Last reviewed 2 April 2019
The concept of “person-centred” care has underpinned health and social care approaches for many years and forms the basis of modern care planning. It involves the service user being placed at the centre of their own care and for care to be centred around the needs of the individual, Martin Hodgson explains.
Personalisation is a social care model which builds on the theme of person-centred care where service users are enabled and empowered to exercise more choice and control in how their needs are met.
Personalisation is a contrast to previous approaches where individuals were expected to fit in with the services available for them. Placing the individual at the centre of their own care ensures that it is individual-needs-led, not service-led, and services must fit around the needs of the service user.
While it is often associated with direct payments and personal budgets, under which service users can choose to purchase the services that they receive, personalisation also means that services cannot be delivered in a one-size-fits-all fashion. Services themselves must be “personalised” and will typically include investment in preventive services to promote the independence and self-reliance of individuals.
Direct payments and personal budgets
Perhaps the most visible sign of the development of a personalisation model for care is the appearance of different ways of paying for services, especially direct payments and personal budgets.
Users of health and care services have in the past often complained that the support they really need is unavailable and that they are forced to accept only what is offered, which may not meet their individual needs or aspirations. Personalisation through direct payments or personal payment budgets is designed to answer such complaints and put in place a system whereby service users themselves can buy what they need with their own care budget, rather than have it done for them.
In the case of direct payments, cash payments are given to service users who have been assessed as needing social care support. This means tested payments can be used by the individual to purchase services to meet their own needs.
Personal budgets are an allocation of funding given to users after an assessment. Users can either take their personal budget as a direct payment or leave councils with the responsibility to commission the services. Here the money remains for administrative purposes in the hands of the public funding body but the user is consulted as to how they wish the money to be spent.
Personal budgets and direct payments are designed to provide flexible arrangements under which people who are eligible for services make their own choices and decisions about what care and support they need and want.
Some people use their personal budgets to employ a personal assistant to perform a range of daily care and support duties. Those fulfilling such roles can be employed by agencies or directly employed by service users. They generally help with everyday chores and enable a person to maintain their independence.
In 2011 the Department of Health and Social Care (DHSC) published a framework for such care provision, Working for Personalised Care: A Framework for Supporting Personal Assistants Working in Adult Social Care.
Careers guidance and training resources to support personal assistant roles is available on the Skills for Care website.
It has been government policy to modernise social care in England in line with the personalisation agenda since the publication in 2007 of Putting People First: A Shared Vision and Commitment to the Transformation of Adult Social Care.
Key to its implementation as a mainstream approach, the personalisation agenda is at the centre of the Care Act 2014 reforms in England and the Social Services and Well-being Act 2014 in Wales. Both support the greater use of personalisation, especially personal budgets.
With regard to regulation, a requirement for “person-centred care” underpins the Health and Care Act 2008 (Regulated Activities) Regulations 2014, compliance with which is required for health and care service providers in England for registration with the Care Quality Commission (CQC).
Examples of person-centred “fundamental standards” include:
Regulation 9: Person-centred Care requires care to be focused on the individual and consider their expressed needs and preferences
Regulation 10: Dignity and Respect requires that people are always treated with dignity and respect.
Person-centred care is also a fundamental element in the latest Key Lines of Enquiry (KLOE) guidance provided to CQC inspectors to use in awarding quality ratings to service providers.
For example, inspectors visiting healthcare services, such as general practices, are encouraged to ask if people receive personalised care that is responsive to their needs.
Services rated as “good” are described in the KLOE guidance as where people’s needs and preferences are considered and acted on. “Outstanding” services are described as being “tailored to meet the needs of individual people” and delivered in a way to ensure flexibility, choice and continuity of care.
In Scotland, the new national care standards, My Support, My Life also reflect a strong commitment to person-centred care.
Care and Support Statutory Guidance, issued under the Care Act 2014, states that local authorities should facilitate the personalisation of care and support services, encouraging services to enable people to make “meaningful choices” and to take control of their support arrangements, regardless of service setting or how their personal budget is managed.
In making commissioning arrangements, the statutory guidance states that local authorities must “promote wellbeing, social inclusion, and support the vision of personalisation, independence, choice and control”.
Guidance is also provided by the Social Care Institute for Excellence (SCIE). SCIE has been at the forefront of championing person-centred care and personalisation. The following are available on the SCIE website:
Changing Social Care: An Inclusive Approach
Personalisation: A Rough Guide
The Implementation of Individual Budget Schemes in Adult Social Care.
Choice and control
Health and social care providers must remember that personalisation is not just about personal budgets. Key to personalisation is people having more choice and control in their lives. Such choice and control is particularly important when providing genuinely “person-centred” care.
Delivering personalised services means different things to different people. It is about self-determination and self-directed care, both of which are fundamental to a service user maintaining their dignity and autonomy.
The advent of direct payments and personal budgets has had a considerable impact on the way services are commissioned. Local authorities and commissioning groups increasingly need to seek flexible and responsive services that support the personalisation agenda.
Commissioners must increasingly shape the social care market to provide a diverse range of high-quality services from which service users can choose themselves. Care services, particularly those offering care at home, are in many areas being given greater autonomy to negotiate different forms of care. Providers have had to adapt their services and adopt flexible care models based on what people want. Changes include an expansion in the number of directly employed personal assistants.
Market changes and the adaptation of providers to the new commissioning models is of key importance to the success of personalisation as personal budgets are of little use without a responsive market.
The effectiveness of personalisation
In 2016 the National Audit Office (NAO) published Personalised Commissioning in Adult Social Care. The report stated that many local authorities had successfully transformed their services to support personalisation. However, the NAO found that others were finding “personalising commissioning” a challenge, particularly in the current funding climate.
The NAO recommended that the DHSC needed to gain a better understanding of the different ways to commission personalised services for users, and how these lead to improvements in user outcomes.
While the use of personal budgets has been generally popular there are concerns.
For instance, research suggests that younger adults are more enthusiastic about individual budget-holding. This means that some older people may be less likely to benefit from personalisation. There are also concerns that a number of groups including people with dementia, those with other mental health problems and those who lack mental capacity, are also less likely to benefit from the approach.
In addition, there are concerns about vetting and service quality. Every service user with an individual budget can recruit a personal assistant and these will not always be vetted or regulated in the same way that they would if working for registered service providers.
People cannot make informed and sensible decisions about their care if they are not given adequate information on which to base their decisions. It is therefore vital that people are given sufficient information to support personalisation. It should also be in a format that makes the information accessible to those concerned.
Many believe that this “information” agenda is as important as personalisation itself and should lead to services which are far more open and transparent in future.
Service providers in England must by law meet the NHS Information Standard. Where necessary, advocacy should be provided.
Listening to service users
Another key to the delivery of the personalisation agenda is listening to service users and patients and respecting their views and choices.
Service users need to have the confidence to state their views about services and to know that these will be listened to. This is especially true for those who have limited capacity to express themselves who will need additional help in the form of particularly sensitive attention to what they want to say. Primary care doctors and staff may play a crucial part in this, helping to support their patients by listening to their views and supporting their decisions.
Even relatively articulate people sometimes find it difficult to express a point of view on subjects where they are unfamiliar with the language used and are not confident about their place in what is going on. When a service user is consulted on matters relating to their care, they need to be sure that their views are being taken seriously and that they will play a real part in the decisions taken.