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In 2023, at what is believed to be a cost in excess of £1M, Bristol City Council commissioned the Peopletoo management consultancy to help them address the problem of an over-spending service. Despite an initial refusal because Peopletoo wanted to keep their work out of the public domain, a Freedom of Information request by Bristol Reclaiming Independent Living (BRIL), a Disabled Peoples Organisation, was successful to see the Peopletoo reports. They revealed a shocking truth.
The strategy they designed serves only to provide an elaborate and expensive façade that conceals how the required reduction in spending is actually being addressed.
At the heart of the Peopletoo strategy is a proposed transformation in social care. But it is just a rehash of strategies with a long history of failure. Remarkably, Bristol Council had already tried a nearly identical strategy to transform its service just six years earlier using a different management consultancy. The hiring of Peopletoo is testament to its failure, contrary to all claims of great success at the time.
The Peopletoo strategy
The key output of the consultancy is what they have called a Target Operating Model (TOM). It is designed to ensure all support plans are created using best practice principles. Support plans will build on each person’s strengths, through assessments that are person centred and outcome focussed.
These are the acknowledged hallmarks of a personalised system. Through finding the most cost effective ways to achieve the best outcomes, personalisation results in the greatest possible value for money. It is a view amply supported by research over many years, but never achieved.
The Peopletoo plan aims to reduce spending in Bristol by getting rid of inefficiencies in the system. The report says these inefficiencies come from practices that are resource led not person-centred. The current approach is driven by reacting to crisis rather than being focused on outcomes. It is routed in identifying people’s deficits not their strengths.
Evidence was put forward by Peopletoo that Bristol has much to gain from such a transformation. They said Bristol is behind other councils in key measures of efficiency - the numbers of people served and the cost of meeting their needs.
The Target Operating Model
Central to the TOM, and driving it, is a declaration of a vision.
‘Our vision is that all of us in Bristol City will have the support that we need to live in a place that we call home, with the people and things that we love, in communities where we all look out for one another, doing the things that matter to us’.
It is taken directly from that proposed by Social Care Future, a group hosted by In Control, the charity that created the personalisation strategy some 15 years ago. Delivery of the vision will be through social workers adopting a series of commitments to best practice. These are taken from the work of Think Local Act Personal (TLAP), the body funded by Government to drive the personalisation agenda nationally. Known as the ‘We will’ statements, they were first published in 2012 under the banner Making It Real, with ‘it” being - personalisation.
The ‘we will’ statements describe best, personalised practice. They include commitments to individuals to;
Be kind and take time to get to know you and to understand what is
important to you
Be flexible and creative, supporting you to find solutions that work for you
Believe in you and help you to do the things that matter to you
Build on your strengths, your networks and the resources available in your
local community
Be flexible and creative to find solutions that work for you
Use our resources wisely so that we can focus on what matters most to you
Delivering the ‘we will’ statements would make the social worker a true advocate for the wellbeing of the individual they serve.
The Director has described the strategy as the Council’s ‘North Star’, the mythical symbol that guides us to our destination and true purpose in life.
The person’s strengths are best hidden, their aspirations an irrelevance. Crises and dependency, not aspirations, determine who gets support.
An extraordinary omission - reality
But the TOM has a gaping hole. It assumes the only people who need to change are the social workers. It proceeds as if no other officers play any part in the decisions about the needs of people and the resources they require.
But that cannot be, and is not, the case. If individual social workers were in charge of allocating resources, it would be impossible to spend within any given budget, no matter how mean or generous the budget may be. Each person’s needs are unique, and the cost of meeting them varies greatly. It would be mathematically impossible to ensure spending stays within any set budget.
This makes it inevitable that the people who make the decisions about what individuals receive are the managers responsible for ensuring spend is within budget. We will shortly publish a dossier that exposes how this works. The following is a summary.
The responsible managers’ moral purpose is to share the resources at their disposal as fairly as possible, however meagre those resources may be. But in doing so, they must follow a strict policy rule – they must deny the existence of any need they don't have the resources to meet. They are prohibited from acknowledging any need for which they have no resource.
This is the way what is called ‘eligibility’ is determined. Once a need has been deemed ‘eligible’, which only happens if there is resource to meet it, the need becomes a legal duty to meet.
Social workers, whose own moral purpose is to secure as much support as they can for the person they serve, must calibrate their assessments accordingly. They dance to the budget holder’s tune. The person’s strengths are best hidden, their aspirations an irrelevance. Crises and dependency, not aspirations, determine who gets support.
Social workers cannot advocate for the person’s wellbeing as the ‘we will’ commitments describe.
The process is contrary to all the principles and requirements of personalisation. Decisions are therefore made behind closed doors with the manager responsible invariably kept anonymous. This maintains the illusion that it is the social worker who makes the decisions, and that they do so with only the person's best interests in mind.
Desperate for help and up against a powerful structure that controls their future, people who draw on social care usually accept whatever is offered. They do this even if it's too little or doesn't fit their needs. Very few people have the strength or courage to challenge this system. It is a level of reluctant acceptance essential to maintain the concentration of power at the top.
The TOM says nothing about the managers who actually have the most power over the lives of the people in need of care and support. Peopletoo have protected their anonymity.
It’s not so much an elephant in the room as a mammoth, reducing the TOM to a mere fantasy disconnected from reality.
The reality in Bristol
The events as they unfolded in Bristol makes this disconnect abundantly clear. At the same time as the Council was promoting the idealism of the TOM to the residents of Bristol, it looked to the real world to achieve its cost cutting objectives.
It launched a ‘Fair and Affordable’ policy that identified 160 people supported at home at a cost above residential care. Substantial savings would be made by either offering these people residential care, or reducing their support at home to the equivalent cost. A team of 10 social workers – a hit squad – was recruited to carry out the necessary reviews.
In order to appear compatible with the Care Act, all the needs for wellbeing that derive from living “in the place we call home” were re-classified to be nothing more than mere ‘preferences’. The Care Act requires councils to meet only needs, not preferences.
This brutal reality could not be more at odds with the idealism of the TOM.
There was a public outcry and campaign led by Bristol Reclaiming Independent Living (BRIL). The Council responded by actually widening the disconnect between the fantasy and reality. It said the Fair and Affordable policy would be withdrawn. But in the same week, it agreed a budget strategy for 2024/25 that not only included the same plan to secure ‘efficiency’ savings through reviewing the cases of people whose care cost more than residential care, but actually increased it by lowering the cost threshold. This meant 190 people would now be targeted.
In March 2024, Peopletoo reported the ‘success’ of their plan. Cuts to the support of individuals totalling £254K has already happened. If all goes according to their strategy, that could increase to £1.6M by March 2025. And, maintaining the illusion, all the people whose support will be be cut will have 'agreed' to their new plan because it will make their lives better. The more likely reality, however, is that they will have 'agreed' because they believed the alternative would be no support at all.
Bristol has been here before
In 2017, another management consultancy – Impower – was commissioned to help Bristol Council address an overspending service. At the conclusion of its work, Impower reported it had enabled the Council to have created a ‘brand new culture’ that
‘supported practitioners to think about approaching conversations differently drawing on service users assets, strengths and networks’.
adding that;
‘63% of Practitioners ‘strongly agreed’ or ‘agreed’ that they had changed the way they had conversations with clients’
with glowing testaments from practitioners;
’Starting with the positive has really lifted everything, even I feel lifted…it’s been really positive.’’
‘’It’s a whole mind-shift…starting with the positive.’’
’I have been able to change the conversation to focus on a support conversation…clients take this seriously’
And Impower reported great success in cost reduction;
‘A predicted financial outturn position showing in-year benefits of £6m coming from reduced spend’
declaring the projected savings to increase to between £11 and £17M.
Bristol’s Director of the day expressed his gratitude;
‘Building on our passion to get into the culture change that was needed, IMPOWER brought expertise, challenge and insight when it was most needed’
How could the Director in 2023 think the same strategy, that had so obviously failed by his own assessment of the situation, would work again?
If Bristol is putting resources before needs, it would mean it is delivering all the dysfunctional practices that Bristol itself, the LGA and the leadership of the entire system know leads to depersonalisation of supports and, with that, misuse of public money.
A national or local issue?
A key part of the rationale for the Peopletoo consultancy was that Bristol was exceptional in that it was lagging behind other councils in efficiency and so was wasting public money. This helped create a sense of Bristol being a failing service as the driver for change.
But publicly available data on NHS Digital shows this is simply not the case. Dividing all councils into three groups – high, low and middle - Bristol sits comfortably within the middle group against the three key measures used by Peopletoo – number of people served, the amount spent on them and the price paid to providers for their care. The actual data is included in the Appendix below.
And there are other reasons why it should have been plain to Peopletoo, and indeed to the Council’s senior management, that Bristol is no different from other councils.
Peopletoo identified a ‘fire fighting’, culture with practitioners constantly battling crises. Yet this is a known national issue. Indeed, social care’s leaders routinely base their pleas for resources on exactly this claim.
They noted that the assessment process was highly complex and bureaucratic. But this too is known to be a national concern.
Even more telling is work carried out by the Local Government Association in December 2023. The Council called upon them for a ‘Peer Review’ to help it prepare for their inspection by the Care Quality Commission, expected in 2024.
The review team could see no fault with the Peopletoo work;
‘The analysis and recommendations from the Peopletoo diagnostic were recognised as accurate by the peer team’
The LGA team’s acceptance of the Peopletoo analysis exposed that they saw the way
Bristol addressed the core challenges facing local authorities as to be expected .
But this was despite them making the following observation;
‘There is a belief, whether justified or not, amongst some disabled people that the Council is interpreting the Care Act from a cost-saving perspective rather than from a ‘rights and needs’ position’
The team didn’t concern itself to learn of the evidence upon which the belief was based to determine for itself if it was indeed justified.
Yet if the belief is justified, the implications couldn’t be more serious. It goes beyond unlawfulness. If Bristol is putting resources before needs, it would mean it is delivering all the dysfunctional practices that Bristol itself, the LGA and the leadership of the entire system know leads to depersonalisation of supports and, with that, misuse of public money.
The national situation
But most telling of all, Bristol is merely delivering the national prescription. It has been devised by the Association of Directors of Adult Social Services. Last year ADASS published a Roadmap for Reforming Care and Support. Below is a link to a critique that sets out why the roadmap is going nowhere.
It too adopts the Social Care Future vision and it too describes it as the ‘North Star’. It too says the Make It Real statements are the means to bring about the necessary transformation in professional practice.
What is happening in Bristol is likely to be happening up and down the country. What may be different in Bristol is the level of scrutiny following the disclosures. This was only made possible by the determination of local disabled people to seek the truth.
Questions for the Director
As the individual with legal responsibility for the strategic delivery of social care to the people in Bristol who rely on it, there are serious questions for the Director.
For the conversation with the person to determine the support they receive to achieve the Social Care Future vision as the TOM promises, the resources must be available. There are only two ways this can happen;
Bristol ceases to work within a budget. The uniqueness of need and unpredictability of the cost would make budgeting in advance impossible. Does the Director have a plan to make this happen?
If he accepts that social care will always be a budgeted service, how will sufficiency of budget ever be achieved all the time he declares that whatever budget he happens to have is already sufficient to meet all needs for wellbeing? How will he counter the political inertia that is the inevitable consequence? How will he elevate the public and political narrative to the aspirational language of the TOM vision when day in day out, case by case the language he and his staff use is rooted in crisis, risk and dependency, and when he makes the case for better budgets on the basis of risk and legal sanctions? Is he not killing off any hope of changing perceptions and increasing public and political support with such self defeating behaviour?
Alternatively does he believe that the prevailing system, despite knowing it to be profoundly dysfunctional, offers the best hope for the people he serves. Calibrating needs to the available resource, and then making it a legal duty to meet those needs, has enabled social care to weather austerity. Nationally, spending is now the same as in 2010. But that ignores how those funding levels were leaving large swathes of needs unmet and how since 2010, demand has increased with a 15% growth in the older population alone.
Does he believe the community he serves cares so little for older and disabled people?
The Director describes the vision within the TOM as a North Star. No matter how brightly a North Star might shine, it can only guide those who are looking up to see it.
Appendix
Peopletoo and use of resources
The basis of Peopletoo’s intervention rests on the following statement
‘The current Adult Social Care operating model is unsustainable, with higher than average numbers of people receiving care, high average spend per person, and high unit costs in most settings and support reasons’
However, the data available on NHS Digital does not support this view.
Number of people receiving care per head of population
The national average for older people was 56.9 per 1,000 population 65+, ranging from 30 (Dorset) to 115 (H&F). Bristol ranked 60th most with 60.5 placing it broadly within a middle band.
A more accurate measure of performance is in relation to levels of deprivation of the community served. There is a strong relationship between number of service users and deprivation. Bristol’s Index of Multiple Deprivation is 26.4, making it above average. The expected number of service users for a council with that level of deprivation would be 62.9.
Bristol actually had fewer, not more, than their expected number of older service users.
The national average for working age people was 8.5 per 1,000 population 18-64 ranging from 4.1 (South Glos) to 16.6 (Middlesborough). Bristol ranked 58th most with 9.2, again placing it broadly within the middle.
Bristol’s expected number of service users for a council given its IMD of 26.4 would be 9.2. So Bristol had exactly the number of service users expected.
Spend per person
Its important to allow for regional price differences. Unit costs vary around the country. South West Region happens to have the highest unit costs in the country. The following are all adjusted to the national averages and so control for regional price differences
For older people, the average spend was £18.3K per annum, with a range from £8.9K (Wirral)) to £27.4K (Sandwell). Bristol ranked 105th lowest at £20.6K, broadly in the middle.
For working age people, the average spend was £32.8K per annum, with a range from £18.5K (Hartlepool) to £49.9K (Bromley). Bristol ranked 76th lowest spend at 32.2K, broadly in the middle.
Unit costs
Given the variation in regional costs, the most appropriate comparison for unit costs is a council’s region. Bristol operates in the South West Region.
The average unit cost of residential and nursing care for older people in the South West was £996.3K per week. Bristol’s unit cost was £1.020.9, which is just 2.5% above the regional average.
The average unit cost of residential and nursing care for working age people in the South West was £1,719.2 per week. Bristol’s unit cost was £1,812.8, which is just 5.4% above the regional average.
Summary
It may be Peopletoo used other data for comparisons. But on the data above, even if Bristol tends to be a little above averages, it is certainly not of an order to justify declaring Bristol to be lagging behind others in an unsustainable way.