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Transcript of Personalisation Edge
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Personalisation: On the Edge o an Innovation
PersonalisationOn the Edge o an Innovation
Research Paper | April 2010
By Sarah Thelwall
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Personalisation: On the Edge o an Innovation
Contents
Introduction 3
. Implementing Personalisation no longer the why but the
how? 4
. Maintaining enough stability to keep innovating 5
.3 TUPE and the perpetuation o a two tier workorce 8
.4 Upgrading the inrastructure to enable smooth spot
contracting 9
The day to day challenge o implementing personalisation
Barbara Martin and Brandon Trust
. Barbara and her background
. Independence and decision making
.3 Three examples o day to day decisions - money, medication
and activities
.4 Barriers and risks
.5 The Cornwall context 4
.6 Development o the Brandon Trust team 5
3 What needs to change i we are to scale up the provision o
personalised care? 6
3. The need or suciently stable conditions (to support
innovation) 7
3. An ability to take positive risks and ront load the budget
or change 7
3.3 The development o social markets 8
4 Bibliography 9
5 Endnotes 0
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3 Personalisation: On the Edge o an Innovation
The wind o personalisation is blowing
through public services in the United
Kingdom. Its principles o individual
empowerment, inclusion, and partner-
ship are being adopted beyond the
health care setting in social services,
and in parts o the education and
employment systems. Recognisingthe broad benets o the person-
centred approach beyond the niche
requirements o adults with learning
disabilities where it was initiated in
00 is a antastic validation o the
core principles o personalisation. But
as Leadbeater and Bartlett1 note, the
biggest challenge or personalisation
indeed any innovation is scaling
it up into a long term sustainable
approach. In that sense we are still on
the edge o an innovation.
The Association o Chie Executives
o Voluntary Organisations (ACEVO)
notes that the government has set
a minimum target or 30 percent o
local authority-unded adult social
care service users to be on a per-
sonal budget by April 0, but many
authorities have gone urther settingtargets o 60-00 percent2. Although
every council has introduced personal
budgets, in reality many authorities are
working at levels much lower than the
8 percent national average3. In order
to achieve those bold targets, service
users, commissioners and providers
will be required to scale up and speed
up processes o personalisation. To
be successul there will need to be
greater clarity on what is working well,
why that is, and how to build upon it.The concept o personalisation takes
people orward into a place where
they can be empowered to have real
control. To make this happen there
are immediate barriers which need
addressing.
This paper looks at the leadership
role that Brandon Trust (www.
brandontrust.org) is playing in the
implementation o personalisation
o services or adults with learning
disabilities. It considers the challenges
that personalisation brings, both on an
organisational level and or individual
tenants and the people who Brandon
Trust support. The paper indicates the
areas where collaboration is required
between policy and delivery leaders i
personalisation is to become truly em-
bedded within the provision o servicesto adults with learning disabilities.
Based in Bristol, Brandon Trust is a
charity employing nearly 000 sta
1. Introduction
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4 Personalisation: On the Edge o an Innovation
supporting approximately 500 people
with learning disabilities. It was ormed
in 994 as a result o the closure o
long term hospitals. Institutional learn-
ing disability services were transerred
rom the NHS into community
residential care provision (serviced
by both private and not-or-prot
providers). Since 994 Brandon Trust
has expanded its activities and now
operates teams across Bristol, South
Gloucestershire, Gloucestershire,
Bath and North East Somerset, NorthSomerset, Plymouth and Cornwall. It
has also developed a reputation as an
innovator in the eld o care provision
or individuals with learning dis-
abilities. Its commitment to delivering
personalised services to the people it
supports can be seen not only in the
shits made rom large group living to
small groups and individual housing
options, but also in the wide range odevelopments in work, learning, and
leisure opportunities which Brandon
Trust has pioneered with its partners
and the people it supports. This
refects Brandon Trusts attitude to
service development the organisa-
tion develops services with rather than
forthe people it supports.
1.1 Implementing Personalisation
no longer the why but the how?
Whilst the 00 white paper Valuing
People: A New Strategy for Learning
Disability for the 21st Centuryset out
the governments commitment to
providing new opportunities or children
and adults with learning disabilities, it
was the 005 Mental Capacity Act
(MCA) which created the leverage
to ensure its implementation. ValuingPeople articulated its new vision based
on the principles o rights, indepen-
dence, choice and inclusion. The MCA
set out principles which assume that
an individual has the capacity to make
a decision, and that decisions made on
their behal should only be taken i it
is demonstrated that the person lacks
that capacity.
Valuing People and the MCA have been
key markers in the personalisation o
services as they supported the shit
rom establishing whythe agenda
is imperative, to understanding how
personalisation might be achieved inpractice. Indeed the MCA has led to
the establishment o processes or as-
sessing an individuals capacity to make
decisions which are now a regular part
o planning and service development
with service users and the proessionals
with which they work.
As a provider committed to the ongoing
development and improvement osupport provision, Brandon Trust has
positioned itsel at the leading edge o
service innovation. The charity started
developing supported living packages in
00. Supported living enables people
to live more independently by giving
them greater infuence over their living
environment. It also gives them a
stronger voice in discussions about how
their support will be provided, which
tends to lead to greater fexibility over
the hours and types o support they
receive. Supported living gives people
both the rights and the responsibilities
o being a tenant in their own home.
This is an enormous shit away rom
large group residential care and nursing
homes. Reconguring long term ser-
vices in this way is presenting a number
o structural challenges or Brandon
Trust, their sta, the health and socialcare services proessionals with whom
they liaise, as well as the people they
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5 Personalisation: On the Edge o an Innovation
support. It is this change process that is
the ocus o this paper.
As we move rom pilot projects with
small numbers o service users to
mainstreaming personalised services
and associated contracting, we should
expect to see challenges o scale aris-
ing. With providers who are embracing
the shit rom block to spot contracts,
these challenges are already evident.
IThe scale up o personalisation is
having a signicant eect in three keyareas:
the ability o organisations
to maintain enough stability
to keep innovating;
TUPE (Transers o Under-
taking, Pension and Employ
ment) and the perpetuation o a
two tier workorce; and
upgrading the inrastructure to
enable smooth spot contract-
i ing.
This rst section o this paper explores
these three challenges, drawing on the
experience and perceptions o Brandon
Trust. Sharing how one organisation
is meeting the challenges o person-
alisation, the paper hopes to develop
insights that might be instructive or
other providers working to personalise
services in the social care sector, and
shed light on how a national policy is
being translated into action.
1.2 Maintaining enough stability to
keep innovating
Brandon Trust aims to balance theongoing innovation and development o
new services with a process o main-
streaming innovations once they have
been piloted and proven. Both o these
require a marketplace which provides
sucient stability to enable them to
achieve a return on their investment
i.e. a marketplace which rewards the
calculated risks they are taking. A mar-
ketplace which oers spot contracts
lasting no more than six months would
not be ideal in this scenario.
Brandon Trusts Gloucestershire
contract provides an interesting
comparison to the spot contract marketo its Cornwall operations. Set up in
006 between Health/the Adult Social
Care Gloucestershire Partnership and
Brandon Trust, this 5 year contract
covers the provision o services to
6 people. In theory the contract
allows Brandon Trust to charge or all
6 people irrespective o the actual
number o services users (i.e. they can
charge or empty beds). At rst glanceone might suggest that this would
hinder innovation. In reality the contract
provides stability to the partnership
which has enabled ongoing innovation
in the services provided, controlling the
move rom a residential care model to
one o individualised supported living
environments. The shrinkage o the
original contract is managed through
annual renegotiations. These discussions
provide a mechanism or negotiating
whether new services are held under
the original contract or negotiated
separately. In this way both parties are
able to manage the costs and benets
o the changes.
There need to be mechanisms which
minimise the length o time or which
beds remain empty. The question is how
is this best achieved? I we assume thatboth the local authority and the provider
are working towards this goal then the
crucial issue is around the period o time
between a bed becoming empty and
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6 Personalisation: On the Edge o an Innovation
the services being recongured. In small
group accommodation with budgets
based, or example, on 5 people sharing
night cover, it is a challenge to ensure
the quality o service i one o the beds
suddenly becomes empty. Providers
struggle to reduce the cost base the
moment the bed becomes empty, and
rom Brandon Trusts perspective it
would make a huge dierence to have
external cover to support these periods
o transition. The challenge o reducing
the cost base by 0 percent i a bedbecomes empty is not something which
can be addressed by reducing cover by
0 percent you cannot, or example,
have 80 percent o a sta member
present.
Equally the local authority is no longer
making the decisions about weekly sta
allocations, nor is it managing the group
accommodation and thereore it needsto pass the responsibility or empty bed
cost minimisation to the provider.
One o the ways Brandon Trust
interprets the personalisation agenda is
a willingness to maintain a central ethos,
while at the same time making adapta-
tions depending on local circumstances.
In Cornwall the strong emphasis rom
the beginning has been on individualised
negotiated independent living (see
Barbaras story or details, p. ). This
produced the clear goal o measurable
and high quality outcomes or each
person. However, inherent in this model
is fux and change as peoples individual
circumstances are open to the ebb and
fow o lie. This situation is not neces-
sarily undesirable even though it does
not contain the core stability o a teen
year change programme, as agreedand monitored with the Gloucestershire
Partnership.
A structure which didnt ensure the
continuity o care or users and which
risked disruptions could be deleterious
to the health and wellbeing service
users. I a provider had to keep chang-
ing provision mechanisms in order to
reduce costs this would be counter-
productive both or the service users
and or Gloucestershire. The contractual
structure thereore ensures that the
wellbeing o service users is the primary
driver or both decisions about current
provision and uture innovation. Bran-don Trust would argue that this stability
o working environment has enabled it
to innovate aster and to aect wider-
reaching change.
The second challenge o the (in)stability
o the environment relates to the
questions who has responsibility or
ensuring the ongoing development o
services and how is this paid or? Whenwe compare the two year political cycle
o the local authority and councillors, to
the ve year strategic plans o providers
such as Brandon Trust we can see the
argument or putting the responsibility
with the providers and thus making
it one step removed rom the orces
o local politics. In block contracting
scenarios this works well as there is
a suciently long term view on both
sides to see the benets o ongoing
service development. However in spot
contracting the risk is that not only will
shopping around between service pro-
viders drive down cost (as wed expect
to see in any open market), but service
users will be unwilling to pay or the
cost o uture innovations, particularly
i they will not individually benet rom
them. In this scenario who pays or
innovation and where is it located? Theclassic adoption curve rom innovators
and early adopters through to laggards
where the innovators pay more to
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7 Personalisation: On the Edge o an Innovation
receive innovations rst and the lag-
gards pay less but achieve the benets
ar later should not necessarily be
applied in this setting. However the
cost structure whereby innovations are
more expensive when being piloted and
less expensive once mainstreamed will
no doubt continue to apply. Who then
is responsible or covering the early and
higher costs? In a scenario where the
majority o service users have individual
budgets and take direct payments there
is likely to be a need or a separatedevelopment budget into which
providers could pitch. The risk o this
structure however is that, by separating
innovation rom delivery the processes
o innovation would slow down as it
could not easily be woven into the
overall delivery plans (as it currently is in
regions such as Gloucestershire).
The history o providers such asBrandon Trust indicates that they see
themselves as a key source o innova-
tion in the sector. The shit o personnel
over the past 0 -5 years has resulted
in many o the key innovators moving
rom commissioning roles into provider
roles. This leads to questions about the
size o organisations capable o deliver-
ing innovation in this sector. Much
o the literature cites the new-ound
reedom o individual budget holders to
employ carers o their choice without
being limited to picking rom the sta
and services o the larger providers.
Clearly this has benets to the service
user in that they can seek out care
providers who do not just possess the
skills they require, but are also locally-
based and conveniently accessed. Why
sign up or use o a day care centre i
you can work with the local communitygardening team i you preer? Anec-
dotal eedback the Brandon Trust care
teams indicate that service users with
individual budgets do indeed use their
budgets to buy more varied services.
The challenge in this diversication o
care is to locate the organisations that
still have an overview o the service us-
ers needs and care packages in addition
to detailed day to day knowledge. This
allows an organisation to spot trends
in needs and to innovate accordingly.
Such a view is unlikely to be held by
service providers working with one or
two people or providing only very niche
services.
Key regional and national providers are
well placed not only to deliver innova-
tions based on their own experience
but also to act as hubs o innovation
working in partnership with more spe-
cialist providers. There is nothing terribly
new in such an approach indeed
Brandon Trust has a growing number o
partnerships. However it is importantto recognise and actively support the
role providers play as innovators or the
sector and to look at whether there are
opportunities to extend the approach
to encompass the learnings o micro or
niche providers. This brokerage role has
been explored in detail by Innovation
Exchange, a pilot prgramme or the
Oce o the Third Sector in the Cabinet
Oce4. The challenges to the environ-
ment or innovation have also been
identied by both Geo Mulgan5 in his
study o innovation in public services
and by Matthew Horne6 in his review o
innovation brokers or public services,
in particular the lower tolerance or risk
and preerence or tried and tested
techniques, and the need to cut across
organisational and proessional boundar-
ies (ie to get beyond the proessional
and budgetary silos).
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8 Personalisation: On the Edge o an Innovation
1.3 TUPE and the perpetuation o a
two tier wo rkorce
TUPE is the UKs implementation o the
European Union Acquired Rights Direc-
tive. It has protected the undamental
employment contractual terms o
thousands o sta as they have moved
rom government and local authority
employment to outsourced roles with
independent providers. It governs
their pay, hours, place o work, annual
leave entitlements and sick pay. Thisethical approach to the provision o a
stable working environment or these
sta has kept good sta in the caring
proession, which has beneted the
service users, as well as the sta and
their amilies. No-one could argue with
the airness o intentions that underly
this approach, particularly or those
sta close to retirement who have quite
reasonably planned or a retirementbased on the NHS or local authority
guaranteed benets pension scheme to
which theyve contributed during a long
working career.
The issue o the sustainability o these
transers has arisen not rom the act
itsel but rom the negotiations with
providers such as Brandon Trust and in
particular the liability or pensions and
redundancy provision. Furthermore the
transer o sta under TUPE results
in a liability which ar rom diminishing
as sta retire is perpetuated via the
Cabinet Oces Code o Practice or
Workorce Matters and expands the
liability to cover new, non-TUPE sta
whose terms and conditions would
otherwise be set by market orces.
Employers taking on sta covered byTUPE ace a number o contractual
challenges around employment terms,
redundancy terms and pension provi-
sion. These require careul negotiations
with the commissioner in order to
ensure that not only will the contract
with the local authority cover the
TUPE commitments but also to ensure
that no additional legacy liabilities are
transerred. For example there are cases
where a pension decit caused whilst
sta were in local authority employment
has been transerred to the indepen-
dent provider. The appropriateness o
this is questionable i no provision or
the cover o such decits is transerred,i.e. i the liability alone is transerred.
Brandon Trust carries approximately
750,000 pension decit on their
balance sheet as a result o one such
contract. This issue is exacerbated in
smaller providers without the resources
to oset such liabilities even on paper.
Add this to ongoing commitments to
xed benet pensions which demand
variable contributions going orwardwhich can be in the region o 0
percent o salary (to be met by the
independent provider) and we start to
build a picture o the serious sustainabil-
ity issues acing organisations wishing
to continue to utilise these capable and
experienced sta members.
TUPE creates two urther challenges
or providers; fexibility and cost. On
fexibility, TUPE limits the extent to
which providers can transorm their
services to respond to personalisation.
Sta covered by TUPE can be moved
rom one work base to another, within
reason, and this opportunity may be
used to acilitate the re-conguration
o a service, say rom group care to
independent living. However, the oppor-
tunity is limited by the scope to move
TUPE and Code o Practice protectedsta. Where more radical change is
needed, this risks reducing the speed
o transormation to the speed o the
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9 Personalisation: On the Edge o an Innovation
retirement o TUPEd sta. While it is
possible to achieve change to pay and
terms in respect o protected sta,
this requires an onerous and risky legal
procedure, which may be successully
challenged. As a result, no matter the
legitimacy o protecting employees pay
and conditions, the result is to limit the
options or making the changes that
personalisation demands.
The second challenge TUPE creates
relates to cost, where tensions betweenthe needs to protect employees and
to reduce costs are creating perverse
consequences that risk slowing the
growth o personalisation. For example,
where there are sta covered by TUPE,
new sta will be hired on similar terms.
However, in a team where there are
no sta covered by TUPE, new sta
can be hired at market rates. Where
Brandon Trust rates or care stamight be 6-7,000 FTE (higher than
that oered by individuals with direct
payments) the ex-NHS (Agenda or
Change) rate is likely to be in excess
o 0,000. Thus the stang costs
depend on the extent to which sta
members covered by TUPE are dis-
persed across the workorce, creating
arbitrary dierences in remuneration
across the country. Where commis-
sioners such as those in Cornwall are
asking or substantial reductions in
costs (despite TUPE commitments to
infationary pay increases), dierent
organisations and teams thereore have
dierential abilities to respond, distorting
the market. While protecting employeesWhile protecting employees
and reducing costs are both legitimate
objectives, there are huge political and
administrative complexities to the issue
o TUPE. TUPE is being managed in amanaged in away that risks disprupting the work o
organisations like Brandon Trust and
reducing the ability o providers as a to
respond to the needs o citizens and
public services.
1.4 Upgrading the inrastructure to
enable smooth spot contracting
The systems which were put in place to
support the outsourcing o block con-
tracts rom the NHS to organisations
such as Brandon Trust were simply not
designed to meet the needs o spot
contracting. It is unsurprising thereore
to see increasing transaction costs andwastage o administrative resources, as
organisations try to keep the systems
updated with the changes being made
to users services. This challenge is
exacerbated by the act that each
region uses dierent systems and
protocols to manage budgets, invoicing
and payments.
The approach taken by Brandon Trusthas been to develop the regional inra-
structure to enable switer responses
and greater autonomy. Furthermore
by training the sta to a higher level
on subjects such as nance and HR
practices, issues can be dealt with on
the ground immediately rather than
being picked up centrally at a later date
(by which point there will probably have
been a longer term impact on the cost
o a users services). This can be seen
in the restructuring o the organisa-
tion and the creation o the Locality
Manager roles when compared to the
old ront line manager roles we can see
that this post has greater responsibility
or implementing services to meet
local needs. This means greater budget
responsibility, covering income as well
as expenditure, so that it eels much
more like running a business rather thanreporting through a hierarchy. Working
in connection with the development
managers to maintain standards and
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Personalisation: On the Edge o an Innovation
The challenges and successes o
personalisation operate on a very
dierent level in a policy and strategy
context to the way they play out in
individual lives. By researching the
impact o personalisation on Barbara
Martins lie we can very quickly see
what the practical dierences are andwhere the challenge lies. From this we
can draw conclusions about where
the bottle necks are likely to appear
when scaling up personalised support
nationally.
2.1 Barbara and her background
Barbara Martin lives in her own home
in Launceston, Cornwall. These days
she makes many o the decisions
about how she wishes to live her lie,
rom choosing the colour o paint in
her fat through to deciding what to
cook or dinner and how to spend her
money. These sound like the basics o
lie but or many years such decision
making was undertaken without
Barbaras involvement. Barbara was
diagnosed with a learning disability as
a child; the response was to provideinstitutional care in the orm o large
NHS long term accommodation. It was
not a question o whether an individual
might be capable o taking medication
o their own volition; more a case
that all medication would be provided
eciently at allocated times. Yet or all
that eciency, it was not until Barbara
reached her thirties that she was
diagnosed as having hearing loss. Until
that point it did not matter how manytimes she said she could not hear the
issue was not addressed. Literally her
voice not being heard and she could
not hear the voices o others. How
times have changed.
Ater years o institutional care Bar-
baras lie started changing. First the
Care in the Community changes o
the Thatcher government meant that
Barbara moved to smaller group ac-
commodation. She was accompanied
by a smaller team o dedicated sta
supporting a group and their specic
needs. However it was only once the
authorities accepted that Barbara
would unction better i she had her
own individual accommodation that
signicant steps were taken to support
Barbara individually rather than just as
a part o a group.
2. The day to day challengeo implementing personalisation
Barbara Martin and Brandon Trust
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Personalisation: On the Edge o an Innovation
2.2 Independence and decision
making
Barbara has strong views about
independence and eels that the
service that Brandon Trust provides
must promote her rights and indepen-
dence. The MCA has given providers
and supporters the ramework to
promote and implement a change in
how decisions are made. No longer
are decisions restricted to the support
workers and the amily; instead there isa partnership which starts with Bar-
bara hersel. She makes the decisions.
For example Barbara now manages her
own money and, whilst her supporters
will inorm her as to where they eel
money will need to be spent, ultimately
Barbara makes the decision. In order
to achieve these sorts o changes a
greater proportion o the time spent
with Barbara is allocated to developingher learning. Pictoral inormation is
used in day-to-day decisions which are
then passed on. The rota o support
sta is now available to Barbara and
the shopping list uses pictoral rather
than text based lists. The rst things
that Barbara sought to change in order
to give hersel greater independence
were processes which would enable
her to manage her own medicationand her own money and the removal
o locks in the house. In prioritising
these changes Barbara was choosing
changes which enable her to spend
more time alone.
2.3 Three examples o day to day
decisions - money, medication and
activities
Managing her own money comes with
risks as there are situations in which
Barbara would be vulnerable. Once
a month Barbara will work through
possible scenarios with her team to
equip her to deal with situations which
may occur e.g. being coerced into
giving money to a stranger.
Barbara also manages many more
aspects o her medication. Brandon
Trusts role in this was to devise
creative solutions that enabled such
positive risks to be taken i.e. to man-
age the real risk o Barbara orgetting
to take her medication and balancing
this against the quality o lie andincreased independence. In this case
the changes involved providing the
medicines in a blister pack so that she
could see how many to take and when.
She also uses a light with a timer on it
which alerts Barbara in the mornings
to take her medication at the right
time. These changes were backed by
fexible support so that she had extra
help to learn to make the change inthe initial stages and less support once
the activity had become embedded in
her daily routine. The level o support
needed or this and other activities is
reviewed at monthly meetings be-
tween Barbara and her support team.
Role play activities and discussions are
included to cover saety issues and
to ensure that Barbara knows how to
respond in less common situations and
where to turn to or help.
2.4 Barriers and risks
Lack o knowledge was probably the
greatest barrier to change or both
Barbara and her support team. They
had all come rom a background o
institutionalised care. Barbara hadnt
learnt the basic skills that would be
required to participate in independentliving; equally her supporters were
not used to supporting her in these
settings. Previously Barbara had little
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3 Personalisation: On the Edge o an Innovation
understanding o the concept o
money or concepts o choice. Like
many people her understanding o law
was based on how they play out in her
lie (wearing seatbelts, not stealing,
cleaning up ater your dog). Barbara
nds more abstract denitions o
the law or even the laws that have
made a dierence in her lie, such as
the Mental Capacity Act, dicult to
conceptualise.
Bridging this conception gap hasto come via the team who support
Barbara. For these sta, having access
to positive learning and development
programmes which enhance their skills
and knowledge is crucial. This is one
o the impressive commitments that
Brandon Trust has made to their teams
o supporters; real, relevant, in-house
training. The changing role o sta
rom carers to supporters has beenachieved not only through education
and training but also inclusion in the
process o change and the develop-
ment o assistive technologies.
Unsurprisingly changes to core support
such as that around the taking o
medication and management o her
mental health were seen as signicant
risks. The concerns by both proes-
sionals and amily members were that
Barbara would not be able to cope
with choice and change and that her
support sta might not spot i medica-
tion errors arose.
The risks o change are being miti-
gated in two main ways. From Brandon
Trusts side, when proposing a solution
to a need or change identied by
customers like Barbara, they will pres-ent the need, their proposed solution,
and a risk analysis to their liaison point
in the local authority. They have ound
that presenting solutions along with
the needs speeds up the process o
change signicantly. From Barbaras
perspective by undertaking entry level
education, similar to NVQs, she can
demonstrate that she has acquired the
skills required to undertake household
activities such as using the washing
machine, making a phone call or playing
a DVD as well as community activities
such as catching a bus, joining and
using the library and so on.
The response rom Barbaras amily has
been mixed. There are those who are
very happy with the changes and are
pleased that Barbara is more indepen-
dent. However there are also those
who think that Barbaras condition and
the challenges that it presents place
her at such risk as to require continual
support.
Barbara started to manage her own
medication when she transerred her
provision to Brandon Trust in 007, she
started to manage her own money in
September 008 and the locks that
had previously been placed on doors
and cupboards or the kitchen, ood
cupboards, medicine stores and laundry
areas were progressively removed
between 007 and May 009. These
changes have reed Barbara up to
spend more time alone and to spend
this time as she chooses; she now
goes shopping alone, attends a gym,
and has joined a walking group. By
undertaking these activities rather than
attending a day centre or adults with
learning disabilities not only is Barbara
more independent but she is known
in the community and is thus saer as
people in the community look out orher. Barbara is also more assertive and
empowered so when unplanned situ-
ations arise, such as getting lost, then
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4 Personalisation: On the Edge o an Innovation
she is better equipped to ask or the
help she needs.
2.5 The Cornwall context
Cornwall went through a series o
dramatic changes in the healthcare
inrastructure under the supervision
o a Special Measures team rom the
Department o Health. One o these
changes was in the way in which
budgets or the care o adults with
learning disabilities are managed. As aresult o shiting to individual budgets
Barbara was able to choose both the
organisation who provided her care
and the individual carers who support
her. Barbara chose Brandon Trust
rom a shortlist o three providers and
wrote out a list o names o people she
wanted to support her. Why them? I
liked Brandons DVD My Unique Lie
the woman who had the cleaningjob, she was just like me. I like the way
Brandon Trust wrote out the plans as i
direct to me. Lynn and Nick, they came
to meet me and were interested in my
lie. It is important to note that up until
this point Barbara had no choice over
who provided her support nor on the
carers she saw on a day to day basis.
There was simply no one through any
part o the process that sought her
opinion on such things.
The commitment to personalise
service provision has caused Brandon
Trust to make signicant changes in
the way they operate both locally and
as an organisation. Whilst Brandon
Trust has a long record o high quality
care provision in Bristol and the sur-
rounding area they had not provided
services in Cornwall beore nor hadthey worked with so large a number o
people with individual budgets. Instead
o the head oce team pitching or
a centrally awarded contract the
regional director Lynn Toman and her
team spent their time attending com-
munity events, discussion meetings
and in one-to-one conversations with
service users. This Hearts and Minds
campaign resulted in Brandon Trust
becoming the single largest provider
o care services to adults with learning
disabilities in Cornwall. Brandon Trust
currently supports 93 people in the
region.
As Brandon Trust was new to Cornwall
they had the reedom o a blank sheet
o paper when it came to structuring
the local team. They operate a very
fat structure with very high levels o
communication between the senior
team members (about 0-5 people).
External assessments o sta views
on this have repeatedly concluded
that this has made the senior teammore accessible and transparent and
that sta eel comortable bringing up
ideas, and articulating the needs and
problems o the people they support.
In the changing roles o service users,
the way services are bought in a
market place rather than allocated to a
provider and the changing roles o sta
rom nurses and carers to acilitators,
community builders and educators this
transparency and accessibility is more
crucial than ever; as both sta and
service users need to easily see how to
eect change.
This changing role o sta was not
without its challenges. In particular
those with nursing qualications
and many years o experience went
through a phase o eeling that their
skills were no longer valued in this newmarket place where people wanted
acilitators not carers, advisors not
duty-o-care managers. However as
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5 Personalisation: On the Edge o an Innovation
the team were embedded it became
clear that the core people and care
skills were still very much o value,
even i the ways in which they were
provided were changing dramatically. A
ar greater emphasis is now placed on
the sta role in building connections in
communities, researching opportunities
and acilitating education and train-
ing. The result is that both sta and
service users eel much more closely
connected to decision-making pro-
cesses and ar more involved in them.
2.6 Development o the Brandon
Trust team
The Brandon Trust Cornwall team
requires a ar greater knowledge o the
internal management processes which
enable the smooth running o the
contracts and budgets this means
tighter nancial management monthto month, and greater knowledge o
what causes over or under spending.
They have established indicators
earlier in the delivery process to fag up
dierences between the service level
that has been contracted and actual
delivery. This is particularly important
when making provision or unplanned
or emergency changes in the support
provided or example, i a service
user alls ill and requires hospitalisa-
tion. Brandon Trust has changed its
contracting so that such eventualities
are costed and approved at the start
o a contract and only charged or i
circumstances require it.
The challenges o TUPE and the ways
in which the ongoing service delivery
and development costs are covered is
a live issue in Cornwall as service usershave the fexibility to change providers
at six months notice. Approximately
80 percent o Brandon Trust sta
were transerred over rom the local
authority or the NHS. We see a market
place where the service users are ar
more acutely aware o the market rate
or the services they are purchasing,
and thus more aware o the impact o
increased costs resulting rom highly
variable yet pre-dened sta rates o
pay. An example o the sorts o con-
versations and dilemmas this presents
comes when a service user is planning
a holiday and deciding who to take with
them as their support sta. Dependingon the sta member it could double
the cost o the holiday and thus call
into question whether the person can
aord to go.
The issues o the perpetuation o a
two tier workorce and the need or
organisations to build in the costs o
managing a workorce, their training,
and new service development is put-ting services under urther strain now
that the local authority in Cornwall
have capped the rate that they are
willing to pay to 5.69/hr (with excep-
tions being made or certain types o
highly specialised provision). To date
Brandon Trust has demonstrated that
when they are transparent with their
customers about how services cost
are created, then there is denitely a
willingness to pay extra or the quality
that Brandon Trust represents. There
is o course a limit to how much extra
people will pay. The business challenge
that Brandon Trust is acing is how
to decide which business to pitch
and which business would require a
compromise o their core values and
quality levels (and is thus not business
worth winning).
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6 Personalisation: On the Edge o an Innovation
The goal is clear a minimum o 30
percent o local authority-unded
adult social care service users to
be on personal budgets by April
0. But the path to achieving this
goal is not without obstructions.
The drive to make personalisa-
tion a reality across social careservices would be a challenge in
any economic climate. In the cur-
rent conditions the risk is that the
momentum will slow and learning
rom implementation so ar will
not be used to strengthen service
development and the mechanisms
which support it. Indeed the
greatest risk o all is that the
current economic climate and the
state o the public purse is used
as an excuse or not implementing
personalisation properly because o
the higher early costs associated
with helping people become more
independent.
The personalisation o support
does require more intensive invest-
ment in its early stages in order to
equip people with the skills neededto be more independent. However
the payos or service users are
signicant increased quality o
lie, better physical, mental, and
emotional health. For those people
with a very high cost o support
(the largest budget or a single
individual who is supported by
Brandon Trust is some 350,000
per annum) there are certainly
savings to be made in the cost o
support. It would be rash howeverto expect that the levels o savings
achieved or those individuals in
the top 0 percent o annual sup-
port costs will translate into savings
or individuals in the middle o the
bell curve o annual cost.
The question thereore is how we
can maintain and even increase
momentum whilst taking into
account the impact o the reces-
sion and its eect upon public
spending. We are, ater all, talking
about the long term health o
two percent o the UK population
(roughly 985,000 in England). Until
recently the approach taken in
regions such as Cornwall had been
held as an example, not only o the
goal we should be aiming or, but
as the implementation approach toollow. The changes in regions such
as Gloucestershire are resulting in
personalised support because o,
rather than despite, the teen year
3. What needs to changei we are to scale up the
provision o personalised
care?
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7 Personalisation: On the Edge o an Innovation
contract. Clearly there are lessons
to be learnt here in Cornwalls
contrasting approach. Comparing
these two examples, we might end
up with a set o hybrid models or
the implementation o personalisa-
tion. The goal would be to deliver
benets without the insecurity o
very short contracts which limit the
ability to recover costs invested in
change. Instead the hybrids would
aim to provide a combination o
the ability to operate a market orservices with stable high quality
services which orm the baseline
or new innovations and service
developments.
By looking at the details o how
personalisation is being imple-
mented by Brandon Trust with
people such as Barbara Martin, we
can see that there are some veryparticular challenges in the scale up
o personalisation. The challenge
o a suciently stable base rom
which to develop innovation; the
need or the reedom and the
support to take positive risks that
lead to an enhanced quality o
lie and the need or inrastruc-
tural developments to support the
implementation o personalisation
are all key issues to solve.
3.1 The need or sufciently
stable conditions (to support
innovation)
In Gloucestershire the managed
reduction o large group care
ensures a stable environment
or the people being supported
whilst managing the cost o empty
beds as eciently as possible. So
although this does not devolve the
nances down to direct payments
to service users, it does oer
innovations in personalisation and
greater transparency in terms o
individual costs. I budgets are
devolved too ar we risk a position
where no one budget holder can
und innovation themselves (they
dont have enough resources to do
so) yet the mechanisms or group
spend have been discontinued so
there is no structure or pooling
resources. I liabilities are shited
rom the local authority to theservice providers and users we risk
too much emphasis being placed
on risk mitigation and insucient
ocus on progression and develop-
ment.
3.2 An ability to take positive
risks and ront load the budget
or change
Developing the emotional, nancial,
and intellectual assets o service
users means ront-loading the cost
o change due to the educational
needs o the service-users and the
need or additional support through
the change. In the current climate
this can eel like a greater risk than
local authorities are prepared to pay
or, yet we cannot aord to reducethe momentum o the shit to per-
sonalisation. There is also a need to
support the amilies as well as the
service users not least because the
enabling o independence tends to
eel high risk and uncomortable as
the outcomes are not assured at
the outset.
The challenge in terms o organisa-
tional development is that existing
management structures tend
to ocus on the top down when
the business is won centrally but
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8 Personalisation: On the Edge o an Innovation
delivered locally. As carers shit
their role and become more akin
to acilitators or the service users
they support, there will be a greater
need or mechanisms o bottom-up
eedback, ideas generation and
piloting. This shit o roles rom
carer to acilitator will require
training and development or many
sta.
3.3 The development o social
markets
The TUPE and Concord Acts
restrictions on sta movement are
presently preventing the develop-
ment o a social market. The liability
or redundancy costs represents
too high a risk or independent and
non-prot providers to consider
making job descriptions, sta and
structural changes to supportpersonalisation. The very structures
that were put in place to prevent
a two tier workorce are in act
perpetuating it. Furthermore they
are keeping the cost o provision
o services above current market
rates which reduces the amount o
support that any individual can buy
with their budget.
The inrastructure or these social
markets needs to be put in place
so that nance systems can handle
changes to billing quickly and wont
hinder the cashfow to individuals
or organisations who are currently
shouldering a nancial burden that
was not intended. This means
pump-priming both local authori-
ties and providers to implement
changes to nancial and relatedsystems.
Overcoming these very practical,
implementation based challenges
will require greater partnership
between commissioners and
providers and more co-ordination
between departments o health,
employment and education. It is
however essential that person-
alisation is not just the ethos at
the centre o individual support
strategies but is built in to the
inrastructure and systems which
make personal support a practicalreality. For as long as the systems
strain under the weight o issues
such as sta mobility, pensions
and redundancy liabilities, return
on investment risks (played out as
variations in pricing between block
and spot contracting) invoicing and
related cashfow issues, then the
risks or providers to scale in the
scale up o personalised care willcontinue to hamper the transition.
It is not reasonable to simply shit
the liabilities rom local authorities
to independent providers. Instead
ar greater collaboration and part-
nership working is required to solve
these challenges, risks and liabilities
within the current economic con-
straints whilst maintaining a stable,
high quality system which builds
on the momentum and experience
already established.
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9 Personalisation: On the Edge o an Innovation
4. Bibliography
ACEVO, Making it Personal: A Social Market Revolution, 009
ADASS, Putting People First: Progress Measures for the Delivery of Transforming
Adult Social Care Services, 2009
Brandon Trust, Outside In: 15 Years of Brandon Trust, 009
Brandon Trust,A Short History of Brandon Trust, 008
Brandon Trust, Unique Futures: A Background Paper, 006
Brandon Trust, Unique futures: Strategic pPan 2006-11, 006
Bollard, M. (Ed), Intellectual Disability and Social Inclusion, 009HM Govt, Valuing People: A New Strategy for Learning Disability for the 21st
Century, 00
HM Govt, Putting People First A Shared Vision and Commitment to the Trans-
formation of Adult Social Care
HM Govt, Mental Capacity Act, 2005
HM Govt, Our Health, Our Care, Our Say: A New Direction for Community
Services, 007
Horne, M., Honest Brokers: Brokering Innovation in Public Services, Innovation
Unit, 009
Innovation Exchange, Innovation Exchange: Supporting Third Sector Innovation
through Brokerage, 009
Leadbeater, C., Bartlett, J., Gallagher, N. (DEMOS), Making it Personal, 008
Mulgan, G and Albury, D., Innovation in the Public Sector, PMSU, Cabinet Oce,
London, 003
SCIE, Personalisation: A Rough Guide, 008
UNISON, Tackling the Two Tier Workforce (Problems and Issues), 008
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0 Personalisation: On the Edge o an Innovation
Leadbeater, C., Bartlett, J., Gallagher, N. (DEMOS),C., Bartlett, J., Gallagher, N. (DEMOS), Making it Personal, 008
ACEVO, Making it Personal: A Social Market Revolution, 009
According to the ADASS/LGA survey as quoted in ADASSs report on the
milestones www.adass.org.ukimages/stories/Milestones%0or%0PPF%0-
%Final%09.0.09.pd
Innovation Exchange, Innovation Exchange: Supporting Third Sector Innova-
tion through Brokerage, 009
Mulgan, G and Albury, D., Innovation in the Public Sector, PMSU, CabinetOce, London, 003
Horne, M., Honest Brokers: Brokering Innovation in Public Services, Innovation
Unit, 009
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3.
4.
5.
6.
5. Endnotes
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Personalisation: On the Edge o an Innovation
The Innovation Unit
28-30 Grosvenor Gardens
London
SW1W 0TT
The Innovation Unit 2010