3.3 From 'professional gift' to citizenship
A key feature of personalisation is an emphasis on outcomes rather than on needs. A focus on outcomes as a means of evaluating the provision of care services is not new. In 1995, the the UK government signalled that the future development of community care would focus more on outcomes than on processes, and the introduction of direct payments was seen as one way to achieve that shift of emphasis. You can see the influence of outcomes-based thinking in Scotland, for example in policy initiatives such as and Getting it Right for Every Child (Scottish Government 2010a, 2012a).
This focus on outcomes is a move away from the emphasis on needs-based assessment incorporated into the Social Work (Scotland) Act 1968 and introduced, for adults, in the NHS and Community Care Act 1990. 'Need' is also the basis for assessment of children in Scotland (Children (Scotland) Act 1995, Section 22). Although needs-based assessment was intended to promote access to services, many younger disabled adults objected to the language of ‘needs’, arguing that this promoted a perception of disabled people as dependent and passive. Simon Duffy – one of the early proponents of direct payments and individual budgets, and a founder of the UK-wide organisation ‘In Control’ – argues that this emphasis on needs leads to a ‘ professional gift model ’ of care.
Contrast the ‘professional gift model’ with this statement about the outcomes identified as important by the User and Carer Panel for Changing Lives : The 21st Century Review of Social Work in Scotland:
We expect services to make a positive difference to our lives. We are people first. The outcomes we want include having power and control, being able to take risks and contribute to society. This means that there needs to be a shift in power away from people who commission and provide services to service users and carers.
A citizenship model
The shift from a focus on needs, often identified by professionals, to working with outcomes that are determined by the individual who uses services, can be seen as supporting the right of individuals and families to self-determination and control of their life.
Simon Duffy from In Control sees the alternative to the ‘gift model’ as the citizenship model , which starts by placing the individual, their family and their community at the centre:
Instead of seeing services as gifts from the professional, the citizenship model treats services as a negotiated partnership between the citizen and the professional and that the citizen’s ability to do this is underpinned by their entitlement to direct any necessary resources.
This focus on outcomes is evident in the definition of self-directed support set out in Scotland’s National Strategy for Self-Directed Support:
Self-directed Support (SDS) is the support individuals and families have after making an informed choice on how their individual budget is used to meet the outcomes they have agreed. SDS means giving people choice and control.
It seems, then, that there is broad agreement that establishing what outcomes people want is a key aspect of accessing and delivering personalised services. However, in 2011, the Christie Commission into the reform of public services in Scotland highlighted continuing outdated attitudes and approaches to providing services:
- The philosophy and attitudes underpinning the design and delivery of public services have changed little since the birth of the welfare state. Services are provided to individuals rather than designed for and with them.
- Models of provision fail to empower and enable people and communities to achieve positive outcomes in their own lives. Services often impair individual incentives and foster dependencies that create demand.