Innovation in social care: it’s the how as much as the what

Catherine Needham

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.

For more details about the project please see the website or contact Catherine directly.

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.

Direct Payments Act 1996: a legislative game-changer on a slow burn

Catherine Needham

Some legislative game-changers have a high-profile passage through Parliament, with much media fanfare about how things will never be the same again: gay rights legislation, for example, fits into this category. Other game-changers proceed more quietly, with their immediate implications limited to a relatively small number of people. This latter type can be characterised as ‘valve’ legislation, in the sense that once passed there is no going back, even if this is not fully appreciated at the time.

The Community Care (Direct Payments) Act 1996 is an example of valve legislation. Its passage followed from the persistent and passionate campaigns of people with disabilities to gain more control over their support. It made legal the transfers of cash to people eligible for local authority funding. Some local authorities had been finding ways to make such payments for years, with a wary glance at the apparent ban on such activity in the National Assistance Act 1948. But the passage of the Act gained little media interest beyond the Society Guardian, and it was assumed by government that the payments would only be taken up by a minority of younger people with physical disabilities. Indeed people over 65 weren’t eligible for the payments. The Act gave local authorities the power but not the duty to grant the payments, meaning that access to them was heavily dependent on a supportive social services department.

Nearly twenty years later the English government is committed to getting a direct payment or managed budget (where the local authority or third party holds the money on your behalf) to 70 per cent of people receiving local authority-funded social care – more if possible. In a succession of modifications to the law and its regulations, direct payments are now expected to be the default funding mechanism for people with physical disabilities, learning disabilities, older people and people using mental health services, and are available to carers. They have expanded to parents with disabled children and are being proposed for children with special educational needs and for adoptive parents. They are being introduced for aspects of NHS care as personal health budgets, which constitutes a radical change to health funding albeit on a small scale at present. The policy has cross-party support, being pursued as assiduously by the Coalition government as by their New Labour predecessors.

Why was the 1996 legislation able to trigger such a systemic change? Here are four suggestions.

  1. It was a simple idea: give the money straight to the user. Although the implementation has been enormously complex, it was an easy idea to explain, helping its proliferation and popularity
  2. It fitted the political mood, both to expand choice to people as consumers of public services (seeing that as the best way to improve outcomes) and to break down barriers for people with disabilities on rights basis. Governments since the 1980s have promoted both strands of legislation, even though there are tensions between them.
  3. It didn’t seem to cost anything, since money was simply being allocated differently. This aspect of the policy appealed to the Conservative government that first introduced the policy and to subsequent New Labour and Coalition governments. It is particularly appealing in a period of public spending austerity. Evidence for cost-savings has been harder to establish in practice, however.
  4. It created a wedge that could be used by policy entrepreneurs to push for further change. Once the principle was established that disabled adults under 65 were eligible for such payments it was very hard to argue on a principled basis that they should not be extended to other people in receipt of local authority support. Organisations such as In Control pushed at the boundaries of the legislation to broaden its range and built national alliances of supporters to agitate for its extension.

All these factors created a permissive legislative and policy context in which devolved budgets have come to be seen as the way to respond to a whole range of social issues. However behind the simplicity and potency of the idea lie two challenges which have not yet been resolved, and will continue to pose issues for future government.

The first is implementation. The simple insights of personal budgets and direct payments have proved very difficult to apply to a hugely complex, variable and underfunded social care system. Personal health budgets may help to integrate health and social care provision but it is difficult to do this when social care funding is means-tested and health funding is not.

Second, there is a normative challenge: if people are better at spending their own money than the state is at spending it on their behalf, what is the state for (aside perhaps from channelling money from rich consumers to poor ones)? This vision of a voucher state has long been cherished by some on the right of the political spectrum. Raising questions about the need for a welfare state was not the vision of any of the advocates of the Direct Payments Act 1996 but such debates affirm that the full consequence of that Act are not yet known.


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.

What do MMR and personal budgets have in common?

Catherine Needham

The recent spike in measles cases in Swansea and elsewhere has a particular salience for local government, occurring just as authorities took on new responsibilities for public health. Events in Swansea brought back into public attention the decline in uptake of the MMR (Measles, Mumps, Rubella) vaccine that followed a spate of media stories several years ago reporting an apparent link to autism. Despite the thorough discrediting of the link, MMR take-up rates have not recovered.

Declining rates of vaccination are not a UK-phenomenon and cannot wholly be laid at the door of a single rogue study. Research that I have been doing with Anat Gofen from Hebrew University in Jerusalem has highlighted that vaccination rates are dropping across western democracies. Often, in each country, the decline will be associated with a particular vaccine and a set of commonly circulating myths surrounding it. In the US, for example, it has been a rise in cases of whooping cough that has provoked most concern.

Whilst vaccine take-up rates have always been low within some disadvantaged communities, what has grown is the prevalence of parents practicing a form of so-called ‘scientific citizenship’, in which they research issues for themselves, make use of official and oppositional websites, and weigh the perceived risks. They may opt to delay the jabs until a child is older or to split combined vaccines into separate shots rather than not vaccinate at all. If they decide not to proceed with vaccination, they will find an online community of fellow resistors with whom to share stories and provide support.

What has this got to do with personal budgets in social care services? In both cases, citizens are challenging conventional notions of professional expertise and authority, and making a claim to know what is best for them and their families.

The two cases have many dissimilarities: accepting that older people and people with disabilities know best about their immediate care needs and should have choice and control about how they spend their time is clearly very different from accepting that parents know best about a medical intervention like vaccination. Personal budgets have been the culmination of many years of campaigning by disability organisations for recognition that the person using services is an “expert on their own life” and has widespread support in government and civil society. Vaccine refusal is a widely criticised activity with dangerous consequences for public health.

However for health and social care professionals on the frontlines, navigating the boundaries of citizen expertise is a growing challenge. With personal budgets expanding into the NHS as personal health budgets, it is no longer assumed that health interventions should always be determined on the basis of a traditional clinical evidence base. Like ‘expert patient’ programs, health budgets have been principally targeted at people with chronic conditions which require self-management and enable them to develop knowledge over the long-term. Other areas of health, such as vaccination, remain off limits.

However, citizens themselves may not accept this demarcation. Declining vaccination rates highlight the difficulties that officials face in attempting to ‘hold the line’, encouraging citizen expertise in some sectors of health and care whilst denying it in others. There are challenges for practitioners in explaining why you can be an expert patient but not an expert parent.


Catherine Needham is a Senior Lecturer 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, public by the Policy Press in 2011, is entitled, Personalising Public Services: Understanding the Personalisation Narrative.