Reflections on in Control -2

Reflections on in Control - 2John O’Brien and David Towell

Comment on this document at http://incontrolreflections.blogspot.com

The in Control initiative, focusing on self-directed support and individ-ualized funding, has become an important practical intervention in UK social policy. Ideas from this initiative have figured significantly in re-cent national policy statements and by May 2007, more than 90 Eng-lish local authorities had become members of in Control and 10 au-thorities had committed to in Control Total, a fast track to transforming local capacity so that everyone is able to exercise choice and control in social care. In recent months, much of the national debate appears to have shifted from whether self-directed supports are a good idea to how self-directed supports can best be implemented.

As a research and development community, in Control is investing in a number of ways of evaluating this work and sharing the experience widely. As one route to extend this learning, the in Control core team invited David Towell and John O’Brien to convene and facilitate a group representing multiple perspectives to review and comment on in Con-trol’s work in a series of three discussions over a year’s time and to of-fer their own reflections on these discussions. We offered a framework of questions to guide the evolution of this dialogue (see Annex A).

The second discussion, held on 21 May 2006, engaged national policy leaders, civil society leaders, and leaders in local systems changes complementary to in Control’s work, with leaders in local implementa-tion and members of in Control’s core team. This session focused on local implementation of self-directed supports, as it is informed by and as it informs in Control’s approach.

Contents

May require advanced hardware 3

Making a cultural shift 5

Leading transformation 9

Technical tasks have adaptive dimensions 10

The work of directing an individual budget 12

Disrupting equilibria 14

Make the themes of citizenship even more explicit 19

Expand reflection on adaptive work 21

Look in other public service reform efforts 22

Annex A: In Control: A framework for systematic reflection 24

Annex B: in Control’s approach to change 25

in Control Reflections-2 May 2007 —2

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The meeting oriented the group to local change through a dialogue between Anna Cross and Andrew Tyson, who have been engaged in transforming social care in West Sussex and a background paper prepared by Simon Duffy, Director of in Control (see Annex B). Small group discussions produced reactions, many ideas, and specific recommendations which were noted by the core team members who acted as recorders for the small groups. This document is the second of John O’Brien and David Towell’s reflections. It describes our understanding of some of the lessons so far from in Control’s local imple-mentation, offers some commentary, and invites re-sponse. It is primarily written for use by the core team and for participants in the next discussion. Indeed we have established a way for participants in these discussions to continue the dialogue by commenting on this paper on a weblog between the face-to-face meetings.

Our appreciation of the issues in implementing in Control at the local level may differ from those who are more di-rectly involved. Our knowledge of in Control’s work is lim-ited, and the mirror we have constructed here reflects our own experience and vocabulary. We hope any differences of perspective will be interesting for the core team to think about and any misunderstandings will be corrected.

This document includes our description of what seem to us to be important features of in Control’s approach to change in this column, our commentary in the middle col-umn, and a space to add the comments and corrections that participants post on the in Control Reflectiions Blog.

This column includes comments by David and John.

This column is for comments by partici-pants in the reflection day.

Comments: http://incontrolreflections.blogspot.com


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May require advanced hardware

Upgrading to a new Operating System* promises the computer user greater functionality, productivity, security, and efficiency, as well as the satisfaction of being up-to-date. But upgrades often create a gap between what the Operating System makes possible and what the existing hardware and software they mediate can deliver. As the fine print on the brochure says, “certain product features require advanced or additional hardware”. And invoking new features often requires replacing comfortable habits with new routines.

Implementing In-control offers great potential benefits: people with disabilities and their families have control of supports to fulfill the roles of citizenship; public expendi-tures produce tangibly better outcomes as demographic shifts and rising expectations drive new demands; and collective security from social exclusion increases. Real-izing these benefits demands a culture shift that reaches much deeper than the purchase of new equipment and the mastery of new keystrokes.

At its core, this shift entails systematically increasing the number of people who confidently engage social networks, civic associations, and publicly funded resources with the expectation that they will be able to generate adequate support to pursue what mat-ters to them in life. For commissioners this may mean seeking ways to understand the perspective of those responsible for managing mainstream resources and developing mutually beneficial initiatives. For care man-

* Reflections on in Control - 1 (pp. 15-17) discusses the operating system metaphor that helps in Con-trol’s thinking about its contribution to transforming social care.


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agers this may mean engaging reluctant gatekeepers of mainstream resources with the expectation of building a working relationship that will sustain principled negotia-tion of conflicts. For personal assistants this may mean joining the person they assist to work out practical ways to overcome barriers to participation in desired activities. For people and their families this may mean mobilizing naturally available support.

Regardless of role, moving to self-directed support in-volves revising expectations and practices in light of at least three important changes.

A shift in perception: seeing citizens with something to • offer rather than clients to be served and managed.

Increased willingness to form new connections that • reach beyond typical boundaries

Developing capacity to learn how to co-produce neces-• sary assistance.

In Control signals the depth of these changes by naming the process Total Transformation. In moving to implement self-directed support, transformation requires more than the implementation of new polices or the adoption of new procedures. It also requires sustained and systematic ef-fort to shift culture.

“” The process starts with disabled people and their families feeling empowered and liberated to set out what they want and need (p. 14).

Self Directed Support requires Local Authorities to see disabled people in a different way, as active citizens with something to offer their families, friends and com-munities, rather than as passive recipients of the gift of welfare (p. 13).

The shift to Self Directed Support is dependent first and foremost upon a transformation in our perception of disabled people, about their place in society and about the contribution they can make to the life of our communities. Social care leaders need to make this shift for themselves, in their own thinking. They then need to work to nurture organisational cultures which make this new thinking come to life. This is what we mean by “changing the culture” of social care (p. 6).


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Making a cultural shift

Anna Cross and Andrew Tyson provided the foundation for our reflection on local implementation of self-directed support by conversing about their experience in West Sussex, one of the original pilot authorities for in Control, Individual Budget pilot for older people, and one of nine Total Transformation sites. The form of presentation they chose, conversation prompted by important questions, carries an important message: while cultural shift can be framed by authority, its primary medium is learning among engaged people and one important aspect of that learning is conversation to make sense and find meaning in what is happening. What follows is a reflection on their contribution and the ensuing group discussion rather than a minute of it.

Culture shifts when people work together because they intend to produce new results, do something significantly different, and then adjust their practices and their lan-guage in light of what worked.

The local and national social care environments are filled with contradictions which could justify inaction, waiting for more favorable circumstances, or cynicism. Comments on self-directed support like these can be expected:

This is just a way to dress-up budget cuts.•

This can not work for the people we serve/represent.•

This will not achieve sufficient savings.•

Individual budgets can’t attain the economies of scale • that bulk purchasing can.


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Working for a cultural shift means acting on the assump-tion that a sufficient number of people have the capacity and willingness to make significant local improvements within existing contradictions and constraints. When this assumption takes hold, more and more people will give up the idea that they must have full control and certainty in order to be effective and instead see themselves as influential actors able to make alliances with other influen-tial actors in a changing environment.

Culture shifting action is motivated and directed by a shared realization of the gap between a desirable future state –The lives of people who use social care will be transformed by giving them more control and choice*– and what the future is most likely to be if things continue as they are. This means that creating opportunities for people to own a vision of a system capable of supporting self-direction is one important aspect of cultural shift. An important sign of this ownership is people’s clear recog-nition of the tensions with current reality that their vision generates.

The West Sussex Transformation Programme posted on the in Control website communicates an important per-spective on culture shifting. Unlike many strategic plan documents, this one clearly identifies the uncertainties that accompany learning to do something new in order to accomplish something new that depends on what new partnerships and evolving projects will yield. Its function is to aid discussion and provide a context for projects

*Independence, Wellbeing and Choice (2005) DOH p. 10

“” The Adults Transformation Programme is still evolv-ing and is likely to change… While some projects are clearly articulated, others require further analysis and

until this is completed the full scope of the programme cannot be confirmed…

Costs cannot be fully assessed until the new business model is designed and the projects to achieve it are planned in more detail…

Detailed and measurable benefits cannot be fully determined at this stage in light of the evolving end-state and dependencies upon other programmes and projects…

Until the shape of each element of the new service is known, the full impact of the Adults’ Transformation Programme on our people resources cannot be determined. However, our aim is to improve the Capacity and Capability of our people to deliver the service outcomes described [here]…

This document will be updated as the way forward emerges and form a reference document to aid dis-cussion and to place the projects in context as they move through the change management process.


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that create spaces in which new capacities can grow. At this stage, costs cannot be fully assessed, benefits can-not be clearly measured, activities will evolve, and the implications for staff will only become clear as change occurs. Definite commitments to investment in the capac-ity and capability of people and to continual updating of the programme in light of experience anchor the process of turning uncertainties into capacities.

The actions and the words of people in key positions influence the cultural shift.

Hold the frame around the whole effort and each of its • parts by questioning and interpreting actions and prob-lem solutions in terms of their impact on the chances that people will be seen and treated as fellow citizens with something to offer.

Invest in efforts to organize disabled people and family • members to develop their own perspectives on self-direction.

Provide disabled people and their allies an effective • voice in design, investment, and evaluation.

Initiate projects that will bring people together for ac-• tion across boundaries.

Create flexibility around projects that offer opportunities • for important learning about self-direction. Assure that projects open the way for co-production. Keep projects large enough to learn from and small enough to limit and learn from failures.


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Demonstrate limits by visibly saying “no” when pro-• posed policy or action would detract from the capacity to support self direction.

Give people access to tools, such as those developed • by in Control. Encourage people to refine existing tools, create new ones and share them through the in Control network.

Challenge yourself and others to think ahead of where • you are so that you have ways to leverage the results of pilots and stay alert for new openings to move self-direction forward.

Approach meetings as opportunities to engage topics • of conversation and employ new language that permits exploration of the implications of self-direction for the group’s everyday activities.

Convene people for the purpose of building a coherent • narrative about how we most effectively build the ca-pacity for self-direction.

Model speaking-up for change and offer others oppor-• tunities to go public with their account of why change is necessary and what change is desirable.

Systematically capture, broadcast and build on what • works to increase the capacity for self direction.


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* See Ronald Heifitz (1998). Leadership without easy answers. Cambridge, MA: Belknap Press. Also see R. Heifitz (2003) Adaptive work. In T. Bentley and J. Wiliston, Eds. The adaptive state: Strategies for personalizing the public realm. London: Demos. Pp. 68-79.

Leading transformation

Total Transformation can be mapped in a linear way to index its milestones, but living the process is more de-manding than any sequence could capture. It involves two different sorts of work. There is technical problem solving to do as local authorities work out how to design and implement the resource allocation system and how to disburse and account for individual budgets and consul-tants design formats to guide planning. There is adaptive work* to do as people struggle to assimilate the implica-tions of new ways of understanding citizenship for the way supports are designed and delivered.

1Secure Leadership & Legitimacy

2bMap Community & Readiness for Citizenship

2aSet the Resource Allocation System (RAS)

3Plan. Set Financial & Performance Targets

4bRefocus Direct Payments System

4aRefocus the Care Management System

5bChange contracts with independent providers to Individual Service Funds

5aImplement Self-Directed

Support for all new people & when there is a change

in need

5cRefocus in-house services

18 to 24 months


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Technical Problem Solving Adaptive Work

Mange the current system to its highest potential output within existing bound-aries.

Re-design own roles, boundaries and practices in order to learn how to thrive under changing conditions.

Address problems that can be fixed through a known or discoverable series of steps (no matter how complicated) which can be described and dissemi-nated.

Address the political and emotional is-sues in identifying gaps between de-sired and actual capacities, what must be conserved and what must be lost, and how the costs of transformation are to be distributed.

Necessary learning can be done by instruction.

Necessary learning requires engage-ment in acting/reflecting under real life conditions of risk and uncertainty.

Necessary change can be accom-plished through exercise of authority.

Necessary change requires mobilizing commitment among people with differ-ent perspectives and interests.

Technical tasks have adaptive dimensions

Legitimating transformation includes assuring that proce-dures conform to legal requirements. In part, interpreting the intersections of different areas of law and regulation with the aim of putting people in effective charge of their fair share of social care money is a complex technical problem. Using the in Control network to develop and share knowledge and to seek expert advice increases the odds that local interpreters will take an expansive view of


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what is lawful and advise in favor of changes that will in-crease people’s control. Interpretations of legitimacy also have an adaptive dimension which touches an organiza-tion’s stance toward risk and the role and status assigned to local experts on the rules. Sometimes these roles seem to have been assigned the function of providing enthusi-asts for new agendas with “adult supervision”. Finding a collective voice for transformation involves reconsidering organizational risk and renegotiating roles in light of the principles of self-directed support.

Consider the possible range of work involved in refocusing in-house ser-vices. If those responsible for these services take “re-focus” to mean adapting to an environment in which they will need to attract a sufficient number of customers to spend their in-dividual budgets in order to stay in business, the change process may be framed primarily in a vocabulary of mar-keting, pricing, and efficiency. Appeals to customer loyal-ty, efforts to assert the distinctiveness of current offerings, or assertion of worker’s privileges will be central con-siderations. If those responsible understand “re-focus” to include considering the fitness of current offerings to support citizenship and self-direction, the work becomes even more demanding as the services’s culture and social architecture come into question.

5cRefocus in-house services


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The work of directing an individual budget

Consider the melding of technical problem solving and adaptive work from the perspective of people who rely on social care. As the System Transformation Map points out, their capacity to freely set out what is important to them and for them is essential to the process. And, to realize the benefits of co-production, their willingness to reach out to seek support from extended family, neigh-bors, and local associations matters, as does their choice to assume at least some responsibility for arranging and directing the assistance they require.

People (and those who support them in decision mak-ing) will need technical competence to understand their options and carry out the tasks necessary to get, make choices about how to expend, and perhaps to arrange and manage supports with an individual budget. There are many effective ways to assist people in developing these competencies; a look at in Control’s website will show a good sample of them.

People and families who rely on social care may also have adaptive work to do. They may have made a decision about their future without information about possibilities: “When I can no longer manage for myself, I will have to go into a care home.” They may not think of themselves as contributing citizens but as clients who need and deserve to be taken care of or protected. The very word, “citizen” may seem alien or freighted with politics. It may challenge family member’s imagination to understand people with dementia or profound cognitive impairments

An Aid to Technical Learning


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as contributing citizens. People might have internalized social devaluation of disability and believe that their need for assistance renders them unable or even unworthy to pursue a life that makes sense to them. They may not trust the social care system or think that self-direction is too complicated for them.

This adaptive work is hard when people are tired, strained, in crisis and under time pressure. It is even harder when people are isolated or have been coping as best they can for a long time with minimal help, or feel that they have already had as much support as it is rea-sonable to expect family and neighbors to offer.

There are many ways to support people to gain a sense of freedom and self-efficacy, including peer counseling as practiced by Independent Living Centers and Partners in Policymaking, an intensive group learning opportunity for disabled people and family members. Direct support in planning can sometimes re-frame and re-direct even the most difficult situation when it is provided by some-one with the gift of communicating respect for people’s capacities and real hope for positive outcomes. Invest-ment in expanding these kinds of supports is more than a matter of sponsoring training courses. This necessary capacity is itself the product of people doing their own adaptive work and discovering ways to see possibilities for genuine citizenship, make sense in difficult situations, and discover ways to address tough problems.

A Forum to Support Adaptive Work

These extra difficulties can strongly affect people who become disabled in conse-quence of aging or trauma, especially at the point of discharge from acute health care. There is a great deal to learn about what works to support people to choose self-direction in these circumstances.


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Disrupting equilibria

People are seen & treated as fellow citizens with

something to offer us all.

People are able to spend the money in ways that make sense to them

People are in control of their lives

People have individual budgets





People are in control of their lives

The aim and practical logic of self-directed support are clearly stated, in Control and its widening network of member authorities, associated consultancies, and part-nerships offer an expanding range of solutions for local use, and a growing number of people with local and na-tional influence and authority have spoken up in its favor. Confirming information about positive effects on satisfac-tion and costs continues to flow. A central policy shift to individual budgets as the means to modernize social care seems within reach.

As the tide of support swells, there is some danger that local implementation will focus more on means than purpose and shrink transformation to the adoption of new

Developing more ways to gage people’s exercise of the keys to citizenship would support deeper learning among those who chose to use them.


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assessment and disbursement procedures. This is partly because the change to individual budgets can be made more manageable when it is treated as a matter of tech-nical problem solving and total transformation is defined more narrowly as a commitment to assure that, over time, everyone who counts on social care will have an indi-vidual budget. The number of budgets for each category of eligible people can be counted and progress toward targets monitored. Under this approach to change, it is possible to focus on activities and procedures in a way that avoids a good deal of adaptive work by local authori-ties –though this increases the work that disabled people and their allies must do if they want to move beyond typi-cal service arrangements.

Clearly recognizing local responsibility for decisions about the depth and pace of change and providing an array of supports for different levels of commitment is a great strength of in Control’s approach. The emergence of a growing number of authorities committed to total trans-formation raises a question: how can in Control acceler-ate development in those local authorities most commit-ted to self-directed supports?

In these places, technical problem solving remains im-portant. Indeed, the technical issues these authorities encounter and solve will define the growing edge of the procedural shift to self-directed supports. And the chal-lenges of evaluating and re-designing in terms of a deep-ening understanding of the conditions of citizenship will grow as more and more practical problems arise from assuring that people who are eligible for social care are in

Discovering that public bureaucracies are capable of no more than implementing a individual budgets for a substantial number of people who rely on social care would be disappointing to those of us who believe publicly funded services can learn how to actively support citizenship. However, even if a grey cloud covers the higher potentials of self-direction within social care, active disabled people and their allies will con-tinue to contribute to the common welfare, assert their human rights, and exercise con-trol of their lives. And increasing people’s control of service money, even well short of social care transformation, will strengthen their citizenship.


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control of their own lives and expected to make sensible decisions about how to spend social care funds.

The diagram identifies some of the aspects of the so-cial care system that will affect what total transformation means in practice. What people eligible for social care ex-perience is powerfully influenced by the degree to which the people responsible for each of these functions choose to search for a better understanding of how they can do their jobs in ways that promote the conditions of citizen-ship.

Frame for advocacy agenda

Interpretation & application of laws,

rules & efficiency strategies

Demand for access to mainstream services

Contracted service providers offerings, prices, business model, marketing

strategies & culture

Role, options & expectations for people & families

Support from social networks &

community associations

Care Management roles, practices (assessment &

care management) & relationships

Contracting & financial

management

New investments/ disinvestments

Service workforce size, composition, structure &

working conditions

In-house services: offerings, prices,

marketing strategies, culture





People are in control of their livesDemand on

leadership across boundaries


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As a whole, the social care system is currently in a state of equilibrium which in Control and its allies believe to be dysfunctional for the purpose of supporting citizenship for the rapidly growing numbers of people eligible for social care. Implementation shows that self-directed support has the marks of a disruptive innovation. As DVD’s have disrupted the market for video players, self-directed sup-port aims to shift the social care system’s set point. Mov-ing from an interesting reform idea implemented through pilot projects to full scale implementation will affect every part of the system.

Consider, for example, the way activists frame the advo-cacy agenda. Many effective advocates for older people and disabled people work in terms of a picture of ac-countability that emphasizes the commissioner-provider relationship. Commissioners are responsible for assuring a sufficient supply of good quality providers to meet as-sessed need for all of the eligible people in a population. Direct investment in organizations of people with disabili-ties (such as Independent Living Centres) or historically associated with advocacy for people eligible for social care either as service providers or as service coordina-tors offers the best chance of fulfilling this responsibility. Setting self-directed support for active citizenship at the center of reform calls for a revised picture of account-ability. How do commissioners fulfill their responsibilities without the mechanism of block contracts? How do some advocacy organizations deliver on their missions with-out funding for service coordination? The challenge here is not just for in Control to have good answers to these

The scale of change is daunting when considered nationally. In the provider sector alone more that 25,000 organizations em-ploy over a million staff. (All Our Lives, DOH 2004)

It seems likely only a small number of these organizations have the purpose of assisting people to realize the benefits of self-direct-ed support. This highlights the importance of creating ways to engage providers at the level of discovering purpose rather than simply reacting to economic changes. To identify the importance of this work is not, of course to suggest that in Control must do it.


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questions but to have good opportunities for people to work through the disruptive possibilities offered by self-directed support.

Unlike DVDs, which provide consumers something new to buy, self-directed support provides people who are eligible for social care with opportunities to work at direct-ing their lives. Unlike DVDs, where engineering expertise is the primary source of innovation, innovations in self-directed support will come from co-creative relationships in which people eligible for social care, their friends and family, and their assistants discover new possibilities for citizenship.

Those engaged in Total Transformation can learn to im-plement self-directed support so that it generates innova-tions in the ways that people at risk of marginalization ex-press their citizenship. This does not mean that everyone who receives social care will be an innovator. Especially in the early stages of transformation, many people are likely to use their individual budgets to purchase typical sorts of assistance in typical service settings. To maintain legiti-macy, Total Transformation needs to keep room for these less innovative choices while establishing the conditions that will encourage people and their assistants to gener-ate a wider range of support options.

A significant proportion of technical problem solving can be delegated. Ideas, examples, procedures, policies, guides and templates that stimulate and support innova-tion can be developed, tested and refined in a network of problem solvers. Thanks to web pages and electronic

Self-directed support initiatives for people with developmental disabilities in the US might provide one crude benchmark: somewhat fewer than 10% of people (or their families) who require 24 hour support choose to self-manage their supports when they have the choice. Working out how a locality could substantially exceed that number could be a worthwhile exercise.More benchmarks are necessary. Self-management is not a necessary condi-tion for generating powerful supports for citizenship. Committed service providers are important partners for many disabled innovators.


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documents, the marginal cost of disseminating the results for others to build on is very reasonable. In Control has built exemplary competence in this mode of support for change.

Moving change deeply into the way people see the citi-zenship and capacities of people with disabilities and re-shape their relationships, roles, and practices requires a kind of work that cannot be delegated, though it can be supported. At it’s best, in Control understands this work well; its members question, search for better ways, and try new roles and new forms of organization to better serve its purpose. Its members have successfully facili-tated other people’s journeys of change. However, even if it were desirable, the scale of change that now appears possible makes it very difficult to imagine a way to active-ly support even a small fraction of the adaptive work that people throughout the country will need to do to make to-tal transformation more than a slogan that flickered briefly in the late ‘00’s.

In Control might explore at least three paths to better support for transformation.

Make the themes of citizenship even more explicit

In Control has made good use of stories from those whose lives have been positively affected by self-directed support. Many of the stories told on the website highlight the common sense improvements that people and their allies have made in their supports and the resulting im-provements in their daily life. In Control has found allies among thought leaders in the movement to reform pub-


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lic services and they have told similar stories in order to provide concrete examples of their ideas. (The quote on the right, from Charles Leadbeater and Hillary Cottam is a good recent example).

While Joe’s ride to school serves very well to illustrate people’s resourcefulness as an antidote to excessively costly system rigidity, there are other stories that would highlight the possibilities of citizenship, like this one.

In Wigan, Joseph Tomlinson, with the support of his mum and dad, used [Small Sparks Grant] money to print a flyer advertising a sponsored cycle ride. 200 people came. £7,000 was raised for Wigan Scope. Joe became well known in the neighbourhood for his part in the ride. His mother, Caroline, says ‘Lots of people knew Joseph before, but a lot more people know him now’.**

This story shows Joe in a civic role, actively supporting a local association by promoting an enjoyable and health enhancing activity. Seeking and sharing stories of civic contribution and employment will encourage people to recognize control of an individual budget as a key to citi-zenship and raise their eyes to see what the key unlocks.

A great strength on in Control’s approach is the coher-ence between practice and philosophy. The philosophy underpinning self-directed support is an under-utilized resource. Setting up opportunities for interested people to study and debate it intensively might both provide an-

“” Caroline Tomlinson’s disabled teenage son, Joe, had a problem. He wanted to go to school with all the other teenagers in Wigan, on the bus. But when Caroline

approached the social services department to see whether that would be possible, she was told that the department already had a block contract with a local taxi firm to take Joe to school, and sending him on the bus would be an additional cost it was unprepared to pay, especially as in the department’s assess-ment Joe would need to be accompanied by two care workers to make sure he came to no harm. A few months later, however, Caroline and Joe enrolled on an initiative called In Control, run by a social enterprise for the Department of Health, which helps young people with learning disabilities take control of their own care. Everyone going on In Control gets their own annual budget – the cash equivalent of what they would have got in services – and help to decide how to spend it on the kind of support they need. Caroline and Joe quickly drew up a plan to get to school on the bus, with the help of two fellow sixth-formers who were studying for care qualifications. Joe was happy. Where once they were dissatisfied, complaining consumers, they found themselves turned into participants and co-investors in finding better outcomes for themselves.*

*Charles Leadbeater and Hillary Cottam (2007) The user generated state. In Patrick Diamond (Ed.) The progres-sive agenda: Revitalising service reform. Solace Foundation Imprint www.sfi.uk.com

**A report on in control’s first phase, 2003-2005. P. 95.


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other safeguard against loss of purpose and strengthen in Control’s philosophical skeletal system.

Expand reflection on adaptive work

As our colleagues from West Sussex demonstrated during this discussion, there are many valuable lessons about shifting culture to harvest. In Control has been effective in naming and sequencing the steps to Total Transforma-tion. There may be room for looking into what happens as people live their way into the steps:

The ways that local people address the emotional • and political issues their system encounters in shifting power toward people eligible for social care.

The ways that people build commitment to measuring • their efforts in terms of establishing the conditions for citizenship.

The processes that people have found helpful for shift-• ing culture.

This inquiry could form the basis for case studies of the change process as a resource for later adopters. As well, there might be additional processes to support change to add to the repertoire of consultant members of the in Control network.

It could be that following some of these steps risks inviting the paralysis of analysis. However, the human dimension of trans-formation is in fact challenging. And hard experience shows how dynamically stable human systems can be, especially when money, status, power, and dependency are in play. It’s not easy to shift out of the producing and promoting and persuading mode required of in Control’s advocates on most occasions, but learning to do so might prolong the life of the effort.


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Look for relevant resources in other efforts at public service reform

There are many streams of thought and somewhat fewer live experiments aimed at creating better public services. The concept web below sets in Control alongside some of the ideas explored in several recent publications that have featured self-directed support as an example.

Many of these labels are little more than trial balloons in an attempt to capture the qualities and paths to change necessary for an effective public service, but the bolder ones reflect themes for action in wider currency. Each label represents one end of a thread that might lead to informative, inspiring or influential networks; to ideas and processes that might strengthen in Control’s case; and to signals that could provide orientation to new resources.

co-production user-led

Public Services 2.0 innovation

disruptive technologies community

citizenship social inclusion

disability rights self-organizing & bottom-up

user involvement independent living

social interprise in Control self-direction citizen collaboration

personalisation social cooperation-

participants v consumers empowerment

the adaptive state information technology public

service reform the empowered user

the user-generated state

This richness of association may reflect the ideational productivity of the networks as-sociated with Demos more than the breadth of in Control’s influence, but that does not diminish the point made here.

Some wisdom is needed to discern which threads are worth following and to avoid distraction into spending too much time talking to new and interesting people. However the benefits of cross-pollination may be great enough to recruit one or two people from these networks who might be interested to learn enough about in Control to take up the role of honeybee scout in the garden of public service reform.


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Annex A: In Control: A framework for systematic reflection

David Towell

1. What are the goals of the in Control initiative and what elements in the programme are designed to achieve these goals?

2. More specifically, what are the outcomes in people’s lives which in Control is seeking to help individuals achieve? What do different stakeholders (as represented in our discussions) see as the strengths and limitations in this definition of outcomes?

3. What does experience to date suggest about success in relation to these outcomes? What is being learnt about the conditions and pro-cesses required to optimise success?

4. What are the strengths and limitations in the in Control definition of best practice in organising self-directed support, as this has emerged to date? How far is this likely to work well across all (potential) us-ers of social care? What are our views on the mission of in Control to

achieve the complete transformation of social care into a system of self-directed support?

5. What is the distinctive change methodology guiding this initiative? What does experience to date suggest about the strengths and limita-tions of this methodology for implementing the in Control approach in many localities? What might be needed to do better?

6. What issues is spread of the in Control approach raising for wider systems change in local government and more widely? How might these issues best be addressed?

7. What are the lessons for national policies and implementation ar-rangements emerging from experience in the in Control initiative, especially as it spreads more widely?


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Annex B: in Control’s approach to change

Simon Duffy

Q1 Universal Transformation: What are our views on the mission of In Control to achieve the complete transformation of social care into a system of Self-Directed Support?

It was very early in the life of in Control that we set ourselves the goal of the univer-sal transformation of social care into a system of Self-Directed Support; and while the wisdom of such a mission can be questioned, there is a sense in which we were impelled to develop such an ambitious mission. I think there are at least 3 factors:

1. Permeable Client Groups Within the UK social service departments are not engineered to be overly-respectful of client group labels. Although there are differ-ences in how older people are treated to how people with mental health problems are treated etc. these differences do not seem to run very deep:

Funding can be shifted between groups and the relative priority of client groups • changes with geography and local politics.

There are no hard and fast rules that determine whether one label has prior-• ity over another. (So an older person with a learning difficulty can be treated as primarily subject to older people’s services, or learning disability services etc.)

While many services ‘specialize’ in serving one group many do not and it is hard • to identify any critical boundaries in skills or expertise to make client boundaries meaningful.

This differs from some countries where getting a label, diagnosis or IQ test become the primary event - from which all subsequent services flow. This means that in other countries ‘reform’ can be limited to one silo - but in the UK any deep-seated reform of social care must be universal and cannot be restricted to labels. This makes the challenge bigger - but it seems an inevitable part of being serious about reform.

2. Systematic Reform The second reason for aiming for whole scale reform is that anything short of whole scale reform is liable to suffer from the overwhelming damp-ening effect of a gradualist process which must be implemented slowly or must be led by demand. An incremental process is reasonable if one believes that the system will respond to new demands and has a bias towards recognising capacity in people.

But that does not seem to be the reality of the current social care system where it is much easier to keep old systems and services running, however poor, running than to invest significantly in new systems or services.

in Control’s view was that it was better to design a system that could be implement-ed as a universal model, so that it then could be introduced systemically. In particu-lar this meant building in three, seemingly conservative, components:

Letting people choose to have very low levels of control: e.g. letting care manag-• ers commission services on their behalf

Letting people choose very conservative service: e.g. letting people buy residen-• tial care placements

Letting social services determine if someone is not an appropriate person to • manage their own support or someone else’s

By allowing for these conservative options what in Control is able to do is say: let’s change the whole system, but allow people the level of choice they want or is ap-propriate. This means that, from the beginning in Control can help authorities avoid the creation of an internal demarcation line between the us and them: between those who get Self-Directed Services and those who don’t.

3. Radical Reform Of course both these two reasons are connected to perhaps the most important reason for aiming at universal system change - these reforms are radical in the literal sense (radix - root) - they require change at the deepest level, change to fundamental systems of funding, organisation and culture. These are just a few of the possible areas for change:

Skills, training and personal development •

Organisation of care management •

Local authority management accounts •

This consideration grows in importance when we start to look to further ahead to the long-term policy agenda:


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The long-term funding of social care and the role of private contributions, • means-testing and the link to the benefit system.

The boundary between health and social care and the role of charging and • means-testing

The future roles of local authorities, and national organisations such as the ILF et al. •

Thinking about reform in a way that is shallow will limit effectiveness. Only when you can engage with the deep and powerful forces that determine the shape of social care can you begin to hope to have systemic relevance.

Q2 Change Methodology What is the distinctive change methodology guiding this initiative?

in Control Reflections 1 gave a very clear outline of much that is distinctive about in Control’s approach to change and our use - not to everyone’s taste - of the image of the Operating System. This is probably the central strategy and it is certainly dis-tinctive, although I also think it is important to put that approach in a slightly broader context; for in Control is not simply an intellectual approach and you can see other strategies running in parallel to this central thread.

But let us begin with our map of the current situation.

Opportunity

Awareness of the need for a review of the economics of current system

The existing system is structurally inefficient - resources can be unlocked

Dissatisfaction from present and future users with the current system

The public desire that people control their own money

Local authorities are frustrated with the current system

Networks of individuals and families do exist and can lead change

Many professionals want to change and want to be accountable to those they serve

Social workers are dissatisfied with the current form of care management

Business and services could start to market more effectively to people directly

Growth in internet usage, putting tools and information into people’s hands

Government interested in possibility of wider reform

Challenge

Fear that the new system will further worsen existing cost inflation and inefficiency

Providers fearing loss of business in consumer-led market

Incoherence of different approaches within children and adult systems

Uncertainty about the interface with the NHS and free health care

Continuing failure to build community capacity or prevent needs escalating

Continuing failure to develop appropriate flexible services for people with complex needs

Fear that our community infrastructure of family and friends is eroded beyond repair

Fear that the infrastructure of self-directed support will become too costly

Fear that the public may perceive reforms as a ‘trick’ or as ‘privatisation’

Belief that Self-Directed Support cannot be adapted to work for all

Belief that some people really do not ‘belong’ and must be institutionalised

This analysis implies an incredibly broad canvas and it would be impossible for in Control to begin to make any kind of significant impact if it could not narrow its fo-cus. in Control’s approach has been to distinguish strategic levels and to find its own niche within those levels:

Much of the activity of in Control is carried out without being under the direct control


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Level Goal Niche

PoliticalTo make SDS politically ac-

ceptable

Offer information and data,

sensitive to political interests

(e.g. Discussion Paper on

Economics of Self-Directed

Support was published)

Civil ServiceTo solve technical policy

problems

Provide data and policy

solutions, as required (e.g.

work out details of how

funding streams might be

integrated).

Leadership Bodies To ensure ownership of SDS

Make in Control account-

able, ideally to find sponsor-

ship (e.g. ADSS is now a

sponsor of in Control).

Local GovernmentTo develop positive engaged

community

Affordable membership

framework (e.g. affordable

subscriptions scheme).

Support different levels of

commitment up to Total

(Levels 1, 2 and 3 identified)

Consultancy BodiesTo limit competitive theoreti-

cal ‘fractures’

Accredit and market partner-

ship network

Not in competition with

partners

Service ProvidersTo offer a positive sense of

possibility

Membership support net-

works developed

Advocacy Organisations To strengthen and equipFree information and tools,

advice and support

Real People & FamiliesTo generate demand and

understandingPR and direct support

of in Control. Instead partners operate autonomously; members try to bring about change locally and many who use our ideas without acknowledging in Control’s contribution.

However in Control also attempts to build further partnerships by focusing energy onto particular keys boundary areas:

It is for these reasons that in Control’s current strategic priorities are as follows:

ModelDevelopment

Towards health

Towards entitlementTowards community

Effective Change Across Whole System

Towards children’s services

in Control1. Total - supporting a number of authorities to make a full shift to Self-Directed Services in a 2-3 year period

Citizen Leadership 2. - supporting people and families directly

Community Innovation3. - making Self-Directed Services easy, natural and efficient

Taking Control4. - making Self-Directed Services work for children

in Community 5. - identifying an Self-Directed Services approach to prevention and community development

Staying 6. in Control - making Self-Directed Services work on boundary with


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health services

Leadership Academy7. - supporting development of a new wave of providers

Efficiency8. - making sure changes are sustainable and that people control as much of the money as possible

Communication9. - communicating information, stories and ideas effectively at every level

Critical Evaluation10. - making sure the model adapts as we learn more

There are also a range of R&D communities supported by in Control working on the following issues:

Support planning•

Employment•

Community•

Research & Outcomes•

Q3 Progress What does experience to date suggest about the strengths and limitations of this methodology for implementing the in Control approach in many localities?

Ten local authorities have decided, at the highest level, to work to convert all of their services over to Self-Directed Support and to work with in Control to share their learning on how to make this happen with the wider community.

Today in Control tests and develops good practice in Self-Directed Support and helps local communities to promote Self-Directed Support for everybody using so-cial care:

Older people who need support •

People with physical disabilities •

Children with extra support needs •

People with learning difficulties •

People with mental health problems •

Children and adults with long-term conditions •

People with brain injuries •

Skills & Workforce•

Provider Development•

Resource Allocation•

Brokerage & Advocacy•

Language & Identity•

By February 2007 the numbers of people now managing their own money using Self-Directed Support within in Control’s membership has grown to 958 people, controlling £11.3 million. in Control is supporting growing numbers of people using Self-Directed Support from all different groups, children and adults:

58 older people (6%) •

86 people with mental health problems (9%) •

345 people with physical disabilities (36%) •

469 people with learning difficulties (49%) •

in Control currently supports local authorities, particularly within the Individual Budget Pilot Programme, to include 7 additional funding streams within mainstream social care funding:

Supporting People funding •

Independent Living Funds •

Learning & Skills Council funding •

Disabled Facilities Grants •

Funding for Integrated Community Equipment Services •

Access to Work •

There have also been a number of initiatives to integrate funding from the NHS • where that funding is essential to the coherence of individual budgets or indi-vidual need.

in Control’s website (www.in-control.org.uk) is the leading source of information on Self-Directed Support. There are currently 165 live publications; there were 8,300 visits in January and 10Gb of information was downloaded. in Control has organised or sponsored over 100 events or conferences for local leaders, disabled people and families and service providers that have been used by over 3000 people. in Control has also developed and led 4 leadership programmes for champions of Self-Directed Support within local authorities.

in Control works directly to support disabled people and their families through the National Family Carer Network, Partners in Policymaking and Mencap and other advocacy groups. In addition 40 service providers have joined in Control’s Provider Network and 7 Chief Executives of large service providers have committed to re-organising their whole service around the principles of Self-Directed Support.


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in Control• receives a modest level of funding from central government and has multiplied that funding by thoughtful partnership working:

2004 DH investment: £30,000 multiplied by • in Control to £120,000 (400%)



Furthermore in Control’s model of partnership working has generated approximately £1 million of autonomous in Control activity coordinated with partners in 2006-07 (making a full multiplication effect of over 600%).

in Control is governed by a Steering Group, chaired by Dame Jo Williams, and repre-senting in Control’s key sponsors:

Department of Health (DH) •

Association of Directors of Social Services (ADSS) •

Care Services Improvement Partnership (CSIP) •

Commission for Social Care Inspection (CSCI) •

Mencap •

in Control has a Core Team of 11 staff who work to coordinate the activities of in Control and it works closely with over 20 partners ranging from universities (e.g. University of Lancaster) consultancy organisations (e.g. Paradigm, HSA), develop-ment agencies (e.g. North West Training & Development Team, Inclusion North), government bodies (e.g. CSIP) and private firms (e.g. Symmetric). in Control’s Edito-rial Board is made up of 18 independent experts on Self-Directed Support from a wide range of fields. Together they ensure that in Control is constantly learning and improving its account of how best to achieve Self-Directed Support.

in Control’s sister organisation in Control Scotland was launched in Glasgow on the 16th January 2007 at a conference attended by 300 people. Plans are in progress to set up in Control Wales and in Control Northern Ireland.

What does all this mean?

Well, given the very limited resources provided to in Control I think this means that we are tapping into something where there is real demand, interest and energy. The system has powerful negative intertia –but so far so good.

Q4 Improvements What might need to be done better?

What none of this captures is the complexity of driving in Control forward within the complex and conflicted world of policy development and power. e.g. It is hard to do justice to the challenges faced by those within the civil service who have tried to support in Control when others have been opposed to it.

In particular the following developments are required:

More clarity about the meaning of partnership with • in Control - it is a powerful concept, but needs further work

Strengthening links to the worlds of older people and mental health - alliances • have been hard to forge

Better access to senior policy-makers - • in Control has been placed very low down the policy food chain and key messages are not getting through

Finding star providers - some services are talking about change positively, but • no English provider has made the full-scale change necessary for Self-Directed Services

Managing the demand - • in Control gets tremendous support from Mencap and others, but it is always in danger of doing too much and not finding ways of get-ting others more involved

Q5 Local Government What issues is the spread of the In Control ap-proach raising for wider systems change in local government and more widely? How might these issues be best addressed?

This is an enormous issue and I cannot do full justice to it here. In some respects in Control in its first two phases has only skimmed the surface of these issues and now the central challenge for in Control is precisely to both identify and solve the prob-lems that will emerge as authorities –particularly those who are participating within in Control Total– begin the work of transforming large sections of their existing system over to Self-Directed Support.

There are also possible opportunities for change in other local services (education, health, leisure etc.) but I think in Control’s instinct is that, while we must be mind-


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ful of these possibilities, it would be a mistake too rush into expanding the scope of Self-Directed Support too quickly. We need to root change within social care ef-fectively and systemically before being tempted to explore too widely. Of course if the idea leaks into other areas of reform that may be helpful –but until real progress has been made on the ground it feels fool-hardy to be concerned with pushing the boundaries of Self-Directed Support too quickly.

Here then is a sketch of the emerging terrain, although I am sure I will not have cap-tured every trap, block or dead end:

Economic sustainability The evidence that Self-Directed Support is more efficient seems overwhelming. But in a highly rationed system efficiency brings problems and opportunities. There will be more demand for this more attractive approach. Hard questions ethical questions about means-testing, prevention, family support, the boundary with health and different understandings of ‘need’ will all be brought into sharper focus. Efficiency offers some slack to create a better ‘deal’ for society and the individual –but it will not answer every question.

Performance Whether or not performance management has been successful in improving people’s lives it has certainly provided motivation to authorities to im-prove performance against measured criteria. Moreover there could be enormous congruence between Self-Directed Support and regulators and there has been an encouraging focus on the value of autonomy in recent years. But there are also ten-sions and confusions and to date in Control has only provoked the slightest flicker of interest amongst regulators.

Legal framework There is no doubt that, while Self-Directed Support appears to be (just about) congruent with the current legal system, there are enormous oppor-tunities to create better laws that could build a proper framework for entitlements, supported decision making and guarantee the funding flexibility that Self-Directed Support calls out for.

Strategic direction Local government has genuine autonomy; however only the bravest authority would seek to set off in a direction that central government didn’t bless. The current rhetoric from central government does support Self-Directed Support. But the depth of understanding is very low and there are as many initiatives that compete with Self-Directed Support as support it. Moreover while in Control itself is sometimes seen as helpful it is also seen as threateningly: independent, entrepreneurial or evangelical.

Care management, contracting and commissioning Self-Directed Support in-volves the complete redesign of the engine room of the local authority systems that drive the current shape of social care systems. The obvious changes required in skills, behaviour and organisation are minor compared to the broader challenge of setting a new culture that reflects the citizenship of disabled people and older people and enables these lead professionals to redefine their roles positively.

In-house services Many authorities are still heavily reliant on in-house services. In fact one of the selling points of in Control’s model of Self-Directed Support is that these services are not excluded from the options available to people. But the rel-evance of in-house services will depend upon whether they can provide an attractive way of marketing their services and there will need to be much more thought given to how these services are priced.

Behind the scenes There also many more services that will be impacted by this shift: accounts, invoicing, charging, personnel, administration and many more inter-nal services will need to be radically reorganised.

It is arguable whether in Control’s own organic and light-touch approach to change management will be adequate. We may need to either change our own behaviour or to forge partnerships with those who can provide a different style of support. On the other hand there is also a danger that an overly structured approach will ‘miss the mark’ and will not be sensitive to merging patterns of good practice.

Last thoughts

I want to end by just asking one last question of my own: should we be working through local authorities? To date in Control has found that the greatest levels of motivation, energy and enthusiasm has come from champions within local govern-ment. But there are interesting questions to explore:

Should we really aim at a national model (through ILF, benefits, tax system etc.)? •

How do we ensure that Self-Directed Support does not become imposed upon • local communities?

Should national policy set the pace, or follow good practice? •

Reflections on in Control -2

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Transcript of Reflections on in Control -2