BROKERAGE

‘The customer rules.’ But who is the customer of intellectual disability services? John Buckley challenges current practice, and suggests the need for revolutionary rethinking in how the funding of services should be organised. John Buckley, Day Service Leader, St Patrick’s, Upton, Innishannon, Co. Cork

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The current situation

What term is used in the service you are most familiar with to refer to the people who access that service? One term in use is ‘client’, which suggests a relationship between a professional and a client—as in the case of an accountant or lawyer. Often, however, the reality has been one of ‘the professional knows best’, hence it is seen to be tainted by use. (This attitude is very clearly identified by John McKnight, see references.) Service user is in vogue at present; this suggests a very passive relationship of receiving a service without input or influence over that service. Some organisations and authors talk of developing a ‘customer-driven service, by which they mean one which is more client-centred (e.g. Brooke et al).

The problem is that services are customer driven—and the customer is the funding agency, because ‘A customer is a person who buys’. The organisations providing service are responsive to the wishes of funding agencies and will produce whatever programmes, statistics and literature required to get them more funding. Effort will be put into presentations and management attention focused on the negotiations surrounding the current allocations. Much of the ‘core-funding’ is provided for doing whatever the organisations were doing before. If this is what the customer pays for, this is what they get—more of the same.

Thinking in relation to service provision for people with disabilities has been turned on its head in recent years. Instead of asking, ‘What part of the system will we put this person into?’, the question is ‘What are this person’s needs and how can we meet them?’ There has been both progress and rhetoric on this: person-centred planning, self-advocacy, empowerment, informed choice, quality programmes, etc. Progress is where real change takes place, and rhetoric is where an old system is dressed up with new words, mission statements and programmes—the right words, but no substance.

How could this situation be improved? The funding agencies could develop more sophisticated quality measures setting out in detail what should be achieved (How it should be achieved should be left to the organisation.) and a feedback mechanism to see if it is being achieved. Properly applied, this would improve on current service provision—but only to a certain point. It would also require considerable cost and effort, much of it administrative, to ensure its development and maintenance.

Ultimately the issue is about delivering a service to an individual that meets his/her needs. By definition, each individual’s needs are different; no top-down definition or specification can possibly take this into account.

 

Individualised funding

The process of assessing the level of need for individuals, and what funds would follow, is a key but separate issue. Long-term planning and funding requirements for individuals are already being addressed through the National Intellectual Disability Database.

Giving the individual control over funds would mean that they become a customer and have the ‘purchasing power’, and the negotiating strength associated with this. The principle is that the individual is encouraged to express their own choices and that these are respected. An individual with a learning difficulty may need support, or even someone to speak for them, to express their needs; such advocacy will generally come from family or friends.

In the UK there is a system of ‘direct payments’,” where people in receipt of community-care services can opt to receive money to purchase the services they need (details given in BILD fact sheet no.3). In Autumn 2000, Social Services Directorate figures showed only 216 out of 3700 people in receipt of direct payments were people with a learning disability. The local authority makes the decision as to whether someone is ‘willing and able’ to manage a direct payment—there can be confusion as to whether someone with learning difficulties has ‘the capacity to consent’. The scheme is only available for limited purposes and does not apply to local authority services which include residential care, or nursing home care, or services or equipment otherwise arranged by other authorities (e.g. the NHS or housing authorities). Despite the recognised limitations of this scheme, it must be seen as a positive start—and to be heading in the right direction. It would be a major step forward for all areas of disability if a similar (or possibly more progressive) scheme were introduced in Ireland.

Giving the funding directly to individuals with learning difficulties and their families without giving supports and guidance risks considerable problems for funding agencies, service providers and the individuals and families themselves. It would increase stress levels and could result in major disruption to the lives of those receiving service.

Service Brokerage

The concept of service brokerage started in Canada in the 1970s, with the Community Living Society set up by the parents of people with special needs at the Woodlands School in British Colombia. This group found that to have real influence on what services were provided, and how they were provided, they needed to have control of the money. Without individualised funding, brokerage is not possible.

A service broker must be independent of funding agencies and service providers. Without this, the concept would be totally compromised. In the UK ‘Independent Living Trusts’ are acting in this role to a limited extent.

The Service Broker needs to have the experience, knowledge and ability to provide the advise and assistance to the individual and family in planning and decision-making. They need to be familiar with the services providers in the area and to put together a ‘package’ of services to suit the individual’s needs and to achieve the best value for the funds available. Steven Dowson defines service brokerage as:

Technical mediating support service, with the primary job to assist individuals to capably use their allocated funding and cross system and organisation boundaries to meet

identified needs.’

The question arises as to how service brokerage would operate and be monitored. There would need to be a client-centred code of practice, a level of relevant experience/training, and a governing body/appeals process. Without this, there would be a risk of unscrupulous persons taking advantage of the trust of vulnerable people. There are a number of models for the operation of brokers, including independent agents and brokerage services. In the interests of consumer choice, the client should be able to chose their broker, as well as which services to access.

The role of a service broker can be outlined under five headings:

  1. Planning: The broker may act as a facilitator in a person-centred planning process to help the individual, with their circle of support, to identify what their priorities are. This plan would cover long-term as well as immediate requirements. It is essential that some sort of plan be developed before a package can be constructed.
  1. Advice: The broker would be someone with the training and experience to provide advice on what sort of package of services would meet the individual’s identified needs and which organisations might provide the elements of this. The package might include elements form outside ‘special needs’ providers—e.g. renting a flat, leisure club membership, and supports in accessing these facilities.
  1. Development of services: In some cases the services required might not already exist. The service broker would be in communication with service providers to see if it is possible to develop such a service or adapt current services. Long-term planning on behalf of the individual and service providers is key to this; new services take time to develop. It is also an area where cooperation and coordination between individuals is important; if twenty clients pool their purchasing power, it is much more likely that they will get a service than if they act individually.
  1. Negotiations: The service broker will negotiate the best service for the least amount of funding for each element of the service package for each client. If successful, the result of the negotiations would be a Service Level Agreement (SLA) setting out what is to be delivered, when it is to be delivered, to what standard and what will be paid for it. The SLA would also set out what is expected of the individual (e.g. behavioural or attendance issues).
  1. Monitoring and review: Review points would be written into the contract. The performance of the service provider would be assessed against the SLA criteria. If the service were not provided, this would trigger a credit/refund (‘Sorry we did not provide the adult literacy instruction. The instructor left and we could not get a replacement.’) Changes in circumstance or problems arising for the individual or the agency could result in renegotiations during the period of the SLA.

In the competitive environment where customers can chose between competing products, an organisation that does not make the effort to understand its customers loses them to one that does—and with them goes funding. Are we ready for this in Ireland?

1 COMMENT

  1. Article References:
    1. McMcKnight, J. 1997 Professionalized service and disabling help. In Illich, I. et al, eds. Disabling profession. New York, Marion Boyars, 69–91.
    2. (Brooke et al) Brooke, V., P. Wehman, Inge, K. and Parent, W. 1995 Towards a customer-driven approach to supported employment. Education and Training in Mental Retardation, 30 (4), 308–320.
    3. (Dowson et al) Dowson, S. 1995 What is service brokerage? Means to control. A review of the service brokerage model in community care. Values into Action. London: Joseph Rowntree Foundation.

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