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Faced with the dangers of choice

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With local government's reputation still reeling from the Baby P tragedy, could the personalisation of social care open the floodgates for the abuse of vulnerable adults?

Placing those entitled to publicly funded social care in the driving seat for their own services is at the heart of the government’s Putting People First transformation programme .

There is no shortage of stories about people with complex needs who have had their lives transformed by the ability to design and run their own care packages instead of having them prescribed by social services. However, there is a darker side to personalisation: the risks that freedom can bring.

According to charities, academics and the nation’s largest public service union, the personalisation agenda contains huge scope for both financial and physical abuse.

By March 2011 “fundamental system-wide change” is expected of all councils, with authorities in a position to offer individual budgets to all residents who become eligible for funded care, allowing them to choose how to spend their cash.

Meanwhile, the programme - which has the potential to turn some care funding recipients into fully fledged employers - is rapidly gaining momentum with well over 70,000 people already receiving payments.

None of the experts LGC spoke to believe that the personalisation route for social care is the wrong path, but many expressed fears that proper consideration has not been given to ways to safeguard vulnerable adults, who make up a significant chunk of those eligible for individual budgets.

One director of adult social services even expressed the fear that a tragedy on the scale of Baby P or Victoria Climbié could have the potential to completely derail the programme.

In October 2008 the Department of Health published findings of research into individual budget pilots that began in 2005 at 13 councils , based on research by the University of York, King’s College London, the University of Kent, the University of Manchester, and the London School of Economics.

A four-page summary document for Evaluation of the Individual Budgets Pilot Programme referred to “particular concerns” about safeguarding vulnerable adults, while its 50-page summary reported front-line staff voicing fears about “risks of poorer quality services, misuse of funds, financial abuse, neglect, and physical harm”.

Readers needed to trawl through the whole report for the most chilling pictures to emerge. Interviews with adult protection leaders, team leaders, and care co-ordinators unveiled a host of concerns, but chiefly that in at least one of the 13 authorities evidence was already emerging of the financial and physical exploitation of individual budget recipients.

One unidentified adult protection lead added: “The risk is they will be targeted and groomed by people who abuse vulnerable adults. There is local evidence that some people who’ve abused children have moved over to abuse vulnerable adults.”

Added to these concerns were fears for the increased difficulty of monitoring service users who no longer have their care provided by councils or council-contracted services.

Staff also worried about the potential for users to spend their budget hiring unqualified assistants, who had not been checked by the Criminal Records Bureau . They were also concerned that the assistant would be unable to monitor properly the health of those they were paid to look after, making them even more isolated and at risk.

There were also worries that local authorities would still be left to pick up the pieces for those who misspent their budgets or were left without services through exploitation.

Gary Fitzgerald, chief executive of Action on Elder Abuse , said he believed vulnerable adults killed by relatives or neighbours in several recent high-profile abuse cases would have been considered suitable to manage their own budgets.

And he said that the likelihood that many current service users would end up hiring family members or neighbours as their paid careers was a particularly worrying scenario.

Mr Fitzgerald said that elderly people being coerced out of their homes and savings by their own families was already a major problem. A situation that opened up new possibilities for exploitation would add fuel to the problem, he warned.

“Sixty-seven percent of the abuse reported on our care line takes place in people’s own homes, and the majority of people responsible are family, friends and neighbours,” he said. “It’s almost certain that there’s going to be an increase in family abuse.”

Mr Fitzgerald added that so far the government appeared to have put little thought into devising a robust safeguarding structure for the personalisation agenda.

”There’s a failure to understand that people have a right to choose and a right to protection, and that one doesn’t negate the other,” he said. “It remains a duty of care for local authorities and a duty of care for the government.”

The DH has an ongoing consultation on its No Secrets safeguarding guidance from 2000 , which asks for input on dozens of questions of abuse. However just a handful are directly linked to the personalisation agenda.

Helga Pile, Unison’s head of social services, agreed that the government had so far provided too little guidance to councils, leaving much of the so-called “positive risk taking” that self-directed care involves open to local interpretation.

“Our worst-case scenario is that we have floods of cases coming to light where there’s been abuse of an older person by an unregulated person,” she said.

“The other big fear is that we get some unscrupulous providers who have poor practice in terms of where they direct people to spend their money.

“Then we’ll see vulnerable and older people finding that unless they put their own money in, they’re going to lose their care.”

Ms Pile said that the still-to-be determined regulation framework for personalised social care would be crucial in determining how protected vulnerable adults were.

John Dixon, president of the Association of Directors of Adult Social Services (ADASS), added that it was wrong to see safeguarding and personalisation as incompatible, but that it was clear that a new set of agreed practices needed to be found.

“It’s a bit too ad hoc and we need to get to a common position on this,” he said.

He added that a new set of guidelines to help councils was likely to be drawn up between ADASS, the new Care Quality Commission, and the DH in the near future.

However, he said it would be crucial to ensure that any guidance did not prevent people who were perfectly capable of organising their own care from doing so.

Nevertheless, ADASS has issued its own seven-point safeguarding plan that it believes should be implemented even before the No Secrets review is complete.

As an immediate need, the plan calls for the resources to develop staff skills on risk-management, with a longer-term goal of better legislation to provide vulnerable adults with the kind of robust protection framework that was introduced into children’s services following the death of Victoria Climbié.

The DH insists it is committed to “integrating choice and control into the safeguarding process” but concedes that “an effective way of enabling people to make supported decisions built on appropriate safeguarding arrangements” still needs to be found.

In a statement to LGC, it said the ongoing No Secrets review consultation - which closes this month - was seeking to “explore the interface” between personalisation and safeguarding.

“What the consultation is telling us that the two policies are coming closer together and learning from each other’s experiences,” it said.

However, it said that no timescale for acting on responses was currently available.

In the meantime, councils will have to find their own ways of ensuring that the risks of personalisation are properly managed.

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