Summary of the impact

A major element of modernising English adult social care is the introduction of individual, user-directed budgets. The Social Policy Research Unit (SPRU) led a major, multi-method and multi-centre research programme evaluating the Individual Budget (IB) pilot projects in England; and a linked study of the impact of IBs on family carers. Through this, SPRU has influenced: the content of the Department of Health's (DH) good practice guidance for personal budgets; the DH's approach to piloting and evaluating NHS Personal Health Budgets; the Department for Work and Pensions (DWP) piloting and evaluation of `Right to Control' trailblazer projects; and, the agenda for an Audit Commission investigation into financial management of personal budgets. Most importantly, it has helped shape the agenda for national and local organisations striving to successfully implement personal budgets, particularly for older people.

Underpinning research

In 2007-08, around 1.75 million working age and older people in England used social care services provided by, or commissioned on their behalf from, local authorities and private and voluntary organisations. In 2006-8, Individual Budgets were piloted in 13 English local authorities as a new way of enabling social care users to exercise choice and control over their support. An evaluation of the pilots (named the IBSEN project, 2006-08) led by Professor Glendinning (at York since 2004), SPRU, assessed the benefits and cost effectiveness of the pilots and the challenges involved in implementing IBs.

IBSEN included a Randomised Control Trial (RCT) — rare in English social care research — that compared outcomes against conventional methods of allocating and using social care and other resources. This was complemented by almost 1000 in-depth interviews with IB users; interviews with front line staff and senior managers; and analyses of practitioners' time use. SPRU also designed and led a linked study of the impact of IBs on carers.

IBSEN involved researchers from Personal Social Services Research Unit (London School of Economics, Manchester and Kent); and Social Care Workforce Research Unit, (Kings College London). Professor Glendinning co-ordinated IBSEN and contributed to all stages of the main evaluation; led additional SPRU research on early outcomes of IBs, (specially commissioned to inform the Comprehensive Spending Review); and was responsible for all contractual matters. Mark Wilberforce (research fellow) managed the project and investigated the implications of IBs for social care markets. Dr Moran (research fellow, York, since 2006) led strands on IB implementation and qualitative outcomes. Glendinning also designed and led the linked study of the impact on carers. Dr Arksey (senior research fellow, at York 1995-2010), Moran and Dr Rabiee (research fellow, at York since 2001) were responsible for outcome interviews with carers and local authority implementation of IBs and carers.

The research team met regularly with DH research customers and a Reference Group of representatives from other government departments with interests in the pilots. It also had close links with the implementation team supporting the pilot projects and attended meetings organised by them for the pilot sites throughout the project.

The research findings showed that users generally welcomed IBs because they offered more opportunity for choice and control over support arrangements than conventional social care arrangements. However, there were variations in outcomes between different groups of IB users: satisfaction was highest among mental health service users and physically disabled working age people and lowest among older people.

Receipt of IBs was significantly associated with positive impacts on carers' reported quality of life and also, when other factors were taken into account, with carers' social care outcomes. The study generated extensive data on the challenges for central and local government and the social care workforce in implementing IBs.

SPRU published full and summary reports of the main evaluation: a report of the linked study of impact on carers and three widely circulated lay summaries (one specifically for front-line staff). SPRU organised two very well attended national conferences. Researchers undertook a wide range of speaking engagements to social care audiences in the UK and internationally in order to disseminate the research findings as broadly as possible.

Presentations summarising the evaluation findings were made to the Minister for Adult Social Care, Ivan Lewis, and the Improving the Life Chances of Disabled People Inter-Ministerial Group. Discussions of emerging findings were held with directors of adult social care services. Other presentations included the Office for Disability Issues, James Purnell (Secretary of State, DWP), Association of Chief Executives of Voluntary Organisations, NHS Confederation, Princess Royal Trust for Carers, Local Government Association. International presentations included policy makers and academics from Canberra, Budapest, Dublin and Seoul.

References to the research

The study was the first robust UK evaluation of the implementation of personalised approaches to social care and the impact on users, support process, workforce, commissioning and providers. The particular strength of the evaluation lay in the randomised controlled trial, supplemented by the more detailed qualitative investigation of the processes and perspectives of this wide range of users and stakeholders. The randomised controlled trial enabled exact like-with-like comparisons of the costs, outcomes and cost-effectiveness of IBs over conventional service delivery. The evaluation used well-respected and internationally recognised instruments for measuring social care outcomes.

The two final reports from the study (1 & 2 below) continue to be very extensively cited in national and international policy and academic papers. They have to date generated 17 papers in leading social policy and social work peer-reviewed journals. There were 7 articles in the professional press and two pieces in The Guardian.

Grants - Four grants to fund the programme were awarded to Professor Glendinning:

• IBSEN development work, 1/4/2006 to 31/12/2006, DH (£12,545)

• IBSEN project: National Evaluation of the Individual Budget Pilot Projects, 1/4/2006 to 31/3/2008, DH (£784,224)

• Individual Budgets: impact and outcomes for carers, 1/1/2007 to 30/0/2008, DH (£91,921) IBSEN Dissemination, 1/4/2008 to 31/3/2009, DH (£114,046)

Details of the impact

The IB approach was made Government policy and rolled out in England and Wales as `personal budgets' (PB). The detailed IBSEN findings and the linked carers study primarily shaped and contributed to the future implementation of the PB policy at local and national levels in England as the findings revealed which systems were most effective for implementing IBs and what to look out for as problems with changes in funding streams. There has also been considerable international interest from countries and regions interested in adopting the IB approach. The official target is for 70% of social care users to have a personal budget. 1.3 million people received services in 2012-13 (Health and Social Care Information Centre).

The following is a selection of the major impacts, and is indicative of the breadth and depth of the impact of the research on policy and practice:

• DH published a detailed 37 page report specifically addressing IBSEN's findings. This stated: `The Department of Health welcomes the independent evaluation reports produced by [IBSEN].....The IBSEN research greatly improves our understanding of these issues... it will strongly inform [personal budget] implementation.... In moving forward, strong attention will be paid to those issues where the risks highlighted by IBSEN are most significant....The lessons learned from the separate research into carer's experiences of IBs ... are also important.' (passim, DH, 2008)<sup>1</sup>. The Appendix included details of the actions taken by DH in response to 26 elements of the recommendations from IBSEN. These included: Ministers looking at the issues around incorporation of income streams when considering further development of individual budgets and feeding this into public consultation via the welfare reform green paper No One Written Off. Feeding insights from the evaluation into the planning for personal health budget pilots. Collating learning and best practice from IBSEN when creating the Personalisation Toolkit for councils. Feeding into Departmental reviews on charging and also a CSCI review of Fair Access to Care Services.
• IBSEN findings on the poorer experiences of older people were particularly problematic. The Social Care Institute for Excellence (SCIE), on behalf of DH, commissioned further research from SPRU to identify good practice in delivering PBs to older people and people with mental health problems (Newbronner et al., 2011)<sup>2</sup>; this further study is also widely cited in policy and practice guidance. IBSEN also prompted the English Association of Directors of Adult Social Services (ADASS) to commission a further review of evidence and practice in delivering PBs for older people (Routledge and Carr 2013)<sup>3</sup>.
• The IBSEN research was used to inform guidance on how best to implement IBs in relation to improving outcomes for carers. DH (2010)<sup>4</sup>
• IBSEN shaped the DH approach to the design, piloting and evaluation of NHS personal health budgets (PHBs)<sup>5</sup> between 2009-12: the DH commentary on the IBSEN findings stated `the issues and complexities raised have influenced the decision to pilot Personal Health Budgets'¹. SPRU also played a key role in the PHB evaluation.
• IBSEN evidence on the pilot projects' difficulties in integrating funding streams shaped the design of the Department for Work and Pension's (DWP) Right to Control `trailblazer' pilot projects introduced by the Welfare Reform Act 2009. Before commissioning its evaluation of the `trailblazers' DWP commissioned a feasibility study to learn from the experiences of the IBSEN evaluation. The report of the evaluation of Right to Control⁸ says "The Right to Control pilot .... builds on the Individual Budgets pilot .... The Right to Control [pilot] also addresses the legal and accountability barriers to integrated funding streams identified in the evaluation of the Individual Budgets pilot.'
• Professor Glendinning contributed to policy debates by using examples from IBSEN in oral evidence to the House of Commons Health Committee's 2010 investigation into social care. From this, the Committee concluded that, despite consensus in favour of personalisation, 'the details of implementation are contentious'⁶
• The new Coalition Government's Vision for Adult Social Care⁷ Green Paper cited both the main IBSEN evaluation and the linked carers study in support of its proposals to `make personal budgets the norm for everyone who receives ongoing care and support'.
• The Audit Commission report on PBs<sup>9</sup> cited evidence from IBSEN on the costs of IBs to justify the expectation that personal budgets should be cost-neutral.
• A review<sup>10</sup> of the published literature on self-directed support for the Scottish Government, commissioned to aid policy decisions in this area, drew attention to IBSEN as a core report in this policy area in England. It recommended the principles underpinning IBs, as set out in the `influential and detailed' IBSEN evaluation.
• The South Australia State Minister for Disability and the Head of the Disability Service visited SPRU in 2011 to learn about the UK's experiences of implementing personal budgets and to discuss our recommendations. Australia was starting to look at its disability provision in order to reform it and bring it up to date. In 2013 Australia launched a new disability insurance scheme Disability Care Australia, with an emphasis on independence and control for the service user and including personal budgets to spend on care. South Australia is one of the launch sites for this policy and fed into the debates about its creation. There has been subsequent research collaboration between researchers in SPRU and Australia to compare aspects of personal budgets in each country.

The range of impacts demonstrates how the IBSEN research influenced the final implementation of personal budgets in England by highlighting the challenges in applying this level of personalisation at local and national levels, and by recommending where extra care was needed for different user groups. It is an example which has been heeded by other countries as they look to implement more personalisation in their social care and health systems.

Sources to corroborate the impact

1. DH (2008) Moving Forward: Using the Learning from the Individual Budget Pilots. Response to the IBSEN evaluation from the Department of Health, London, Department of Health. (DH 2008: 29)
2. Newbronner, L., Chamberlain, R., Bosanquet, K., Bartlett, C., Sass, B., Glendinning, C. (2011) Keeping Personal Budgets Personal: Learning from the Experiences of Older People, People with Mental Health Problems and their Carers, London, Social Care Institute for Excellence.
3. Routledge, M. and Carr, S. (2013) Improving Personal Budgets for Older People, Phase One Report, London Social Care Institute for Excellence.
4. DH (2010) Carers and Personalisation: Improving Outcomes, London, Department of Health
5. Forder, J., Jones, K., Glendinning, C., Caiels, J., Welch, E., Baxter, K., Davidson, J., Windle, K., Irvine, A., King, D. and Dolan, P. (2012) Evaluation of the personal health budget pilot programme: Final report, Kent: Personal Social Services Research Unit, University of Kent.
6. House of Commons Health Committee (2010) Social Care. Third Report of Session 2009-10 Volume 1, London House of Commons. (HC 2010 vol 1:88)
7. DH (2010) A Vision for Adult Social Care, London, Department of Health. (p16)
8. Office for Disability Issues (2013) Evaluation of the Right to Control Trailblazers: Synthesis Report, ODI, DWP, (p19.)
9. Audit Commission (2010) Financial Management of Personal Budgets, London, Audit Commission
10. Scottish Government Social Research (2011) Self-Directed Support: a Review of the Barriers and Facilitators, Edinburgh, Scottish Government. (p.16)