People with personal budgets need to have something to buy. For some people the money will be spent on a personal assistant. But there will be lots of people who don’t have a big enough budget to employ someone, or don’t want to take on employer responsibilities. For them a more attractive option may be to buy some support from within the community. What budget-holders probably don’t have in mind is buying care slots from a big domiciliary care agency employing a high turnover workforce on zero hour contracts, replicating the local authority offer. The transformational stories that have spread about personal budgets have been based on people thinking much more creatively about the kinds of choices that budget-holders might want to make. Of course some people might want short visits from agency carers; plenty of self-funders already opt for that. But local commissioners of care services, particularly as they become market-shapers, need to ensure that 15 minute services aren’t simply chosen because there is nothing else to buy or nothing else that can be afforded.
One way to get more cost-effective and innovative services could be for commissioners to stimulate the growth of micro-providers: very small local care providers who keep costs low through minimal bureaucracy but who can find innovative ways to offer support. The Putting People First consortium has endorsed these micro-enterprises (employing 5 people or fewer) as a key element of the move to personalisation: ‘Micro social care and support enterprises established and managed by local people are in a good position to deliver individualised services and are vital elements of a diverse market’.
But is it true that very small organisations are more innovative and cost-effective than larger ones? The University of Birmingham is leading a project to evaluate the contribution that these micro enterprises make, testing if they outperform larger care providers in delivering services to users that are valued; innovative; personalised and cost-effective. We will be speaking to people who use services, and to carers, in micro, small, medium and large care providers, as well as to the providers themselves and the local authorities in which they are based.
The existing literature on scale and innovation is ambiguous: small organisations can be more versatile and lean, intimately knowing their customer-base and innovating quickly. On the other hand, large organisations have the inhouse expertise and the financial security to be experimental, utilising economies of scale. However existing studies have rarely looked at micro-providers (with 5 or fewer staff), as opposed to small organisations (classed as having 6-25 staff). Micro organisations may magnify the benefits of smallness, providing very personalised support to just a few people, and drawing on the ‘natural networks’ of the community to keep costs low. However micros may be more fragile than small providers, heavily dependent on one or two staff, and unable to participate in local tendering processes that are more accessible for small organisations.
A central issue for the research team is the extent to which micro-enterprises can become a new core offering for social care, or whether they offer creativity at the margins, for people who have the resources or imagination to step outside the domiciliary or residential mainstream. This links to the question of what kind of innovation is on offer from micro-providers: is it a what innovation, i.e. a new kind of support. Or is a how innovation: delivering ostensibly traditional services such as residential and domiciliary care in more personalised ways, being better attuned to what kind of support is being asked for, and developing more relational forms of support which utilise the assets of those being supported.
Some of the micro-enterprises supported by the national body Community Catalysts are very much offering what innovations. There is no obvious ‘old world’ equivalent of an animal-human therapy service or a bike-powered smoothie business, just two of the diverse services which Community Catalysts helped to get started. What innovations hit the headlines and help to generate excitement about how personalisation can break the mould of social care service-land. However it is the scope for process-based how innovations that constitute the most radical challenge to the mainstream of social care. People will continue to need help getting out of bed, getting washed and dressed; for some people residential care will continue to be the best place to get this support. If micro-enterprises are an affordable way to get the personalised, responsive, dignified, domiciliary and residential support that we would all wish for our families, that will be a radical finding from the project.
Catherine Needham is Reader in Public Policy and Public Management at the Health Services Management Centre, University of Birmingham, and is developing research around public service reform and policy innovation. Her recent work has focused on co-production and personalization, examining how those approaches are interpreted and applied in frontline practice. Her most recent book, published by the Policy Press in 2011, is entitled, Personalising Public Services: Understanding the Personalisation Narrative. Follow Catherine on Twitter: @DrCNeedham.