Self-directed support

Self-directed support describes a way of redesigning the social care system so that the people who get services can take much greater control over them. Direct payments and individual budgets give people who use social care the opportunity to control their care.

The underlying principle of self-directed support is the development of a culture and the tools to enable people to take greater control of their lives and the support they receive, so that they can make decisions and manage their own risks. This puts people at the centre of assessing their own needs and tailoring support to meet their needs.

Moving from traditional service delivery to larger scale self-directed support requires changes in the way local authorities commission social care as service users become their own commissioners. Fundamental reform of social care is needed if individual commissioning is to become the norm for the majority and this has been promoted and supported by successive governments since the 1990s.

The coalition government committed to increasing the use of personal budgets in the coalition’s ‘Programme for Government’ and in the White Paper on health reform in June 2010. Caring for our future clearly sets out that people should have more choice and control over their care arrangements with better information to help them make the right decisions about their lifestyle and care arrangements. Personal budgets are key ways in which people can exercise this choice and control.

Direct payments

Direct payments enable people to have cash instead of services, which they may use as they wish to meet their support needs. Direct payments can be used in a variety of ways, such as buying special equipment, spending time away from home, going to a gym, eating out or employing a personal assistant to help with everyday tasks. They are a different way of fulfilling existing social services responsibilities by giving people the flexibility to find ‘off the peg’ solutions, although they cannot currently be used to purchase permanent residential care, local authority provision or health care.

Direct payments started to be used in 1996, initially for disabled people and their use has been gradually extended to other care groups since. Despite a slow and uneven take up of direct payments, recent policy has demonstrated the intention of government to place self-directed support at the centre of social care provision. Not only have direct payments become a mandatory responsibility rather than an option, they have also been used as a social services performance indicator.

Individual budgets

Individual budgets are similar to direct payments in that they have the same principles of service user choice and control. However, an individual budget, unlike direct payments, does not have to be in the form of a cash payment. A single transparent sum is allocated to a person in their name and held on their behalf rather like a bank account. They can choose to take this money out either in the form of a direct payment in cash, as provision of services, or as a mixture of both. Individual budgets have a number of key features:

  • It should be clear to each individual how much money has been allocated to them to spend on their care and support packages.
  • The individual should be central to the process, using their money in a way that suits their own situation and needs, with more of a focus on self-assessment.
  • Resources from different agencies, not just social care monies, can be collated together and accessed from the one individual budget to give the individual a more joined-up package of support.

In Control

Many local authorities are adopting the 'In Control' system of self-directed support, which involves a seven step process for self-directed support. The service user can decide what degree of control they would like to take over their funding and support and they can choose to receive help with the process from family, friends, care managers, independent brokers or others.

A self-assessment determines the level of severity of an individual’s need and the level of severity gives an entitlement to an allocated budget. Once people are aware of the level of funding they can plan how best to use it to meet their support needs via in-house or independent sector services, or a direct payment, or a combination of these. Crucially in this system service users know how much they have to spend and how much things cost.

Implications for strategic commissioning

Many people using direct payments presently choose not to purchase services from a service provider, instead preferring to become an employer and employ their own personal assistant. This may cause problems in the future as there may not be a large enough supply of personal assistants as the number of direct payment users grows. Workforce planning will be crucial.

The present care-management system will need to be re-designed. Care managers still need to agree support plans and take part in the review but their time may be freed up from some of the administration and assessment. Care managers may be able to put greater energy into brokering new services for those who need extra help and focus their work on people in the most complex situations.

Strategic commissioning will be required to ensure that good quality, value for money services are available for people who decline self-directed support, or for users who choose not to become employers. In order to have funding available to make increasing numbers of direct payments, local authorities need to develop financial flexibility to enable money to be withdrawn from unpopular services, so that it can be given to users who wish to commission their own support. Funds will need to be easily accessible and not tied up in long-term contracts with the independent sector, or by in-house provision. Existing in-house services and external services will need to be funded on the basis of clear, individual pricing mechanisms, which may be difficult as many local authorities have used long-term block contracts to manage the social care market and reduce transaction costs.

The 2007 White Paper Our health, our care, our say required authorities to adopt a new strategic commissioning role and to plan for the needs of the whole community, including those people who fund their own care. This requires consultation and involvement with a larger group of stakeholders and local authorities need to develop new ways of hearing the voices of service users and the local community. Commissioners need to become strategic bridge builders as they drop the role of large scale purchasers of blocks of service. Plans outlined by the government in 2010 for the transformation of adult social care further developed these ideas. Local authorities will increasingly have to develop and influence their local markets to encourage a wider range of provision from more diverse providers.

Providers may also find the transition to self-directed support challenging. Commissioners must find ways to influence the behaviour of providers so that self-directed support increases, such as encouraging providers to consider a role as support brokers or discussing the model of support/care to arrange services around achieving outcomes for individuals.

One of the key innovations necessary to help local authorities develop self-directed support on a large scale is a resource allocation system - often known as the RAS – a system which enables a quick and easy self-assessment of need and an indicative financial allocation, based on the current allocation of social care or other funding. In-Control argued that the current system of social care is inherently wasteful and that greater efficiency will be achieved through self-directed support, a message now accepted, with plans for personalisation to be rolled out to all service users as soon as possible.

A key function for local authorities and their commissioners is to develop independent advisory and advocacy facilities which people can use in deciding how to make sense of available options and the range of services.

Similarly the role of social workers and case managers is likely to change with a greater emphasis on providing information about choices and facilitating decision making.

Perhaps the biggest change is the transformation of the culture which underlies existing service provision, which In-Control calls the ‘professional gift model’, where “care comes as a gift, something you cannot control or reshape, something decided for you by the professionals who have decided what you need”. Many current assumptions about control, purpose and responsibility are being revisited.

Sources of further help - external links

  • Personalisation and Carers: Whose rights? Whose benefits? 2012 (Nicola Moran et al, British Journal of Social Work, Vol 42). This paper reports the findings of an evaluation of the impact and outcomes of Individual Budgets (IBs) for carers through analyses of qualitative interviews with IB lead officers, carers’ lead officers and carers of IB holders; and analyses of structured outcome interviews with carers of IB holders and carers of people in receipt of conventional social care services. The evaluation found that, despite their primary aim of increasing choice and control for the service user, IBs had a positive impact on carers of IB holders. The findings are important in that they have implications for the widespread roll-out of Personal Budgets in England and may also provide wider valuable lessons nationally and internationally about the tensions between policies to support carers and policies aimed at promoting choice and control by disabled and older people.
  • Social Care in Older People's Services - Facilitating the Flexible Use of Resources. 2012 (Caroline Sutcliffe et al, Care Management Journals, 13). Personal budgets in social care are a mechanism for the allocation of resources for care that permits users' greater choice and flexibility. This study was designed to explore developments in care co-ordination arrangements by examining flexible use of resources. Two national surveys identified agencies with such arrangements in older people’s services in advance of this agenda, described here as innovative authorities. Telephone interviews with their representatives explored salient factors in the development, focus, and operation of personal budgets. Carers were the main recipients, and there was also evidence of more appropriate use of resources structured around service users' needs. Implementation of personal budgets requires authorities to be more creative and flexible in respect of internally held budgets to meet the needs and wishes of older service users. This study provides evidence that some of these requirements have already been adopted by a few agencies.
  • Payment by Results – How can payment systems help to deliver better care? November 2012 (King’s Fund). This report reviews the role and objectives of payment systems in the English NHS, focusing on Payment by Results (PbR), which accounts for around 30% of the total English NHS budget. It also considers the experiences of other countries using similar payment systems. It explores whether payment systems in general, and PbR in particular, are still fit for purpose, given changing policies and priorities, such as the need for disease prevention, the prevalence of long-term conditions, the changing economic environment. It argues that more flexibility should be encouraged in payment systems to accommodate change and offer the right incentives for cost-effective, high-quality care.
  • Joint personal budgets: a new solution to the problem of integrated care? October 2012 (NHS Confederation). Like many health systems around the world, the NHS struggles to find ways of delivering integrated care. Nowhere has this struggle been more evident than in services cutting across the health-social care divide: a decades-old problem that has, for the most part, confounded local and national leaders. Now a new tool offers a radically different approach – starting with the individual service user and giving them control of a single joint budget. This Briefing introduces joint personal budgets for health and social care. It gives the context behind their development, explains how they might work and lists some of the issues that need to be considered before they could be used at scale.
  • Making sure personal budgets work for older people. October 2012 (Think Local Act Personal). Think Local Act Personal (TLAP) agreed to lead a review of personal budgets for older people including people with dementia. It has reviewed key challenges to successful implementation of personal budgets for older people and has started to identify positive practice and solutions. It has identified that most councils are identifying significant challenges in implementing personal budgets with older people – and in particular achieving good numbers while also being confident they are making a positive difference. However they have also highlighted that there is considerable emerging positive practice in each of the areas identified as challenging.
  • Best Practice in Direct Payments Support – a guide for commissioners. 2012 (Think Local Act Personal). This guide describes how to commission really good direct payments support by showcasing examples of innovative practice. It provides a practical toolkit to benchmark against best practice, identify gaps and build a shared view with local people and providers of how to develop the support needed to make DPs an attractive option for more people.
  • How self directed support is failing to deliver personal budgets and personalisation. Colin Slasberg, Peter Beresford and Peter Schofield, Research, Policy and Planning (2012) 29(3). Over the past five years, social care has been experiencing a period of change described as 'transformational'. It has largely been based on a model variously called 'personalisation', 'personal budgets' and 'self directed support'. The drive to create personalised services through self directed support and personal budgets was implemented before the model was fully tested. It is essential that legislation takes on board what the evidence says about this model – its strengths and weaknesses. This discussion shows why the underpinning notion of self directed support seems to have failed in its ambitions.
  • Commissioning for Community Inclusion. September 2012 (National Development Team for Inclusion (NDTi)). Commissioning for community inclusion focuses on building community capacity and encouraging and strengthening community action. This report is about empowering local people to provide support to others and enabling older and disabled people to contribute to community life.
  • Follow-on study: Older people who pay for care. January 2012 (Think Local Act Personal). This is a follow-on study to the Putting People First Consortium's publication, People who pay for care: Quantitative and qualitative analysis of self-funders in the social care market (2010). Undertaken by the Institute for Public Care on behalf of Think Local Act Personal (TLAP), it is a more in-depth analysis of the local factors which may influence self-funded and unregulated care. The project explored the extent to which there are local variations in the rate of self-funding across the country related to factors such as affluence, levels of owner occupation, and level of FACS criteria in operation. A second element of the project was the collection of data on self-funded and unregulated care in the home to identify what type of assistance, if any, may be needed to enable the smooth running of this section of the social care market.
  • Leaner approaches to council operating systems. October 2011 (Think Local, Act Personal). Think Local, Act Personal has developed three linked papers to show that to achieve good results that make a difference to people's lives, there needs to be simplicity and clarity around the processes of Personal Budgets. These three linked papers include Adult Social Care Minimum Process Framework; Improving Direct Payment Delivery; Re-thinking Support Planning: Ideas for an Alternative Approach.
  • Making it Real - Marking Progress towards personalised, community-based support. October 2011 (Think Local, Act Personal). This paper offers a set of statements from people who use services and carers which set out what they would expect, see and experience if personalisation is working well in an organisation. These statements are then set against key elements that would need to be in place within an organisation to make personalisation possible. The markers will help organisations involved in commissioning and delivering care and support - from councils to providers of in-home, residential or nursing care - to look at their current practice, identify areas that need improvement and develop plans for change.
  • Personal Budgets: Taking Stock, Moving Forward. October 2011 (Think Local, Act Personal). This paper provides an overview of the latest evidence in how the sector is progressing with the delivery of personal budgets. There has been some important progress made, with encouraging evidence showing improved outcomes for people. However, research also suggests action is needed in a number of key areas, including: access to direct payments, ensuring authenticity in council, managed personal budgets, better information and advice, improving equality of access, reducing unnecessary process, and increasing flexibility. Action in these areas will allow the sector to deliver on the promise of personal budgets. As an immediate first step, this paper points to where to go for further information to help address some of the challenges that have been identified and lists a number of useful documents for further reading.
  • Personal Health Budgets: Early experiences of budget holders. October 2011 (DH). Personal health budgets are being piloted in English Primary Care Trusts (PCTs) between 2009 and 2012. This evaluation report looks at the early experiences of a small subsample of budget holders and their representatives. It reports in-depth interviews with 58 people from 17 PCTs, around three months after the offer of a personal health budget, about their experiences of personal health budgets so far.
  • Whose risk is it anyway? Risk and regulation in an era of personalisation. September 2011 (Joseph Rowntree Foundation). This paper argues that ‘risk’ is often perceived negatively by people using services (used as an excuse used for stopping them doing something) – but risk needs to be shared between the person taking the risk and the system that is trying to support them; it also states that although some people fear that personalisation may increase risk, it could help people to be safer by putting them more in control of their lives, helping them plan ahead, and focusing our safeguarding expertise on those who really need it. Finally it considers the fact that in an era of personalisation, approaches to risk and regulation will need to be equally personalised.
  • ADASS Report on Personalisation Survey. September 2011 (ADASS). This paper reports on a national survey in which all councils in England with a statutory remit for adult social care were invited to take part. The survey concludes that ‘councils are generally making good progress towards universal personal budgets by 2013 and are confident they will achieve this target’. Councils said that they are fully engaged in promoting direct payments and have worked out ways to do this. Respondents also highlighted particular issues for further consideration.
  • Paying for Long Term Care in England. August 2011 (Age UK). This information has been developed by a group of public organisations and charities to help people make better and more informed decisions about paying for care. It encourages people to get impartial and independent advice about how to use their money.
  • The National personal budget survey. June 2011 (Hatton C and Waters J) Summary paper of the findings of the POET (Personal Budgets Outcomes Evaluation Tool) surveys undertaken by In Control and Lancaster University for the Think Local Act Personal partnership. The report compiles the outcomes and experiences of people and their carers using personal budgets to identify what is positive and what works to develop and continue good practice. The summary report is very user friendly and covers headlines, different experiences, processes and experiences and conclusions. The full report is available Think Local Act Personal website and on the In Control website.
  • Transforming social care: sustaining person-centred support JRF (May 2011) Summary paper on the four year JRF The Standards We Expect project. The project provided an in-depth look at the development of person centred support or personalisation from the service users, carers, practitioners and middle manager perspectives. The paper considers what person centred support means to people, how to develop it, the barriers and how these might be resolved. Findings include that good practice is possible despite fiscal constraints, open communication between all stakeholders is required and that there are still cultural blocks and power imbalances which results in less than quality personalised practice.
  • The British Association for Supported Employment (BASE) is the national trade association representing hundreds of agencies involved in securing employment for people with disabilities.
  • Keeping personal budgets personal: learning from the experiences of older people, people with mental health problems and their carers. February 2011 (Social Care Institute for Excellence (SCIE)). A research paper, conducted by the National Centre for Independent Living (NCIL) and the Social Policy Research Unit (SPRU) at the University of York, that analyses the experiences of older people, people with mental health problems and their carers using personal budgets (PBs). It makes recommendations for good practice including the importance of professional face to face communication with people about their personal budget, the importance of clear jargon-free written information about personal budgets, accommodating flexibility in the self-assessment process and clear guidance on risk and safety and how it should be incorporated in the assessment.
  • Transforming community services transformational guides. February 2011 (Department of Health) The Department of Health have produced six community service guides for frontline clinicians, commissioners and providers:
  • Self care resources: e-learning tools. January 2011 (Department of Health). The DH has developed e-learning tools to support the NHS and social care workforce to deliver personalised services in line with reform. Apart from self care resources they have developed an e-learning programme to enable professionals to deliver personalised care planning for people with long term conditions. They have also developed e-learning tools to improve skills and competencies required for assessing information needs and prescribing appropriate information for patients. The resources can be used both by patients and professionals.
  • Personalisation, productivity and efficiency. December 2010. (Social Care Institute For Excellence - SCIE report 37). This report looks at the potential for personalisation to provide cost efficiencies, improved productivity as well as good quality services. It provides useful information on cost efficiency evidence from direct payments and emerging cost evidence from Personal budgets.
  • Think Local, Act Personal. Next Steps for Transforming Adult Social Care. November 2010. The proposal sets out what needs to be done to ensure further transformation of adult social care. It reiterates the need for integration of health and social care, in particular, around outcome based commissioning and procurement and effectively engaging with local markets to deliver on the choices and outcomes people require. To target supply effectively requires commissioners to develop stronger and more collaborative relationships to develop new models of provision and reduce cost; to work with providers to diversify their services and commissioners to develop better ways of gathering and utilising market intelligence. It states that market position statements as developed by the Market Development Forum is key to this process as is the need to support people using services to influence, commission and procure services such co-production initiatives. It also sets out the need for councils to set up appropriate operating systems to enable personalisation to happen more effectively and the need to develop a responsive work force.
  • Financial management of personal budgets: challenges and opportunities for councils. 28th October 2010. (Audit Commission) This report examines personal budgets in adult social care. It considers the financial management and implications for local authorities in rolling out personal budgets. The report looks at different approaches to transition to personal budgets, looks at choices for allocating money and how councils can plan for the potential financial impacts. It also considers changes in social care commissioning and the governance arrangements needed for personal budgets. It provides useful self assessment check list for Local Authorities to assess their progress.
  • At a glance, 30: Personalisation briefing: implications for NHS staff. Social Care Institute For Excellence (SCIE) October 2010. This briefing looks at how the personalisation agenda will impact on NHS staff. It looks at the importance of partnerships with local authority commissioners who are experienced in implementing personalisation and also the importance of more integrated working arrangements. It also highlights the need to work effectively with the community and voluntary sector.
  • Getting personal: measuring providers’ progress towards personalisation. Social Care Institute For Excellence (SCIE). October 2010. A self assessment tool kit that allows providers to find out how ready they are to deliver personalised care services. SCIE has developed this tool with the Voluntary Organisations Disability Group. The tool kit consists of domains: person, team, organisation and market.
  • Person Centred Planning Advice for Commissioners. March 2010. (Department of Health). This document informs commissioners how to use person-centred planning approaches to enable person-centred commissioning to take place. It sets out what is expected of commissioners to ensure person centred commissioning, describing what processes are available for commissioning at both an individual and strategic level and how the market can be developed to facilitate such arrangements. It also provides a reflection on upon the success of personalisation and draws attention to relevant National indicators that may be used to demonstrate successes.
  • Market facilitation - Transforming the Market for Social Care is a series of six papers (plus a useful bibliography) about market facilitation. The first three papers provide a background, context and model of market facilitation as well as provider and purchaser perspectives on the transformation of social and health care markets. The final three papers concentrate specifically on activities and tasks necessary to facilitate the market such as outcome based approaches, good practice contracting between providers and commissioners and the emerging area of good practice contracting for self funding individuals.
  • Putting people first: Working together with user-led organisations outlines the benefits that local organisations and their residents enjoy when they work with user-led organisations. These benefits range from helping local authorities deliver greater personalisation to improved engagement with hard-to-reach population groups.
  • Individual Budgets, Micro-Commissioning and Extra Care Housing raises concerns about the potential damage to Extra Care housing and outcomes for residents, of the blanket application of individual budgets to commission the care and support in Extra Care.
  • Commissioning for Personalisation: A Framework for Local Authority Commissioners aims to help councils reconceptualise commissioning in a self-directed support system.
  • A report on in Control's second phase: Evaluation and learning 2005-2007 (in Control 2008) assesses how offering individuals budgets for self-directed support is working in practice. It considers factors that contribute to positive outcomes, such as the help people have in planning how to spend their budget and the variety of provision they can choose from. Generally outcomes are good, with nearly half those surveyed reporting improved health and well-being. The report also features a series of articles reflecting on lessons learned in key areas, including how commissioners and providers can change their approach to better cater for self-directed support.
  • Published by the Housing LIN, Older People's Services and Individual Budgets describes how Individual Budgets for older people have been implemented by national pilot sites. It suggests individual budgets should be embedded within normal care management processes, supported by strong leadership and commitment to the underlying principles.
  • Smart Commissioning: Exploring the impact of personalisation on commissioning by In-Control provides an early framework for commissioners who wish to transform their existing contractual structures into a system of Self-Directed Support. It is a provisional discussion paper offering some ideas about possible steps forward.
  • Individual Budgets and the interface with health: a discussion paper for the Care Services Improvement Partnership, was commissioned by CSIP as a stand alone piece of work to capture the issues and learning from the Individual Budgets pilot regarding the interface between Individual Budgets and Health. A "think tank" session was organised with key stakeholders from the Cabinet Office, Department of Health, In Control and Individual Budget pilot sites to discuss these emerging issues and any relevant activity. This document is a summary of the discussions on the day.
  • The Commission for Social Care Inspection published Relentless Optimism: creative commissioning for personalised care in September 2006 to to challenge current thinking on commissioning, identify barriers to personalised services and propose creative solutions.
  • Making It Personal by Jamie Bartless, Niamh Gallagher and Charles Leadbeater, and published by DEMOS, advocates a simple yet transformational approach to public services – self-directed services – which allocate people budgets so they can shape, with the advice of professionals and peers, the support they need. This participative approach delivers personalised, lasting solutions to people’s needs at lower cost than traditional, inflexible and top-down approaches, by mobilising the intelligence of thousands of service users to devise better solutions.
  • The Direct Payments Survey Group conducted a national postal questionnaire whose findings were launched in March 2006. Online papers, dissemination presentations and interim findings from the survey can be accessed via the Centre for Disability Studies at the University of Leeds. Additional information About the Direct Payments Survey is available from the PSSRU (Personal Social Services Research Unit), and a full text article Direct Payments in England: Factors Linked to Variations in Local Provision (December 2006) in the Journal of Social Policy, Volume 36, Issue 01 explores the demand, supply and related factors associated with patterns of local variability in uptake and intensity of care package provision.
  • The Health Services Management Centre at Birmingham University published a joint discussion paper with 'In Control' What could the NHS learn from individual budgets and direct payments? which proposes extending the personalisation agenda via pilots in the NHS.
  • The In Control programme is a national programme which aims to change the organisation of social care in England so that people can take better control of their own lives - self-directed support. In-Control has developed a whole system for self-directed support, with policies and procedures for resource allocation, support planning, supported decision making etc. Although originally focussed on people with learning disabilities, in-Control's system of self-directed support is designed for everyone who uses social care support. It offers a series of 7 downloadable Guides to self-directed support (and associated tools and examples) intended to help local authorities set up self–directed support: resource allocation and assessment; planning and brokerage; decision making; individual contracting; market management; community development; and quality improvement. Other publications accessible from 'In Control' include:
    • A report on in-Control’s first phase
    • Economics of self directed support
    • Individual budgets
    • The implications of individual budgets
  • Think Local Act Personal explains what individual budgets are in The Individual Budgets Pilot Projects - Impact and Outcomes for Carers and publishes the Individual Budgets Evaluation Report.
  • The Joseph Rowntree Foundation publishes relevant reports including Person-centred planning in social care: a scoping review (July 2006), which explores issues relating to service users, their families, frontline staff and implementation of the approach, identifies barriers to person-centred planning and ways to overcome them. Implementing Direct payments in mental health considers how take-up of direct payments by people experiencing mental health issues could be increased. Findings with hyperlinks to related evidence and the full report can be downloaded.
  • The King’s Fund commissioned Sir Derek Wanless to undertake a major review of social care, entitled Securing Good Care for Older People: taking a long term view (March 2006). One of the appendices to the report is direct payments and older people which discusses take-up rates and barriers, looks at other countries’ experiences, considers the scope for future take-up and the impact on funding.
  • The National Centre for Independent Living is designed to be a resource on independent living and direct payments for disabled people and others working in the field. It produced a report on the Direct Payments Development Fund in June 2006.
  • Research in Practice for Adults offers news and policy updates, details of learning events and of a number of ‘change projects’ plus a resource bank. Its evidence clusters provide a good overview of the issues - see Cluster Three: Direct Payments for those using mental health services (2007). The publications section offers ‘outlines’ or short reviews of research evidence including Outline 3 How can local authorities increase the take-up of direct payment schemes to adults with learning disabilities?
  • The Social Care Institute for Excellence published the research briefing The implementation of individual budget schemes in adult social care, an update of their 2007 briefing, 'Choice, Control and Individual Budgets: Emerging Themes' and the discussion paper Will community-based support services make direct payments a viable option for black and minority ethnic service users and carers? (August 2006).