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

Messages

'we do want self-directed support but we still expect good quality services so our sons and daughters can be truly in control' (Anon 2008).

Practitioner level

The practitioner level relates to how frontline practitioners and first line managers are providing choice and control alongside ensuring the safety of people using services.

This includes how decisions are being made about risk as part of person-centred assessment and support planning and how practitioners should be trained and supported by local authorities and organisations to implement self-directed support and personal budgets, including direct payments.

The evidence so far suggests that practitioners working within fragmented systems where risk management strategies are focused on protecting the organisation are less likely to feel confident and supported in their practice in supporting people to take positive risks in their lives.

They may fear blame or liability or be confused about balancing safeguarding duties within the context of personalisation. This can then compromise their capacity to work in a risk enabling way at the front line and may restrict their ability to focus on exploring risk and safeguarding with the individual using the service.

Click on the links below to explore findings in the four areas below:

• Balancing empowerment and interventionOpen

  Key points from the literature:

  • the most effective way to manage risk and enable positive risk taking is to work closely with a person in their own context (in order to negotiate the levels of risk enablement and safeguarding that are appropriate for that particular individual).
  • one study showed that care managers
    1. had difficulty in balancing professional intervention and empowering approaches
    2. rated their concern about possible risks above their belief that consumers should have greater choice and control
  • there may be a conflict between 'accountability for resources and professional advocacy'
  • one UK author has noted that practitioners often find themselves in the role of frontline manager 'gatekeepers'. This results in continuous risk assessment, but actually very little time to sit down and work directly with clients in, thinking and planning ways to address the risks users have identified in their own lives
  • US research showed that what really made consumer directed support appropriate for a client or how it affected them really depended on the clients' unique characteristics and circumstances.

• Relationship-based workingOpen

  Key points from the literature:

  • Working within systems designed to protect organisations against fraud can prevent social workers from identifying and managing risk with individual personal budget users.
  • There is evidence that the relationship between worker and client is essential to effective working and yet is being undermined by the language and politics of risk management.
  • Understanding the individual, their support networks and socio-economic circumstances has been found to be an effective way of understanding risk, particularly in relation to people with learning disabilities who are getting person-centred support.
  • High trust relationships are crucial and anything that undermines these relationships (for example staff turnover or questions of perceived professional competence) is likely to reduce 'person-centredness'.
  • Understanding what makes people who use services safe requires understanding them as people – understanding their personalities, their experiences, their family relationships, their wishes for the future and their past histories and choices.
  • The quality and consistency of the relationships that people using services and their carers have with frontline practitioners when identifying and managing their own risks is very important.
  • Good quality, consistent and trusted relationships and good communication is particularly crucial for emerging practice in self-directed support and personal budget schemes. But one of the factors that lessens this is the administrative approach to risk identification and management.
  • Cambridge (2008) proposes a model of 'person-centred care management' which includes individual risk enablement and emphasises the care manager getting to know the person and the development of a supportive working relationship.
  • Research on the identifying and reducing elder abuse has shown that if a carer and the individual who is being cared for do not get sufficient support from service providers, any abuse is more likely to remain undetected.
  • In the US Cash and Counseling Scheme, counsellors were trained to detect any problems with abuse, neglect or fraud and as a result very few cases of neglect or fraud' were reported.
  • In Denmark, the 'structured conversation' assessment approach in preventive home visits for older people has been found to be effective in detecting risks such as social isolation and particular events which may affect the individual's resilience.
  • The importance of knowing the person, their relationships and circumstances has been emphasised in research on self-directed support for older people, as has the role of the voluntary sector, community resources and peer support in safeguarding.
  • Research on ethnicity and elder abuse in the UK has shown the particular importance of being sensitive to culture, listening and communication when assessing risk.  It also highlights the important role that black and minority ethnic voluntary and community sector services play in facilitating people to report and manage abuse and neglect.

• Training and awarenessOpen

  Key points from the literature:

  • staff training and awareness has an important role to play in effective risk enablement in self-directed support and personal budget schemes
  • counsellors working in the US Cash and Counseling Program had specialist risk management and abuse detection training as an integral part of the program
  • UK research into older people, personalised care and risk management has also shown that staff require specialist training to recognise and address patterns and incidents of abuse
  • The IBSEN study demonstrated the need for specialist training and awareness raising in order to implement personal budgets and promote choice and control for individuals
  • the IBSEN study showed the clear need for linking with adult safeguarding
  • crucially, the IBSEN study showed that initial training may help distinguish whether roles are supportive (along the lines of counsellors or consultants), or whether they  focus on monitoring and scrutiny
  • the majority of IBSEN pilot sites recognised the need for communication and awareness raising events and activities for the wider local authority and/or partner organisations
  • such events should recognise the need for a significant cultural shift to enable self-directed support and personal budgets to be successfully implemented and to address the concerns of staff, particularly around risk
  • the emphasis should be on how staff can be supported to be part of system and culture change, rather than 'bolt on' training for staff working within an unchanged system
  • research is already beginning to show that risk management and enablement for individuals using a personal budget is more likely to be supported by the 'counsellor' approach, as shown in the US literature, and demonstrates how relationship-based working can be effective in identifying and managing individual risk
  • over-reliance on risk assessment tools has been shown to replace rather than inform professional judgment
  • social workers need to be able to develop risk management strategies and safeguarding processes in partnership with the person using services as part of the personal budget and support plan.

• Who is defining risk?Open

  Key points from the literature:

  • Overall, research on risk and social care is showing that if people who use services are really to be empowered, they must be allowed to identify factors that present them with risks. As well as the risks they are prepared to take, users' views of risk will vary according to how much choice and control they think they have.
  • Practitioner views of risk often differ from risks which are meaningful to people using services. The terms used to express risk can also differ.
  • Practitioners may turn to colleagues rather than the person using the service to explore issues of risk.
  • One study found that people using mental health services are not necessarily using the same 'risk' terminology as practitioners and have their own unique, individual approaches to, and understandings of, risk.
  • Similarly, a piece of research on safeguarding and older people from black and minority ethnic communities showed that people did not identify their situation or experiences with 'official' language.
  • Others have noted that there is often a mismatch between how people define themselves and public stories about the category or group they happen to be in when encountering services.
  • For people with mental health problems, access to the type of choice and control offered by self-directed support may be compromised by practitioner fears about risk and 'danger.'
  • Because of prejudice, for people with mental health problems, choice and control may be viewed as a 'privilege to be earned' rather than a basic human right.
  • Research relating to the implementation of direct payments for people with mental health problems has highlighted the fact that some people are not offered the option because of professionals' perceptions of risk and risk avoidant practice.
  • This research has also emphasised the need for practitioners to be supported and skilled enough to be able to negotiate some elements of support they may see as 'risky' but which the person using the service would find helpful.
  • One study concludes that forward planning tools such as advanced directives, independent planning and advocacy services should be developed to ensure that people using services are fully supported to make and implement their own decisions.

Further reading

• Cambridge, P. (2008). The case for a new 'case' management in services for people with learning disabilities. British Journal of Social Work, 38(1)
• Barry M (2007) Effective approaches to risk assessment in social work: An international literature review Edinburgh: Scottish Executive Social Research
• Bowes A & Daniel B (2010) Interrogating harm and abuse: A lifespan approach Social policy and society 9 (2)
• Manthorpe J, Jacobs S, Rapaport J, Challis D, Netten A et al (2008) Training for change: early days of individual budgets and the implications for social work and care management practice: a qualitative study of the views of trainers British journal of social work, (Advance access 7 March 2008)
• Stalker, K. (2003). 'Managing risk and uncertainty in social work: a literature review.' Journal of social work, 3(2)