Briefing paper 4: Service users’

attitudes to risk in using

personal budgets
Findings from the second round of a three-year
longitudinal study in Essex

ecdp

May 2011

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 Briefing paper 4: Service users’ attitudes to risk in using personal budgets

Introduction
In 2008 Essex County Council (ECC) commissioned OPM and ecdp to do a longitudinal
study of people receiving cash payments for adult social care within Essex. The study
provides a unique opportunity to fully understand the experiences of people living with a
personal budget over a three-year period, and also to engage with stakeholders from the
council and the wider service market who are working to facilitate self-directed support within
the local area.
The study has two main objectives:
1. To capture the impact of self-managed cash payments on the lives of people who use
them, including evidence of how and why impact is being achieved over time
2. To assess the effectiveness of practices and processes being used by ECC and its
partners to support the delivery of cash payments, including evidence of how the market
is evolving over the study period
This is one of a series of briefing papers containing findings from the second annual round of
research with service users, frontline practitioners and providers in Essex. These brief
papers have been produced to share key findings with audiences involved in personalising
social care, including practitioners, managers, commissioners, service providers and policy
makers.
Other papers in this series include:
 Briefing paper 1: Positive impacts of cash payments, for service users and their families
 Briefing paper 2: Understanding demand
 Briefing paper 3: Developing the service provider market
 Briefing paper 5: ‘In our own words’ – the impact of cash payments on service users and
their families
For copies of any of the above or for a copy of the full report, which contains details of our
findings, please email Sarah Holloway at OPM (sholloway@opm.co.uk).

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 Briefing paper 4: Service users’ attitudes to risk in using personal budgets

Key findings
 Service users don’t spontaneously mention issues of risk in the context of personal
budgets. But social work professionals and providers do.
 In general service users do not perceive a risk in contracting with ‘unregulated’ and
informal carers, and they will tend to trust carers who they know or can get along well
with. Their focus is on receiving services from an individual that they get on with, or to
whom they are well matched and have the potential to get on with.
 Any potential risks or issues associated by a service user taking an informal approach to
organising their care and support, or with being directly responsible for this, are far
outweighed by the positives of a personalised approach, which specifically includes
having more choice and control – or ‘being in the driving seat’, as one of our sample put
it.
 Where it exists, service users tap into social capital by using informal networks – both in
a family setting and in the community more widely – to find PAs or others who can
support them to meet their care and support outcomes. Formal risk and safeguarding
approaches could possibly undermine this approach and the basis of trust that this is built
on.
 Though they were very supportive of cash payments and what they enabled service
users to achieve, practitioners perceived that employing freelance PAs, for example, can
be a high risk strategy for service users, given that they are not regulated, or in some
cases even CRB checked. This is contrary both to the views and practice of service users
themselves. This could, in part, be explained by the idea that practitioners felt that they
could not play an ongoing role in safeguarding service users because of the limited
contact they had.
 Practitioners talked of service users gradually ‘getting used to the idea’ of taking on more
‘risk’, but feel that service users and their families will continue to take more conservative
approaches to risk. Again, this is contrary to the actual views and practice of service
users in our sample.

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 Briefing paper 4: Service users’ attitudes to risk in using personal budgets

Overview
A recent report by the Social Care Institute for Excellence1 made a useful and timely
contribution to the literature on the issue of risk in the context of the personalisation of adult
social care. The report noted that:
 The views of people who use services are largely absent in the literature on risk.
 Being risk averse has resulted in some front line 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 the individual or understanding of their
circumstances.
 Corporate risk approaches can result in front line practitioners becoming overly
concerned with protecting organisations from fraud when administering direct payments.
This reduces their capacity to enable positive risk taking with people who use services.
 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.
Although recognising that risk was not a specific area of interest considered as part of our
second round of research, the interviews with service users and practitioners nonetheless
raised a number of interesting, and indeed differing, perspectives on the question of risk.
This brief paper therefore presents some of the contrasting views on this topic. First we
present the views of service users within our research sample, particularly in relation to how
carers and personal assistants are employed. Then the views of practitioners are presented,
allowing us to examine the issue of risk from the perspective of a local authority.

Risk and personalisation: Service user perspectives

The language of risk is not widely used by service users

In our sample of 26 service users, across a range of impairment and age groups, service
users did not spontaneously discuss issues of risk during our interviews with them. In
general, their focus was much more on the overall benefits and also the challenges arising
from using cash payments. This in itself is an interesting finding, because it suggests that the
language of risk is not one that service users use, and that these issues aren’t ones that they
consciously consider. By understanding what service users find valuable about the cash
payment system and the ways in which they choose to use it, we can, however, elicit their
attitudes towards risk.

1
SCIE (2010), Enabling risk, ensuring safety: Self-directed support and personal budgets

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 Briefing paper 4: Service users’ attitudes to risk in using personal budgets

Contracting ‘unregulated’ carers is not seen as risky option

A number of the service users in our sample were achieving extremely positive outcomes as
a result of the flexibility, choice and control offered by the personal budget system. A key way
in which improved outcomes were achieved was through the type of provision secured
through a cash payment. More specifically, we know that service users and their family
members are contracting services from a wide range of types of providers within Essex,
including freelance individuals, some of whom will be friends/family members.
In general service users do not perceive there to be a risk in contracting with ‘unregulated’
and informal carers, and they will tend to trust carers who they know, or can get along well
with. Indeed, fewer service users are willing to directly employ individuals to provide care and
support, and will pay friends and family carers in cash to avoid the PAYE system.
The use of freelance individuals and/or family members is not equally present across all
age/impairment groups. For example:
 None of our older service user sample were contracting services from friends or family
members.
 PSI users in our sample did tend to purchase services from freelance individuals, and
particularly from friends and family. In some cases, cash payments were used to pay
friends/close family members who were already providing care prior to cash payments.
For this group within the sample, the emphasis was on the importance of personal care
being provided by a known and trusted individual.
 The LD sample used a broad range of providers, and the majority chose to work with
private agencies. But some chose to contract with a known individual who had already
worked with the service user in a different capacity, for example, as a teaching assistant.
PSI and LD service users can, more easily than older service users, rely on known
individuals to provide highly flexible and personalised care and support. This trend underlines
the importance of social networks in securing positive outcomes for personal budget holders.

Positive impacts of choice and control can outweigh risks and responsibilities

A number of service users and their families reported that since the introduction of their
personal budget, they had experienced a greater level of control over the lives.
‘I've been able to have the carers that I want for my son and that I'm happy with, because
when I've spoken to people before that are in the system, that are on the old style then
there’s carers that have been sent that they weren't happy with and they didn’t like at all.’
(Mother of LD service user)
This suggests the idea of a positive-sum game in which potential risks and responsibilities
associated with a personal budget are far outweighed by improved choice and control.

Michael: an example

An example of this approach is Michael. On moving to his new home, Michael had support
from a social worker who supported him to arrange a personal budget which he uses to
directly employ live-in PAs to support him to live independently. Receiving a cash payment
means Michael can exercise control over who he shares his home and his life with.

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 Briefing paper 4: Service users’ attitudes to risk in using personal budgets

Michael uses an online recruitment website to source suitable Pas, which has made the
whole process an ‘absolute breeze’. On the website he can browse PA profiles finding out
where they’re based, their interests and experience, and their preferred shift patterns. Having
made initial contact via the website he can then arrange an interview, and subsequently a
trial week. Over the first few months he will wait to see if things ‘stabilise and get into a habit’.
‘I mean that's one thing that's odd with the whole aspect of this, it's basically I'm
sharing my home on a weekly basis at first with people who are complete strangers.’
Before employing PAs directly Michael used a care agency. As well as being an expensive
way to employ people, he became frustrated by the sometimes poorly matched care staff
living in his home and the unexpected and excessive level of staff turnover.
What Michael’s experience shows – as do many of the experiences of our sample – is that
the ‘what works’ dynamic is far more important when engaging personal assistants than the
source of that particular individual and the issues of risk that this may present from the point
of view of safeguarding.

The role of social capital and its relation to risk

Findings from our study clearly showed the importance of social capital, in the form of family
relationships and wider social networks, both in encouraging people to choose cash
payments over council-managed services and in helping them to identify and choose service
providers. As reported above, this has included individuals choosing to pay relatives and
family friends to deliver their care, which, in many cases, means care can be flexible. There
are also a number of examples where relatives provide unpaid backup when things go wrong
or situations unexpectedly changed, for example, if a PA is on holiday or was unwell, or a
carer fails to turn up.
By enabling this, and by putting responsibility in the hands of service users, a personalised
approach allows service users to make the most of natural networks that they have, without
formal mechanisms (such as those required by risk frameworks) undermining this support.

Risk and personalisation: Practitioner perspectives

Practitioners were positive about the potential of cash payments to improve outcomes for
service users, often calling on particular cases they themselves had worked on and the
satisfaction they get from a visit to a service user whose support plan is in place and
delivering positive outcomes. Practitioners highlight the flexibility offered by the system, and
the potential for control and independence among service users.
But it is interesting that – contrary to the views and practice of service users themselves –
practitioners noted that, for example, employing freelance PAs can be a high risk strategy for
service users, given that they are not regulated, or in some cases even CRB checked.
Practitioners note that they have a role in safeguarding service users, but that their ability to
safeguard service users is limited by the fact that they may not see an individual for an
extended period of time.
From the point of view of practitioners, service users still continue to see the council as being
accountable for outcomes. Over time, practitioners feel that service users will become more
accustomed to taking increased responsibility and assuming incremental amounts of ‘risk’,
but in the main will continue to make conservative support choices. This, however, is not
directly supported by the experiences of service users in our sample.

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