Social Care Summary 4 - May 1995
Increasing user control in social services: The value of the service brokerage model

A number of schemes have been set up in the UK with the aim of giving more control to people who require social care at home, by enabling them to purchase their own services. National policy changes are now being considered which would support this kind of arrangement. Meanwhile there has been growing interest in service brokerage, a system developed with the same aim, but by parents of disabled people in Canada. Steve Dowson, from the voluntary organisation Values into Action, has been reviewing the service brokerage model and its possible value for services in this country.

• 'Service brokerage' is a method of allocating and using public funds for people who require social services which aims to increase their choice and control. It involves individualised funding, by which a negotiated sum of money is placed under the control of the user; and a service broker, who gives advice, information and practical help to the user. The model is based on strong commitment to the rights of disabled people.
• Service brokerage provides the same functions as the assessment and care management arrangement introduced under the 1990 NHS and Community Care Act, but offers much more control to service users.
• Independent Living Projects (ILPs) and Personal Assistance Schemes operate by very similar principles to service brokerage. Many of the differences are matters of style and emphasis, due to the different origins of the models.
• The review found three projects in the UK which describe themselves as service brokerage. The operation of these schemes, and also the ILPs, is made more difficult by the variety of sources which may provide funding, and by the current law which makes it illegal (except in Scotland) for a local authority to pay money direct to service users.
• While service brokerage is being discussed favourably within the Labour and Social Democratic parties, very few service users have heard of it. The model aims to increase user empowerment, yet the way it has been promoted in the UK has largely excluded, and so disempowered, service users.
• The model's most distinctive feature is that the broker (unlike the care manager) is independent, but does have an acknowledged, functional role within the system of social services (unlike most advocates). This feature would strengthen ILPs in the UK.

The development of the service brokerage model

The set of arrangements known as 'service brokerage' was developed during the 1970s by parents of people with learning disabilities who were all resident in Woodlands School, an institution in British Columbia. It has since been developed and refined in Canada, and also adopted by projects in the United States and in the UK. However, some schemes do not entirely follow the Canadian model; and, equally, some schemes which are not called service brokerage may incorporate the main features.

As developed in Canada, the service brokerage model has three main ingredients:

• A strong belief in the right of disabled people to live in the community, to have access to community facilities, and to have control over their own lives. This accent on the resources of the community - and also the original concern of brokerage with people who have severe learning disabilities - leads also to an emphasis on the importance of the support given by the disabled person's family and friends.
• A 'service broker', who helps the person make a plan, assists negotiation for funding, helps to organise and monitor the services, and acts as a 'fixed point of contact' between the service user and the whole system of social services. The broker is independent from the organisation which holds money for services, and from the agencies which offer services, and is employed by a brokerage board, which is controlled by service users and carers. The broker is often likened to a travel agent, who gives advice and information, and makes practical arrangements but has no control over decision-making.
• A system of 'individualised funding', by which money for services is negotiated between the service user and the organisation which holds money for social services, and is then placed under the control of the user. The money may be given to the service user or their family, but is more typically held by a separate agency, such as the brokerage board, on their behalf. In the latter case, a written contract is agreed which specifies how the money may be spent, and the right of the user to purchase services from a different source.

Service brokerage in the UK

Three UK projects were identified in this review which describe themselves as service brokerage. These are:

• a project in Bristol, which operates as part of Assert, a local voluntary group;
• service brokers who work within Southwark Consortium in South London;
• the Archway Service Brokerage Project, which is linked to Archway Housing in Aberdeen.

All these are small projects, with three staff or fewer, and are primarily concerned to assist people who have learning disabilities, though Archway also aims to help people who have only physical impairments.

Service brokerage and Independent Living

Independent Living Projects (ILPs) and Personal Assistance Schemes developed in this country, mostly by disabled people, have similar ingredients. They are based on the same commitment to the equal right of disabled people to access the opportunities and resources available to other citizens. These schemes identify the value of support, both paid and unpaid, which is available outside formal services agencies; but the emphasis which brokerage puts on family involvement in planning and decision-making is absent.

Independent Living and Personal Assistance Schemes are, in part, a response to the creation of the Independent Living Fund, which provides money for personal assistance. ILPs have also worked with local authorities to develop direct payment systems which pass money to users so that they can buy their own services. As it is currently illegal, except in Scotland, for a local authority to make payments direct to an individual for the purchase of services, money is paid to the Independent Living scheme, which then passes it to the user or makes payment on their behalf. Thus direct payment and individualised funding systems are very similar. ILPs are usually controlled by disabled people, and play a similar role to that of the brokerage board.

ILPs and similar schemes also have workers who advise, assist and advocate on behalf of service users. These tasks are very similar to the work of the service broker.

The role of service broker is distinctive because it combines two qualities: firstly, the broker is independent from the fund-holding and service provider agencies, unlike the assessment officers and care managers introduced nationally under the recent community care changes. But secondly, they are nevertheless acknowledged within the system of social services as having a role in the process of planning services and allocating public funds. In this respect, their position is significantly different from that of the independent advocate, who aims to influence services, but without an acknowledged functional role with the service system.

Service brokerage schemes and independent living projects share the common aim to give more control to service users. The issue of control arises at all stages in the processes of obtaining and using services:

• Deciding what a person needs and wants out of life and out of services (assessment)
• Applying and negotiating for the money to pay for the services
• Planning and organising the services required
• Paying for the services when they are received
• Administering the services
• Monitoring and managing the services

Service brokerage, ILPs, and care management differ in the way they address the issue of control at these different levels:

• Independent living projects offer a very high level of control over purchase and management, especially for users who are able and willing to receive the money and use it to hire their own support workers. The brokerage model does not offer any further increase in control to these users, and may in fact give less control. The model tends to assume (though does not require) that the required services will be available from an agency; and that, rather than giving the money to the user, it will be paid by the brokerage board (or an equivalent independent body) direct to the agency.
• Brokerage does, however, offer ways to improve the level of user control for people who are unable or unwilling to take sole, direct responsibility for their own services.
• Whereas the main focus of independent living projects has been on service purchase and management, the special strength of the brokerage model is in its capacity to shift the balance of control at the earlier stages of making plans and obtaining money for services. Brokerage removes the 'assessment of need', done to the user by a representative of the fund-holding agency, and replaces it with a planning process centred on the user with the help of an independent broker. Although local authorities are increasingly willing to pass money, through ILPs, to individual users, they appear less willing to hand over responsibility for 'assessment'. The small sample of ILPs surveyed in the review all have to work within, or alongside, the standard assessment and care management procedures operated by the local social services department.
• There are similarities between care management and an individualised funding arrangement in which money is paid to a service agency on behalf of the service user. The crucial difference is that, in the service brokerage model, there is a formal contract, based on the user's own plans, which sets out how the money will be used, and the user's right to change the arrangements.

View of service users in the UK

The review aimed to gather the views of service users about brokerage, but this proved very difficult. One of the main reasons was that very few organisations representing service users had heard of service brokerage and several of these had an inaccurate understanding of it. Service brokerage is plainly not on the list of priority issues for the attention of service user organisations.

Some groups representing disabled people have adopted a policy of opposition to service brokerage. These organisations declined to participate in the review, but published statements indicate that they see brokerage as an unwanted foreign import which takes no account of UK initiatives in Independent Living led by disabled people; and as a model promoted by non-disabled people to preserve the power of social services professionals.

In fact, the values and aims of service brokerage are very similar to those of the Independent Living movement. As developed in Canada, the model does greatly increase user control, at the expense of professional power. On the other hand, the criticisms of these two organisations and the wider lack of awareness of brokerage amongst service users, suggests errors in the way that brokerage has been promoted in the UK. It is obviously not satisfactory that a model which is intended to promote user empowerment has been promoted without the substantial involvement of disabled people and other social services users.

Other issues which need discussion

The review identified a number of issues which need to be addressed if service brokerage or any other system based on individualised funding, is to be introduced.

Finding the right balance of power

Individualised funding increases the control of the service user. However, the state may claim that it has a continuing right to determine which users should be allowed this degree of control and how the money is spent. Where is the correct balance between these conflicting rights and how should it be maintained?

The relationship between broker and user

Although service brokers and similar advisers are supposed to be the neutral servants of the user, they still carry their personal and agency values into the relationship with the user. Even the best-intentioned adviser/broker may have too much influence in decision-making. How can this be prevented? One safeguard, often suggested, is to employ only advisers who have personal experience of being service users - but how feasible would this be if service brokerage or a similar model became common practice in social services?

The boundary between giving help and providing a service

The loyalty of the broker or adviser to the user is founded on their independence from fund-holding and service provider agencies. However, the independent living project or brokerage board which employs the adviser may also take on the recruitment, management, and payment of support staff. This could develop to the point where the project became, in effect, the service provider. How can this be prevented?

Flexibility and consumerism

Individualised funding and direct payment are intended to avoid the worst features of 'traditional services': a block treatment and disempowerment of service users. On the other hand, a service which is not restricted to a fixed budget for each user may be more flexible. Moreover, while the development of consumerism in social care may have the benefit of giving more power to users, it could also encourage funding and provider agencies to retreat from a continuing sense of responsibility, and to be less willing to assist services users who find themselves in difficulty.

About the study

This review is based on a postal survey of service brokerage schemes in the UK and a small sample of other independent living and care management projects. It involved extensive discussions with people offering a wide range of informed viewpoints, including some user organisations.

Further information

The full report, Means to Control: A review of the service brokerage model in community care is available from Values into Action, Oxford House, Derbyshire Street, London E2 6HG, price £6.95 + £1.00 p&p.