WORKING WITH PERSONAL BUDGETS
IN MENTAL HEALTH-SHIFTING CONTROL
FOR BETTER LIVES
What is self directed support and what is its
Citizenship and Health.
Changing and cherishing
Latest policy and some of what’s stopping us
Risk enablement some ideas
Discussion of real life examples.
From institution to citizenship
Professional gift model
• The underlying system of power:
‘we know best’.
• Professionals and commissioners
work out, in good faith, what they
think we need.
• They buy things they think will
• We have to slot in.
• We feel we should be grateful
and stay as passive recipients.
• We have not rethought power
• Citizen at the centre
• Services negotiated
• Entitlements defined
• Community fully engaged
• Outcomes improved
Personal budget-what is it?
A personal budget is an allocation of resources made to a person
with an established need ( or their immediate representative)
The purpose of the personal budget is to ensure the person is
able to call upon a pre-defined level of resources and use
these flexibly to meet their identified needs and outcomes.
The person must:
Know how much money they have in their personal budget, at
the start to plan with and in an ongoing way.
Be able to spend the money in ways and at times that make
sense to them.
Agree the outcomes that must be achieved with the money.
Ways to “hold” the money
Budgets alone won’t work
Our experience suggests that while personal health budgets can
be transformative, they will only work if there is also a great
planning process which includes:
Clarity about the “deal”
Opportunities to meaningfully plan and shape treatment and
Clear criteria for plans including contingency planning and
risk identification and enablement.
Effective systems of support, information and advice
A range of effective options of ways to “hold” the money
Appropriate systems for professional input, sign off and
A shift in the power between an individual and the State
Tilting the balance of power
Its about shifting power and creating an improved
Central focus is improving the dialogue between
the citizen and the professional to create:
Greater mutual respect & understanding
Better quality decision-making
This should produce a Personal Plan which is co-
signed by the citizen and professional
How does citizenship impact on Health?
Citizenship in Health
Our health is influenced by many more things than
good health care. It is impacted by:
Poor housing etc..
A society that excludes people from
citizenship guarantees poor health e.g.-look at
the early death rates of people with mental health
Purpose: active citizenship and healthy
communities-not simply consumerism.
The purpose of Self Directed Support is to enable improved
decision making and a better relationship between people
and the Welfare State, so that people get better lives, as
active and included citizens, part of healthy communities.
It is not simply about giving people money; sometimes people
are most impoverished when they are using their own money
since they have no information, no connections, no
confidence, no knowledge of other possibilities and no one to
help them plan.
We know that people’s lives don’t split into health and social
care. Our support needs to focus on whole people in their
whole context with contributions to make as well as needs to
“Our findings on how well people using mental health
services are involved in the care that they receive
remains of particular concern. Independence is as
important for people who experience mental health
problems as it is for cardiac or diabetes patients. Sadly
however, many services still do not seem to realise
this…” (“No voice no choice” CSCI and Health Care
Commission July 2007.)
Times are changing....
“Ensuring older people, people with chronic
conditions, disabled people and people with
mental health problems have the best possible quality of life and the
equality of independent living is fundamental to a socially just society...
“ Inthe future we want people to have maximum
choice, control and power over the support services
(“Putting people First DH 2007)
“No decision about me without me” NHS White paper 2010.
“No Health without Mental Health”
“Personalisation is about respecting a person’s human
rights, dignity and autonomy, and their right to shape
and determine the way they lead their life. Personalised
support and services are designed for the purposes of
independence, wellbeing and dignity.
Every person who receives support should have choice
and control, regardless of the care setting. This is of
critical importance for people with mental health
problems – we know that feeling in control leads to
better mental health.”
“The Government will take steps to extend as much as
possible the availability of personal health budgets to
people with mental health problems.”
Self Directed Support in mental health-what are
some of the things that get in the way?
Generic and some specific blocks:
Lack of knowledge and misunderstandings of the purpose
and nature of self directed support and split from other Local
Inherent resistance to change in systems
Concerns- personal and professional, including approaches
to risk/benefit analysis
Understandable suspicion and cynicism from people who use
Fear of loss- individuals/family carers and staff
Perverse financial incentives for Provider Trusts
Stigma and assumptions around mental illness.
Risks can feel like this.....
What kinds of risks concern us?
Risks to ourselves and our families’ health and wellbeing
Risks to some-one with whom we’re working and feel responsible
Financial risks to our organisation or to us
Public risks of embarrassment by negative publicity
Professional risks to our careers/professional status
Risks of having no life worth living
Risk we lack capacity to make a good decision
Risks we may harm some-one else
Risks no one will believe in us.
Risk of being out of control
Risk of having no control.
Risk enablement and personal health and social
care budgets- what can help?
So how do we move from fearfulness and risk
aversion to risk enablement?
If possible, agree with the person or their
representative how they think risk can be
Is there is anything that the person is worried
about or has happened in the past that might
Adapt existing risk management tools
Use a prompt list to identify any further risks
Risk enablement and personal health and social
care budgets- what can help?
Be up front about possibility of harm or abuse
Ensure that all needs identified are being met in
the support plan
Ensure support is in place if person wishes to
use direct payments to employ their own
Risk enablement groups can be useful initially to
develop confidence in personalised risk
A great planning process will...
A great planning process will integrate what
matters most to some-one with what matters most
for their health.-
It’s that interaction and joining together of best
clinical practice with some-one’s own motivations
and creativity which leads to plans being acted on
to the plan being a live participative process not a
and to making use of both perspectives
knowledge and ideas of what will work best.
Cherishing as well as changing
Whilst we shift our focus towards outcomes and
keeping processes around personal health
budgets as simple as possible, we must also
sustain current good practice. Thus we must
ensure we have:
A clear process for authorising plans,
Expert clinical input alongside an individual’s
own views and ideas,
Continuous appropriate monitoring and review of
some-one’s health condition over time.
There is already ample evidence that, given the
chance, people with mental health problems
make creative and effective use of Self Directed
Many of the fears and objections to Self
Directed Support have been named and seen to
be based in myth or misunderstanding.
Successful strategies are available.
Ultimately this is an issue of equal opportunities
to rights of citizenship.
One person’s voice…..
“It’s not just about getting hold of the
money. It’s permission to have a life
again. Permission to dream.”
Whole people changing whole systems......
It’s early days and there’s much to be
considered but people’s lives can’t wait...
Self Direction -working together to create useful