Personalisation and expansion

The places within which people experience care and support are shifting in a context of personalisation. Personal budgets are designed to be a permissive intervention which allows people to make their own choices about how and where they want to receive care and support (HM Government, 2007). This facilitates individualised commissioning of support which is more tailored to the individual. It also aims to make it easier for people to access ‘universal’ environments, such as leisure centres, libraries, shopping centres, cinemas, bowling alleys and parks (HM Government, 2007). This may be achieved through facilitating the employment of a personal assistant and/or making places more accessible and welcoming. There are examples of people with a disability using a budget to facilitate a family holiday to Centre Parcs or abroad, rather than assuming that respite care or another kind of bespoke setting is the only option for a break (Leadbeater et al., Reference Leadbeater, Bartlett and Gallagher2008). Dementia cafes are growing in popularity, either as informal places for information and support, or more formal places for themed discussion on the Alzheimer Cafe model (Graty, Reference Graty2008). Within the NHS, the personal health budget pilots have shown the scope for people to use budgets to widen the settings within which support is being given (Forder et al., Reference Forder, Jones, Glendinning, Caiels, Welch, Baxter, Davidson, Windle, Irvine, King and Dolan2012). People can access alternative therapy centres, for example, which are not conventionally supported by the NHS (for example, for aromatherapy and massage), or attend private gyms or Weight Watcher meetings.

There are also new virtual spaces emerging for care and support. Although not a causal effect of personalisation, the co-occurrence of social media and personal budgets has fostered a linkage between the two. Social media can facilitate the pooling of budgets, so that sufficient support can be arranged to allow a group outing or shared purchasing of equipment (Stephens and Michaelson, Reference Stephens and Michaelson2013). Online portals have made it easier for people to access support and brokerage for personal budgets. Sites such as Shop4Support help people to make choices about how to spend a budget.

Personalisation then can facilitate access to a range of new places which people can utilise as groups or individuals. If this access costs money, then personal budgets enable people to withdraw from collectively funded services such as day centres and use the money as individual ‘commissioners’. This clearly has consequences for the sustainability of collective services, highlighting that personalisation may be about a withdrawal of some places as well as the opening of new ones. A survey by the journal Community Care and the trade union Unison found that 56 per cent of social care workers agreed with the statement, ‘Services such as day centres are being closed down in my area on the grounds that personal budgets will mean reduced use’ (Dunning, Reference Dunning2010a: 15). In the current fiscal context, with local authorities making up to 25 per cent cuts in social care budgets (Dunning, Reference Dunning2010b), financial concerns are also prompting local authorities to close or restructure day services in favour of more personalised alternatives (Beresford et al., Reference Beresford, Fleming, Glynn, Bewley, Croft, Branfield and Postle2011). Mencap, a charity for people with learning disabilities, used a Freedom of Information request to 151 English local authorities to report that ‘almost 1 in 3 (32%) local authorities have closed day services. 1 in 5 (20%) of these did not say they have provided replacement services . . . 3 in 5 (60%) local authorities have increased charges for day service attendance and related services such as transport, on average by 70%’ (Mencap, 2012).

The implications of this are highly contested (for a discussion of this see Needham, Reference Needham2014). For some people, day centres are an example of a segregated, low-quality service that needed phasing out. For others, the centres are places of community, and their closure has been bitterly contested. This contestation is in part a reflection of the battle over policy framing which is evident in other aspects of welfare reforms. It also reflects the diversity of views of the users of those services (Needham, Reference Needham2011). Advocates of personalisation envisage that day centres will be replaced by community hubs, and this is happening in some areas. In Surrey, for example, they have set up a network of user-led hubs, which aim to be ‘drop-in shops on local high streets for information, advice, advocacy and other services about care and support [which] . . . help people stay independent’ (http://www.thesurreyhubs.org.uk/). There are examples of charities and user-led organisations taking over day centres and changing the ethos and activities, with greater focus on member participation and self-determination. ‘Day clubs’ in Australia are an example of such an approach (Fawcett et al., Reference Fawcett, Weber and Wilson2012), and Age UK has similarly moved in such a direction with its Wellbeing centres. As statutory funding is withdrawn, such places could offer a set of services for people with personal budgets (and indeed self-funders) to purchase.

However, the research by Mencap highlighted the extent to which the shift to personal budgets, in a context of large-scale budget cuts, is leading to people being ‘Stuck at home’ as the title of the report puts it (Mencap, 2012). A survey of day centre workers, in association with Unison, highlighted that many of these workers were suspicious about the motives for the shift away from centre provision. As one respondent put it, ‘[Personal budgets] has given management the excuse to close Day Centres despite the fact that the number of service users wanting to use them has not dropped’ (cited in Needham, Reference Needham2013: 7). It can be argued that personalisation, like the deinstitutionalisation narrative that accompanied the closure of long-stay hospitals, is having more success as a narrative of closure and critique than as a stimulus for the emergence of new collective spaces (Needham, Reference Needham2014).

Thus the promise of spatial expansion, which is a key element of personalisation, needs to be recognised to be highly contingent and person-specific. Some critics of the current incarnation of personalisation have argued that personal budgets expand choice and control for people who are already well supported and networked, just as direct payments before them did. Advocates of personal budgets suggest that this is not a reason to abandon choice and control, but to pursue it more ardently so that the benefits are more diffused (on this see the debate between Slasberg and Hatton, Reference Slasberg and Hatton2011). Certainly, the roll out of personalisation in a context of fiscal austerity and bureaucratic complexity ensures that as local authority services are withdrawn, it can be difficult for people to access or even know about what is replacing them (Baxter and Greener, Reference Baxter and Greener2011; Slasberg et al., Reference Slasberg, Beresford and Schofield2012a, Reference Slasberg, Beresford and Schofieldb). The 2013 National Personal Budgets (POET) survey found that although ‘responses relating to impact on life were overwhelmingly (97 per cent) positive . . . people's experience of the personal budget process was mixed, with over half (60 per cent) of the responses relating to process being broadly negative’ (Hatton and Waters, Reference Hatton and Waters2013).

Process barriers are likely to be particularly off-putting for those who lack skills of self-advocacy or do not have people to advocate for them (Slasberg and Hatton, Reference Slasberg and Hatton2011). There was wide variance across councils in the POET findings, highlighting geography as a relevant factor in explaining unequal access to the benefits of personalisation. There may also be an age-relevant distinction here, with the policy aiming to open up the spaces of care in ways which are less relevant for older people than they are for younger disabled people (Barnes, Reference Barnes2011). Lloyd notes the prevalence in policy documents on personalisation of the discussion of access to ‘further and higher education, training to prepare for a job, employment, bringing up children, caring for other family members, volunteering, involvement in sport, leisure and social activities’ (2010: 193). She suggests that this highly instrumental view of social care, as a means of restoring people to their functions, fails to reflect ‘dependencies that arise from frailty and ill-health in old age’ (Lloyd, Reference Lloyd2010: 193).

Personalisation and contraction

Moving to an emotional conception of space, it is possible to argue that personalisation has implications for the professional distance and formalisation which characterised the care management era (Sowerby, Reference Sowerby2010; Ellis, Reference Ellis2013). As Lloyd puts it, ‘A key characteristic of the personalisation agenda in social care specifically is that an individual's interpretation of his/her needs and the ways in which these should be met must be at the heart of any intervention’ (2010: 189). According to an Association of Directors of Adult Social Services (ADASS) document, The Case for Tomorrow: ‘For many older people the choices they want are not so much about who provides, but what is available, when and whether they feel they have a rapport and relationship with that particular care worker’ (ADASS, 2012: 51).

Particularism has long been seen as an essential element of an ethic of care (Tronto, Reference Tronto1993; Sevenhuijsen, Reference Sevenhuijsen1998; Mol, Reference Mol2008; Lloyd, Reference Lloyd2010; Barnes, Reference Barnes2011, Reference Barnes2012). Barnes (Reference Barnes2012) writes of the importance of care being ‘attentive’ and ‘particularistic’, oriented around what is appropriate for the care receiver. This is very much the animating principle of personalisation as promoted by advocates such as In Control, the Think Local, Act Personal consortium and the Social Care Institute for Excellence. As Lloyd puts it, ‘Tronto's concept of responsiveness is at the heart of the personalisation agenda, since enabling those using services to define their needs and how these should be met is, ostensibly, what personalisation is all about’ (2010: 191). This is suggestive of an attentiveness which marks a clear point of departure from some aspects of the service-led approach in English social care services in which ‘the promotion of personhood’ was underdeveloped (Fawcett et al., Reference Fawcett, Weber and Wilson2012), although the ‘ostensibly’ in Lloyd's quote must not be ignored and is returned to below. For people delivering care, or working on a support plan, personalisation then requires a repertoire of skills that include listening, relating and emoting (Carr and Dittrich, Reference Carr and Dittrich2008). As expressed by its advocates, personalisation offers the potential for care to be what Yeatman calls ‘an inter-subjective relationship between selves’ (Reference Yeatman2009: 18).

Yeatman argues that welfare services in market economies do not foster sensitivity to the self in this way, instead designing services so that ‘the service client is repositioned as a consumer whose will is to be served by the professional/service worker’ (ibid.: 93). Such claims reprise the citizen-consumer debates which have been live within public services for several years, and are particularly pertinent to personalisation (see, for example, Clarke et al., Reference Clarke, Newman, Smith, Vidler and Westmarland2007; Ferguson, Reference Ferguson2007; Needham, Reference Needham2007; Scourfield, Reference Scourfield2007). Claims of a consumerisation of care are very plausible, particularly given the system-level commodification which has taken place since the 1990s (Lymbery, Reference Lymbery2012). The ‘ostensibly’ in Lloyd's quote is a reminder to be attentive to the differences between the promise of personalisation and the practice of social care reform. Houston, for example, develops a critique of personalisation which highlights an individualistic rather than relational account: ‘at the heart of [personalisation] is an impoverished ontology, namely one that fails to accord sufficient weight to the primordial and existential realities of human inter-dependence, inter-being and symbolic interaction’ (Reference Houston2010: 842).

However, it is possible to argue that the experience of personal budget implementation in a series of sectors has shown the potential for a more relational foundation than Houston allows. The Department of Health-funded evaluations of personal budgets (Glendinning et al., Reference Glendinning, Challis, Fernandez, Jacobs, Jones, Knapp, Manthorpe, Moran, Netten, Stevens and Wilberforce2008) and personal health budgets (Forder et al., Reference Forder, Jones, Glendinning, Caiels, Welch, Baxter, Davidson, Windle, Irvine, King and Dolan2012), along with a Joseph Rowntree Foundation evaluation of a rough sleepers pilot (Hough and Rice, Reference Hough and Rice2010), have all suggested that the support planning process can facilitate new relationships of particularism and attentiveness. The personal budget pilot evaluation, for example, found that:

The evaluation of personal health budgets similarly identified one of the positive impacts of the budgets as being: ‘Improved relations between the NHS and personal health budgets holders as views are being listened to’ (Jones et al., Reference Jones, Welch, Caiels, Windle, Forder, Davidson, Dolan, Glendinning, Irvine and King2010: 15). According to one of the health professionals interviewed:

The Joseph Rowntree Foundation evaluation of an individual budget approach for supporting rough sleepers reported something similar. As one of those who had had a budget put it, ‘I’ve got to be honest here, it wasn't just the individual budget, it was the fact there was [co-ordinator] there as well . . . We was meeting [regularly] to discuss it, and I’d actually gone from the stage of wanting nothing to do with these people, to actually looking forward to seeing them’ (cited in Hough and Rice, Reference Hough and Rice2010).

These findings, all of which are from the early stages of planning and using personal budgets, at least suggest a need for caution in claims that personalisation and personal budgets are by necessity individualising and consumerising interventions. Changes to the provision of care within a context of personalisation and personal budgets, the time spent on care planning and the increased prevalence of personal assistants, may foster the emotional attentiveness which personalisation promises. It is important to note that the quotations here are focused on the support planning phase, which precedes the delivery of support services themselves. Support planning is a highly variable practice, dependent on the skills and attitudes of planners and the extent to which their activities are funded and supported by local authorities (Williams et al., Reference Williams, Porter and Marriott2013). Within the provision of support itself, the impact of personalisation again may be distributed according to income inequalities and geography, but there may also be an age-based pattern, with older people funded less generously by the state than younger disabled people (Lloyd, Reference Lloyd2010).

Space and distance in caring labour

The interpersonal contraction and physical expansion, which personalisation demands, may require a more intense kind of ‘caring labour’ from the formal workforce than in the care management era of the recent past. ‘Caring labour’ is a term which Himmelweit (Reference Himmelweit1999) puts forward as a subset of the broader concept of emotional labour. Emotional labour is defined as, ‘the expression of one's capacity to manage personal emotions, sense others’ emotions, and to respond appropriately, based on one's job’ (Mastracci et al., Reference Mastracci, Newman and Guy2010: 125). Although the emotion work, which people in service sectors undertake has been written about for decades (Menzies, Reference Menzies1960; Hochschild, Reference Hochshild1983; Smith, Reference Smith1992; Guy et al., Reference Guy, Newman and Mastraci2008; Mastracci et al., Reference Mastracci, Newman and Guy2010), it appears to have a contemporary salience within British public services. In its response to the Francis Report into events at Mid-Staffordshire NHS Foundation Trust, for example, the government explicitly evokes the concept of ‘The Emotional Labour of Care’ and writes: ‘Working in health and care is inherently emotionally demanding. To support staff to act consistently with openness and compassion, teams need to be given time and space to reflect on the challenging emotional impact of health and care work’ (Department of Health, 2013: 31).

As in this quote, the literature on emotional labour often deals with spatial considerations, either directly or in passing: where do workers go to restore themselves after a difficult emotional encounter? Literature on the NHS suggests that this may be a sister's office for nurses, or back to base for ambulance crews (Sawbridge and Hewison, Reference Sawbridge and Hewison2011). In a care context, Tronto (Reference Tronto2010: 169) similarly has drawn attention to the importance of spaces which are conducive to identifying and resolving ethical conflicts relating to care. As Barnes puts it, ‘Having spaces and times in which [troubling or upsetting] issues can be explored and discussed is an important way in which responsibilities for care become shared beyond a specific dyadic relationship’ (2012: 76).

The physical spaces in which reflection and recovery take place appear to be disappearing in a range of professions, as workplaces are streamlined in order to make services more efficient. Nurse handovers are more likely to occur at the bottom of a bed rather than in a sister's office; paramedics are more likely to spend time between calls in a layby than back at base (Sawbridge and Hewison, Reference Sawbridge and Hewison2011). What Cooper and Lousada (Reference Cooper and Lousada2005) characterise as the ‘vanishing organisation’ within modern welfare services is increasing the exposure and anxiety of those undertaking care work. For those working in social care services, such spaces have always been underdeveloped. Barnes notes that home care in particular lacks opportunity for ‘collective ethical reflection’, compared to hospitals and residential care homes, given the fragmented and isolated settings in which it takes place (2012: 82).

Although the social care workforce may lack physical places of support and recovery, Himmelweit (Reference Himmelweit1999) suggests that an ameliorating factor may be the emotional closeness they build up with the person they are caring for. She argues that whereas the emotional labour literature has emphasised the role of performance, in which workers ‘suppress their private feelings, in order to show “desirable” work-related emotion’ (Mastracci et al., Reference Mastracci, Newman and Guy2010: 125), this may be less necessary in a care setting. According to Himmelweit, ‘Caring . . . specifically involves the development of a relationship, not the emotional servicing of people who remain strangers’ (1999: 35). Over time, this continuing relationship should ‘be all that is needed to generate the appropriate emotional ties’ (1999: 35). She recognises though that such relationships will not always develop, and if they do not, ‘maintaining appropriate emotional engagement may be as hard and as wearing as in the more transitory forms of emotional labour’ (1999: 37).

How this plays out in practice is likely to be different for different parts of the care workforce. For social workers, personalisation is expected to facilitate new kinds of conversations, based on surfacing people's assets and aspirations rather than focusing on their deficits and care needs (Lymbery and Postle, Reference Lymbery and Postle2010; Leece and Leece, Reference Leece and Leece2011; Lymbery, Reference Lymbery2012). Social workers may be involved in drawing up a support plan, foregrounding skills of advocacy and brokerage rather than needs assessment and rationing (Lymbery, Reference Lymbery2010; Leece and Leece, Reference Leece and Leece2011). This process has been described as a rediscovery of ‘real’ social work, from a lost era of community social work or the unrealised promise of ‘tailor made’ care in the community care reforms of the 1990s (Hudson, Reference Hudson2009; Lloyd, Reference Lloyd2010: 192; Williams and Tyson, Reference Williams and Tyson2010). It may facilitate the therapeutic and relational kinds of social work that users value (Sudbury, Reference Sudbery2002; Trevithick, Reference Trevithick2003; Beresford, Reference Beresford2007). However, it may also weaken links between social workers and users of care services as people choose to make more use of independent support workers and/or have limited access to dwindling numbers of qualified social workers (Scourfield, Reference Scourfield2010; Leece and Leece, Reference Leece and Leece2011; Lymbery, Reference Lymbery2012). As Lymbery puts it, writing about personalisation, ‘The place of social work in the new policy is contested and unclear’ (2012: 784).

Within a domiciliary care setting, the availability of direct payments is shifting the balance between agency care workers, who attend several people for short periods, towards personal assistants, who can focus on a one-to-one support relationship. Personal assistants have the opportunities to build up long-term relationships in the way that Himmelweit describes. Glendinning et al. drew on focus group discussions with personal assistants to observe that, ‘Personal assistants also appreciated the emotional quality of the relationship which they developed with an employer over time’ (2000: 206). However, Leece highlights the difficulties which personal assistants may experience in establishing boundaries and appropriate working practices: ‘the direct employment relationships were designed by employers primarily to serve their own interests, and the friendly, family-type arrangements they created resulted in obligations that made it difficult for workers to exit the arrangement, despite the many shortcomings of their position’ (Reference Leece2010: 202, see also Spandler, Reference Spandler2004; Yeandle and Steill, Reference Yeandle, Steill, Ungerson and Yeandle2007; Leece and Peace, Reference Leece and Peace2010). Glendinning et al. (Reference Glendinning, Halliwell, Jacobs, Rummery and Tyer2000) found that direct payment holders preferred to train personal assistants themselves rather than encouraging access to formal training, so that they did not become too ‘professionalised’. Williams has written about the blurring of boundaries that can go on for migrant care workers, in which being treated like a ‘member of the family’ means being ‘continually on call’ (Reference Williams2010: 386). Contra Himmelweit, the development of a long-term relationship may not in itself generate the ‘emotional ties’ that distinguish caring labour from the emotional labour of the service sector.

For agency care workers, the personalisation context raises a different set of issues. It may provide a further casualisation and commodification of the care relationship (Leece and Peace, Reference Leece and Peace2010). The extension of personal budgets and the growth of individualised commissioning may reduce job security for agency staff, leading to greater use of zero hour contracts as agencies try to pass on the risk of uncertain demand to their staff (Baxter et al., Reference Baxter, Wilberforce and Glendinning2011). As Mullin observes, ‘Care laborers who barely have time to assist their clients with bathing will not have time to listen to and learn from their clients about how they may best meet not only their physical needs but also their need to maintain their dignity and privacy in the midst of their vulnerability’ (Reference Mullin2011: 120). Interviewing care agencies about the impact of personal budgets, Baxter et al. note that providers were keen to ensure that ‘professional distance’ between care workers and clients was maintained:

The impact of personalisation on caring labour is therefore likely to be variable across the workforce (as well as in different geographies and for people with different levels of impairment and isolation). A shared tension for social workers, personal assistants and agency home care workers is between professionalisation and particularism. Professionalism is equated with worker expertise and discretion, and can also be suggestive of distance, reflection and self-care which can help workers to sustain and contextualise the labour of care (Davidson, Reference Davidson2005). As Yeatman puts it, ‘if there is no support for the worker's capacity to contain the emotional aspects of service work, it is not likely that the worker will be able to sustain careful and individually-respectful as well as responsive care’ (Reference Yeatman2009: 113). Yet professionalism is highly contested within a personalised welfare state (Needham, Reference Needham2011; Evans, Reference Evans2013). The tensions are most obvious in the rejection of professionalisation by the employers of personal assistants (Glendinning et al., Reference Glendinning, Halliwell, Jacobs, Rummery and Tyer2000; Leece and Leece, Reference Leece and Leece2011). They are also evident in the fears that personalisation constitutes a deprofessionalisation of social work and the devaluing of social work expertise (Ferguson, Reference Ferguson2007; Lymbery, Reference Lymbery2012). Changes to the working practices of agency care workers, with the increased use of zero hour contracts and the further casualisation of the sector, similarly indicate a retreat from professionalisation, albeit one in which the importance of ‘professional distance’ is averred.