Integration through Personalisation

Author: Simon Duffy

Local public services are constantly being separated, joined, separated and rejoined by central government. The process is damaging and futile. Only a model which examines the value and role of integration from the perspective of the citizen will begin to bring some much needed clarity into the current system.

Introduction

Integration of public services has been the Holy Grail for government in recent years. But, just as the Grail could not be acquired by any ordinary knight, so integration cannot be achieved by traditional administrative means. Attempts to organise our way to integration (through restructuring, or sophisticated forms of coordination and planning) will continue to frustrate the aspirations of their architects. For at bottom any organisational structure (quite properly) demands the creation of ‘departments’ with different ‘purposes’.

A better route to the integration of service delivery is to enable citizens to achieve it for themselves. Only the individual citizen can sensibly determine what they want, when they want it and how they want it. Our very individuality, the distinctness of our preferences, our lifestyle, our networks and our location demands that integration be achieved, not through system integration, but through personalised integration:
This is not just a theoretical paradigm shift. Today we are seeing increasing numbers of people using Individual Budgets to develop integrated services that suit their individual lives.

Many people find that they can better:

Integrate services with each other - The citizen is often in a better position to determine which services add value and to act as the lynch-pin for their coordination. No one else has a better incentive to make integration work.
Integrate services with ordinary life - Mostly people do not want ‘services’ they want a life and the value of public services increases when those services can both support, and be woven into, the fabric ordinary life.
Integrate services into their network of family, friends and community - Most care and support does not come from public services, it comes from family, friends and our communities - good systems support and encourage (rather than replace) those supports.
Better engage fixed or inflexible services or treatments - Even when services cannot be directed by citizens they can still better integrated when other services can be flexible and personalised.

The key to integrated service delivery is personalisation - through and with the individual citizen.

Practical Implications

In order to achieve personalised integration a whole range of practical changes need to be made to the current system:

Decentralised authority - Systems like Self-Directed Support and Budget-Holding Lead Professionals are systemic reforms that legitimise the necessary power shift towards citizens to shape and reshape services at the level of the individual.
Flexible resources - Resources must become more flexible and there must be sufficient transparency to enable effective decision-making. This requirement has led to the development of Individual Budgets in health, social care and education.
Appropriate coordination - Personalised integration requires a clear decision-maker and systems to determine such a suitable decision-maker when there is any ambiguity. Within Self-Directed Support there are 6 possible budget holders as shown in the diagram below.
An array of services - Personalised integration requires an array of possible services, however as long as the threshold for qualification is not raised too high it seems unproblematic to create such an array. So far market capacity has not been obstacle to the current reforms in social care.
Information about possibilities - Information is vital to better quality decisions. This is not just information about services; in fact in the new system the individual’s knowledge of themselves, their networks, their preferences and their communities adds significant value to the final decisions.

None of this implies that making this shift is easy. It is not, it is very difficult. But (a) the technological challenges for the system can be overcome, (b) cultural change can be achieved if it is pursued in tandem with the necessary technological changes and (c) even in imperfect systems, in the early stages of development, the outcome and efficiency improvements can be great.

Personalised integration demands new systems of power, funding, decision-making, support and information.

Strategic Implications

It is natural for managers, commissioners and civil servants to be challenged by these claims. However personalised integration is not the end of management, commissioning or public policy; instead it requires a refocus of current efforts on new strategies that are more consistent with personalisation. There are some obvious priorities:

Managing the change process

The transformation must itself be managed, and it demands time, skill and leadership in order to succeed:

Working with key stake-holders - There a range of key groups from members, partners, professional groups and local people who need to understand the new vision.
Setting leadership structure - Change only happens in complex systems where there is sufficient real will, planning and appropriate structure.
Policy coordination - As different systems change at different rates the need for co-ordinating or challenging other policy areas will continue.

Developing the new market

Commissioning is often conceptualised as ‘buying’ or ‘procurement’ - instead it must focus on the real conditions for market success:

Market development - Existing and new service providers can be encouraged to become directly accountable to citizens.
Quality improvement - Innovations like Shop4Support offer new possibilities for improving quality.
Community capacity - Thinking about communities, not services, will be the natural next step in promoting personalisation.

Designing the new infrastructure

Individual choice will not determine every feature of the underlying system; for instance, we are only just beginning to explore the different ways in which support to manage a personal budget can be provided or unlocked from within the community. Interesting innovations include:

Peer support - Many people’s best support comes from being linked to one or two other people with similar experiences e.g. systems like Plan UK build self-sustaining networks of peer supporters.
Citizen leadership - Citizens are coming together to learn about public services and to teach each other how best to use them.

Personalised integration demands a renewed focus from local leaders on the genuine conditions for successful communities.

Long-term Implications

Predicting the future is foolish, but sometimes it helps to be foolish. So let us for the sake of this paper make some predictions, based upon some simple assumptions. If we imagine that (a) the current political support for personalisation continues, that (b) government puts in place the necessary legal and regulatory changes to avoid its frustration, that (c) none of the existing vested-interests organises a coherent campaign against personalisation and that (d) the ideas continue to move from social care through children’s services, education, health services and into the welfare reform agenda then we might expect to see some of the following over the next 5 to 10 years:

Nearly all of current social care spending (c. £20 billion) in control of citizens or their representatives and managed through an array of different mechanisms.
A significant level of NHS spending, funding for care and support (rather than medical treatment) in the hands of citizens.
Special education funding, and may be even general education funding, in the hands of individuals who can personalise their families educational support.
Funding for employment and training fully personalised and separated from institutional delivery systems.
The radical simplification and integration of the tax and benefit system to create clearer systems of entitlement and contribution.

What this will lead to is increasing attention on an important question: When are decisions best made by the individual and when are they best made by the state (or an agent of the state)? The answer to this question will not be simple, but it might be increasingly empirical - informed not by ideological simplifications but by practical research into which arrangements are more effective at promoting social justice.
In particular it will become increasingly clear that the on-going development of personalisation cannot simply be left in the care of distinct of government departments, for there are too many vital policy issues left undetermined:

Will we have a national system of entitlements to personal budgets in health, social care or education or will we have an utterly local and discretionary system?
In any national system which decisions will be a matter of local discretion?
How will any system be integrated into the tax and benefit system?
How will the different entitlements and funding streams be related to each other?
Which funding streams need to be fully integrated into the new system?

Currently personalisation is largely developed within the distinct departmental silos of Social Care, Health, Children Services, Education and Work. But actually it must be understood, owned and integrated into local government by a partnership between the Department of Communities & Local Government and local government itself. Personalised Integration may be a pathway to radical reform of the welfare state - but if so the role of local government must be reviewed and clarified.

The publisher is The Centre for Welfare Reform.