SCIE Report 36: Enabling risk, ensuring safety: Self-directed support and personal budgets

Conclusion

'Individuals who use social care and support services and/or their carers should be able to make their own decisions and take risks which they deem to be acceptable to lead their lives their way.' (Close 2009)

Despite the lack of research on the perspectives of people who use services and carers, the evidence examined for this report has shown some clear messages and conclusions.

• The systematic literature review of US, UK and Australian research on consumer directed care for older people with complex needs (a group for whom this approach is not always seen as suitable) clearly outlines some key factors for good practice in implementation for all groups:

• The successful implementation of self‐directed care depends on:
  • Well‐designed and clear policies on risk management, duty of care, and client review procedures. These need to balance agency and worker responsibilities with the aspirations of their program and its participants for self-directed care and support.
  • Thorough staff training and organisational change management before implementation. This should address ageism in professional culture and concerns of older care professionals around abuse, neglect, fraud, exploitation, contractual agreements, the capacity of older people; and realistic workload assessments.
  • a review and continuous improvement process should be in place to improve care outcomes.
• The evidence suggests that a major barrier to achieving choice and control for people who use services is frontline practitioners operating within systems where there is fear of putting the organisation at risk (financially, in terms of public relations, reputation or in breach of the law). The most effective organisations are those with good systems in place to support positive approaches rather than defensive ones. The corporate approach to risk that an organisation takes overwhelmingly influences the practices of its workforce.

• It is clear that if frontline practitioners are overly occupied with protecting organisations from fraud, this reduces their capacity to exercise their duty of care at the frontline. This means that practitioners are less able to engage with individuals to identify safeguarding issues and enable positive risk taking.

• Defensive risk management strategies or risk averse frontline practice may result in individuals not being adequately supported to make choices and take control and therefore being put at risk.

• Practitioners need to be supported by local authorities to incorporate safeguarding and risk enablement into relationship-based, person-centred working. Good quality, consistent and trusted relationships and good communication is particularly crucial for good practice in self-directed support and personal budget schemes.

• People using services need to be able to define their own risks and be empowered to recognise and identify abuse, neglect and safeguarding issues with the support of frontline staff. They should be supported to identify their own risks; with clear information and advice about what to do if they have concerns. This should be a core part of self-directed support, including assessment and regular outcome review.

• As self-directed support and personal budgets become implemented, innovative practice showing how risk enablement can be balanced with ensuring safety is being developed. Risk enablement practice has not yet been evaluated, but still shows approaches to promoting independence, choice and control and enabling positive risk taking while maintaining the balance with duty of care and ensuring people stay safe.

• Risk enablement panels are beginning to emerge as a way of helping with challenging or complex decisions which may arise as part of signing off a person's support plan. They show how local authorities can approach the implementation of self-directed support and personal budgets in ways which empower individuals while ensuring risks are managed and responsibility is clear. The emphasis is on shared decision making which supports person-centred frontline practice and improve practitioner confidence. Duty of care decisions can be made in a shared and informed way, with transparent, shared responsibility.

• One indication of a supportive system is one which clearly incorporates self-directed support with safeguarding policy and practice, with abuse detection and risk enablement training for both staff and people using services, particularly self-directed support and personal budgets. Practitioners need to be supported by local authorities to incorporate safeguarding and risk enablement into relationship-based, person-centred working.

• From the research and practice evidence examined here, it appears that risk enablement in the context of self-directed support and personal budgets (as well as adult safeguarding) must be an integral part of the adult social care transformation process, rather than as a 'bolt on' solution to existing systems which do not place the person using the service at the centre. Change and transformation must include all stakeholders – people using services, their carers, friends and family, frontline practitioners and safeguarding staff.