Self Directed Futures founder Chris Watson on care personalisation
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He founded Self Directed Futures in 2018, and today, works with Local Authorities to open up choice and creativity within the care space, empowering people to have more control over how care is delivered.
Tell us a little bit about yourself and your experience in this space
I’ve worked in social care since I was 18 years old, starting off in direct support, for adults with learning disabilities in NHS settings. I then moved into providing support to people in residential care, supported living, and floating and domiciliary home care support.
I’ve worked as a Personal Assistant, so I’ve had quite a big grounding in the actual delivery of support to people based out in communities. And then I moved over into local authorities, to do some commissioning projects, where we did a lot of transformation programs, moving people into our inpatient units, and into hospital settings.
I spent about six years working as part of a team that was commissioning, with a focus on getting value for money, particularly at the start of austerity, so looking at how we could use personalised support and other commissioning techniques to get best value for the person, and for the commissioning organisation as well.
Then I left to set up Self-Directed Futures, which is a small collective of people who believe in self-directed support, and that it’s the right thing to do for commissioners, and for people.
Everybody has control in their life, except often when they come into contact with social care, so we believe that people coming into the space should have absolute choice and control over how their support is delivered, and shouldn’t just be given a tiny range of options.
Would you say there was a defining moment, or an unmet need that motivated you to get involved in the movement and start Self-Directed Futures?
I think it was probably having spent quite a few years working in care, recognising how simple it is as a process, and then moving into commissioning and seeing how complicated sometimes we could make it.
In commissioning, I’d spent a long time working alongside inspirational people who had been using Personal Budgets or Direct Payments to create incredibly bespoke support arrangements for people, just absolute creativity. But then we’d look into commissioned services, and there wasn’t so much of that, and the barrier to that innovation was effectively how we were commissioning those services.
When the Care Act came out in 2014 and mentioned Individual Service Funds (ISF), which is this opportunity to allow almost the same flexibility under a commissioning service, as a direct payment, it was a revelation. It was a massive opportunity to radically change how we’d been commissioning in the Local Authority where I’d been working.
From that moment onwards I knew this was the future – the moment we started giving people ISF, and started to see the outcomes for the individuals, and an organic reduction in support for people. Money was getting handed back because people were like ‘put it back in the social care budget, we don’t need this because we’ve solved our problems more creatively’.
I just knew I couldn’t sit there and just keep doing the same commissioning over and over again. I wanted to inspire other Authorities, and the NHS to start to think differently about how they do commissioning, so that was the spark really that made me want to set up the company
Individual Service Funds explained
An Individual Service Fund (ISF) is a way of managing a Personal Budget.
A person needing care, (alongside their family, advocate, or carer, if they wish) can ask an organisation to manage their Personal Budget for them. The individual then works with the organisation to choose the right care and support services that will help them achieve the outcomes they want.
This approach relies on more creativity and flexibility from commissioning authorities in how they contract providers, and can help people access a greater variety of care options.
What’s your perspective on the power and effectiveness of Personal Budgets and Direct Payments as they currently stand? How do you think they need to evolve, and what do you think the key barriers are to them becoming more widely adopted?
I think the starting point for this would be the Care Act. It’s a very powerful, and in many ways a brilliant set of legislation which underpins people’s rights to take a Personal Budget, to have it as a managed service if they want – but still control how it’s delivered.
A Direct Payment, obviously gives you that full flexibility, completely designing your support around you. And then more laterally we have Individual Service Funds.
We’ve seen some amazing outcomes for people using Direct Payments, but we haven’t seen so much innovation in commissioning for a while. So I think personalisation got as far as Personal Budgets, so understanding how much your care support is, and being able to act a bit more like an informed consumer within that process.
Where I think we were struggling was commissioning was very much doing for people rather than with them, or allowing them to design their support.
We’ve seen Direct Payments around the country plateauing, I would say it’s different in every local authority area, but in some areas 15 percent perhaps of the population are using Direct Payments, other areas maybe around 52 percent, so there’s a huge variance in people being offered that Personal Budget to take control of their support.
What we want to do is fill that gap and say that Direct Payments is the number one best solution from a control point of view, but if you don’t want a Direct Payment, or you can’t necessarily manage it, we think the ISF is the solution to have a lot of that choice, control and flexibility, but without the bureaucratic elements of Direct Payments that can sometimes put people off.
So, if we said our national average was about 30 percent of people with a Direct Payment, I’d say we’re targeting the 70 percent of people who are using a commission service, but wanting to give them the same access to flexible support as the guys that have Direct Payments.
How does Self-Directed Futures support commissioners and local organisations in achieving that vision?
We’re quite lucky because we’ve got quite a few perspectives – we’ve got providers who support people via ISF, we’ve got family carers who are experts in Personal Budgets and are using them creatively to support their children and young people, and we’ve got commissioning experience.
So, we bring in a plethora of examples, go to an area and our mission is to inspire people, to say ‘look, we’ve all been there, we’ve done 20 to 30 years of commissioning the same stuff over and over again, it’s time for a change’.
I think we’re pushing an open door, a lot of times the conversations are very easy to have, commissioners know this stuff – what they don’t know is the mechanics of how to make that change.
Where we come in is saying ‘here’s what it is, it isn’t that scary, we can do this’. We go into those areas and we work alongside them, we’re not consultants to fly in and fly out again, we develop long-term support, because having worked in the public sector, we know real change takes three to five years.
We like to be there alongside them for as long as possible, providing commissioning support, but also practical support for social workers, and for provider organisations. What’s been quite a revelation is bringing support organisations and social workers together to jointly problem solve, and think together collaboratively about how best to support people using ISF.
It’s not rocket science, but it’s that relationship and trust building between all the parties, with the view to empower the person who’s taking the ISF to design their support. So we do our end-to-end support process, but very much focused on the business architecture – the commissioning, the contracting, but also that cultural change and trying to build lasting partnerships that are designed to enable personalisation to happen.
We look at person-centered risk, we look at examples of how budgets can be used, we talk through issues, we look at making legally defensible kind of decisions, trying to link decision-making back to the Care Act, so the providers can feel confident that they can work with people much more creatively, but still feel under the umbrella of what social services wants from them.
Would you be able to tell us about the discussion paper you authored – ‘Meeting urgent demand with new models of care and Individual Service Funds’, published by the Institute of Public Care?
When the pandemic started there was a lot of focus around what was going to be the impact for people in receipt of support at an individual level, but also as a sector.
What I’d seen, and from conversations with provider organisations during the outbreak was that a lot of Authorities were delegating almost completely to those organisations, to work with the person they were supporting as flexibly as they needed.
They were working with them so effectively in some areas, that they’d basically set up a blanket ISF arrangement, allowing providers to take that budget and use it however they saw fit, to make sure that person was safe and supported, and that they had continuity of care. So that happened quite quickly.
I thought this was really interesting, with our work being around ISF, and thought let’s have a discussion about how that ISF model, combined with those micro providers could offer a solution to the problems generated by the pandemic, around staffing and continuity of support, but also, a more longer term as a solution to some of the sector challenges.
We know from talking to people on the ground, they want the same person, they want to be able to choose, they don’t want to have a random stranger – but we’ve created a care system that’s very much based around that, rather than local people supporting people locally.
We know systematically that care workers and commissioners have been under a lot of pressure since austerity. There’s been a constant pressure on local authorities and the NHS to find savings. I think wages have stagnated in the sector, rates have been held down, and this is pre-COVID.
As a result you’ve had this growing workforce issue, a notion that there’s an undersupply of people to work in care, probably linked I would say to low levels of available income from those roles.
We wanted to explore how we can increase the pay for people who are in support, how can we address the fact that some workers do want the flexibility of working part-time, to control their own work pattern, and they don’t necessarily want to work for a big organisation and be rota’d. Essentially, how could we use this new funding model to open up this approach to a much wider group of people?
The paper focuses on addressing that systematic problem. There’s 130,000 full-time equivalent vacancies in social care. just to meet current demand, and obviously that’s not even predicting population demographic changes over the next 10 years.
The paper was a description of how we see ISF as a commissioning tool that could then be used to enable people who didn’t want a Direct Payment, to have access to this growing flexible workforce of sole traders and self-employed workers.
Having worked as a self-employed PA, it works brilliantly. I picked what I did, it suited me but it suited the people I was supporting too, it’s a win-win situation. I felt like there was a fair rate for me per hour, and I think the whole concept around the movement towards micro enterprises is a response to that need for more flexibility, more person-centeredness.
I think the workforce gets frustrated with the mechanisation of care, with people being scheduled, and driving around miles between different visits, and not even seeing the same person two days in a row.
We know from talking to people on the ground, they want the same person, they want to be able to choose, they don’t want to have a random stranger – but we’ve created a care system that’s very much based around that, rather than local people supporting people locally, in a way that works for them as the support worker, but also works for the person being supported.
Broadly speaking, a lot of innovation in social care over the last 10-15 years has been because of Direct Payments, not necessarily because of commissioning. There’s some examples of good commissioning, but really ISF offers us the opportunity to create that community-led support out in the domain of what would have been traditionally commissioned services.
The paper is framed around a response to COVID, but actually structurally and longer term, it makes sense that this isn’t just a response. There’s a long-term shift in the dynamic of how support is delivered for people. Harnessing networks of community sole-traders or small providers locally, having that continuity of support, having choice and control, and being funded as flexibly as a Direct Payment, but as a commissioning service.
What would you say is the role for citizens, communities and commissioners to make sure that this remains a sustainable way of delivering and paying for care?
Citizens need good information and access to local support. You need to be working on an information and advice offer, or provide platforms citizens can access to find their own support. It’s really important that people are aware of what the care options are around them.
The role of commissioners for me, should shift towards market-shaping, so bringing loads of good options into an area, and enabling people to see what those options are.
And then the community side of it, it’s really harnessing the wealth of the community to deliver support for people. Sometimes that’s using volunteers or community groups, making sure that people have access to things beyond their care needs. Often, around their holistic, well-being needs, but also trying to harness local people to come into the social care space to provide support for people.
So commissioners’ role again, is to help catalyze that to happen, so bringing in organisations that want to focus on doing something differently, connecting local people with local support, creating a structure that means there’s a fair salary to that local workforce, then creating and sustaining that ecosystem.
It’s also saying let’s create networks for the micro providers, let’s help them collaborate and explore how they can link up with big organisations and form a hybrid with traditional forms of care, whatever’s going to work best for those individuals in that area. But I think it’s got to start with commissioners being open to this change.
Finally what we also need is citizen driven change. We need people knocking on the door of commissioners and asking ‘I want my personal budget, it’s in the Care Act, tell me where I get, and I need to know where that support is’. All of those ingredients add up to a good paradigm shift I would say to how support is done at the moment.
What potential do you think these models have for impacting quality and affordability of home care services, and maybe also live-in care specifically?
I think the overall impact will be to drive up quality. Having lots of available options in an area I don’t think is ever a bad thing, so I think you’ve got that natural competition.
Having choice and control means people are going to gravitate towards good support, whatever that might look like to them, so I think there’s a natural squeeze on poor quality when you devolve the budgets to those individuals. It’s not commissioners deciding what’s good quality, it’s the people receiving support who increasingly are then sharing their views on micro providers.
There’s always going to be space for traditional home care organisations to exist as well. Some community-led support can work quite well, but there’s some particular ways that home care might fill gaps where community support doesn’t quite work for people, so I think we’re going to see an increasing range of options, that go across a whole plethora of support needs.
In the future when I need care, I want to look at a list of 50 options, not just four options that have come out of a commissioning computer and been given to me. But, I also need good information to make decisions around what’s best for me.
And, increasing the availability and the types of support available gives the opportunity to foster collaborations between these organisations. That for me is the exciting bit where we see different organisations collaborating to give people the best outcomes.
It could be a hybrid, where you’ve got a home care organisation that also commissions micro enterprises to work alongside them, and then when people want to go on annual leave, they can supply support to fill those gaps. There’s a range of different things we’re going to end up with, but from my perspective it’s going to positively impact quality.
I think value for money is about good outcomes for the individual, and it’s about a fair rate of pay to the worker. Having been a care worker, I know the biggest factor around quality is paying people a fair amount for their support, so anything that can drive up the base rate of pay will have a massive impact on quality.
Within that is the localism element, it’s about that relational based care you can get from having a good range of local providers collaborating, and people being able to select somebody who lives within half a mile. Not somebody who lives 25 miles away, who’s got to drive a two-hour round trip to come and do your support, and you’ll never see them again. So there’s inherent quality benefits on that localisation side.
So it’s important for commissioners to make sure that there’s not just lots of one type of organisation, but lots of types of care organisations?
You need a smorgasbord of options. You want to have live-in care, self-employed live-in care, domiciliary care, hybrid domiciliary care, community micro enterprises, introductory agencies – you need all of that because it’s about giving people a real choice.
In the future when I need care, I want to look at a list of 50 options, not just four options that have come out of a commissioning computer and been given to me. But, I also need good information to make decisions around what’s best for me.
If we’re all talking about healthy aging and sustaining people’s lives, then people may want something different at some point in their life too.
Absolutely right. Those micro enterprises, the way they operate might suit people for a while, but they might need something a little bit more in the future. It’s just having a continuum of flexible options that are with people wherever they are on their life course.
Could you give us an update on some of the projects you’ve been involved in different local authority areas in the UK?
We’re lucky enough to work with some of the most forward-thinking Local Authorities in the country. I think of particular note is the work in Somerset – some of this is seriously radical change, which can take months and or years to get anywhere near implementing, but I think is really interesting.
They have this growing network of 800 plus micro enterprises, and what they’ve recently done is commissioned a domiciliary care organisation to come in and work in a hybrid model.
The domiciliary care agency is going to be brokering for people using ISF, working alongside the micro-enterprise network to create this hybrid, so people have the choice of local micro providers, and a regular supply of support staff from within the organisation. It’s allowing people to have access to micro enterprises that they potentially wouldn’t have been able to with a Direct Payment, and therefore would have been excluded from that flexibility.
It’s also giving the micro enterprise network some kind of support structure, to allow the self-employed to take time off, and to cover each other if there’s an emergency. The network can work together with the person being supported, to design what that would look like, and I think that could be a model for the future for many areas.
I think Essex council have really big aspirations around personalisation which are very much focused on devolving control back down to citizens. We’re doing some work there which is a place-based offer, which is trying to give everybody in a pilot area access to an ISF, but I think their view is to potentially scale that up and offer it to everybody once we finish the pilots.
I think over the next few years it’s going to really start to scale as people get used to these new ways of working. It’s building trust, risks are high, it’s really important that people get good quality support so I completely understand there’s a cautiousness.
There’s some interesting stuff going on in Bristol too, looking at introductory agencies and how they can be feeding into the voluntary community social enterprise sector, creating some sustainable arrangements around funding, and looking at people more holistically, rather than just looking at what care they need. Looking at their goals, their outcomes – trying to fix some of those problems as a collective.
I think a lot of this space we’re working in is actually quite avant-garde because it’s flexible funding, but also new models of care and trying to bring those two things together to actually demonstrate that it really does work for people.
How do you see all of this developing over the next five maybe ten years?
I think we’re gonna see an increase in introductory agencies, helping people find good support locally and matching people, which is really important.
My gut feeling is there’s going to be growth. We’re going to see more people being able to take flexible Personal Budgets through ISF.
I see a growth in micro enterprises, and absolutely in this hybrid offer as well, and collaboration between organisations and the micro enterprises, so they start to see themselves as part of a wider ecosystem of giving people good options.
I think we’re gonna see an increase in introductory agencies, helping people find good support locally and matching people, which is really important.
I think there’ll be a change in the dynamic of domiciliary care, it might find a different place on the continuum we discussed earlier. Perhaps working with people that need a slightly higher level of support, whereas the micro enterprises might work with people who need less support.
Some of this will organise itself over the next few years, but I think the bottom line for me is it will be a higher uptake of ISF, and hopefully more uptake on Direct Payments.
I think a lot of councils are looking for big numbers, because they’re recognising that their commission arrangements have been a barrier to creativity. So the more we can get individuals taking Personal Budgets, the faster the rate of change will be, because people will organically go off and solve their own problems, they won’t be waiting for commissioners to go around a commissioning cycle that takes two or three years.
So I’d say more flexible funding, more new models of support aimed at giving people maximum choice in control, driving up the quality of support, and driving up the rates available to people within the sector.
Contact Chris at Self Directed Futures here
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