The problems of personalisation

Personalisation is at the centre of the prevailing belief system about how social care should be managed and run. It asserts that people should decide for themselves how their support needs will be met and that people will be “more directly involved in the services they use as well as taking responsibility for costs and risks” (SCIE: Coproduction in social care, 2013). It translates into practical systems of self-directed support and personal budgets that have been universally adopted by local authorities. People are encouraged to ‘shop for support’ rather than waiting for support to be arranged and allocated. No longer are professionals trusted to decide how services will be organised and public money spent. ‘Choice and control’ is the mantra. The job of authorities is to facilitate and regulate the market of providers from which individuals will purchase. Over time, people’s decisions to buy will determine the nature and shape of that market.

Apparently, there are few dissenters. After all, this seems like the way we all behave day-to-day: we don’t need an official to organise our groceries or accommodation or transport; why shouldn’t we minimise official involvement in the care and support we require.

Some people have articulated possible concerns about the impact of markets in public services:

  • People don’t want choice; they want a good local service.
  • The better off will make good choices; the poor will be left with poor facilities.
  • Choice and competition in public services will undermine the public service ethos.

(Legrand, 2010)

However, we’re probably too late to debate these points in a care market that is well down the path to becoming largely privatised.

This note comes at personalisation from a different angle. It argues that, personalisation, as many staff in social care organisations have received it, is oversimplified and that, as a consequence, we are at risk of missing the point of what people need and want.

Let’s start with the predicament of someone who, quite suddenly perhaps, find themselves dependent on social care services to manage and to get through the next few weeks and months. Becoming dependent on others may have rocked their confidence and sense of who they are. They may find themselves all at sea, directionless, fearful and massively disconcerted by the problems they have to deal with. Of course they want to be treated in a considerate and personal way but ‘personalisation’ and ‘choice and control’ may not, at the time, rank among their priorities. At such a time people look for reliable, solid, uncomplicated and competent support. They are looking for people who know exactly what to do. They may be looking for someone to come in a take control for a while: to provide guidance, direction and practical help. They won’t be looking to shop for anything. There’s no arbitrary time limit to this kind of want and need. Some people will take time to find the confidence to set their own direction and begin to exercise small measures of control.

Then there is the person who supposes that they have a ‘contract’ with the welfare state. It is a supposition they have grown up with and it means they have an expectation of what public services are there to do. Their choice might be to stick with the conventional services that they have known and used over the years, services that are predictable and that are run by the state for the public. This person might find the idea of involvement strange: ‘Tesco’s doesn’t ask me to  help run the shop; BT doesn’t ask me to co-produce my phone service; the refuse service doesn’t give me control over the colour of my wheelie bin .. so why, when it comes to caring for me, am I suddenly responsible in some way for organising what goes on?’

We might see ‘choice and control’ as an absolute value to be asserted at all times for all people who rely on social care services. It is a version of the older social work idea of ‘self-determination’. Both are derived from the broader, but not straightforward, concept of ‘freedom’, and both are associated with the idea of ‘human rights’. However, in everyday life many of us voluntarily concede large chunks of the choice and control we could have. Think of marriage and other personal relationships in which personal choice and control is conceded and shared in order to allow those relationships to work. Think of families. Think of affiliation to faith groups and other associations where people voluntarily submit to the control of others or to a belief system. In these examples people contend that they have met their needs (and sometimes found freedom) by relinquishing control. The social work task is more subtle than simply promoting choice and control. The question may not be: ‘How can you give me the purchasing power so I’ve got more choice and control?’ but: ‘How can you use your resources and skills to help restore relationships, roles and affiliations I had where choice and control was shared and mediated by family, friends and others’

It is a mistake to imagine that choices about what to do in life are easy things to make. But our systems of ‘personalised social services’ seem to imply that they are. We talk to someone about our needs; then draw up a plan; then arrange to receive and manage a budget; and then get on and spend it. Simple? We could be lulled into thinking that it’s just a case of choose and buy, just like our online shopping. People in the middle of an, often critical, dilemma about their health and care needs are often not well placed to choose and buy. Very few people understand the ‘care market’ and how to weigh up what it has to offer. Most of us haven’t had the practice or training to decide whether to put our health and wellbeing in the hands of this agency or that. Few of us want to become employers or commissioners and run the business of our own care. This is what people are frequently faced with while, at the same time, being told about how liberating and empowering this business of choice and control is. Making decisions about how to re-organise your lives that many people with social care needs (and their families) have to face is hugely complicated and full of many risks. Yet the provision to help people and families embark with confidence on and then navigate the route to a re-organised life is very hit and miss.

It is a feature of the current legislation, not significantly changed in the Care Bill, that services are provided to individuals, either service users or carers. Assessment in its present form concerns each individual, one at a time. The policy of personalisation follows suit. We treat each person as a separate and largely self-contained unit, then find solutions for each person, again, one at a time. What happens between and amongst people is something of an afterthought. When most of us sustain ourselves through our family and social relationships this could be seen as a problem: ‘I don’t want something for me but for us’; ‘My choices are always made with my family and friends’; ‘We want a budget to do things sometimes together and sometimes separately.’ This suggests that, for some people at least, assessment and resource allocation makes sense when rooted in a social context from the start and that solutions are often more social than personal.

Think Local Act Personal tells us ‘There is still a considerable way to go to ensure people experience genuine choice and control and personalised support in all settings.’ (TLAP 2013). However, there is no let up in their enthusiasm to take the project forward for all groups. Tentatively, it is proposed here, that we may need a modified language for some people. Families of adults with profound cognitive or memory impairments who have spent many years trying to elicit responses from their relative and meticulously identifying their signs of pain, discomfort, pleasure and so on, may find it patronising, to say the least, when someone arrives with an offer of ‘genuine choice and control’.

For many people the system is just as paternalistic and controlling as it always was. Tens of thousands of older people in residential care have little prospect of things becoming more personal or within their control. Tell the man who has had to put up with being bathed by a new and inexperienced young person almost every week that his care has become more personal. Tell the profoundly disabled young adult who finds that cuts to her day service staff mean she’s spending even more of her time without a meaningful conversation that there’s more choice.

Personalisation is an important idea. However, it is not, in the way it is often presented, the sole basis for a comprehensive programme of social care. As with any idea that translates into far-reaching policy change, we need to evaluate the idea in practice and assess how far it matches the requirements of all the people it is intended to serve.

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