Summary of the impact

Research by Jonathan Wolff provided the intellectual framework for pioneering work on self-directed support in social care by In Control, a national charity whose mission is `to create a fairer society where everyone needing additional support has the right, responsibility and freedom to control that support'. Wolff's work with In Control has shaped recent government policies including the Putting People First strategy (adopted 2008), which have improved health provision generally and service provision for disabled persons in particular. The specific impacts described here are (1) shaping government policy at both a national and local level and (2) improving the health and quality of life of more than 600,000 disabled citizens and their carers by improving service delivery.

Underpinning research

Within many liberal egalitarian approaches to political philosophy, a standard approach to remedying disadvantage is to recommend economic redistribution in the form of `tax and transfer' policies. Jonathan Wolff (joined UCL as Lecturer in 1986; Professor of Philosophy since 2000) became dissatisfied with this approach on the grounds that, first, it assumes that all goods are commensurable and their lack can be remedied with cash, and second, that it ignores the social structures that can profoundly influence our well-being. Wolff began exploring alternative approaches in the early 1990s and, in a project starting in 1997, Wolff turned his attention to the question of how a society of equals should treat issues of disability. He has since presented his findings on disability in the UK, Europe, the USA and Africa.

In developing his own approach, Wolff suggested that the transfer of resources is not always the best way to overcome disadvantage in cases of disability. Transferring resources to a disabled person, in virtue of their disability, appears to convey the message that they are to be compensated for an inherent defect that makes them less able than others in some relevant respect. This initially led Wolff to focus on a social model of disability, in which the disadvantages faced by disabled people are remedied by altering the social environment to allow them to function more successfully within it. In 1999, Wolff wrote a paper integrating the social model of disability into contemporary theories of equality. Although this paper was widely circulated and later used in a 2002 USA National Endowment for the Humanities summer school on disability, it was never published in its original form because Wolff continued to develop his thinking in more detail and came to question whether the social model of disability was capable of covering all cases, especially those of intellectual disability. Following discussions with disability activists around 2001 and consideration of new experimental policies (especially those of Simon Duffy, see section 4), Wolff concluded that in some cases transferring money to disabled people is the most defensible strategy after all. Even though changes to the physical, legal or cultural environment will almost always be highly beneficial for people with disabilities, such changes will not always be enough to remedy their disadvantages. Consequently Wolff modified his view, allowing that tax and transfer has a role alongside other approaches. That modified view — which is of central importance to the impacts described here — was first sketched out [a] and then more fully developed [b, c] in a series of publications between 2002 and 2013, which first of all showed how the social model of disability could be used to develop a new account of `addressing disadvantage' more broadly in political philosophy, and then went on to show that nevertheless it needed to be supplemented by other forms of redress in the case of disability. Wolff drew on his experience with In Control (as described in section 4), to present the joint work to a philosophical audience [d], which was the first time he had explicitly applied his framework to cognitive disability in detail. The work was further developed in the context of a wide-ranging analysis of disadvantage in a joint study with Avner de-Shalit (Hebrew University, Jerusalem) in 2007 [e]. A further version was included as a chapter of Wolff's solely authored book on ethics and public policy in 2011. [f]

At the centre of this research is Wolff's distinction between two different rationales for providing money to people with disabilities: `pure compensation', in which alternative goods are provided to make up for the miseries or lack of `internal resources' of disabled people, and what Wolff called `targeted resource enhancement' (later renamed `Conditional Resource Entitlement' — see section 4), in which people are provided with the means to buy goods and services so that they can achieve a flourishing life in their own way. Wolff remains critical of pure compensation policies, but argues that the disadvantages faced by a disabled person can sometimes be best addressed by providing her with money, not on the grounds that she is to be compensated for an inherent defect, but rather that society should provide her with the means to flourish in her own way. This has every chance of advancing not only the individual's well-being, but also his or her autonomy, which, especially for younger people with cognitive disabilities, has often been ignored or overlooked.

References to the research

Details of the impact

Wolff's research on alternative approaches to injustice helped provide the intellectual framework for pioneering work on self-directed support in social care by a national charity, In Control. A collaboration between Wolff and Simon Duffy, then Chief Executive of In Control, began in 2002 when Duffy, who had been experimenting with personal budgets for adults with intellectual disabilities, attended a seminar at the University of Sheffield, given by Wolff on the subject of disability. In subsequent discussions, the two realised that Wolff's conceptual framework could support Duffy's practical work, and this conjunction of Wolff and Duffy's respective skills as a theoretician and a policy maker resulted in the expansion of self-directed support and its adoption by the UK government. Since 2008, the two major impacts of this have been:

1. Shaping government policy at both a national and local level.
2. Improving the health and quality of life of disabled citizens and their carers by improving service delivery.

Self-directed support enables people eligible for social care to make decisions regarding their care using a personal budget allocated to them. This enables individuals to direct resources where they are most needed and thus take control of their own care, and reduces the burden on social workers and others working in social care. As a result, in 2012-13 alone, over 600,000 people with intellectual and physical disabilities, including many older people and people with mental health problems have been able to direct their own care through personal budgets [10].

The idea of personal budgets had been treated with suspicion in some political circles, in the belief that it was a revival of a `voucher' system designed simply to save money, and would undermine collective facilities such as day centres. Wolff's research provided a way to justify personal budgets by emphasising the positive benefits of developing the autonomy of disabled people who previously had little control over their own lives, as well improving the efficiency of government spending. Those receiving personal budgets could choose to spend money on collective goods, as many did when the collective goods were of a decent standard. Having the choice meant that individuals can design their own care package which would typically also have other elements. Duffy renamed Wolff's concept of `targeted resource enhancement' `Conditional Resource Entitlement' (CRE) and used it as the basis for the development of an innovative and workable concept of adult social care [see for example 2]. CRE provides a way to explain the nature of an individual budget as a resource under the control of the person to whom it is delivered, but subject to some conditionality or rules. According to Duffy, Wolff's research paved the way for expansion of In Control's work by setting out a conceptual framework that helped strengthen the intellectual foundations of the work, clarified and framed the central questions it needed to address and to explore novel ways of differentiating and conceiving policy choices. This is acknowledged, for example, in the introduction to a 2010 article, where Duffy states: "This article builds on initial analysis first presented to the English Department of Health in 2007 via Waters and Duffy's report for In Control on Individual budget integration. As acknowledged in this initial report and in the current article, much of In Control's initial thinking in this area has been influenced by the work of Jonathan Wolff on disadvantage, inequality and different forms of redress (see, for example, Wolff, 1998, 2002, 2003)" [3, p. 506. Wolff 2003 is [a], above]. Duffy's adoption of Wolff's approach enabled him to present its advantages in seminars and meetings with local and national government officials, such as to the Cabinet Office in 2004, in a concise and rigorous fashion that made it appealing to local and national agencies alike [9].

Wolff continued to be involved in In Control's later, larger experiments, connecting disability service provision with the `capability approach' in political philosophy and stressing the importance of evaluating the service to ensure that the burden of care was not simply transferred to others in the community or family, such as mothers.

Self-directed support has since formed a key part of the personalisation movement, which seeks to increase choice and control for adult users of social services. This has influenced several national government policies. In 2006, after successfully testing self-directed support model, the Department of Health commissioned an In Control report on individual budgets. That report, to which Wolff was a contributor, appeals to conditional resource entitlement and draws `heavily from the recent work of Jonathan Wolff on disadvantage, inequality and different forms of redress' [1, p. 58]. It formed one of the bases of the development of the Putting People First ministerial concordat, signed by 6 cabinet ministers in December 2007, implemented from 2008, and adopted as a national strategy from 2009 to 2011 [4]. Putting People First explicitly recognised In Control as the pioneer of personal budgets. It has, in turn, catalysed and informed over a hundred local government policies directly affecting service provision, and influenced further government policy and programmes such as Think Local Act Personal (January 2011), the cross-sectoral partnership that succeeded Putting People First and which is based on `self-directed support' [7]. In Control's influence among policy-makers across the UK continues to grow and can also be seen in the newly implemented Social Care (Self-Directed Support) (Scotland) Act 2013.

By leading to improved social care service delivery, Wolff and Duffy's collaboration has improved the health and quality of life both of citizens who receive self-directed support, and of their carers. By March 2011 all councils in England had implemented Putting People First [6], to the benefit of at least 338,000 service users: in this context alone, the research informed the deployment of more than £1.5 billion of government allocations in support of personal budgets [7, p. 3]. Specific examples of local councils are Barnsley and West Berkshire, both of whom implemented Putting People First from 2008 [6]. In 2012-13, "the number of people receiving self-directed support was 609,000 (an increase of 16% from 2011-12). Of these, 151,000 received a direct payment — up 8% from 2011-12. The number of carers receiving self-directed support was 100,000 (an increase of 28% from 2011-12)" [10, p. 5]. Evaluations of the service found those receiving personal budgets were significantly more likely to feel in control of their daily lives, the support they accessed and how it was delivered [8]. This confirms Wolff's hypothesis that `targeted resource enhancement' can improve an individual's autonomy, independently of any other effects on well-being. And as Wolff also argued, such policies are likely to have further positive effects on the well-being both of the individual who receives the budget and his or her carers. Even when other factors were accounted for, personal budgets were also found to be associated with statistically significant positive effects on carers' quality of life and social care outcomes, without increasing public expenditure [8]. Use of personal health budgets was further found to be associated with a significant improvement in care-related quality of life and psychological wellbeing [8].

The principal direct impact of Wolff's collaboration with In Control is, of course, its effect on the more than 600,000 people who were in receipt of self-directed support by 2012-13. However it is also important to note that it has only been able to achieve this scale of influence through two other types of impact. One is its impact on national government policy [4] [5], which was essential for the programme to be implemented at scale. The other is the way in which the programmes have been embedded in local action [6] both prior and subsequent to its adoption as a national programme. Putting People First was itself unique in establishing a collaboration between central and local Government, the sector's professional leadership, providers and the regulator; In Control's role in pilot programmes — supported by Wolff's research — also represented a new partnership between government and the third sector.

Sources to corroborate the impact

[1] For Wolff's contribution to the In Control report commissioned by DoH in 2006 and used as a basis for the for the Putting People First concordat: Duffy, Simon; Waters, John `Individual Budgets: Report on Individual Budget Integration' June 2007. http://bit.ly/14ntiOz, see esp. p. 58.

[2] Example of Duffy's use of Wolff's research in developing the concept of Conditional Resource Entitlement: "The Conditional Resource Entitlement is an idea developed by Simon Duffy from the work of the philosopher Jo Wolff." http://bit.ly/1b0AsHG.

[3] Acknowledgment of the importance of the research to In Control: `Personalisation and adult social care: future options for the reform of public services', Duffy, Simon; Waters, John; Glasby, Jon. Policy & Politics, 38: 4. 2010, pp. 493-508(16).
http://www.asdinfowales.co.uk/resource/r_s_simon_duffy_paper.pdf p. 506.

[4] Putting People First, HM Government, signed by Alan Johnson, Secretary of State for Health, and 18 other major government office holders, dated Dec 2007. http://bit.ly/1b0AUph [National Archives: dh.gov.uk] Implementation from 2008: http://bit.ly/144HitI [local.gov.uk].

[5] `Personal Health Budgets: first steps.' Department of Health, January 2009. http://bit.ly/137aihc [National Archives: dh.gov.uk] states that: `This study's findings were supported by findings from In Control' (p. 17), and that: `The DH Putting People First team and In Control will be key partners in the community'(p. 46). In Control are cited frequently throughout.

[6] Examples of local governments using Putting People First policies for young adults with disabilities: `Putting People First in West Berkshire 2008-2011: Adult Social Care Strategy': http://bit.ly/13GJWBM [westberks.gov.uk] and `Barnsley Metropolitan Borough Council Key Decision' (2008) http://bit.ly/1b0B0gL [barnsley.gov.uk].

[7] Centrality of self-directed support to `Think Local Act Personal: `Personal Budgets: Taking Stock, Moving Forward', Think Local Act Personal, 2011: http://bit.ly/1efSxRL esp. pp. 3-5; for the implementation of self-directed support see p. 3.

[8] Evidence of service users' perceptions of the benefit of self-directed support: `The Individual Budgets Pilot Projects: Impacts and Outcomes for Carers', Glendinning et al, Social Policy Research Unit, University of York, (Research Commissioned by the DoH), February 2009. http://bit.ly/16ogXHU [york.ac.uk]; and Improvement in care related quality of life: `Evaluation of the personal health budget programme', Glendinning et al, Social Policy Research Unit, University of York, (Research commissioned by the DoH), November 2012. http://bit.ly/144I2iq [dh.gov.uk].

[9] Duffy's use of the research to inform local and national policy-making and governmental groups can be verified by the former Chief Executive, In Control.

[10] 2012-13 figures for receipt of self-directed support: Community Care Statistics, Social Services Activity: England 2012-13, Provisional Release: http://bit.ly/17ojRt7 [nhs.uk] p. 5.