personal budgets for all

414 Pages·2013·2.82 MB·English

University of Plymouth
PEARL https://pearl.plymouth.ac.uk
04 University of Plymouth Research Theses 01 Research Theses Main Collection
2013
Personal Budgets for all? An Action
Research Study on Implementing
Self-Directed Support in Mental Health
Services
Hitchen, Sherrie
http://hdl.handle.net/10026.1/1529
University of Plymouth
All content in PEARL is protected by copyright law. Author manuscripts are made available in accordance with
publisher policies. Please cite only the published version using the details provided on the item record or
document. In the absence of an open licence (e.g. Creative Commons), permissions for further reuse of content
should be sought from the publisher or author.
PERSONAL BUDGETS FOR ALL? AN ACTION RESEARCH

STUDY ON IMPLEMENTING SELF- DIRECTED SUPPORT IN

MENTAL HEALTH SERVICES

by

SHERRIE HITCHEN

A thesis submitted to the University of Plymouth in partial fulfilment

for the degree of

DOCTOR OF PHILOSOPHY

Faculty of Health, Education and Society

OCTOBER 2012
COPYRIGHT STATEMENT
This copy of the thesis has been supplied on condition that anyone who consults it
is understood to recognize that its copyright rests with its author and that no
quotation from the thesis and no information derived from it may be published
without the author‟s prior consent.

2
Abstract
Personal budgets for all? An action research study on implementing
Self-Directed Support in mental health services

Sherrie Hitchen

Background
The recent political agenda for health and social care requires more client-
centred, personalised services. Self-Directed Support, encompassing Direct
Payments and Personal Budgets, is designed to provide people with more choice
and control over how their needs and outcomes are met. Personal budgets are
available for eligible people however take-up is low in mental health services.

Research Aims
The study was set in an NHS Health and Social care Trust covering a large
predominantly rural area.The aims of this study were: (1) to develop Self-Directed
Support within one mental health Trust and; (2) understand more fully service user
and carer involvement in the process.

Methods
This study used action research incorporating: a spiral methodological framework;
a project steering group; and service user and carer co-researchers. Data
collection took place between 2007 and 2011, and the project ran in three
sequential spirals using qualitative methods to triangulate the findings and identify
any divergence in data.

Findings
Findings showed that organisational language, structures and power relations
provide barriers to effective involvement of service users and carers. Action
research is very relevant for researching projects involving transformational
change in health and social care, and including service user and carer co-
researchers adds rich and authentic data.

Findings concerning Self-Directed Support concluded that it afforded people more
choice, flexibility and control than previous policy, and an improved quality of life.
Concerns about bureaucratic processes, lack of information and knowledge of
Self-Directed Supportwere found. Workforce concerns about safety of service
users under Self-Directed Support and cultural shifts to more democratic methods
of working were reported.

Conclusions
This study‟s results correspond closely with national studies: staff attitudes and
culture need changing to empower people to take up Self-directed Support.
Concerns about quality assurance and safety are prevalent. Mental health
services pose additional obstacles in their structures and reliance on the medical
model. Social care knowledge cannot be assumed for all mental health Trust
practitioners.

3
List of Contents

Abstract………………………………………………………………..…………….. 3
List of Tables..……………………………………………………….……………… 12
List of Figures………………………………………………………….…………… 12
List of Abbreviations……………………………………………………………….. 14
Author‟s Note……………………………………………………………………….. 14
Acknowledgements……………………………………………….……………...... 15
Author‟s Declaration……………………………………………………………….. 16

Chapter One
Introduction………………………………………………………………………... 17
1.1 Setting the scene………………………………………………………… 17
1.1.2 Definitions………………………….……………………………………... 17
1.2 Self-Directed Support and social care commissioning………………. 18
1.2.1 Local context……………………………………………………………... 21
1.2.2 Personal motivation……………………………………………………… 23
1.2.3 Selecting action research……………………………………………….. 23
1.3 Study aim, design, methodology and methods of data collection
and analysis……………………………………………………………… 24
1.4 Thesis structure………………………………………………………….. 25

Chapter Two
Self-Directed Support in mental health literature review……...………….. 27
2.1 Introduction……………………………………………………………….. 27
2.2 Methods…………………………………………………………………… 27
2.2.1 Searching the literature……………………………………….……….… 27
2.2.2 Review strategy……………………………………………….………….. 28
2.2.3 Existing literature reviews……………………………………...………. 28
2.2.4 Quality assessment…………………………………………………….… 29
2.3 Themes from the literature……………………………………………… 33
2.3.1 Low take-up of Direct Payments in mental health services…………. 33
2.3.2 Benefits and uses of Direct Payments…………………………………. 35
2.3.3 Barriers to taking up Direct Payments…………………………………. 37
2.4 Summary: Direct Payment Research……………………………….…. 39
4
2.4.1 Key themes……………………………………………………………….. 39
2.4.2 Direct Payments: Areas for further research………………………….. 40
2.5. Self-Directed Support: Introducing individual and Personal Budgets 41
2.5.1 „In Control‟…..…………………………………………………………….. 41
2.5.2 Individual Budget programme…………………………………………... 43
2.6 Themes from the literature: Self-Directed Support…………………… 44
2.6.1 Mental health Personal Budgets: Differences to other disability
areas……………………………………………………………………...... 44
2.6.2 Quality of life and satisfaction with support…………………………… 45
2.6.3 Health and well-being……………………………………………………. 48
2.6.4 Choice and control outcomes…………………………………………… 48
2.6.5 Carers……………………………………………………………………… 49
2.6.6 Risks to Personal Budget recipients………………………………..….. 50
2.6.7 Resource Allocation Systems, assessment and support processes... 52
2.6.8 Training and information……………………………………………….... 54
2.6.9 Impact on work-force………………………………………………….…. 55
2.6.10 Staff culture change……………………………………………………… 56
2.6.11 Personal health budgets………………………………………………… 57
2.7 Summary: Personal Budget research…………………………………. 58
2.7.1 Research literature………………………………………….…………… 57
2.7.2 Key themes and critique of research design………………………….. 58
2.7.3 Areas for further research…………………………………………….…. 62
2.8 Discussion…………………………………………………………….…... 63
2.8.1 Research prior to my study…………………………….……………….. 63
2.8.2 Rationale for this study………………………………………….………. 64

Chapter Three
Selecting action research methodology as an approach for this study.. 66
3.1 Introduction………………………………………………………………. 66
3.2 Section One: Research paradigms and action research……………. 66
3.2.1 Social Research…………………………………………………………. 66
3.2.2 The contrast of action research……………………….……………….. 68
3.3 Section Two: Origins of action research…………………………….… 69
3.3.1 The work of Kurt Lewin (1890 -1947)…………………………….……. 69
3.3.2 Action research and change……………………………………………. 71
3.3.3 The action research cycle ………………………………………..….…. 73
5
3.3.4 Reducing the theory-practice gap……………………………………… 77
3.4 Section Three: Action research in health and social care contexts... 79
3.4.1 The relevance of action research to health and social care………… 79
3.4.2 Service user involvement in health and social care settings………... 80
3.5 Section Four: Assessing quality in action research………………….. 83
3.5.1 Research validity, rigour and quality…...……………………………… 83
3.5.2 Generalisability and action research………………………………….. 87
3.6 Section Five: Researching your own organisation………………...… 88
3.6.1 „Insider‟ research………………………………………………………… 88
3.7 Section Six: Political and ethical considerations of action research.. 91
3.7.1 Political considerations………………………………………………….. 91
3.7.2 Ethical considerations…………………………………………………... 95
3.8 Section Seven: Using action research in this study………………….. 98
3.8.1 The action research approach used in this study……………..……... 99
3.8.2 The implications of being an insider researcher………………..……. 104
3.8.3 Quality assurance and rigour in this study…………..………………... 105
3.9 Summary……………………………………………………………......... 107

Chapter Four
Methods of data collection and analysis…………………………………... 108
4.1 Introduction…………………………………………………………….... 108
4.2 Section One: Aims of the study………………………………………. 108
4.3 Section Two: Design of the study……………………………………. 109
4.4 Section Three: Service user and carer co-researcher recruitment.. 113
4.4.1 Recruitment process…………………………………………………... 113
4.4.2 Training for co-researchers in research methods…………………... 118
4.5 Section Four: Methods of data collection……………………………. 118
4.5.1 Focus groups as a research method………………………………… 118
4.5.2 Reflective diaries as a research method……………………….……. 124
4.5.3 Reflective diaries in action research…………………………………. 125
4.5.4 Interviews, workshops and meetings with the co-researchers……. 126
4.5.5 Steering groups and other meetings data collection…..…………… 127
4.5.6 Documentation as a method of data collection…………………….. 129
4.5.7 Triangulation and validity in action research………………………... 130
6
4.5.8 Triangulation and validity in this study..……………………………… 132
4.6 Section Five: Ethical issues and approval in this study……………. 134
4.6.1 Ethics relating to recruitment of service users and carers to this
study………………………………………………………………………. 134
4.6.2 Ethical aspects of methods…………………………………………… 136
4.7 Section Six: Data analysis in this study……………………………… 138
4.7.1 Recruitment process data analysis………………………………….. 138
4.7.2 Focus group data analysis…………………………….……………… 139
4.7.3 Steering group data analysis…………………………………………. 141
4.7.4 Co-researcher group meetings and workshops data analysis……. 143
4.7.5 Reflective diaries and their analysis…………………………………. 143
4.7.6 Documents and their analysis………………………………………… 144
4.8 Section Seven: Summary of data collection methods and analysis 145

Chapter Five
Findings of the action research project…………………….………………. 149
5.1 Introduction…………………………………………………………..…. 149
5.2 The action research cycles……………………………………………. 149
5.3 Project chronology…………………………………………………...... 152
5.4 Transcription notations………………………………………………... 153
5.5 Abbreviations…………………………………………………………… 153
5.6 Representation of qualitative data……………………………………. 154
5.7 Section One: Qualitative findings of the first action research cycle 154
5.7.1 The project steering group……………………………………………. 154
5.7.2 First steering group: 19.4.07………………………………………….. 156
5.7.3 Second steering group: 23.5.07……………………………………… 160
5.7.4 Direct Payment workshops: 9.5.07 and 7.6.07……………………... 165
5.7.5 Third steering group: 26.6.07…………………………………………. 166
5.7.6 Fourth steering group: 30.8.07…….…………………………………. 169
5.7.7 Fifth steering group: 18.10.07…….………………………………….. 174
5.7.8 Training Recovery Coordinators in eight areas: 19.10 to 5.11.07… 178
5.8 Emerging themes during the first action research spiral………….. 180
5.9 Qualitative findings of the second action research cycle………….. 183
5.9.1 Sixth steering group: 3.12.07.………………………………………… 183
5.9.2 Further Recovery Coordinator t raining: 4.12.07; 8.1.08 and
16.1.08…………………………………………………………………... 188
7
5.9.3 Workshops: 24.1.08, 28.1.08 and 13.2.08………………………….. . 190
5.9.4 Seventh steering group: 22.4.08……….…………………………….. 191
5.9..5 Meeting with the c o-researchers: 30.7.08…….……………….……. . 195
5.9.6 Focus group findings…………………………………………………… 196
5.9.7 Focus groups with service users and carers: 5.8.08, 17.12. 08,
5.8.09 and 26.8.09…………………………………………..……... ….. 196
5.9.8 Focus group sample and conduct……………………………..…...... 197
5.9.9 Focus group findings summary…………………………………..….... 199
5.9.10 Meeting with co-researchers and Local Authority consultant:
10.12.08…………………………………………………………………. 215
5.9.11 Eighth steering group: 16.12.08……………..…………………….….. 216
5.9.12 Ninth steering group: 10.2.09…………………………………………. 217
5.9.13 Presentation at Trust conference on recovery…………………….… 219
5.9.14 Tenth steering group: 21.4.09…………………………….…………… 220
5.9.15 Third focus group with service users: 5.8.09………………………… 222
5.9.16 Fourth focus group with carers: 26.8.09……………………………… 222
5.10 Themes from the second action research spiral…………………….. 222
5.11 Section Three: Qualitative findings of the third action research 225
cycle………………………………………………………………………
5.11.1 Eleventh steering group: 27.10.09……………………………………. 225
5.11.2 Twelfth steering group: 22.2.10……………………………………….. 227
5.11.3 Thirteenth steering group: 2.7.10……………………………………... 229
5.11.4 F ocus groups with Recovery Coordinators: 29.10.10 and 9.5.11…. 229
5.11.5 F ocus group findings from the third action research cycle…………. 230
5.11.6 Training and evaluation with community based staff: January,
February and March 2011……………………………………………... 241
5.12 Summary of the themes from the third action research spiral……... 245
5.13 Overall summary of themes and findings……………………………. 247

Chapter Six
Discussion of findings………………………………………………………….. 252
6.1 Introduction……….………………………………………………………. 252
6.2 The impact of using action research in this study….…………………. 253
6.2.1 The action research spirals………………………………….…………. . 253
6.2.2 Action research rationale and researcher neutrality in this study…… 255
6.2.3 Steering group collaboration…………………………………..………... 260
6.2.4 Political and ethical issues in this study……………………………..… 266
8
6.2.5 Limitations………………………………………………………………… 271
6.2.6 Contribution to new knowledge…………………………………………. 273
6.2.7 Closure for the co-researchers…………………………………………. 278
6.3 Rigour and reflexivity in this study………………………………….….. 280
6.3.1 My role as insider-researcher in this study……………………………. 281
6.3.2 Personal Learning ……………………………………………………….. 283
6.3.3 Rigour and quality in this study…………………………………………. 285
6.3.4 Rigour in data analysis………………………………………………….. 293
6.4 Learning from the implementation of Personal Budgets…………….. 294
6.4.1 Discussion aims………………………………………………………….. 294
6.5 Benefits of Personal Budgets……………………………….………….. 294
6.5.1 Choice and control……….………………………………………………. 294
6.5.2 Quality of life…………………….………………………………………... 296
6.5.3 Health and well-being……………………………………………………. 298
6.6 Barriers to Personal Budgets…………………………………………… 298
6.6.1 Assessment and application processes……………………………….. 298
6.6.2 Information and training……………………..…………………………... 299
6.6.3 Support and advocacy…………………………………………………… 301
6.6.4 Resources….……………………………………………………………... 301
6.6.5 Differences in mental health services………………………….…….. 303
6.6.6 Carers…………………………..………………….……………………… 304
6.6.7 Risks………………………………………………………………………. 305
6.6.8 Impact on workforce…………………………………….……………….. 306
6.6.9 Staff culture………………………………………………….……………. 307
6.7 Resource Allocation System development……………………….…… 307
6.8 Generic and specific approach to Self-Directed Support……………. 309
6.9 Summary………………………………………………………………….. 313

Chapter Seven
Conclusions and recommendations……………….………………………… 318
7.1 Introduction……………………………………………………….…….. 318
7.2 Section one: Conclusions……………………………………….………. 318
7.2.1 Conclusions regarding Self-Directed Support……..…………………. 318
7.2.2 Conclusions regarding service user and carer involvement………… 322
7.2.3 Conclusions regarding action research……………………….………. 323
9