This paper reports on research exploring how people with enduring mental health problems are affected by personal budgets.
The authors begin by rehearsing debates about whether personalisation is aimed to increase choice and control, or is more focused on increasing market forces and consumerism. This debate is located within different understandings of power. Under the dominant neoliberal world view, power is seen as a commodity, which can be transferred from professionals to people with mental health problems.
Hamilton et al propose a more subtle view of power, seeing it as arising through relationships. Such a view is said to support people with mental health problems and professionals working together to improve social wellbeing as opposed to professionals being constructed as experts who know best. Hamilton et al also acknowledge the evidence of the benefit of personal budgets, particularly in the form of direct payments, in increasing choice and control.
The rationale for Hamilton et al’s research, on which the paper is based, is that there is little in-depth research investigating the impact of personal budgets on people with severe and enduring mental health problems.
The research took place in three local authority areas, selected to cover different geographic areas, urban/rural status and levels of personal budget take-up.
The article reports findings from semi-structured interviews (recorded with permission) with 52 service users with mental health problems and 28 mental health practitioners undertaken in 2012-13.
Information on the characteristics of participants is provided, which is useful and the research methods and approach to analysis appear to be appropriate.
Four overarching themes were identified, one of which was divided into three sub themes:
Attitudes and values
- Attitudes and values are seen to be central in constructing the meaning of choice and control for people with mental health problems.
- Most service users indicated they felt grateful for receiving the personal budget, which led to a reluctance to negotiate over the amount offered. This was opposed to regarding this option as a right.
- Some practitioners felt more comfortable if service users were grateful for the opportunity. Hamilton et al argue that this indicates practitioners’ unwillingness to let go of power.
Perceptions of capacity impacting on the process and decision making
- Being offered the personal budget when service users were still very unwell or when capacity was limited, created a concern for professionals and service users about their ability to take on managing the budget.
- Support from peer organisations or family was felt by participants to be essential in successfully managing a personal budget, particularly where capacity fluctuated.
Power relations and orientations
Control as a transfer of responsibilities
- Many participants described taking on responsibility for each part of the process, assessment, support planning and advocating for the plan with social workers and managers. While this could be empowering for some, others found this somewhat of a burden.
Resistance to transfer of responsibilities
- Service users gave accounts of what seemed more like a passive approach to accepting the responsibilities of managing their personal budgets, rather than deliberate resistance. They reported a lack of interest in having control or that practitioners just took over and did not give them the chance.
- However, some social workers in the study believed that some long-term mental health service users and those who were still unwell were unwilling or unable to assume responsibility for managing the personal budget.
Choice as a shared and supported activity
- Most commonly, service user and professionals worked in partnership to make decisions about the use of the personal budget. This required a good relationship between practitioner and service user.
- However some service users rejected the partnership approach, reflecting a view that the Personal Budget was a right rather than a privilege.
- Furthermore, practitioners reported retaining an element of control if decisions were being made that they felt put the person at risk, or did not meet their needs in other ways.
Local authority approval
- After support plans have been agreed between service users and practitioners, the plan has to be approved by the local authority. Hamilton et al found that service users experienced this process as confusing and disempowering.
- Practitioners also reported feeling powerless over these decisions, although sometimes used this as a way of distancing themselves from responsibility for the decisions made.
The authors conclude that
A key factor in enabling personal budgets to support empowerment and recovery was reported to be the quality and continuity of the professional relationship—which raises particular implications for the organisation of mental health social work and the organisational cultures within which this is situated.
Strengths and limitations
Hamilton et al acknowledge that the study was limited, partly because interviews had taken place in only three authorities, which are unlikely to be representative.
Also as local authorities are undergoing a more rapid than usual set of changes and reductions in their budgets, frequent changes of approach are required, increasing variability of practice.
It would have been extremely helpful if Hamilton et al had distinguished between comments related to managed personal budgets and direct payments. Very different experiences and outcomes of the two forms of personal budgets have been reported (Stevens et al, 2015; Slasberg et al 2014).
Hamilton et al point out that where people with mental health problems had been able to take control over their budgets, it offered more control over support for daily living and facilitated different routes to recovery, including supported employment. In general, service users, preferred to manage these processes in partnership with professionals, instead of going it alone.
However some practitioners were felt to have limited the increase in control, through approaches that continued old styles of exerting power over service users, rather than working in partnership.
Final decisions by local authorities to approve plans (or not) were made without direct input from service users; this was a clearer indication of the continuation of old power regimes.
Public spending cuts were also identified as restricting practitioners’ abilities to foster greater choice and control. Consequently, Hamilton et al argue that achieving choice and control is not only affected by practitioners’ attitudes and skill, but also organisational processes and culture.
Hamilton, S., Tew, J., Szymczynska, P., Clewett, N., Manthorpe, J., Larsen, J., and Pinfold, V. (2015) Power, Choice and Control: How Do Personal Budgets Affect the Experiences of People with Mental Health Problems and Their Relationships with Social Workers and Other Practitioners? British Journal of Social Work, 04/2015; DOI: 10.1093/bjsw/bcv023. [Abstract]
Slasberg, C., Beresford, P. and Schofield, P. (2012) ‘How self-directed support is failing to deliver personal budgets and personalisation’, Research, Policy and Planning 29(3), 161-177. [Full Text]
Stevens, M., Manthorpe, J., Hussein, S., Ismail, M., Woolham, J., Samsi, K., Baxter, K. & Aspinal, F. (2014) ‘Risk, Safeguarding and Personal Budgets: exploring relationships and identifying good practice’, London: NIHR School for Social Care Research. [Full Text]