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| Individualised
funding and support brokers
(and Individual Budgets, Self-directed
services, and self-determination)
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What
is Individualised Funding (IF)?
In the last two or three years, there's been a sudden growth
of interest in the idea of letting people have the money held
by social services, so that they can buy the support services
they want, rather than having them organised by a care manager
and paid directly by the council.
Even in the UK this isn't really a new idea, as we've had Direct
Payments for ten years. But Direct Payments - for all the guidance
from government, and the services that have evolved to help
people manage their Direct Payment - was essentially a simple
response to disabled people who demanded the chance to escape
the social care system and achieve independent living. Although
other disabled people have started to use them, Direct Payments
were mainly geared to people with physical impairments - people
willing and able to make plans and manage the money without
help, and who typically use the money to employ personal assistants.
In contrast, recent UK developments – mainly the In
Control programme, and the Individual
Budget pilots - are attempting a more comprehensive approach.
For example, they put more emphasis on people using their money
to contract with support provider agencies. Direct Payments
have led to Direct Payment Support Schemes which are mainly
geared to helping people after the payment has been received
to manage their money and employ personal assistants. The new
initiatives recognise that, in addition, people may need help
or training to decide how they want to use the money, and to
organise the help they need. Individual Budget pilots are bringing
together several funding sources, rather than being concerned
only with social care money from councils.
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The real history of Individualised Funding
If you read the material on the UK's national initiatives,
you could easily conclude that these new approaches – which
broadly go under the term ‘self-directed supports and services’
– were invented in the UK. In fact, the ideas go back thirty
years, and can be traced to two different starting points. There
was, firstly, the Independent Living movement, which began in
California in the 1970s. Direct Payments really belong within
this ‘tradition’, as do most of the programmes in
Europe, notably Sweden.
The second starting point was completely separate. A group of
parents of people with learning disabilities in British Columbia,
Canada, first clearly defined the twin concepts of individualised
funding (IF) and support brokerage (or service brokerage, as
they named it).
This second starting point led to a series of IF pilot programmes
in Canada. Then, in the 1990s, the idea resurfaced in the USA,
where it blossomed into around 30 small IF programmes in many
different states. Further projects have been developed in Canada,
and some similar projects were also set up Australia.
In all, over fifty IF projects have been developed worldwide.
Not all of them have been very good, but nevertheless they offer
an enormous amount of learning about what works and what doesn’t
work. And, of course, alongside these developments there has
been an international community of people debating and refining
the ideas in the light of experience.
Two people who have played significant roles in this international
community are Brian Salisbury and Steve Dowson. Brian was one
of the original brokers in the first IF pilot, which took place
in British Columbia in the 1980s. He has since become the leading
international advocate for, and expert on, support brokerage.
Steve, now with the National Development
Team, has been involved with individualised funding,
and linked with Brian Salisbury, since the late 1980s. As Emprise
International Training and Consultancy, Brian and
Steve provided consultancy and training in North America and
Australia. They were the programme planners for the First
international Conference on Self-Determination and Individualised
Funding, held in 2000, an event with 70 presenters
from around the world. They also wrote the report from the conference,
which remains the only comprehensive analysis of IF policy issues
from an international perspective. Other work included support
to the Self-Determination
Program in San Diego, covering both system design and training
of support brokers, over a period of three years.
Steve was also involved in a small group of people who began
a campaign in 2002 for the development of individualised funding
in the UK. Their publication, ‘Not
Just About the Money’ set out the principles of
IF, and how it could be implemented in the UK. This publication
can still be downloaded,
free of charge, from the old Emprise
International Web site.
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The NDT viewpoint on self-directed
services and supports
The In Control programme,
though it has clearly defined some procedures (resource allocation,
for example) has not offered a clear model for system-wide
changes in roles and relationships. In
Control and Individual Budget pilot sites have also
developed their local projects in different ways. This makes
comparisons difficult. However, it can be said that the NDT
has substantial concerns about policies and assumptions that
appear to hold sway at the moment. Some of the areas where
the NDT believes current thinking is inadequate or mistaken
are as follows -
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Policy
development requires national leadership based on clear principles
and a coherent model
Although there are some core elements in both the In control
programme and the IB pilots, both initiatives are weak on centrally-defined,
over-arching principles and structures. As a result many aspects
of local projects are left for local people to decide. At first
sight, this seems to make good sense. It seems to offer a more
creative approach, and developing local projects from ‘the
bottom up’ should give local users and carers more chance
to influence what happens.
But in reality there are two flaws. Firstly, it means that a
lot of time is wasted ‘reinventing wheels’. Some very
important principles and practical lessons have emerged from
international experience. UK developments are almost entirely
ignoring this knowledge. Disabled people looking for the chance
to have better lives can ill-afford to wait while people discover
that square wheels don’t work. Secondly, a bottom-up approach
is unlikely to put decision-making in the hands of the people
who use services. It is much more likely to stay with the professionals.
Although there will be exceptions, these people are unlikely
to push forward the radical changes that are required –
not because they are bad people, but because they are immersed
in the assumptions and values of the existing system. Experience
in the UK, and internationally, demonstrates how easily IF systems
are downgraded at the planning stage, or drift back into old
habits, because there is not enough understanding of, or commitment
to, the core principles of IF. (You can download
a short paper that outlines the IF model and discusses some
key issues about the tole of broker.)
The NDT’s view of individualised funding and support brokerage
is based on a model that has developed from international experience.
While there are some aspects of the model that could be implemented
in various ways, it offers a structure and set of principles
that the government could use to make sure development heads
in the right direction.n
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Individualised,
not just individual
The In Control and Individual
Budgets projects are locked into a system that attaches much
importance to ‘fairness’, as in Fair Access to Care
(FAC). A great deal of effort has been going into the development
of systems for allocating individual budgets that will be ‘fair’.
These systems assess people’s needs, and then relate that
assessment to a set of bands that define the level of funding
allowed for each person. It is possible that a well-designed
system will remove some factors that create unfairness, but
the system will still reflect a view of ‘fairness’
that is based on a set of values, not some absolute truth.
More fundamentally, though, do we really want an individual
budgets system that gives people standardised amounts of money
based on some kind of fact-based assessment? If we do, then
surely it should be moved out of social services and across
to the benefits system, which is geared to providing money based
on entitlement.
But the whole point is that standardised, entitlement-based
systems are an inefficient way to hand out public money. There
isn’t – and never will be – enough public money
to set the level of entitlement (or disability benefit) high
enough to cover every person’s support needs. So it’s
necessary to keep some money in a different system (i.e. social
services commissioning, at present) where it can be used to
assist people in a less rule-bound, more flexible way. In other
words, we need a system that is either far less obsessed with
‘fairness’, or at least has a very different idea
of what ‘fairness’ means.
This is an uncomfortable thought for people who are devoted
to simple notions of fairness. One response is to play endlessly
with Resource Allocation Systems, in the vain hope of designing
one that is simple, objective, and yet sensitive to widely ranging
individual need and circumstance. A more realistic approach
is to use a banding system, but to add procedures (for example,
an appeal procedure) that will allow people to get money outside
their assessed banding level.
There is an option to take this further, and abandon the banding
system (except, possibly, as a very general guide). Instead,
the council offers guidelines on the circumstances in which
they are likely to offer funds, and the kinds of thing they
will/won’t fund. People still have to come through assessment
for eligibility for services, but are then free to make and
cost a support plan, taking into account the council’s
guidelines. They then bring this plan to a meeting where they
sit across the table from people who have the authority to agree
allocations, and negotiate. Although the meeting may focus mainly
on the money, it is also an opportunity to look at other aspects
of the plan, such as risks.
The NDT favours this approach. It has been used in North America,
and on a small scale in the UK with the Life Planning projects
developed by the NDT. Certainly, there are disadvantages: it
makes it more difficult to hold allocations within budget, and
it means that some council staff will spend a lot of time in
allocation meetings. As with so many aspects of these systems,
we don’t know whether it will be practical in a large system.
But there is one extremely important benefit to this method.
Ultimately, the social care system has to demonstrate that it
is trustworthy, so that people who use services believe it’s
safe to move away from the policies of “ get everything
I can” and “hang on to everything I’ve got”,
which are the rational response to a system that can’t
be trusted.
Face-to-face, negotiated decisions about the allocation of funding
powerfully signal a move away from a system where people are
victims of a bureaucracy in which decisions are made behind
closed doors, and without accountability to the people who use
services. It creates, instead, a transparent system where the
tensions between individual need and available public funding
are addressed openly, leading to a real sense of contract between
the state (the council) and the individual requiring assistance.
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The
role of the broker, and the function of brokerage, are two very
different things.
IF/IB systems and projects are intended to enable disabled people
to have control over the shape of their lives, translating their
hopes into the reality of supports, services, and community
opportunities. In order to get from the hopes to the reality,
a series of tasks must be completed – defining, planning,
costing, organising, and so on. The In Control programme defined
‘brokerage’ as a subset of these tasks. This can be
considered as a functional definition of brokerage.
In itself, the functional definition is entirely valid. Brokerage
is indeed concerned with a set of tasks. It’s also true
that a wide range of people may be able and willing to do these
tasks – including the person at the centre of the plan,
family members, friends, neighbours, and various people who
have other roles inside the social care system. The problem
arises because brokers – people delivering brokerage as
a service – have simply been tacked onto the list of people
who can do the tasks. This has allowed the In Control and IB
pilot projects to ignore an area of awkward but vitally important
issues – about the overall design of IF/IB systems, the
way in which broker resources will be developed and monitored,
and about the nature of the role itself. Confusion and misunderstanding
has resulted, and is evident in the way that brokerage is being
developed. Fortunately, however, the National Brokerage Network
has started to fill the gap, and some IB pilots have recognised
that they need to explore this issue more fully. (See for example
the draft NBN requirements for the training of brokers.)
When people provide brokerage as a service, they are taking
on a role and delivering a service. This has implications for
the nature of the relationship, about competencies, safeguards,
and freedom from conflicts of interest. In the NDT’s view,
Individual Budgets will not deliver the radical change that
is required unless these issues are better understood and addressed.
The distinction between role and function is discussed in more
detail in a NDT Emerging Themes paper, Is
a broker just someone who does brokerage?
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Brokers
are an important component of an IF system
Statements from In Control
and from organisations linked to government have not presented
a consistent position on the importance of paid support brokers,
but there is now more acknowledgement that paid brokers are
an option that should be available to people using IBs. However,
the predominant argument has been that the functions of brokerage
(and related information/training services) can be offered in
many ways, and that it is better to let these emerge as a result
of local initatives and in response to local demand. In
Control has also argued that it is empowering for people
to carry out their own support planning and brokerage tasks,
with informal help if they need it from family and friends.
This view is reflected in In Control's policy that paid brokers
should not be available as a free service, but paid out of the
individual budget allocation, if the IB recipient considers
it worthwhile. Unless allocations are very generous, it's to
be be expected that most people will be extremely reluctant
to spend their precious funding on a broker.
Two main arguments are offered for this policy. Firstly, that
leaving people to decide whether to spend money on a broker
is consistent with the general aim of putting people in control.
Secondly, that it is empowering for people to plan and organise
their own supports.
There are a number of counter-arguments:
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Some people may find it empowering
to do their own brokerage, and of course should have that choice.
However, many disabled people and their families already feel
they have to fight too many battles and get too little help.
The suggestion that it will be empowering for them to take on
yet more responsibilities is likely to be greeted with hollow
laughter. On the other hand, people plainly do find it empowering
to have a broker – someone they choose, and who works solely
for them, with no decision-making authority. If empowerment
is really the aim, wouldn’t it be logical to make it easier
for people to have that experience?
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Although brokers should be totally
focused on delivering a service to the person who chooses to
use their services, the involvement of brokers also benefits
the council. From the point of view of the council (and central
government) the system needs to work in a way that makes the
best possible use of limited public funds. The council also
has a duty to make sure that vulnerable people are not exposed
to undue risk. So the council needs to see well-written plans
that provide the evidence that these aims are being achieved.
For all these reasons the tasks involved in brokerage require
substantial skills – in planning, creative thinking, organisation,
negotiation, and writing. Some people who use services will
have these skills, or will be able to get the help of family
and friends who have them. But it is not in anybody’s interests
for people to struggle to complete the process – perhaps
because they don’t want to use funding to pay a broker
- when they don’t have really have the skills that are
required.
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An IF system
doesn’t ‘hold together’ without the broker role.
That’s not to say that every person who wants to
take control of their own money and supports should be obliged
to have a broker. But at the level of system design, the role
of broker (whether or not called ‘broker’) needs to
be identified and appropriately located. In essence, IF systems
involve splitting care management into two components: the part
that is concerned with rationing funds, and other duties linked
to the statutory responsibilities of councils; and the part
that is focused on the person and their requirements. The rationing
component properly stays with the council, but the person-centred
component needs to be located somewhere new. Without a clearly
identified place for this component, the IF system is incomplete.
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For these reasons, the NDT believes
that independent brokers should be available, free of charge.
This does, admittedly, create the need for an arrangement for
allocating broker time in a way that broadly corresponds to
each person’s requirements, but there are simple ways this
can be achieved.
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Brokers
should be truly independent
It is widely accepted that the formal systems that surround
us in areas of ordinary life – whether commercial activities,
justice systems, or government – should be designed so
that they avoid conflicts of interest. For example, the public
is suspicious of ‘internal enquiries’ where alleged
errors or corruption are investigated by people who are part
of the same system. In our judicial system, it is a fundamental
principle that the two sides of the case (e.g. defence and prosecution)
should be presented separately, by different people. And there
are now very elaborate regulations to prevent financial advisers
pretending to be independent when in fact they have incentives
to sell particular products. In these and many other situations,
we want to be sure that people who are supposed to be working
in our interests (or the larger public interest) are not subject
to conflicting motives or pressures from elsewhere in the same
system.
The design of the present social care system has disregarded
this principle. Most obvious is the conflict of interest built
into the care manager role, but there are many other examples.
The principle must be restored in the design of the new system.
Moreover, because people who use services have for so long experienced
a system that is fundamentally untrustworthy, the new system
needs to ‘go the extra mile’ to show that it really
can be trusted. Arrangements that compromise on role clarity
and transparency are likely to signal that nothing has really
changed.
For this reason, it is essential that support brokers are truly
independent, and that they are seen to be independent. Although
it may be convenient to create support brokers in salaried posts
within the council, this will not meet the requirement. Even
if they are able to act and think independently, they will not
convincingly demonstrate that the new system is committed to
avoid conflicts of interest. Equally, placing brokers outside
the council is not sufficient to ensure independence, since
it may also be affected by loyalty and perspective. (You
can download a paper which explores in more detail what we mean
by 'independence'.)
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Brokers
should be provided on a basis that offers choice.
It is now widely accepted that it is not healthy for support
services to be offered by one agency that has a monopoly position.
It encourage the agency to become too powerful, to lose its
incentive to deliver high quality services, and it denies choice
for the people who purchase services.
Brokers also offer a service, so the same principle applies.
It is not sufficient for a council to commission one organisation
to provider support broker services in the area.
There is no reason in principle why brokers should not be salaried
employees of agencies, provided that the agencies are not providing
other services that would create a conflict of interest. (This
would rule out provider agencies, of course; and it is also
doubtful whether Direct Payment Support Schemes would be suitable,
if they were providing other services on behalf of the council.)
When broker resources need to be created quickly, the appointment
of one or two salaried brokers may be a good way to get started.
On the other hand, there’s a good case for creating a market
of self-employed, fee-for-service, brokers. For people who want
the services of a broker, it offers choice. It also, under the
right market conditions, means that brokers will have an incentive
to deliver good services, in order to get more work. For the
council, it provides a way to create brokerage resources without
the high fixed costs of salaried brokers. If salaried brokers
are created as a strategy for the rapid development of broker
resources, they should be working, as soon as possible, within
a competitive broker market.
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The
local market of brokers
should be regulated by a local oversight body controlled by
users, families, and their allies.
A small local organisation authorised and grant-funded to oversee
the delivery of broker services, and controlled by people representing
the users of broker services, answers a number of important
issues:
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The oversight
agency provides the regulation that the broker market needs.
It can ensure that local brokers meet minimum standards, by
applying a system of accreditation, and assist the recruitment
and training of brokers. It can deal with any complaints about
broker services, and provide information for people seeking
the services of a broker.
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The oversight
agency helps to keep brokers connected to the requirements of
local people. Although the core skills and services of
brokers will be the same everywhere, it is right that local
people should have the opportunity to ‘fine tune’
the services of local brokers to local requirements.
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The oversight
agency helps to keep brokers connected to the local community.
If ‘professional’ means someone who is remote from
people’s lives, with loyalties that lie with some remote
body, then of course no one wants a new group of professionals
called ‘support brokers’. Unfortunately, the limited
arrangements that are currently being put in place for a national
registry of brokers offer nothing to stop this happening. But
by requiring brokers to be locally accredited, and subject to
the regulation of the oversight body, brokers can be kept connected
to the community in which they operate.
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The oversight
agency can deal with larger issues of community development.
Part of the role of brokers is to find and develop mainstream
services and community opportunities that people require to
achieve their plans. But usually this work will be linked to
one person. An oversight agency can monitor reports from brokers
and spot problems where more general action is required –
for example inadequate resources, or mainstream services that
are failing to be inclusive.
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The overall effect of
the oversight agency is to anchor brokerage where it needs to
be, at the interface between the local community and the service
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