Personalisation: On the Edge of an Innovation

Research Paper | April 2010

Personalisation
On the Edge of an Innovation

By Sarah Thelwall
 Personalisation: On the Edge of an Innovation

Contents

1 Introduction   3
1.1 Implementing Personalisation – no longer the why but the
how? 4
1.2 Maintaining enough stability to keep innovating 5
1.3 TUPE and the perpetuation of a two tier workforce 8
1.4 Upgrading the infrastructure to enable smooth spot
contracting 9

2 The day to day challenge of implementing personalisation –

Barbara Martin and Brandon Trust 11
2.1 Barbara and her background 11
2.2 Independence and decision making 12
2.3 Three examples of day to day decisions - money, medication
and activities 12
2.4 Barriers and risks 12
2.5 The Cornwall context 14
2.6 Development of the Brandon Trust team 15

3 What needs to change if we are to scale up the provision of

personalised care? 16
3.1 The need for sufficiently stable conditions (to support
innovation) 17
3.2 An ability to take positive risks and front load the budget
for change 17
3.3 The development of social markets 18

4 Bibliography 19
5 Endnotes 20
 Personalisation: On the Edge of an Innovation
1. Introduction
The wind of personalisation is blowing
through public services in the United
Kingdom. Its principles of individual
empowerment, inclusion, and partner-
ship are being adopted beyond the
health care setting in social services,
and in parts of the education and
employment systems. Recognising
the broad benefits of the person-
centred approach beyond the niche
requirements of adults with learning
disabilities where it was initiated in
2001 is a fantastic validation of the
core principles of personalisation. But
as Leadbeater and Bartlett1 note, the
biggest challenge for personalisation
– indeed any innovation – is scaling
it up into a long term sustainable
approach. In that sense we are still ‘on
the edge of an innovation’.
The Association of Chief Executives
of Voluntary Organisations (ACEVO)
notes that the government has set
a minimum target for 30 percent of
local authority-funded adult social
care service users to be on a per-
sonal budget by April 2011, but many
authorities have gone further setting
targets of 60-100 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 of personalisation. To
be successful there will need to be
greater clarity on what is working well,
why that is, and how to build upon it.
The concept of personalisation takes
people forward 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 of personalisation
of services for adults with learning
disabilities. It considers the challenges
that personalisation brings, both on an
organisational level and for individual
tenants and the people who Brandon
Trust support. The paper indicates the
areas where collaboration is required
between policy and delivery leaders if
personalisation is to become truly em-
bedded within the provision of services
to adults with learning disabilities.
Based in Bristol, Brandon Trust is a
charity employing nearly 2000 staff
 Personalisation: On the Edge of an Innovation
supporting approximately 1500 people
with learning disabilities. It was formed
in 1994 as a result of the closure of
long term hospitals. Institutional learn-
ing disability services were transferred
from the NHS into community
residential care provision (serviced
by both private and not-for-profit
providers). Since 1994 Brandon Trust
has expanded its activities and now
operates teams across Bristol, South
Gloucestershire, Gloucestershire,
Bath and North East Somerset, North
Somerset, Plymouth and Cornwall. It
has also developed a reputation as an
innovator in the field of care provision
for individuals with learning dis-
abilities. Its commitment to delivering
personalised services to the people it
supports can be seen not only in the
shifts made from large group living to
small groups and individual housing
options, but also in the wide range of
developments in work, learning, and
leisure opportunities which Brandon
Trust has pioneered with its partners
and the people it supports. This
reflects Brandon Trust’s attitude to
service development – the organisa-
tion develops services with rather than
for the people it supports.
1.1 Implementing Personalisation
– no longer the why but the how?
Whilst the 2001 white paper Valuing
People: A New Strategy for Learning
Disability for the 21st Century set out
the government’s commitment to
providing new opportunities for children
and adults with learning disabilities, it
was the 2005 Mental Capacity Act
(MCA) which created the leverage
to ensure its implementation. Valuing
People articulated its new vision based
on the principles of 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 behalf should only be taken if it
is demonstrated that the person lacks
that capacity.
Valuing People and the MCA have been
key markers in the personalisation of
services as they supported the shift
from establishing why the agenda
is imperative, to understanding how
personalisation might be achieved in
practice. Indeed the MCA has led to
the establishment of processes for as-
sessing an individual’s capacity to make
decisions which are now a regular part
of planning and service development
with service users and the professionals
with which they work.
As a provider committed to the ongoing
development and improvement of
support provision, Brandon Trust has
positioned itself at the leading edge of
service innovation. The charity started
developing supported living packages in
2002. Supported living enables people
to live more independently by giving
them greater influence 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 flexibility over
the hours and types of support they
receive. Supported living gives people
both the rights and the responsibilities
of being a tenant in their own home.
This is an enormous shift away from
large group residential care and nursing
homes. Reconfiguring long term ser-
vices in this way is presenting a number
of structural challenges for Brandon
Trust, their staff, the health and social
care services professionals with whom
they liaise, as well as the people they�
 Personalisation: On the Edge of an Innovation

support. It is this change process that is been piloted and proven. Both of these
the focus of this paper. require a marketplace which provides
sufficient stability to enable them to
As we move from pilot projects with achieve a return on their investment
small numbers of service users to i.e. a marketplace which rewards the
mainstreaming personalised services calculated risks they are taking. A mar-
and associated contracting, we should ketplace which offers spot contracts
expect to see challenges of scale aris- lasting no more than six months would
ing. With providers who are embracing not be ideal in this scenario.
the shift from block to spot contracts,
these challenges are already evident. Brandon Trust’s Gloucestershire
IThe scale up of personalisation is contract provides an interesting
having a significant effect in three key comparison to the spot contract market
areas: of its Cornwall operations. Set up in
2006 between Health/the Adult Social
•the ability of organisations Care Gloucestershire Partnership and
to maintain enough stability Brandon Trust, this 15 year contract
to keep innovating; covers the provision of services to
161 people. In theory the contract
•TUPE (Transfers of Under- allows Brandon Trust to charge for all
taking, Pension and Employ 161 people irrespective of the actual
ment) and the perpetuation of a number of services users (i.e. they can
two tier workforce; and charge for empty beds). At first glance
one might suggest that this would
•upgrading the infrastructure to hinder innovation. In reality the contract
enable smooth spot contract- provides stability to the partnership
i ing. which has enabled ongoing innovation
in the services provided, controlling the
This first section of this paper explores move from a residential care model to
these three challenges, drawing on the one of individualised supported living
experience and perceptions of Brandon environments. The shrinkage of the
Trust. Sharing how one organisation original contract is managed through
is meeting the challenges of person- annual renegotiations. These discussions
alisation, the paper hopes to develop provide a mechanism for negotiating
insights that might be instructive for whether new services are held under
other providers working to personalise the original contract or negotiated
services in the social care sector, and separately. In this way both parties are
shed light on how a national policy is able to manage the costs and benefits
being translated into action. of the changes.

1.2 Maintaining enough stability to There need to be mechanisms which

keep innovating
Brandon Trust aims to balance the
ongoing innovation and development of
new services with a process of main-
streaming innovations once they have
minimise the length of time for which
beds remain empty. The question is how
is this best achieved? If we assume that
both the local authority and the provider
are working towards this goal then the
crucial issue is around the period of time
between a bed becoming empty and
 Personalisation: On the Edge of an Innovation
the services being reconfigured. In small
group accommodation with budgets
based, for example, on 5 people sharing
night cover, it is a challenge to ensure
the quality of service if one of the beds
suddenly becomes empty. Providers
struggle to reduce the cost base the
moment the bed becomes empty, and
from Brandon Trust’s perspective it
would make a huge difference to have
external cover to support these periods
of transition. The challenge of reducing
the cost base by 20 percent if a bed
becomes empty is not something which
can be addressed by reducing cover by
20 percent – you cannot, for example,
have 80 percent of a staff member
present.
Equally the local authority is no longer
making the decisions about weekly staff
allocations, nor is it managing the group
accommodation and therefore it needs
to pass the responsibility for empty bed
cost minimisation to the provider.
One of 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 from
the beginning has been on individualised
negotiated independent living (see
Barbara’s story for details, p. 11). This
produced the clear goal of measurable
and high quality outcomes for each
person. However, inherent in this model
is flux and change as people’s individual
circumstances are open to the ebb and
flow of life. This situation is not neces-
sarily undesirable even though it does
not contain the core stability of a fifteen
year ‘change’ programme, as agreed
and monitored with the Gloucestershire
Partnership.
A structure which didn’t ensure the
continuity of care for users and which
risked disruptions could be deleterious
to the health and wellbeing service
users. If a provider had to keep chang-
ing provision mechanisms in order to
reduce costs this would be counter-
productive both for the service users
and for Gloucestershire. The contractual
structure therefore ensures that the
wellbeing of service users is the primary
driver for both decisions about current
provision and future innovation. Bran-
don Trust would argue that this stability
of working environment has enabled it
to innovate faster and to affect wider-
reaching change.
The second challenge of the (in)stability
of the environment relates to the
questions – who has responsibility for
ensuring the ongoing development of
services and how is this paid for? When
we compare the two year political cycle
of the local authority and councillors, to
the five year strategic plans of providers
such as Brandon Trust we can see the
argument for putting the responsibility
with the providers and thus making
it one step removed from the forces
of local politics. In block contracting
scenarios this works well as there is
a sufficiently long term view on both
sides to see the benefits of ongoing
service development. However in spot
contracting the risk is that not only will
shopping around between service pro-
viders drive down cost (as we’d expect
to see in any open market), but service
users will be unwilling to pay for the
cost of future innovations, particularly
if they will not individually benefit from
them. In this scenario who pays for
innovation and where is it located? The
classic adoption curve from innovators
and early adopters through to laggards
– where the innovators pay more to
 Personalisation: On the Edge of an Innovation
receive innovations first and the lag-
gards pay less but achieve the benefits
far 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 for covering the early and
higher costs? In a scenario where the
majority of service users have individual
budgets and take direct payments there
is likely to be a need for a separate
development budget into which
providers could pitch. The risk of this
structure however is that, by separating
innovation from delivery the processes
of 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 of providers such as
Brandon Trust indicates that they see
themselves as a key source of innova-
tion in the sector. The shift of personnel
over the past 10 -15 years has resulted
in many of the key innovators moving
from commissioning roles into provider
roles. This leads to questions about the
size of organisations capable of deliver-
ing innovation in this sector. Much
of the literature cites the new-found
freedom of individual budget holders to
employ carers of their choice without
being limited to picking from the staff
and services of the larger providers.
Clearly this has benefits 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 for use of a day care centre if
you can work with the local community
gardening team if you prefer? Anec-
dotal feedback 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 diversification of
care is to locate the organisations that
still have an overview of 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 of 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 of
partnerships. However it is important
to recognise and actively support the
role providers play as innovators for the
sector and to look at whether there are
opportunities to extend the approach
to encompass the learnings of micro or
niche providers. This brokerage role has
been explored in detail by Innovation
Exchange, a pilot prgramme for the
Office of the Third Sector in the Cabinet
Office4. The challenges to the environ-
ment for innovation have also been
identified by both Geoff Mulgan5 in his
study of innovation in public services
and by Matthew Horne6 in his review of
innovation brokers for public services,
in particular the lower tolerance for risk
and preference for tried and tested
techniques, and the need to cut across
organisational and professional boundar-
ies (ie to get beyond the professional
and budgetary silos).
 Personalisation: On the Edge of an Innovation
1.3 TUPE and the perpetuation of a
two tier wo rkforce
TUPE is the UK’s implementation of the
European Union Acquired Rights Direc-
tive. It has protected the fundamental
employment contractual terms of
thousands of staff as they have moved
from government and local authority
employment to outsourced roles with
independent providers. It governs
their pay, hours, place of work, annual
leave entitlements and sick pay. This
ethical approach to the provision of a
stable working environment for these
staff has kept good staff in the caring
profession, which has benefited the
service users, as well as the staff and
their families. No-one could argue with
the fairness of intentions that underly
this approach, particularly for those
staff close to retirement who have quite
reasonably planned for a retirement
based on the NHS or local authority
guaranteed benefits pension scheme to
which they’ve contributed during a long
working career.
The issue of the sustainability of these
transfers has arisen not from the act
itself but from the negotiations with
providers such as Brandon Trust and in
particular the liability for pensions and
redundancy provision. Furthermore the
transfer of staff under TUPE results
in a liability which far from diminishing
as staff retire is perpetuated via the
Cabinet Office’s Code of Practice for
Workforce Matters and expands the
liability to cover new, non-TUPE staff
whose terms and conditions would
otherwise be set by market forces.
Employers taking on staff covered by
TUPE face a number of contractual
challenges around employment terms,
redundancy terms and pension provi-
sion. These require careful 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
transferred. For example there are cases
where a pension deficit caused whilst
staff were in local authority employment
has been transferred to the indepen-
dent provider. The appropriateness of
this is questionable if no provision for
the cover of such deficits is transferred,
i.e. if the liability alone is transferred.
Brandon Trust carries approximately
£750,000 pension deficit on their
balance sheet as a result of one such
contract. This issue is exacerbated in
smaller providers without the resources
to offset such liabilities even on paper.
Add this to ongoing commitments to
fixed benefit pensions which demand
variable contributions going forward
which can be in the region of 20
percent of salary (to be met by the
independent provider) and we start to
build a picture of the serious sustainabil-
ity issues facing organisations wishing
to continue to utilise these capable and
experienced staff members.
TUPE creates two further challenges
for providers; flexibility and cost. On
flexibility, TUPE limits the extent to
which providers can transform their
services to respond to personalisation.
Staff covered by TUPE can be moved
from one work base to another, within
reason, and this opportunity may be
used to facilitate the re-configuration
of a service, say from group care to
independent living. However, the oppor-
tunity is limited by the scope to move
TUPE and Code of Practice protected
staff. Where more radical change is
needed, this risks reducing the speed
of transformation to the speed of the
 Personalisation: On the Edge of an Innovation
retirement of TUPE’d staff. While it is
possible to achieve change to pay and
terms in respect of protected staff,
this requires an onerous and risky legal
procedure, which may be successfully
challenged. As a result, no matter the
legitimacy of protecting employees’ pay
and conditions, the result is to limit the
options for making the changes that
personalisation demands.
The second challenge TUPE creates
relates to cost, where tensions between
the needs to protect employees and
to reduce costs are creating perverse
consequences that risk slowing the
growth of personalisation. For example,
where there are staff covered by TUPE,
new staff will be hired on similar terms.
However, in a team where there are
no staff covered by TUPE, new staff
can be hired at market rates. Where
Brandon Trust rates for care staff
might be £16-17,000 FTE (higher than
that offered by individuals with direct
payments) the ex-NHS (Agenda for
Change) rate is likely to be in excess
of £20,000. Thus the staffing costs
depend on the extent to which staff
members covered by TUPE are dis-
persed across the workforce, creating
arbitrary differences in remuneration
across the country. Where commis-
sioners such as those in Cornwall are
asking for substantial reductions in
costs (despite TUPE commitments to
inflationary pay increases), different
organisations and teams therefore have
differential abilities to respond, distorting
the market. While
���������������������������
protecting employees
and reducing costs are both legitimate
objectives, there are huge political and
administrative complexities to the issue
of TUPE. TUPE is being managed
�������������
in a
way that risks disprupting the work of
organisations like Brandon Trust and
reducing the ability of providers as a to
respond to the needs of citizens and
public services.
1.4 Upgrading the infrastructure to
enable smooth spot contracting
The systems which were put in place to
support the outsourcing of block con-
tracts from the NHS to organisations
such as Brandon Trust were simply not
designed to meet the needs of spot
contracting. It is unsurprising therefore
to see increasing transaction costs and
wastage of administrative resources, as
organisations try to keep the systems
updated with the changes being made
to users’ services. This challenge is
exacerbated by the fact that each
region uses different systems and
protocols to manage budgets, invoicing
and payments.
The approach taken by Brandon Trust
has been to develop the regional infra-
structure to enable swifter responses
and greater autonomy. Furthermore
by training the staff to a higher level
on subjects such as finance 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
of a users services). This can be seen
in the restructuring of the organisa-
tion and the creation of the Locality
Manager roles – when compared to the
old front line manager roles we can see
that this post has greater responsibility
for implementing services to meet
local needs. This means greater budget
responsibility, covering income as well
as expenditure, so that it feels much
more like running a business rather than
reporting through a hierarchy. Working
in connection with the development
managers to maintain standards and
10 Personalisation: On the Edge of an Innovation

deliver innovation and growth within a

region should create a stronger business
partnership internally and thus benefit
the users and the commissioners by
enabling a more tailored and localised
offer.

Also, at the point when services are be-

ing commissioned, Brandon Trust agree
not just on the main budget but the
levels of care and support which would
be provided under special circumstanc-
es such as hospitalisation. This enables
faster responses to emergent situations
by the care staff with the added bonus
of preventing invoices from being held
up whilst approval is sought.

Nonetheless the impact of these

outdated systems is that organisations
such as Brandon Trust incur greater
cashflow issues in areas where per-
sonal budgets have been more widely
implemented than in regions where
block contracting is still the norm. It
is therefore an issue that will need
resolving before personal budgets are
rolled out on a broader basis. Whilst
it certainly has a cost implication for
large organisations, the impact on micro
providers could be a more immediate
problem as they are less likely to have
the ability to cover gaps in cashflow.
11 Personalisation: On the Edge of an Innovation
2. The day to day challenge
of implementing personalisation –
Barbara Martin and Brandon Trust
The challenges and successes of
personalisation operate on a very
different level in a policy and strategy
context to the way they play out in
individual lives. By researching the
impact of personalisation on Barbara
Martin’s life we can very quickly see
what the practical differences are and
where 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 of the decisions
about how she wishes to live her life,
from choosing the colour of paint in
her flat through to deciding what to
cook for dinner and how to spend her
money. These sound like the basics of
life but for many years such decision
making was undertaken without
Barbara’s involvement. Barbara was
diagnosed with a learning disability as
a child; the response was to provide
institutional care in the form of large
NHS long term accommodation. It was
not a question of whether an individual
might be capable of taking medication
of their own volition; more a case
that all medication would be provided
efficiently at allocated times. Yet for all
that efficiency, it was not until Barbara
reached her thirties that she was
diagnosed as having hearing loss. Until
that point it did not matter how many
times she said she could not hear the
issue was not addressed. Literally her
voice not being heard and she could
not hear the voices of others. How
times have changed.
After years of institutional care Bar-
bara’s life started changing. First the
‘Care in the Community’ changes of
the Thatcher government meant that
Barbara moved to smaller group ac-
commodation. She was accompanied
by a smaller team of dedicated staff
supporting a group and their specific
needs. However it was only once the
‘authorities’ accepted that Barbara
would function better if she had her
own individual accommodation that
significant steps were taken to support
Barbara individually rather than just as
a part of a group.
12 Personalisation: On the Edge of an Innovation
2.2 Independence and decision
making
Barbara has strong views about
‘independence’ and feels that the
service that Brandon Trust provides
must promote her rights and indepen-
dence. The MCA has given providers
and supporters the framework to
promote and implement a change in
how decisions are made. No longer
are decisions restricted to the support
workers and the family; instead there is
a partnership which starts with Bar-
bara herself. She makes the decisions.
For example Barbara now manages her
own money and, whilst her supporters
will inform her as to where they feel
money will need to be spent, ultimately
Barbara makes the decision. In order
to achieve these sorts of changes a
greater proportion of the time spent
with Barbara is allocated to developing
her learning. Pictoral information is
used in day-to-day decisions which are
then passed on. The rota of support
staff is now available to Barbara and
the shopping list uses pictoral rather
than text based lists. The first things
that Barbara sought to change in order
to give herself greater independence
were processes which would enable
her to manage her own medication
and her own money and the removal
of locks in the house. In prioritising
these changes Barbara was choosing
changes which enable her to spend
more time alone.
2.3 Three examples of 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 of her medication. Brandon
Trust’s role in this was to devise
creative solutions that enabled such
‘positive risks’ to be taken i.e. to man-
age the real risk of Barbara forgetting
to take her medication and balancing
this against the quality of life and
increased 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
flexible support so that she had extra
help to learn to make the change in
the initial stages and less support once
the activity had become embedded in
her daily routine. The level of support
needed for 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 safety issues and
to ensure that Barbara knows how to
respond in less common situations and
where to turn to for help.
2.4 Barriers and risks
Lack of knowledge was probably the
greatest barrier to change for both
Barbara and her support team. They
had all come from a background of
institutionalised care. Barbara hadn’t
learnt the basic skills that would be
required to participate in independent
living; equally her supporters were
not used to supporting her in these
settings. Previously Barbara had little
13 Personalisation: On the Edge of an Innovation
understanding of the concept of
money or concepts of choice. Like
many people her understanding of law
was based on how they play out in her
life (wearing seatbelts, not stealing,
cleaning up after your dog). Barbara
finds more abstract definitions of
the law or even the laws that have
made a difference in her life, such as
the Mental Capacity Act, difficult to
conceptualise.
Bridging this conception gap has
to come via the team who support
Barbara. For these staff, having access
to positive learning and development
programmes which enhance their skills
and knowledge is crucial. This is one
of the impressive commitments that
Brandon Trust has made to their teams
of supporters; real, relevant, in-house
training. The changing role of staff
from carers to supporters has been
achieved not only through education
and training but also inclusion in the
process of change and the develop-
ment of assistive technologies.
Unsurprisingly changes to core support
such as that around the taking of
medication and management of her
mental health were seen as significant
risks. The concerns by both profes-
sionals and family members were that
Barbara would not be able to cope
with choice and change and that her
support staff might not spot if medica-
tion errors arose.
The risks of change are being miti-
gated in two main ways. From Brandon
Trust’s side, when proposing a solution
to a need for change identified 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 found
that presenting solutions along with
the needs speeds up the process of
change significantly. From Barbara’s
perspective by undertaking entry level
education, similar to NVQ’s, 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 from Barbara’s family 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 Barbara’s 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 transferred her
provision to Brandon Trust in 2007, she
started to manage her own money in
September 2008 and the locks that
had previously been placed on doors
and cupboards for the kitchen, food
cupboards, medicine stores and laundry
areas were progressively removed
between 2007 and May 2009. These
changes have freed 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 for adults with
learning disabilities not only is Barbara
more independent but she is known
in the community and is thus safer as
people in the community look out for
her. Barbara is also more assertive and
empowered so when unplanned situ-
ations arise, such as getting lost, then
14 Personalisation: On the Edge of an Innovation
she is better equipped to ask for the
help she needs.
2.5 The Cornwall context
Cornwall went through a series of
dramatic changes in the healthcare
infrastructure under the supervision
of a Special Measures team from the
Department of Health. One of these
changes was in the way in which
budgets for the care of adults with
learning disabilities are managed. As a
result of shifting 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
from a shortlist of three providers and
wrote out a list of names of people she
wanted to support her. Why them? “I
liked Brandon’s DVD ‘My Unique Life’
– the woman who had the cleaning
job, she was just like me. I like the way
Brandon Trust wrote out the plans as if
direct to me. Lynn and Nick, they came
to meet me and were interested in my
life.” 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 of the process that sought her
opinion on such things.
The commitment to personalise
service provision has caused Brandon
Trust to make significant changes in
the way they operate both locally and
as an organisation. Whilst Brandon
Trust has a long record of high quality
care provision in Bristol and the sur-
rounding area they had not provided
services in Cornwall before nor had
they worked with so large a number of
people with individual budgets. Instead
of the head office team pitching for
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
of 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 freedom of a blank sheet
of paper when it came to structuring
the local team. They operate a very
flat structure with very high levels of
communication between the senior
team members (about 10-15 people).
External assessments of staff views
on this have repeatedly concluded
that this has made the senior team
more accessible and transparent and
that staff feel comfortable bringing up
ideas, and articulating the needs and
problems of the people they support.
In the changing roles of service users,
the way services are bought in a
market place rather than allocated to a
provider and the changing roles of staff
from nurses and carers to facilitators,
community builders and educators this
transparency and accessibility is more
crucial than ever; as both staff and
service users need to easily see how to
effect change.
This changing role of staff was not
without its challenges. In particular
those with nursing qualifications
and many years of experience went
through a phase of feeling that their
skills were no longer valued in this new
market place where people wanted
facilitators not carers, advisors not
duty-of-care managers. However as
15 Personalisation: On the Edge of an Innovation
the team were embedded it became
clear that the core people and care
skills were still very much of value,
even if the ways in which they were
provided were changing dramatically. A
far greater emphasis is now placed on
the staff role in building connections in
communities, researching opportunities
and facilitating education and train-
ing. The result is that both staff and
service users feel much more closely
connected to decision-making pro-
cesses and far more involved in them.
2.6 Development of the Brandon
Trust team
The Brandon Trust Cornwall team
requires a far greater knowledge of the
internal management processes which
enable the smooth running of the
contracts and budgets – this means
tighter financial management month
to month, and greater knowledge of
what causes over or under spending.
They have established indicators
earlier in the delivery process to flag up
differences between the service level
that has been contracted and actual
delivery. This is particularly important
when making provision for unplanned
or emergency changes in the support
provided – for example, if a service
user falls ill and requires hospitalisa-
tion. Brandon Trust has changed its
contracting so that such eventualities
are costed and approved at the start
of a contract and only charged for if
circumstances require it.
The challenges of TUPE and the ways
in which the ongoing service delivery
and development costs are covered is
a live issue in Cornwall as service users
have the flexibility to change providers
at six month’s notice. Approximately
80 percent of Brandon Trust staff
were transferred over from the local
authority or the NHS. We see a market
place where the service users are far
more acutely aware of the market rate
for the services they are purchasing,
and thus more aware of the impact of
increased costs resulting from highly
variable yet pre-defined staff rates of
pay. An example of the sorts of 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 staff. Depending
on the staff member it could double
the cost of the holiday and thus call
into question whether the person can
afford to go.
The issues of the perpetuation of a
two tier workforce and the need for
organisations to build in the costs of
managing a workforce, their training,
and new service development is put-
ting services under further strain now
that the local authority in Cornwall
have capped the rate that they are
willing to pay to £15.69/hr (with excep-
tions being made for certain types of
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 definitely a
willingness to pay extra for the quality
that Brandon Trust represents. There
is of course a limit to how much extra
people will pay. The business challenge
that Brandon Trust is facing is how
to decide which business to pitch
and which business would require a
compromise of their core values and
quality levels (and is thus not business
worth winning).
16 Personalisation: On the Edge of an Innovation
3. What needs to change
if we are to scale up the
provision of personalised
care?
The goal is clear – a minimum of 30
percent of local authority-funded
adult social care service users to
be on personal budgets by April
2011. But the path to achieving this
goal is not without obstructions.
The drive to make personalisa-
tion a reality across social care
services would be a challenge in
any economic climate. In the cur-
rent conditions the risk is that the
momentum will slow and learning
from implementation so far will
not be used to strengthen service
development and the mechanisms
which support it. Indeed the
greatest risk of all is that the
current economic climate and the
state of the public purse is used
as an excuse for not implementing
personalisation properly because of
the higher early costs associated
with helping people become more
independent.
The personalisation of support
does require more intensive invest-
ment in its early stages in order to
equip people with the skills needed
to be more independent. However
the payoffs for service users are
significant – increased quality of
life, better physical, mental, and
emotional health. For those people
with a very high cost of support
(the largest budget for 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 of
support. It would be rash however
to expect that the levels of savings
achieved for those individuals in
the top 10 percent of annual sup-
port costs will translate into savings
for individuals in the middle of the
bell curve of annual cost.
The question therefore is how we
can maintain and even increase
momentum whilst taking into
account the impact of the reces-
sion and its effect upon public
spending. We are, after all, talking
about the long term health of
two percent of 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 of the
goal we should be aiming for, but
as the implementation approach to
follow. The changes in regions such
as Gloucestershire are resulting in
personalised support because of,
rather than despite, the fifteen year
17 Personalisation: On the Edge of an Innovation
contract. Clearly there are lessons
to be learnt here in Cornwall’s
contrasting approach. Comparing
these two examples, we might end
up with a set of hybrid models for
the implementation of personalisa-
tion. The goal would be to deliver
benefits without the insecurity of
very short contracts which limit the
ability to recover costs invested in
change. Instead the hybrids would
aim to provide a combination of
the ability to operate a market for
services with stable high quality
services which form the baseline
for new innovations and service
developments.
By looking at the details of how
personalisation is being imple-
mented by Brandon Trust with
people such as Barbara Martin, we
can see that there are some very
particular challenges in the scale up
of personalisation. The challenge
of a sufficiently stable base from
which to develop innovation; the
need for the freedom and the
support to take positive risks that
lead to an enhanced quality of
life and the need for infrastruc-
tural developments to support the
implementation of personalisation
are all key issues to solve.
3.1 The need for sufficiently
stable conditions (to support
innovation)
In Gloucestershire the managed
reduction of large group care
ensures a stable environment
for the people being supported
whilst managing the cost of empty
beds as efficiently as possible. So
although this does not devolve the
finances down to direct payments
to service users, it does offer
innovations in personalisation and
greater transparency in terms of
individual costs. If budgets are
devolved too far we risk a position
where no one budget holder can
fund innovation themselves (they
don’t have enough resources to do
so) yet the mechanisms for group
spend have been discontinued so
there is no structure for pooling
resources. If liabilities are shifted
from the local authority to the
service providers and users we risk
too much emphasis being placed
on risk mitigation and insufficient
focus on progression and develop-
ment.
3.2 An ability to take positive
risks and front load the budget
for change
Developing the emotional, financial,
and intellectual assets of service
users means front-loading the cost
of change due to the educational
needs of the service-users and the
need for additional support through
the change. In the current climate
this can feel like a greater risk than
local authorities are prepared to pay
for, yet we cannot afford to reduce
the momentum of the shift to per-
sonalisation. There is also a need to
support the families as well as the
service users not least because the
enabling of independence tends to
feel high risk and uncomfortable as
the outcomes are not assured at
the outset.
The challenge in terms of organisa-
tional development is that existing
management structures tend
to focus on the top down when
the business is won centrally but
18 Personalisation: On the Edge of an Innovation
delivered locally. As carers shift
their role and become more akin
to facilitators for the service users
they support, there will be a greater
need for mechanisms of bottom-up
feedback, ideas generation and
piloting. This shift of roles from
carer to facilitator will require
training and development for many
staff.
3.3 The development of social
markets
The TUPE and Concord Acts’
restrictions on staff movement are
presently preventing the develop-
ment of a social market. The liability
for redundancy costs represents
too high a risk for independent and
non-profit providers to consider
making job descriptions, staff and
structural changes to support
personalisation. The very structures
that were put in place to prevent
a two tier workforce are in fact
perpetuating it. Furthermore they
are keeping the cost of provision
of services above current market
rates which reduces the amount of
support that any individual can buy
with their budget.
The infrastructure for these social
markets needs to be put in place
so that finance systems can handle
changes to billing quickly and won’t
hinder the cashflow to individuals
or organisations who are currently
shouldering a financial burden that
was not intended. This means
pump-priming both local authori-
ties and providers to implement
changes to financial and related
systems.
Overcoming these very practical,
implementation based challenges
will require greater partnership
between commissioners and
providers and more co-ordination
between departments of health,
employment and education. It is
however essential that person-
alisation is not just the ethos at
the centre of individual support
strategies but is built in to the
infrastructure and systems which
make personal support a practical
reality. For as long as the systems
strain under the weight of issues
such as staff mobility, pensions
and redundancy liabilities, return
on investment risks (played out as
variations in pricing between block
and spot contracting) invoicing and
related cashflow issues, then the
risks for providers to scale in the
scale up of personalised care will
continue to hamper the transition.
It is not reasonable to simply shift
the liabilities from local authorities
to independent providers. Instead
far 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.
19 Personalisation: On the Edge of an Innovation

4. Bibliography

ACEVO, Making it Personal: A Social Market Revolution, 2009

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, 2009
Brandon Trust, A Short History of Brandon Trust, 2008
Brandon Trust, Unique Futures: A Background Paper, 2006
Brandon Trust, Unique futures: Strategic pPan 2006-11, 2006
Bollard, M. (Ed), Intellectual Disability and Social Inclusion, 2009
HM Gov’t, Valuing People: A New Strategy for Learning Disability for the 21st
Century, 2001
HM Gov’t, Putting People First – A Shared Vision and Commitment to the Trans-
formation of Adult Social Care
HM Gov’t, Mental Capacity Act, 2005
HM Gov’t, Our Health, Our Care, Our Say: A New Direction for Community
Services, 2007
Horne, M., Honest Brokers: Brokering Innovation in Public Services, Innovation
Unit, 2009
Innovation Exchange, Innovation Exchange: Supporting Third Sector Innovation
through Brokerage, 2009
Leadbeater, C., Bartlett, J., Gallagher, N. (DEMOS), Making it Personal, 2008
Mulgan, G and Albury, D., Innovation in the Public Sector, PMSU, Cabinet Office,
London, 2003
SCIE, Personalisation: A Rough Guide, 2008
UNISON, Tackling the Two Tier Workforce (Problems and Issues), 2008
20 Personalisation: On the Edge of an Innovation

5. Endnotes

. Leadbeater, C.,
�����������������������������������������
Bartlett, J., Gallagher, N. (DEMOS), Making it Personal, 2008
. ACEVO, Making it Personal: A Social Market Revolution, 2009
3. According to the ADASS/LGA survey as quoted in ADASS’s report on the
milestones www.adass.org.ukimages/stories/Milestones%20for%20PPF%20-
%Final%209.0.09.pdf
4. Innovation Exchange, Innovation Exchange: Supporting Third Sector Innova-
tion through Brokerage, 2009
5. Mulgan, G and Albury, D., Innovation in the Public Sector, PMSU, Cabinet
Office, London, 2003
6. Horne, M., Honest Brokers: Brokering Innovation in Public Services, Innovation
Unit, 2009
21 Personalisation: On the Edge of an Innovation

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