g.) neighbourhood
hubs to ease access to healthcare, social care, local services
and facilities.
Halpern (2009), Ironmonger (2006), Steptoe et al (2013), Knapp et al (2013), Foresight
Age-friendly neighbourhoods
Neighbourhoods that are valuable resources for older people are:
• age-friendly
• safe
• changeable in response to preferences of people who live there
They should:
• … not stop people getting to outdoor spaces
• … have a minimum of physical barriers and the right kinds of
facilitator (e.g. longer time intervals for pedestrian crossings)
• … have good and accessible community transport, particularly for
those older people no longer able to drive or be driven
• … have safe spaces to allow full community participation
• … support implementation of community contributions to health
and social care support.
Chris Phillipson (Univ of Manchester) for Age UK volume, 2015
Isolation and loneliness
• Social isolation among older people is growing.
• Isolation is a risk factor for loneliness and poor health
(including depression, cardiovascular problems and cognitive
decline).
• Interventions such as structured befriending programmes
and time banks – that build social capital – may help to tackle
the problem, although evidence in support of their benefits is
not yet overwhelmingly clear. Probably cost-effective.
• Services are acquainted with emerging evidence on social
isolation and loneliness-associated risks, but less clear about
what to commission.
• Neighbourhoods and communities can help to combat
negative effects of isolation.
Emilie Courtin & Martin Knapp (LSE) scoping review for SSCR
Anna Goodman (Campaign), Adrian Adams, Hannah Swift (Univ of Kent) for SSCR
Economic pay-offs from community resources
Time banks
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Cost per time bank member = £607 p.a.
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Economic pay-offs = c.£1300 per member
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… of which £187 = short-term cashable to govt.
Befriending
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Cost per older person = £90 over 12 weeks
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Economic pay-offs = £490 including QOL gains
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… of which £38 = short-term cashable to govt.
Community navigators (benefit & debt advice)
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Cost per ‘hard-to-reach’ person = £611
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Economic pay-offs = £360 (or £1200 including QOL
gains)
Knapp, Bauer, Perkins, Snell, Community Development Journal 2013
Design and
technology
Mismatch in housing
• Housing stock mismatched with needs of older
people: 35% of households consist of 1 or 2 older
people, but most homes are designed for families,
with three bedrooms.
• How much housing more appropriate for families is
being occupied by older people?
• Many older people want to move to ‘appropriate’
properties but they are not available: specialist
housing commonly provides 1-bedroom units,
whereas most people prefer 2-bedroom.
• Changes in mainstream housing provision have
generally been slow.
Foresight Ageing programme; evidence reviews, 2014-15
Design & technology
• Much research into design requirements of
housing for older people
• Support for well-being, accessibility, sensory
contact and support, health and safety. More
attention now to design for dementia.
• Adaptations: grab rails, better lighting and
other home improvements
• As individual needs (and preferences) change,
can housing respond?
Jeremy Porteus (Housing LIN) for Age UK volume, 2015; Foresight Ageing programme
Support in the home
• ‘Handyperson’ services; support for ‘low-level’
needs
• Home care services – changing, but not
always for the better
• Better support for carers (e.g. START)
• E-inclusion of older people? Challenges?
• Telecare – acceptable? adapted to individual
preferences and needs?
• Robotics (e.g. for dementia)?
Sanders et al; Henderson et al for WSD trial; MonAMI results; SSCR on home care
Concluding
comments
Policy and research
• Policy often moves ahead of research
evidence – sometimes good, sometimes bad
• Changing demographics mean that growing
(and changing?) needs of an older population
should not be a surprise
• Research can continue to feed information into
the sector to support better provision and
more-informed commissioning
Changes in attitude / approach over 70yrs
Segregated Medically
institutional based
care
approach
‘Lunatics,
cripples,
idiots’
Cure
Doctor
knows best
Community Duality of
-based care health and
and
social care
support
Clients and
service
users
Care
Professional
intervention
Personalised
support
Citizens
with equal
rights and
opport’s
Independ’t
living
Recovery
SDS
Individual
knows best
Coproduction
Socially
based
approach
(Borrowed from a presentation by Robin Murray-Neill)
Funding, disclaimer, conflicts of interest
Some of the work presented here was supported from:
• the Department of Health (DH) for England
• the National Institute for Health Research (NIHR) School for Social Care
Research
• the Economic and Social Research Council
• the Alzheimer’s Society.
All views expressed in this presentation are those of the presenter, and are
not necessarily those of the DH, NIHR, ESRC or Alzheimer’s Society.
I have no conflicts of interest to report that are relevant to this
presentation.
Thank you for your attention
[email protected]