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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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The Innovation Unit

28-30 Grosvenor Gardens

London

SW1W 0TT

The Innovation Unit 2010

Personalisation Edge

Documents

Transcript of Personalisation Edge