Enabling risk and ensuring safety: self-directed support and personal budgets

Abstract

Purpose This paper aims to present a digest of the main discussion points and key findings from a recent Social Care Institute for Excellence report on risk enablement and safeguarding in the context of self-directed support and personal budgets.

Design/methodology/approach The paper explores how the personalisation agenda and adult safeguarding can work together in policy and practice and addresses some of the frontline concerns about empowerment and duty of care.

Findings Evidence on how self-directed support and personal budgets can be used to enable people to take positive risks while staying safe and emerging practice is examined. It suggests that person-centred working in adult safeguarding, along with the mechanism of self-directed support planning and outcome review, can support the individual to identify the risks they want to take and those they want to avoid in order to stay safe. It is clear that if frontline practitioners are overly occupied with protecting organisations and individuals from financial abuse, this will impact on the capacity of those practitioners exercising their duty of care at the front line. 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 then 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 in their relationship-based, person-centred working. Good quality, consistent and trusted relationships and good communication are particularly important for self-directed support and personal budget schemes.

Originality/value The use of “risk enablement panels” and “personalisation and safeguarding frameworks” are two ways to address some of the issues in practice.

Introduction

This paper presents a digest of the main discussion points and key findings from a recent Social Care Institute for Excellence (SCIE) report on risk enablement and safeguarding in the context of self-directed support and personal budgets (Carr, 2010b). The report is one of the first evidence overviews on the topic and includes findings from recent UK and international literature as well as emerging directions from practice. The focus is on facilitating evidence-informed policy making, good frontline practice and the promotion of choice, control and independent living for people using services. The research identified covered older people, people with physical or sensory disabilities, learning disabilities and mental health problems. The report addresses some of the findings from SCIE Research Briefing 20: The Implementation of Individual Budget Schemes in Adult Social Care, which showed that “perceptions of risk, legitimate use of public funds and concerns about safeguarding and duty of care need to be debated as research is showing that these are potential barriers to implementation” (Carr and Robbins, 2009).

This paper and the report it derives from look at some of the research findings and emerging policy, principles and practice concerning risk enablement in the self-directed support and personal budget process, whilst also recognising the wider context of adult safeguarding in adult social care. While the primary focus is on self-directed support and personal budgets, the paper examines how the concepts and practice of adult safeguarding and personalisation relate. The aim is to build an evidence base drawn from both research and practice to indicate what could work to promote risk enablement, independence and control while at the same time, ensuring safety. The key research findings, evidence-based recommendations and practice points presented here give an indication of new and potentially efficient and effective ways of working that are person-centred and consistent with the principles of personalisation and adult safeguarding.

Personalisation: background and policy context

The personalisation agenda, as initially outlined in the Putting People First concordat (HM Government, 2007), seeks, among other things, to give people more choice and control over their social care and support services to enable them to lead more independent and fulfilling lives. Personalisation (alongside “protection” and “prevention”) in adult social care continues to be a policy, despite government change and increasingly adverse economic conditions in the public sector, as outlined in A Vision for Adult Social Care: Capable Communities and Active Citizens (Department of Health (DH), 2010a) and underpinned by the sector partnership agreement Think Local, Act Personal (Association of Directors of Adult Social Services (ADASS), 2010). One approach is to give people a personal budget, which includes the option to have a direct payment or managed budget as the individual chooses, with the direct payment option being highlighted as preferable, in the A Vision for Adult Social Care. The promotion of choice and control, particularly through the use of personal budgets and direct payments, implies the need for changes in the way that risk is understood, managed, discussed and negotiated with the person using the service. Adult safeguarding shares the underlying principles of personalisation – empowerment, autonomy and independence – which suggests the need for it to be fully incorporated into adult social care transformation so that services focus on the person rather than the process. Overall, there is a growing need for organisational transformation to respond to new person-centred ways of working in all aspects of adult social care, including risk management and safeguarding (Reece, 2010; Rowlett and Deighton, 2009). Good practice in personalisation means balancing empowerment and protection, self-determination, independent living and safeguarding. How risk is recognised, negotiated, managed and enabled is a key part of changing policy and practice in order to implement personalisation. However, research shows that the types of risk management dilemma currently being discussed existed within community social work well before the recent reforms associated with personalisation were clear (Stalker, 2003; Taylor, 2006; Mitchell and Glendinning, 2007). In turn, concerns about abuse and neglect in institutional and hospital settings pre-dated and influenced the National Health Service and Community Care Act 1990, and a series of inquiries into institutional abuse influenced the progress towards independent living and personalisation (Butler and Drakeford, 2005; Johnson et al., 2010).

This statement from the DH (2008, p. 22) on the personalisation agenda reflects and outlines one of the inherent challenges: Putting People First is clear that one of the core components of a personalised system is an effective and established mechanism to enable people to make supported decisions and it needs to be acknowledged that safeguarding policies have resulted in experience and learning which needs to be built in public services. It also needs to be recognised that organisations and professionals need to move away, wherever possible from making decisions for people and towards a role that informs, facilitates and empowers people to think about how they wish to live their lives.

Some concerns about risk and personal budgets have been shown to stem from a perception that personal budgets are only available as cash payments (Glendinning et al., 2008b), and that people needing social care and support will be left to organise their own services with no support. The main study on a form of personal budget (known as an individual budget (IB)) in England (the individual budgets evaluation network (IBSEN) study) found that: […] often the expectation was that individual budgets would take the form of direct [cash] payment and concerns were often expressed about this. To the extent that for some service users the individual budget could take the form of a more flexible care managed budget some of these concerns could be addressed (Glendinning et al., 2008b, p. 172). This shows that it is crucial for all stakeholders to be clear that personal budgets can be taken and managed in a number of different ways (Carr, 2010a). However, the implications of recent policy which states that direct payments are “the preferred option” (DH, 2010a) remain to be seen, although it is important to note that the eligible person would still go through the self-directed support process (planning and review) and should have access to independent support provider organisations, such as centres for independent living or user-led organisations living for advocacy, peer support or assistance with managing and using a direct payment (Newbronner et al., 2010). Such independent support provider and advocacy organisations should also have a role in the “collective response to managing risk” (Manthorpe, et al., 2010, p. 4).

Following the IBSEN study, the DH (2008, p. 23) identified risk and risk management as issues that needed addressing: The goal is to get the balance right moving away from being risk averse while still having appropriate regard for safeguarding issues. Increasingly, it is recognised that personalisation and safeguarding in adult social care should work together in a complementary and integrated way to support and empower people. Both have shared principles about promoting independence and control: Adult safeguarding incorporates the concepts of prevention, empowerment and protection to enable adults who are in circumstances that make them vulnerable, to retain independence, wellbeing and choice and to access their right to a life free from abuse and neglect (Julian, 2009, p. 2).

Personalisation and adult safeguarding

Much of the UK evidence examined for the SCIE report suggests that a greater integration of adult safeguarding and personalisation policy and practice is needed so that people using services can determine their own support and work with social care and safeguarding practitioners to keep themselves safe and supported. Adult safeguarding activity should be underpinned by personalisation; as ADASS (2008) notes, the term safeguarding adults refers to all work which enables an adult “who is or may be eligible for community care services” to retain independence, wellbeing and choice and to access their human right to live a life that is free from abuse and neglect. According to Local Government Improvement and Development (formerly known as Improvement and Development Agency (IDEA)): “Safeguarding” is a range of activity aimed at upholding an adult’s fundamental right to be safe at the same time as respecting people’s rights to make choices. Safeguarding involves empowerment, protection and justice (Williams, 2010, p. 4). In practice, this could mean negotiating “a framework around which councils can construct their prevention agenda and ensure that this forms a coherent part of councils’ wider personalisation agenda” (Reece, 2010, p. 30).

The report of the consultation on safeguarding adults resulting from the review of “No Secrets” was published in July 2009 (DH, 2009a). The report drew attention to a “vision of an inclusive society with opportunities and justice for all”, exploring a future for adult safeguarding that is empowering and person-centred, preventive and wide-ranging. The consultation formed part of the review of the “No Secrets” and the key messages from people who use services on safeguarding and personalisation were:

Safeguarding must be built on empowerment or listening to the victim’s voice. Without this, safeguarding is experienced as safety at the expense of other qualities of life, such as self-determination and the right to family life.
Everyone must help to empower individuals but safeguarding decisions should be taken by the individual concerned. People wanted help with options, information and support. However, they wanted to retain control and make their own choices.
Safeguarding adults is not like child protection. Adults do not want to be treated like children and do not want a system designed for children.
The participation/representation of people who lack capacity is also important (DH, 2009а, p. 6).

Although there is no specific legal or practice framework for adult safeguarding at present, there are many relevant pieces of law and regulation which practitioners need to know about and use (Mandelstam, 2009), including the legal framework for care management, the law concerning mental capacity (SCIE, 2009), developing human rights case law and good practice (Equality and Human Rights Commission, 2009), guidance on information sharing and equality and diversity legislation (HM Government, 2010). As Mandelstam (2009, p. 16) notes: […] despite No Secrets guidance, the scope of what is meant by protecting and safeguarding vulnerable adults is ill-defined. This is partly because there is no specific legislation in England setting out either definitions or statutory duties and powers of intervention. In order to address this situation, the Law Commission (2010) review of adult social care included a review of the various legislative adult safeguarding strands, with reference to personalisation and the principles of choice and control. The recent consultation analysis report gave the provisional proposal that a statutory duty should be placed on local authorities as regards adults at risk (Law Commission, 2011b) and this was followed up in the subsequent report produced by the Law Commission (2011a).

It is recommended that all support for decision-making in relation to self-directed support be in line with the core statutory principles of the Mental Capacity Act 2005 (Close, 2009; DH, 2010b; SCIE, 2010; Manthorpe and Moriarty, 2010). Attention to the core principles of the Mental Capacity Act is key for all stages of the social care process, from assessment to resource allocation, support planning and purchase as well as applying to adult safeguarding activity: The Act makes it clear that there should always be the presumption that a person has the capacity to make decisions unless it is established otherwise [SCIE, 2009]. It provides a statutory framework to protect and empower adults who may lack capacity (ability) to make all or some decisions about their lives. It also makes provision to ensure that advocacy is available for people who lack capacity during safeguarding processes and for their best interests to be explicitly considered through formal processes (Williams, 2010, p. 9).

In practice at local level, adult safeguarding can be a complex, technical task, which can sometimes lead to the individual “getting lost”: The needs of the vulnerable adult can sometimes be lost in the safeguarding process, especially given the large number of agencies and partners that are involved. Therefore, it is essential that we do not lose sight of the purpose of safeguarding to enable people to retain their independence, wellbeing and choice and to access their right to a life free from abuse and neglect. One way in which we can retain this focus is by following a person-centred approach to safeguarding. It is also important to remain sensitive to individuals’ cultural issues (Julian, 2009, p. 4).

Research has shown that a less technical, more person-centred approach to safeguarding could be achieved by:

Remaining focused on the empowerment and wellbeing of the person using services.
Listening to the individual and ensuring that their voice is heard.
Respecting the right of people using services to make choices and decisions themselves, practitioners there to support the decision making of the individual and to respect their rights.
Ensuring that safeguarding processes are led by the individual, supported by the practitioner (Julian and Penhale, 2009).

However, at present there is little robust research evidence on effective interventions that prevent and respond to harm against adults in all care environments. Consequently, the wider evidence base about what works for whom is sparse but some principles and practice points have been identified, with the authors of one major research review concluding: The continuing prevalence of abuse and harm amongst vulnerable adults remains an issue in our communities. There is no “magic bullet” solution. However, there are mechanisms of support, empowerment, training and education, and inter-agency co-operation which could help reduce the risk faced by vulnerable groups (Kalaga et al., 2007, p. iii).

Empowerment is increasingly recognised as being of direct benefit to abuse prevention, with some practitioners arguing that “any work that leads to improved self-esteem will mean that people are more likely to be able to protect themselves from potential abuse” and that “person-centred planning, access to advocacy and outcomes-focused assessments will all support people to protect themselves” (Reece, 2010, pp. 31-2).

Person-centred practice in risk management

Risk decision making is often complicated by the fact that the person or group taking the decision is not always the person or group affected by the risk (Neill et al., 2009, p. 18). The traditional social care model has been identified as no longer being suitable for developing person-centred practice and supporting choice and control for people using services and their carers (Rowlett, 2009). This model affects the way the local authority has understood its duty of care. Local authorities have: […] assumed that they can best fulfil their duty of care for the wellbeing of those in need of social care by retaining direct control over the type and amount of care that each individual receives (Rowlett, 2009, p. 338).

However, personalisation means rethinking and restructuring to recognise that: […] the local authority can best discharge its duty of care for the wellbeing of those in need of social care by doing everything it can to enable individuals to make free and informed choices about the social care services they want to access (Rowlett, 2009, p. 346). Among other things, this means a move from risk assessment being a “tick box” exercise, as “the person and those closest to them bring a distinctive brand of knowledge to bear on the assessment of risk” (Methven, 2009, pp. 26-7).

While a person-centred approach is crucial, social care providers must also foster a culture of positive risk-taking, in contrast to the current risk averse culture that predominates. There must be recognition that: […] for risk management to be effective and empower individuals, a partnership must exist between the person being supported, their unpaid circle of supporters and staff paid by the support provider […] the organisation must demonstrate that it will support staff who take positive risks (Methven, 2009, p. 25).

This type of working has been strongly emphasised for risk enablement for people with dementia: […] risk enablement is not consistent with “tick box” assessments because it is based on detailed, shared discussions among and across individuals […] family carers and other supporters and practitioners. It is an individualised approach to assessing and managing risk for the person (Manthorpe and Moriarty, 2010, p. 10).

Traditional approaches to risk have meant that practitioners often focus on what might go wrong rather than positive outcomes from taking risks, whilst risk enablement “is based on the idea that the process of measuring risk involves balancing the positive benefits from taking risks against the negative effects of attempting to avoid risk altogether” (Manthorpe and Moriarty, 2010, p. 8). Conventional risk management has been characterised by technical approaches which sometimes treat the person “as an object to be assessed by the “experts” rather than as an agent in their own lives, part of a family, community and society, with legal rights and choices” (Neill et al., 2009, p. 19). In order to develop risk enablement practice for personalisation, it is recommended that “learning and experiment rather than rule based processes” (Power, quoted in Neill et al., 2009, p. 20) should be developed. Again this is echoed in risk enablement guidance for people with dementia to: […] shared agreement about risk is not always possible but it is important that everyone involved in reaching decisions about risk reaches a shared understanding of all those who are affected by decisions involving risk (Manthorpe and Moriarty, 2010).

More broadly, the following practice points have been identified for local authorities and social care providers:

make explicit their encouragement of staff to explore what is important to the people they are paid to support, and to take managed risks to make progress;
make it clear in risk management policies that staff engaged in reasonable risk taking are acting under their employer’s instructions; and
provide sincere, swift and whole-hearted support for staff when positive risk-taking results in injury or harm (Methven, 2009, p. 27).

Additionally, evidence from practice suggests that: […] any positive approach to risk must include the basic principles of person-centred approaches:

keeping the person at the centre;
treating the family and friends as partners;
focusing on what is important to the person;
an intent to build connections with the community:
being prepared to go beyond conventional service options; and
and continuing to listen and learn with the person (Neill et al., 2009, p. 18).

Self-directed support and safeguarding

As a basis for developing appropriate, person-centred responses to the predicted dilemmas, the DH (2007) published good practice guidance on “supported decision making”, relevant for the implementation of personal budgets and self-directed support. This sets out a series of principles, including a tool “designed to guide and record the discussion when a person’s choices involve an element of risk”. It includes examples of good practice, and provides a useful framework for exploring questions arising from “risky” decisions, raising awareness about the choices to be made. The guidelines are clear that: […] as part of any assessment process it will be necessary to identify and assess any risks involved in supporting the person. Person-centred planning approaches identify what is important to a person from his or her own perspective and find appropriate solutions. We commend person-centred approaches for everyone (DH, 2007, p. 2).

Outcome-focused reviews for self-directed support and personal budgets should have risk and safeguarding (“living safely and taking risks”) as part of the “outcome domains” framework for reviewing how well personal support plans are working (Bennett et al., 2009). This allows practitioners and people using services to identify both risk enablement opportunities and safeguarding issues as an integral part of individual care and support planning and review. Practitioners with experience of using outcomes-focused assessments, such as those inherent in self-directed support, argue that: […] the greater depth and more holistic nature of the assessment suggests that safeguarding issues are more likely to be disclosed and more likely to be effectively addressed […] there is more chance to develop a relationship of trust between user and social worker which also increases the chance of disclosure [and this] may mean that the social worker is more able to support someone to take the risk of breaking out of an abusive situation (Reece, 2010, p. 32).

The self-directed support framework gives the practitioner and person using the service along with their family, friends or carers (where appropriate) the opportunity to discuss and identify any issues of risk or safeguarding. This then informs the decisions the person makes about the support plan and personal budget management arrangements “risk enablement plans can be developed as part of existing individual care or support plans” (Manthorpe and Moriarty, 2010, p. 10). The practice guidance practical approaches to safeguarding and personalisation says “personalisation and risk management should work hand in hand, empowering people to speak out, enabling them to make informed choices and encouraging communities to look out for one another” (DH, 2010b, p. 5). It also recommends that: For people who are in need of support through health or social care, a more detailed analysis of risks, including the benefits of taking considered risks, should be an integral part of the self-directed support process. Well designed self-directed support processes have checks and balances to improve risk management throughout.

Legal experts in social care have pointed out that the legal framework for care and support planning can inform proactive and preventative safeguarding, making the link between local authority duty of care, preventative safeguarding and good support planning: Councils will not be able to avoid a duty to ensure proper provision for meeting the client’s needs, because they have an ongoing duty of monitoring and reviewing the success of a care package, even after giving a direct payment to a client […] When a council gives a person a direct payment, the duty of care in relation to care provision is suspended […] but the duty to monitor the success of the care package is not altered in any way; that is duty of care management (Schwehr, 2010, p. 48).

In response to some of the resistance to, and concerns about, self-directed support, personal budgets and risk, the DH and ADASS (2009, p. 4) have provided further clarification and guidance on legal and financial issues: […] the understanding of all concerned that safeguarding is a form of risk management which should already be integral to assessment and support planning functions. The rules that apply to direct payments will apply, as modified by any fresh guidance, or legislation, to any part of a personal budget taken as a direct payment. So there will still be monitoring, albeit proportionate to risk and amount, in accordance with Chartered Institute of Public Finance and Accountancy guidelines, and there will still be accountability for those who misuse money or abuse a position of trust in relation to its management (ADASS, 2009, p. 34).

In Control, the organisation which originally developed the practice of self-directed support in England, recommend that support planning should include assessment of risk enablement and safeguarding issues, and highlight the need for people to be supported to take positive risks while staying safe, emphasising: […] the Concept and practice of risk enablement, a part of the support planning process that helps people and those around them to develop plans that include risks they can assess, understand and mitigate. The local authority can agree the plan as it stands, suggest amendments or turn it down depending on its view of the mitigating measures included. Risk enablement is now an important part of the self-directed support process in most local authorities (Tyson et al., 2010, p. 73). They emphasise the need for practitioners involved in self-directed support and personal budgets to work together with adult safeguarding colleagues to ensure that procedures are aligned and person-centred: Risk enablement in support planning is not the only means of helping people to stay safe […] Local authorities also need to review their formal safeguarding procedures […] as they think about the role and remit of their workforce (Tyson et al., 2010, p. 73).

This recommendation is further supported by later reports from the IBSEN IBs evaluation, which focused on adult safeguarding issues. The interviews of adult safeguarding coordinators in the study pilot sites revealed that: […] the personalisation of social care is often interpreted as relating to greater use of direct payments and has yet to consider other facets of this policy transformation that are central to social work practice, including safeguarding (Manthorpe et al., 2010, p. 2).

Risk management and personal budgets: the emerging evidence

Because it is a very new approach for the UK, little investigation into risk enablement practice for personal budgets has been undertaken. Recently, there have been no empirical studies from the UK published in peer-reviewed journals which evaluate particular strategies. For example, no research has yet been published on the efficacy of “risk enablement panels” (Tyson et al., 2010) that are being established by some local authorities to facilitate shared decision making in exceptional, complex cases or those where safeguarding is a concern for an individual’s self-directed support plan and personal budget management. It has been noted that, without further research, much remains conjecture (Glasby and Littlechild, 2009).

National evidence about risk of abuse, neglect or fraud is at a very early stage, as personal budgets (or direct payments) are yet to be established as a standard option. The DH’s response to the IBSEN report (Glendinning et al., 2008b) comments that the research does not present evidence of increased risk as a direct result of personal budget introduction. Equally, it does not demonstrate that none exists, so monitoring and research should continue as personal budgets and direct payments are implemented further. Regarding progress on mainstreaming self-directed support, the ADASS, along with other implementation bodies, noted: While safeguarding is frequently raised as an issue, there is so far no evidence that people taking up self-directed support, including direct payments, are at greater or lesser risk of harm. There is clearly a need to ensure that the move to self-directed support is accompanied by better ways to identify and manage risks […] (DH and ADASS, 2009, p. 10).

Raising local awareness of the opportunities offered by personalisation, together with offering the resources, time and effort which supported decision making requires (Clark et al, 2005, cited in Mitchell and Glendinning, 2007, p. 23, Reece, 2010), are both tasks facing local authorities as well as user-led organisations and the voluntary and community sector, now facing an increasingly difficult financial climate. Research shows the importance of developing support services delivered by independent user-led peer support and advocacy organisations in enabling people to use personal budgets and direct payments to choose and control their own care and support (Arksey and Kemp, 2008; Carr and Robbins, 2009; Newbronner et al., 2010). The role played by community-based voluntary sector agencies, particularly for people from minority groups (such as black and minority ethnic older people), is highlighted in research which shows they can play an important part in enabling people to take risks to increase their independence as well as acting as appropriate, independent sources of support and advice on keeping safe (Manthorpe and Bowes, 2010).

Risk aversion on the part of social care practitioners (often motivated by concerns about mental capacity, physical risk and abuse) has been documented by research and precedes recent developments associated with personalisation (Mitchell and Glendinning, 2007, chapter 4, for a summary of the main studies). This legacy appears to have implications for the implementation of personal budgets and self-directed support and risk enabling behaviour in frontline practice has been found to vary according to whether or not explicit policies, training and leadership exist which promote a positive, informed approach to risk taking and management as well as abuse detection and prevention (Manthorpe et al., 2010).

Research such as the IBSEN study (Glendinning et al., 2008b) provides evidence of apprehension about risk, safeguarding and personal budgets among social care practitioners and local authority officers. Local authorities and service providers are concerned about how duty of care and safeguarding responsibilities can sit within an approach to social care provision designed to strongly increase individual choice and control for the person using services. To promote choice and control, “positive risk taking” or “risk enablement” is central to the philosophy behind personal budgets, but staff may be anxious about transferring responsibility to, or sharing responsibility with, the individual if they do not feel confident to do so. This is despite the fact that even if an individual is arranging and purchasing their own support, the local authority still has the duty to monitor and review the outcomes of the support (Schwehr, 2010). Evidence from direct payments has suggested that frontline practitioners have sometimes made generalised decisions based on assumptions about the capacity of certain groups when deciding whether to offer the direct payment option. These groups include older people, people with learning disabilities and people with mental health problems (Carr and Robbins, 2009).

The IBSEN study findings

The IBSEN study was the main piece of the UK research piloting a version of personal budgets (formerly known as IBs). This was undertaken in 13 English local authorities, with 959 participants from all groups of people using adult social care (Glendinning et al., 2008b). The research gave a clear indication of the particular concerns surrounding personal budgets and risk. It showed that the positive risk taking associated with personal budgets was seen as a “difficult culture shift for care coordinators in light of their responsibilities for safeguarding” (Glendinning et al., 2008a, p. 33).

The IBSEN study authors noted that many social care staff in the pilot sites struggled “to decide how far those risks should sit with the individual, how they should be managed, and, crucially, what were the implications for safeguarding adults” (Glendinning et al., 2008a, p. 33). It was clear that “there was a tension between how far individuals were allowed to take risks and where the (local) authority had to retain responsibility for protecting vulnerable adults” (Glendinning et al., 2008b, p. 177), suggesting the need for a clearer understanding of duties. However, the administration and management of personal budgets had few clear mechanisms for monitoring and identifying risk once the support was in place. Moreover, the development of appropriate monitoring and review systems for personal budgets was seen as essential. Further exploration indicated that the following could help with managing risk in the context of personal budgets:

firming up safeguarding adults policies;
regular expenditure reviews;
building risk assessment into the support plan;
better guidance for care coordinators;
better information for people using personal budgets;
training for staff, people who use services and carers; and
regular (proportionate) audit.

During the IBSEN study, researchers interviewed adult protection lead officers (or adult safeguarding coordinators) in the 13 pilot sites to examine the links between personal budgets and work in adult protection and how the personal budget process fitted with adult safeguarding. The researchers concluded that adult protection lead officers could have unique insights from working at the intersection of the demand for safety and assurances about spending public money with the increased demand for choice and control in social care. Initially, they found that, in some pilot sites, their expertise was not being engaged or used consistently with personal budget implementation and many practitioners were concerned about safeguards that should be addressed at early stages (Manthorpe et al., 2008). Although the second round of interviews with adult safeguarding coordinators showed subsequently improved engagement over all adult social care transformation, “their detailed expertise in adult safeguarding and their local intelligence and experiences were not regularly accessed” (Manthorpe et al., 2010, p. 2). The authors conclude that this lack of engagement with safeguarding expertise “may constitute a missed opportunity to address some of the tensions of personalisation in practice” (Manthorpe et al., 2010, p. 2).

Overall, the IBSEN research suggested that there should be a clear link between the adult protection and personal budget systems and some of the existing mechanisms for direct payments could be built on. Adult protection lead officers recommended the following actions could enhance safeguarding for personal budgets:

incorporating IBs (personal budgets) in adult protection training;
developing audit trails;
improving complaints procedures for people being supported by family members;
enhancing advocacy services to support people in decision-making;
multi-agency training and public awareness training to ensure people know what counts as abuse;
identifying any risk factors for abuse and how these could be recognised in an individual’s support plan; and
preparing a guide for social workers about co-working issues, protection and risk management (Glendinning et al., 2008b, p. 178).

Key messages from the SCIE report enabling risk, ensuring safety

The following sections briefly present the main conclusions and recommendations based on the synthesis of the international evidence base on the management of risk and inclusion of safeguarding issues in personal budget and self-directed support schemes identified for SCIE’s research review. This is supplemented by some of the lessons from emerging practice in the UK. The research identified for the review included findings from the evaluation of the US Cash and Counseling Demonstration Program (Robert Johnson Wood Foundation, 2007), international empirical studies and several relevant systematic and narrative research reviews, including a recent systematic review of the UK, the USA and Australian research on “consumer directed support” for older people with complex needs (Ottmann et al., 2009). Therefore, the key messages given here are based on the evidence identified for the SCIE report, which can be referred to for further detail (www.scie.org.uk).

For organisational transformation and culture change

The promotion of choice and control implies the need for changes in the way risk is understood, managed and negotiated with people using services. This is particularly relevant in the use of self-directed support and personal budgets or direct payments. It also requires organisational change to respond to new person-centred ways of working.
Risk enablement should become an integral part of the transformation of adult social care into a system, which puts the person in control. It cannot be a “bolt-on” solution to existing systems, which do not have the person at the centre.
Personal budgets have sometimes been misunderstood, leading to the idea that people will be left unsupported in organising their own services and will have to take full responsibility for managing risk alone. Practitioners may not be confident about sharing responsibility for risk if their organisation does not have a positive risk enablement culture and policies.
A supportive system is one which clearly incorporates self-directed support with safeguarding policy and practice, abuse detection and prevention. Risk enablement and safeguarding training for staff, people using services, carers and families is important.

For frontline practice

There is evidence that social work skills and relationship-based working with the person using the service are required, both to promote risk enablement as part of self-directed support and to detect and prevent abuse as part of safeguarding.
Research evidence has shown that certain disproportionate corporate approaches to risk management can result in frontline practitioners becoming overly concerned with protecting organisations and individuals from financial abuse when administering and auditing direct payments. This reduces their capacity to identify safeguarding issues and enable positive risk taking with people who use services (Rowlett and Deighton, 2009).
Practitioners need to be supported by local authorities to incorporate safeguarding and risk enablement in their relationship-based, person-centred working. Good quality, consistent and trusted relationships and good communication are particularly important for self-directed support and personal budget schemes.
Emerging research suggests that a rebalancing of social work resources towards frontline activity with people using services, their carers and families could enhance overall organisational risk management and safeguarding.
“Positive risk taking” or “risk enablement” is central to the philosophy behind self-directed support and personal budgets, but social care practitioners can be concerned about how to both empower the individual and fulfil their duty of care. However, research shows that risk management dilemmas are an inherent part of social work practice and existed well before the recent reforms associated with personalisation were clear.

For people who use services, their carers and families

With the support of frontline staff, people using services should be enabled to define their own risks and empowered to recognise, identify and report abuse, neglect and safeguarding issues. Communication which supports risk enablement and safeguarding should be led by the language and understanding of the person using the service. This approach should be a core part of self-directed support, including assessment, planning and regular review of outcomes.
Informed choice is vital for risk enablement. Personal budget holders need access to information and advice about safeguarding, employment, legal aspects, reporting, peer support and accredited people and organisations.
The views of people who use services are largely absent in the literature and there are very few research studies and evaluations of risk management systems and interventions. More research on how practitioners “do” risk is also needed.
Certain studies, particularly those about older people and people with learning disabilities, show that some people who use services may withhold information on “risk taking” from the practitioner or their families in order to remain independent and in control of their own decisions.
Being risk averse has resulted in some frontline practitioners making decisions about direct payments for people based on generalised views about the capacity or “riskiness” of certain groups (particularly people with mental health problems). This has been done without adequate engagement with individuals or understanding of their circumstances.

Lessons from emerging practice

As self-directed support and personal budgets are being implemented innovative practice is being developed showing risk enablement while ensuring safety. 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.
All risk enablement approaches should be person-centred and focus on the perspectives and understandings of the person using the service (and their carers and family, where appropriate). People may be at risk if they become lost in a complex, over technical “risk management” process which does not listen to their voices or account for their individual situations: “Person-centred planning approaches identify what is important to a person from his or her own perspective and find appropriate solutions. We commend person-centred approaches for everyone” (DH, 2007, p. 2).
Social workers and frontline social care practitioners need to be supported by organisational cultures and systems. These should allow them to spend time with the individual and to focus on their safety concerns and achieving their chosen outcomes rather than going through unnecessary auditing processes. Duty of care means supporting an individual to achieve their chosen outcomes while staying safe.
Personalisation and adult safeguarding practice and policy need to be more closely aligned and inform each other. They should be underpinned by the principle of person-centred practice and the promotion of choice, control, independent living, autonomy and staying safe. A shared adult “personalisation and safeguarding framework” can support this. This should be developed by all those involved, including adult safeguarding leads and stakeholders, people who use services and their organisations, social workers and personalisation leads (Richards and Ogilvie, 2010).
Local authorities and social care providers need to foster a culture of positive risk taking which will support frontline practitioners to work in a risk-enabling way with the person using the service.
Social work skills are particularly important for risk enablement and safeguarding in self-directed support. These include helping people to assess, manage and take appropriate risks and as local authorities move away from excessively risk-averse policies and procedures, assisting with more person-centred ways of managing risk (Tyson et al., 2010, p. 69).
Positive risk taking and safeguarding needs to be an integral part of the self-directed support process, including support planning and review and decisions on how best to manage a personal budget. Risk enablement panels are beginning to emerge as a way of helping with challenging or complex decisions that may arise as part of signing off a person’s support plan. They show how local authorities implement self-directed support and personal budgets in ways that empower individuals while ensuring that risks are managed and responsibility is clear. The emphasis is on shared decision-making that supports person-centred frontline practice and improves practitioner confidence. Duty of care decisions can be made in a shared and informed way, with transparent, shared responsibility.

Conclusion

The evidence presented here on how frontline practice is influenced by corporate approaches to risk management support a key recommendation from the DH’s (2007, p. 3) guidance on risk and supported decision making: A major inhibiting factor in achieving good outcomes for people in relation to choice and control is operating within a regime where there exists a fear of putting the organisation at risk, both 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 becoming clear that if frontline practitioners are overly occupied with protecting organisations from financial abuse through disproportionate auditing and administrative activities, this will impact on the capacity of those practitioners exercising their duty of care with the person at the front line (Rowlett and Deighton, 2009). This also 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 then result in individuals not being adequately supported to make choices and take control and, therefore, being put at risk.

What is regarded as “risky behaviour” and whether a risk is worth taking can be viewed very differently by service users, their carers and practitioners. Research has also highlighted the need for practitioners to listen [to service users] and their informal carers, to recognise and value the importance of subjective interpretations of risk and, when assessing and planning management strategies, to place these in the wider socio-economic context of each service user’s personal and family life (Mitchell and Glendinning, 2007, p. 90).

Rather than try to calculate the incalculable, social workers need to regain their former status as experts in uncertainty. They should develop mutually trusting, respectful relationships with their clients, make fine judgments about risk and dare to work creatively and innovatively (Stalker, 2003, p. 228).

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. People need 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. This need has been emphasised in the context of the review of No Secrets, where the consultation document stressed: The concepts of empowerment and of self-determining adulthood, of ensuring that the individual is at the centre at every stage of risk assessment and risk management with (not for) service users were stressed by many respondents. Care management processes and workforce skills, we were told, needed to be refocused on communication, empowerment and enabling people to take considered risks (DH, 2009a, p. 31).