Risks can feel like this

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					WORKING WITH PERSONAL BUDGETS
IN MENTAL HEALTH-SHIFTING CONTROL
FOR BETTER LIVES
Overview
   Snapshot background.
   What is self directed support and what is its
    purpose.
   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




                                  3
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
  help.
• We have to slot in.
• We feel we should be grateful
  and stay as passive recipients.
• We have not rethought power
Citizenship Model

               • 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
  support- flexibly
 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
  shared monitoring.
 A shift in the power between an individual and the State
  (NHS/social services)
Tilting the balance of power


   Its about shifting power and creating an improved
    relationship
   Central focus is improving the dialogue between
    the citizen and the professional to create:
     Greater mutual respect & understanding
     Better quality decision-making
     Better outcomes

   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:
       Poverty
       Isolation
       Unemployment
       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
  problems...
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
    be met.
Universal citizenship?
“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
  they receive..”
(“Putting people First DH 2007)


“No    decision about me without me” NHS White paper 2010.
     “No Health without Mental Health”
                 Feb 2011
   “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
  Authority services/commissioning.
 Inherent resistance to change in systems

 Concerns- personal and professional, including approaches
  to risk/benefit analysis
 Understandable suspicion and cynicism from people who use
  current services.
 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.
Eliminating risk?
Managing risk
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
  managed effectively.
 Is there is anything that the person is worried
  about or has happened in the past that might
  arise again?
 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
    personal assistant
   Risk enablement groups can be useful initially to
    develop confidence in personalised risk
    assessments
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
    not ignored;
   to the plan being a live participative process not a
    “prescription”;
   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.
Conclusion
   There is already ample evidence that, given the
    chance, people with mental health problems
    make creative and effective use of Self Directed
    Support.
   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
                    change.
rita@personalhealthbudgetalliance.co.uk
           07811 176708

				
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