An ownership revolution in public services?
Cuts to services are hurting older and disabled people. But as well as highlighting and debating the effects of austerity on public services, there is an urgent need for us all to engage in a new debate about who should control those services. Whereas previous debates have focused on whether control should rest with public sector or private sector bureaucracies, this debate is all about people power.
The introduction of Direct Payments and personal budgets in social care give both a glimpse of what's possible when people get control of state resources and a good guide to what can get in the way of real change in public service culture.
A significant (but still too-small) group of people who use Direct Payments (direct control over a cash allocation, given in lieu of receiving the support to which a person would otherwise be entitled) are able to hire and fire their own team of personal assistants (PAs) and to shape their own system of support. People with a pessimistic view of human nature in general, or of people with support needs in particular, once argued that this would lead to people frittering their allocation on luxuries (it didn't) and many still argue that it leads to individualism and pulls against collectivism and joined-up services. However, people have often proved to be better integrators than services, and generally much more creative. Becoming an employer has helped people gain new skills, take on educational opportunities, get a job, take part in family and community life and become active, contributing citizens, no more or less selfishly than any of us. Others have used money to help them access mainstream services such as leisure centres, as a way of joining community life and some have invested their budgets in funding shared services and starting up small enterprises which can benefit the local community.
How can we make this work for more people who need to turn to the social care system? Clearly it is not just a matter of having some money. We know that self-funders - that is to say people who pay for their own care and support - often end up paying for the most institutionalising of options, notably residential care. What really seems to make this work is having the support of people with shared experience offering information, advice and sometimes advocacy to highlight what can be possible and to give others the confidence that comes from hearing, 'if I could do it, so could you'.
There are lots of answers to this question of improving the care system, but one which is little-explored is to concentrate on increasing the ownership of care services by people who use them. Direct Payments can help achieve this when people have a large and stable enough allocation to become the employer of their own staff. But many people have much smaller allocations or less stable entitlements (because their support needs fluctuate). They may find themselves consumers of services offered by organisations in which they have no stake and over which they have little control. This can be particularly limiting when someone has support needs which are uncommon so there are few suitable providers from which to choose, or needs which are as much social as physical, making it even more important that services are personally designed by people who have a deep understanding of the individual and their informal networks of support, and who are prepared to organise the service in support of that often fragile support ecosystem.
Whilst there are hundreds of user-led organisations (ULOs) which are set up and run by people with direct experience of disability, mental health problems and so on, we need to see many more ULOs directly providing support services. The evidence shows that these are particularly valued by those who access them.
Another important approach is to encourage 'user driven' commissioning. Instead of traditional bulk purchase and block grants, this is based on a real model of 'co-production' with commissioners and service users and their organisations developing partnerships to match provision more closely to the unique needs of each service user, developing more user-friendly and flexible methods of commissioning. (opens new window)
Some people have achieved this sense of shared ownership and responsibility through gathering into small groups and co-designing tiny 'micro-enterprises', which deliver the particular mix of support and relationships which a small group of like-minded people are looking for. Most micro-enterprises have found that too many restrictions are imposed upon the use of managed personal budgets to allow individuals to spend their money this creatively, so currently most participants have been Direct Payment holders.
These innovations are scarce at present but they carry a lesson in the power of mutualism which could be learned by more traditional and larger-scale providers, particularly those which aspire to be values-led. An ownership revolution in public services which looks beyond private ownership versus public ownership, to insist on ownership which is shared between face-to-face workers and people who use services, would be one way to answer the charges of consumerism and failure to transfer power which have beset personalisation since its inception.
An edited version (opens new window) of this article appeared on the Local Government Chronicle website, 14 May 2014.