e.birt - are we there yet pcp - 201109

Edward Birt of 29

Report: Are We There Yet? Barriers and Facilitators

to Establishing Person Centred Planning Within

Funded Disability Service Systems

Edward Birt, November 20091

Overview:

This paper has been developed to explore the factors that hinder (barriers)

and those that assist (facilitators) in the establishment of person centred

funded disability services.

1. Introduction: A brief literature review exploring person centred planning

and the key recognised best practice approaches to enabling person

centred planning (PCP) within funded disability services,

2. PCP in Australia: an overview of where PCP sits in relation to

Australian disability legislation.

3. Barriers and Facilitators of PCP: An overview of the barriers and

facilitators of person centred planning identified in the literature.

4. Organisational Review:

a) Life Without Barriers Individual Planning Framework: Review of an

implementation plan for a PCP framework for an Australian funded

disability service provider.

b) Research: The results of a structured questionnaire as completed by

34 staff and 5 clients of the service that explores their views in relation

to identifying the key barriers and key facilitators to person centred

planning.

5. Discussion and conclusions: A range of conclusions and

recommendations are presented by way of a discussion at the end of

the paper.

1 Submitted as an assignment as part of a Postgraduate Masters of Health Sciences course (Developmental Disability) to the University of Sydney by the author on 20th November 2009 as part of a final year inquiry topic.

Edward Birt of 29

“…person-centered planning may be best considered an evolutionary

step in the long-standing trend towards the increasing individualization

of and personalization of services. This point is important.”

- Robertson et al, 2006, p. 413

1. Introduction: What is Person Centred Planning?

15 years ago Beth Mount identified that person centred planning is a person

centred alternative to conventional “system centred” planning (Mount, 1994,

p.104). Person Centred Planning (PCP) is a planning methodology providing

a framework for enabling people with disability to design their own services

and to ensure that service delivery is structured around the persons needs

and goals (Dowling et al, 2007, Mansell & Beadle-Brown, 2004). As originally

envisioned PCP is a way of assisting people with disabilities become more

independent and take a strengths based and active role in planning their

futures, using and building on existing social supports to meet goals (Callicot,

2003).

Five essential outcomes of the PCP process were outlined by John O’Brien

over two decades ago; 1) presence and 2) participation in the community, 3)

positive relationships, 4) respect and 5) competence (O’Brien, 1987). PCP is

a way of organising the supports that a person requires to meet their lifestyle

choices and has evolved over many years to now be recognised as a best

practice approach to ensuring that funded disability supports are tailored to

the individual needs and personal aspirations of people with a disability (e.g.

Holburn et al, 2004).

Person Centred Planning is recognised as being associated with a range of

positive outcomes for people with disability who access funded disability

services including:

• Reducing isolation and promoting friendships and networks of support,

• Promoting contact with family,

Edward Birt of 29

• Developing and promoting skills, autonomy and independence,

• Enhancing dignity, respect and valued social roles and

• Increasing choice and self-determination.

These outcomes have been demonstrated in a range of qualitative studies (as

noted in Robertson et al 2007) and more recently empirically with randomised

control trials exploring outcomes associated with PCP (Robertson et al, 2005,

Robertson et al, 2006, Holburn et al, 2004, O’Brien & Lovett, 1992).

The following range of broad recurring themes from the person centred

planning literature in relation to facilitating person centred planning help to

define what PCP:

• Supports the self determination and independence of the person with a

disability (e.g. Holburn et al, 2004),

• Allows the control of planning processes to rest with the person with a

disability and their family enabling them to play a role in the design of

services to meet their needs (e.g. Dowling et al, 2007, O’Brien &

Lovett, 1992, Wiese & Parmenter, 2008),

• Listens to and understands the person (e.g. Thompson et al, 2008),

• Develops positive future focused plans (e.g. CDDS 2004),

• Accesses community resources and promotes community inclusion

(e.g. Mount, 1998), and

• Ensures action planning, commitment and follow through (e.g. Dowling

et al, 2007).

Person centred planning approaches are also designed to facilitate a shift in

power away from service providers and towards service users (Holburn et al,

2004) through enabling the recipients of funded disability services, to shape

these services in order to meet their needs and to assist them to work towards

their future goals and aspirations (Dowling et al, 2007).

2. How does Person Centred Planning sit within the Funded Disability

Service Landscape of Australia?

Planning based on the individual needs and personal goals (i.e. PCP) of

people with a disability is a legislated requirement of funded disability services

Edward Birt of 29

Table 1. Individual Planning and the Law: Some examples of references to

Individual Person Centred Planning from Australian disability legislation.

State / Territory Legislation Reference

Australian Capital Territory

Disability Services Act (1991)

Schedule 2: 4. Services should be tailored to meet the individual needs and goals of people with disabilities

New South Wales


2. Application of Principle (d) [services] to meet the individual needs and goals of the persons with disabilities receiving services,

Northern Territory


Schedule 3: Section 3 (2) Objectives (d) the services should be tailored to meet the individual needs and goals of the people with disabilities receiving those services;

Queensland Disability Services Act (2006)

Division 2 – Service Delivery Principles 25. Services to be tailored to meet individual needs and goals (1) Services should be tailored to meet the individual needs and goals of people with a disability.

South Australia Disability Services Act (1993)

Schedule 1 (Principles) 4. … persons with disabilities— (a) have the right to choose between those services, and to choose between the options available within a particular service, so as to provide assistance and support that best meets their individual (including cultural) needs;

Tasmania Disability Services Act (1992)

PART 2 - Funding of Services for Persons with Disabilities, Schedule 3: 4. Services are to be tailored to meet the individual needs and goals of persons with disabilities.

Victoria Disability Act (2006)

Division 3 — Planning 52 Guiding principles for planning (2) Planning should—(a) be individualised; (b) be directed by the person with a disability; (j) facilitate tailored and flexible responses to the individual goals and needs of the person with a disability;

Western Australia


Schedule 2; Objectives for Services and Programmes: 4. Programmes and services are to be tailored to meet the individual needs and goals of the people with disabilities receiving those programmes and services.

in Australian States and Territories (e.g. Disability Act (Victoria), 2006, Section

52). While PCP is legislated through all Disability Services Acts across

Edward Birt of 29

Australia today (see Table 1, above) how this planning is carried out, what it

means for the client and the service and how to achieve and evidence that

progress is being made are all fundamentally important issues disability

service providers must wrestle with in a service system ever more focused on

demonstrating outcomes for service users.

3. What are the features that have been identified in the literature that

are a) barriers to, or b) facilitators of Person Centred Planning?

a) Barriers to PCP

Despite the centrality of person centred individual planning in the principles

and values, legislation and ethos of funded disability services there are a

range of barriers reported in the adoption and take up of person centred

planning including lack of understanding of the process, insufficient process

ingredients, lack of funding, lack of commitment and lack of training

(Robertson et al, 2007).

Holburn & Vietze emphasise the fact that PCP should be a challenge to the

system as it is truly a harbinger of organisational change (1999) and for this

reason will be actively challenged, much like any organisational change

process is, by the existing power structures. Therefore PCP by it’s very

nature is a barrier to it’s own success.

“Ironically for Person Centred Planning to survive in an agency it

needs support from the very system it views as detrimental and

seeks to change.”

- Holburn & Vietze, 1999, p.118

Kinsela (2000) identified a range of key barriers in terms of the variety of

planning options and formats available and the individualised and complex

nature of person centred planning. He outlines a common error whereby

process becomes all important rather than actual outcomes for people

(Kinsella, 2000). This then is a key danger to consider when implementing

Edward Birt of 29

any new “framework” and should stand as a cautionary note to Life Without

Barriers and other agencies as he states, “Too often people never develop a

repertoire of planning techniques and so many organisations, in the pursuit

of standardisation, stick with one process” (p.5).

Team processes (or the lack of them) can be a barrier to PCP according to

Holburn & Vietze (1999). This is mentioned in relation to the link between

more traditionally formal clinical specializations that are important in

supporting many people with developmental disabilities and ensuring

interdisciplinary processes occur to enable teams to work together to

achieve common person centred goals. To many clinical specialists the

goals and planning methodologies of person centred planning can appear

naïve and / or unrealistic (Holburn & Vietze, 1999) and if these issues are

not explored then the very real risk comes into play of power struggles and

parallel planning processes eventuating. Also outlined in this paper is the

still very real issue (10 years later) of regulatory compliance with it’s focus

on health and safety (and paperwork). To then apply another layer of

planning, for which the parameters may not be clearly understood or

outlined, and hence difficult to regulate, over the top of these regulatory and

compliance issues means that often the clearer (if often largely

meaningless in terms of client outcomes) bureaucratic processes will

continue to take precedence.

The real and apparent inflexibility of the vast majority of funding

arrangements is also identified as a barrier to PCP in the literature (Holburn

& Vietze, 1999, CDDS, 2004). This is clearly an issue with confusion about

the way to realize dreams and goals when one seems tied to a particular

funding arrangement / service user outcome and it is easy for support

workers and clients “wouldn’t it be nice…” (person centred) ideas to be

dismissed by a few words of a (probably overworked and possibly unaware)

manager or simply through stalling silence or further even by offering a

limited, though seemingly rich variety, of choice, i.e. set parameters that

Edward Birt of 29

allow the service provider to tick off the outcomes as having been “provided”

to the funding body.

A study by Everson & Zhang (2000, cited in Robertson et al, 2007) identified a

number of common factors that inhibited person centred planning including:

• Behavioural problems for the focus person effectively limiting the

achievement of identified plan goals,

• Communication impairments and social skills deficits made it difficult to

determine wants and needs,

• Difficulty coordinating members of the persons support circle,

• Difficulty expanding the persons circle of support to include people

other than paid services,

• Difficulty engaging the persons peers, and

• Opposing views held by family members and service providers

(Everson & Zhang, 2000, cited in Robertson et al, 2007)

It also seems fair to say (from this authors perspective at least) that a

potential barrier to PCP is the very literature that aims to promote it. In many

ways the literature seems to be very focused on barriers and what is wrong

with the system. This is likely a necessary step in the evolution towards a

more person centred service system though it can be easy to read many of

these articles as a type of “holier than thou” one upmanship which can

become tiresome and may have the effect of turning people’s attitudes away

from these powerful approaches to working with people with disability and

actually divide teams. A positive strengths based approach focusing on the

facilitators to PCP would be far more conducive to supporting the changing

culture. Indeed it is in the way the information is presented – for each

barrier chosen is in fact a facilitator in disguise. Choose any of the Everson

& Zhang (2000) barriers listed above and you may find it surprisingly easy to

develop it’s positive alter ego.

“It is wise to direct your anger towards problems - not people; to

focus your energies on answers - not excuses.”

- William Arthur Ward

Edward Birt of 29

b) Facilitators of PCP Interestingly, though logically, a recognition and regular discussion of the

barriers and uncertainties that become apparent when PCP is introduced has

been highlighted as an important strategy in a transition to a person centred

service (Holburn & Vietze, 1999). Holburn and Vietze (1999) also recommend

focusing on a small number of people with whom to implement PCP while at

the same time focusing on systemic changes to benefit all clients.

The importance of clear policy, and most importantly training and supervision

around PCP is strongly emphasised in the literature together with giving clear

expectations around processes and, particularly, outcomes (e.g. Lawlor &

York, 2007, Mansell and Beadle-Brown, 2004, Robertson, 2007(b), Wiese &

Parmenter, 2008).

The literature indicates a number of recurring themes in relation to ensuring

the effective implementation of person centred planning processes and these

may be considered “benchmarks” for good practice that may require further

exploration and research.

For example, Wiese and Parmenter (2008) note the fundamental importance

of training in person centred planning. Barbara McIntosh and Helen

Sanderson (in Institute for Health Research, 2005) emphasise the cultural

change process that is required of organizations for the successful

implementation of person centred planning.

The key role of the support facilitator (aka “Key Worker”) is emphasized and

requires in depth training and ongoing formal supports. The importance of the

role of the key worker or facilitator is critical to ensuring the plan is developed,

actions are taken and progress is monitored. This role is described as

“pivotal” (CCS Report, 2007).

The CCS report (2007) outlines the importance of spending time with and

simply getting to know the person as an important facilitator to PCP. In this

Edward Birt of 29

light, service user participation and involvement in the PCP process is noted

as a facilitator and Dowling and colleagues (2007) go on to emphasize the

importance of developing a “framework” to enable service users participation

to design their own services.

Wiese and Parmenter (2008) identify a series of key features or components

applying to a person centred approach to planning for people with disability

that should effectively be considered as facilitators to PCP processes:

• Involving a range of stakeholders,

• Ensuring stakeholders have a shared value base focused on

empowering the focus person,

• A team commitment,

• The presence of an action plan,

• Monitoring and evaluation of outcomes,

• Taking an ongoing approach to planning, and

• The non-compulsory nature of person centred planning.

Individualised service user control of funding is regarded by many as a means

of facilitating a more person centred approach to service delivery (e.g.

Mansell and Beadle-Brown, 2004). While this certainly rings very true to this

author (refer to discussion), there are those who are cautioning that a

wholesale and unplanned move to individualised funding may ultimately result

in less choice and service flexibility for service users in years to come (Baker,

2008) and these warnings must be closely explored.

4. Research: Focus on an Existing National Funded Disability Service

Provider

4.1 Individual Planning at Life Without Barriers

a) Overview of Life Without Barriers

Life Without Barriers (LWB) is a funded disability service provider providing a

range of support services to adults, children and young people with disabilities

and their families and carers across Australia. The agency prides itself on the

Edward Birt of 29

provision of “…innovative community based support for people with a

disability…”2

b) Organisational Individual Planning Framework

Recently organisational attention has been paid to the research, development

and roll out / implementation of the organizations “Person Centred Individual

Planning Framework”. This framework has the stated aims of providing

“…those supporting people with disability at Life Without Barriers with a robust

and comprehensive framework ensuring that people’s support needs are

being provided for at the same time as ensuring planning is person centred

and focused on the personal goals and aspirations of clients of the service.”3

The Individual Planning Framework essentially consists of the organizations

values, policy, processes and resources (Figure 1) all of which are designed

to support person centred planning at the agency. The processes and

resources that underpin the framework include those component parts

identified in the literature (e.g. Callicott, 2003) as necessary for PCP to be

conducted including an emphasis on time management, personal profiles,

listening to and understanding the person, arranging logistics of meetings,

developing future vision and a clear plan and evaluating ongoing

implementation of the plan etc.

Figure 1. Life Without Barriers Individual Planning Framework 2 Life Without Barriers, 2009 Annual Report, Introduction, p.3 3 IPF Framwork Overview, LIfe Without Barriers, 2009.

Edward Birt of 29

e) Person Centred Individual Planning Implementation Strategy

A range of training materials have been developed to assist in the

implementation (“roll out”) of the Individual Planning Framework to the

organization. A “peer based train the trainer” strategy has been adopted to

facilitate the take up of the approaches outlined in the framework at the

operational level and a trainers

pack has been developed (Figure

2). Expressions of Interest for peer

based trainers have resulted in 34

people being trained in the delivery

of the package and regional

training is now underway for

operational teams across the

country. Baseline measures using

internal audits have been

completed in relation to a number

of benchmark indicators to

determine the current quality of

Individual Plans and these will be

reviewed on an annual basis.

Figure 2. LWB Individual Planning Training Package

4.2 Research Methodology

In exploring potential barriers and facilitators in relation to the successful

uptake of Person Centred Planning at LWB the work of Robertson and

colleagues (2007(a) & 2007(b)) was reviewed and the range of issues that

both helped and hindered person centred planning were identified. These

“factors” identified in the Robertson studies related “…to the characteristics of

participants, contextual factors and the process of PCP” (Robertson et al,

2007(b) p.239) and formed the basis of a 67 item questionnaire.

Edward Birt of 29

a) Procedure – Questionnaire

Particpants were asked to complete a questionnaire (Attachment 1) consisting

of 67 items which were ranked according to a 5 point Likert scale in relation to

the perception the respondent had of the item’s impact on Person Centred

Planning in regards to whether they thought the item was:

1. Always a barrier

2. Can be a barrier

3. Has no impact,

4. Somewhat helpful

5. Very helpful,

to facilitating the processes of person centred planning.

Client respondents completed a modified 42-item version of the same

questionnaire written in a plain English format with the removal of repeated

items and a change of language in an effort to make the questions more

relevant and client focused (identifying Item numbers were not altered so

answers could be compared between clients and staff).

b) Subjects

i) Staff Respondents

34 respondents completed the questionnaire. All were members of staff. All

were being trained to roll out Individual Planning training to other staff in the

organization after they had expressed an interest in training other staff in the

new framework for Individual Planning at LWB4. In other words all

respondents had demonstrated a prior interest in PCP as they had put

forward “expressions of interest” to become Person Centred Individual

Planning trainers in their region as part of a peer based, train the trainer, roll

out strategy. The mean period of engagement with LWB for the questionnaire

4 The following essential criteria were required to be fulfilled by IP trainers (i.e. survey respondents): Quoted from the EOI that trainers responded to: “IP trainers must be staff members of Life Without Barriers Disability Services who:

• Are passionate about working with clients to achieve quality outcomes, • Possess a good working knowledge of disability legislation and policy, • Are valued and credible team members who are respected by their colleagues. • Are excellent communicators, • Are people who enjoy sharing ideas with others and mentoring their colleagues, • Have demonstrated experience in training and / or supervising groups / teams.”

Edward Birt of 29

respondents was 16 months with the period of time spent working at the

agency ranging from 2 months up to the longest serving respondent who had

worked at LWB for 6.5 years. Respondents filled a range of positions and

included titles such as Team Leader, Disability Support Coordinator,

Operations Manager and Learning and Development Officer. Respondents

came from around the country from a range of urban and regional locations

(for an overview see Table 2 below).

Table 2. Questionnaire Staff Respondent (N=34) Origin.

State / Territory Capital City Regional

Australian Capital Territory 0 0

New South Wales 2 10

Northern Territory 1 1

Queensland 3 8

South Australia 2 1

Tasmania 0 1

Victoria 1 1

Western Australia 3 0

TOTALS 12 22

ii) Client Respondents

A focus group for clients accessing Life Without Barriers community based

day services in Newcastle NSW was facilitated by the author to gain feedback

from service users about their perceptions of the barriers and facilitators to

person centred planning. A small group of 5 service users reviewed a revised

list of 42 of the items in the questionnaire with support from the author.

4 of the 5 respondents displayed a high level of awareness of the purpose of

person centred planning through their responses to the author’s question

“What do you think person centred planning is all about?” at the beginning of

the session with statements including:

• “This is your goals”

Edward Birt of 29

• “Self-improvement”

• “Long-term goals” and

• “Goals and how to make them possible.”

d) Results: Summary of questionnaire responses

A statistical review of the responses was conducted to identify the mean

scores for each of the items. This allowed the responses to be ranked

according to the mean scores and then the items that were scored at 2.0 or

below listed as “Key Barriers” and 4.0 or above as “Key Facilitators” to person

centred planning. These results are illustrated in the following four tables

outlining key barriers (tables 3 & 4) and key facilitators (tables 5 & 6). Tables

3 and 5 indicate results from staff respondents (N=34) and tables 4 and 6 are

from client respondents (N=5). Ranking of the mean responses in this way

gives an indication of the items that staff and clients perceived to be key

barriers and key facilitators of person centred planning.

Table 3. Summary of items Identified by staff (N=34) as Being Key Barriers to PCP

in Survey Questionnaire in Descending Order (i.e. the strongest barrier is listed first)

with Mean Score on Likert Scale

Factors Identified by Staff as a Being a Key Barrier to PCP Mean Score

12.

41.

56.

48.

33.

43.

49.

62.

40.

The IP facilitator is hostile to PCP*

Staffing issues, e.g. staff shortages*

Inaction, nothing happens*

Lack of knowledge and understanding of PCP*

High support worker turnover

Participant reluctance to engage in process*

Family attitudes or disinterest*

Lack of staff skills and knowledge*

Time management issues*

1.1

1.6

1.6

1.6

1.7

1.9

1.9

1.9

2.0

* These factors were also identified by clients as key barriers.

Edward Birt of 29

Table 4. Summary of Items Identified by clients (N=5) as Being Key Barriers to PCP

in Survey Questionnaire in Descending Order (i.e. the strongest barrier is listed first)

with Mean Score on Likert Scale

Factors Identified by Clients as a Being a Key Barrier to PCP Mean Score

12.

58.

50.

41.

66.

62.

56.

40.

39.

44.

52.

51.

49.

48.

43.

Support worker is hostile to Individual Planning*

Transport issues

Health issues

Not enough staff*

Risk issues

Lack of staff skills and knowledge*

Inaction, nothing happens*

Not enough time (time management issues)*

Not enough choice (rigid routines)

Lack of money

Negative management attitudes

Negative support worker attitudes

Poor family attitudes or disinterest*

Not knowing about or understanding PCP*

Not wanting to engage in planning*

1.0

1.0

1.0

1.3

1.5

1.5

1.5

1.5

1.5

1.7

2.0

2.0

2.0

2.0

2.0

* These factors were also identified by staff as key barriers.

Table 5. Summary of Items Identified by staff (N=34) as Being “Key Facilitators”

(Helpful) to PCP in Survey Questionnaire in Descending Order (i.e. strongest

facilitator is listed first) with Mean Score on Likert Scale

Factor Identified by Staff as Being Key Facilitators to PCP Mean Score

31.

20.

36.

1.

37.

35.

32.

38.

30.

2.

Clear procedures are available for individual planning*

The client makes his/her own decisions*

There are high levels of service user involvement*

IP facilitators have a high personal commitment to PCP*

Clear procedures for assessment

There is regular support worker training*

Clear procedures for activity planning*

Clear procedures for teaching

Support workers provide active support to clients*

The client has a key worker*

4.9

4.8

4.8

4.8

4.7

4.7

4.7

4.7

4.6

4.4

Edward Birt of 29

21.

23.

6.

29.

45.

The client has a large network of unpaid supports*

The client has a large social network*

The IP facilitator has lots of contact with the client*

Clear procedures for support to clients

Developing circle of support and involving others*

4.4

4.4

4.4

4.3

4.0

* These factors were also identified by clients as key facilitators.

Table 6. Summary of Items Identified by clients (N=5) as Being “Key Facilitators”

(Helpful) to PCP in Survey Questionnaire in Descending Order (i.e. strongest

facilitator is listed first) with Mean Score on Likert Scale

Factor Identified by Clients as Being Key Facilitators to PCP Mean Score

27.

36.

1.

20.

32.

2.

21.

60.

48.

30.

45.

46.

31.

23.

6.

35.

Having lots of staff

Being involved in the planning as a client*

Staff and Key Workers have a high commitment to PCP*

Being able to make your own decisions*

Clear procedures for activity planning*

Having a key worker*

Having a big network of support*

Communication between services

Knowing the planning process

Receiving active support from staff*

Developing circle of support and involving others*

Participant communication and understanding

Having clear steps for individual planning*

Having a big social network*

Lots of contact with the key worker*

Regular support worker training*

5.0

4.8

4.8

4.8

4.8

4.6

4.6

4.5

4.5

4.4

4.3

4.3

4.3

4.3

4.0

4.0

* These factors were also identified by staff as key facilitators.

As can be seen from the tables there is a good degree of agreement between

both clients and staff (items marked with an asterisk (*) in the tables are

identified by both groups) that a range of factors can have a significant impact

on person centred planning and this is discussed further in the next section.

Edward Birt of 29

5. Discussion and Conclusions

As per the findings of Robertson and her colleagues the questionnaire

conducted as part of this inquiry topic and based on her work identified that

there are factors “relating to the characteristics of participants, contextual

factors and the process of PCP” (Robertson et al, 2007(b) p.239) that act as

either barriers or facilitators to realizing person centred planning.

It would seem the approach taken to the development and implementation of

the “Individual Planning Framework” by Life Without Barriers as outlined

briefly in this paper appears sound in it’s approach in terms of current

Australian standards to PCP for funded disability services and in taking a

planned approach based on research and recognised best practice as it aims

to ensure the following areas are addressed as per the literature’s

recommendations:

• A recognition and discussion of the barriers and uncertainties

associated with the introduction of PCP.

• A focus on systemic changes to benefit all clients.

• Training (training and more training).

• Development of clear policy to support PCP processes.

• Introduction of the “key worker” role across the agency.

• Enhanced service user participation and involvement through the

development of user friendly forms, templates and checklists and the

emphasis in the training package on “Client Friendly” approaches to

planning.

• Incorporating the views and inputs of a range of stakeholders

• An emphasis on processes that empower the client,

• Team commitment,

• The presence of an action plan, with built in timeframes for monitoring

and evaluation of outcomes.

Also procedurally there are a number of key procedural facilitators as

identified by staff and clients in the questionnaire as being key facilitators that

the framework ensures are addressed including:

• Clear procedures are available for individual planning

Edward Birt of 29

• There are high levels of service user involvement

• Clear procedures for assessment

• Clear procedures for activity planning

• Clear procedures for teaching

• The client has a key worker

• Clear procedures for support to clients

It is worth noting this paper has identified the following barriers that may

cause problems as they have not been fully accounted for:

• Trying to roll out PCP to all clients across all service types may simply

be too much to ask and a more focused group may have been

beneficial to success.

• It may be interpreted in some quarters that PCP is compulsory for all

clients following the same process, tools and templates within the

trainers pack.

The implementation effectively utilises what amounts to an A-B-A research

design to monitor the impacts of implementing the new framework across the

organization. It is also worth noting that where training does not go ahead (as

the author anticipates it may not in some regions due to, for example, natural

staff attrition - one of the 34 trainers has already resigned) it may be possible

to consider these areas as random “controls” in the review of follow up data

collection at the 12 month mark to determine effectiveness of the framework

and the implementation strategy in terms of outcomes for clients.

It is worth noting that in this and other research (e.g. Everson & Zhang, 2000)

barriers and facilitators are often identified as being located within the focus

person or their direct supports (e.g. in this study both “Participant reluctance

to engage in process” and “Family attitudes or disinterest” were key barriers

while “The client makes his/her own decisions” was a key facilitator). When

one considers that PCP is implemented by providers within the disability

sector to meet people with disabilities support requirements it almost seems

disingenuous to then proceed to identify those support needs or a person’s

characteristics as a barrier to PCP. Without individual support needs due to

Edward Birt of 29

disability and impairment the funded services would not exist therefore to

suggest that the person is a barrier to PCP seems very odd though these

findings are fairly consistent (e.g. Robertson et al, 2007(a)). While the

application of PCP is not limited to the disability sector it’s use is legislated

within this sector. This may underscore a deeper lack of understanding about

what PCP is as the process was initially envisaged and designed exactly for

people with severe disabilities (e.g. Mount & Zwernick, 1988) and in many

ways the more severe the impairment of functioning the more applicable and

appropriate PCP actually is.

The identification of the influence of attitudinal barriers to person centred

services is clear in the results of the questionnaire with 33% of the key client

and staff barriers being in relation to attitudinal items on the part of staff,

family or service users themselves. Responses identifying attitudinal issues

leads one to question whether there is a fundamental systemic issue at play

that needs to be addressed – where is this “attitude” coming from? It appears

that with regards to funded services in Australia today that the service user is

not automatically treated with the respect they deserve as an automatic

response from service providers and that this can be “the luck of the draw” for

clients and families accessing funded services. In any other business model if

the service recipient (customer) were so disregarded then the model would

surely collapse. If so much of the formula for success rests on the attitude of

staff and managers and people need absolute procedural clarity before they

can effectively implement person centred planning then it would seem there is

a significant problem. It is worth exploring whether there is the need for a

more fundamental shift towards a more customer service oriented approach

to the delivery of funded services. Presently it is fair to say that funded

disability services in Australia treat their government provider/s of funds as the

customer (as indeed they effectively are) yet this leaves much to chance in

terms of quality services for the true end user, the client receiving operational

support. If a client accessing services in 2009 comes into an agency where

person centred services have become the core way of doing business,

building services one person at a time, then they have got lucky however too

often this is not the case. As Kinsela so aptly put it “Those who pay do not

Edward Birt of 29

feel the pain of poor decisions and, thus, make the same mistakes

repeatedly” (2000, p.10) in his reference to this fundamental flaw of having

the provider of funds so clearly perceived by services providers as the actual

customer.

The feedback about the importance of networks of support for clients as

indicated by both clients and staff in their responses to the questionnaire

administered in this study are consistent with other research findings (e.g.

Robertson et al, 2007(a)) and this must continue to be a focus of PCP.

While PCP has become a part of the mainstream disability lingo it is still the

case that planning is often driven by services and systems more than by

people for whom the services have been created. The development of this

paper will provide a range of useful strategies to continue to strongly drive

service delivery at Life Without Barriers, a large non government provider, in a

person centred direction. It is clear that there is truth in Robertson’s

observation, “Services need to be aware of the potential problems that PCP

may come across so that strategies can be developed to overcome them.”

(Robertson et al, 2007 (a), p. 305)

* * * * * * * * * *

Edward Birt of 29

References

Baker, K. (2008). Individualised funding: What it requires to work. National

Disability Services.

Callicott, K.J. (2003). Culturally sensitive collaboration within person-

centered planning. Focus on Autism and Other Developmental

Disabilities, 18, pp. 60 – 68.

CCS Disability Action (2007). Inquiry into the Quality and Care of Services

Provision for Disabled People: Submission with Recommendations.

New Zealand.

Centre for Developmental Disability Studies (2004). Client participation in the

Individual Planning Process. Prepared for the NSW Department of

Ageing, Disability and Home Care by the Centre for Developmental

Disability Studies, August 2004.

Dowling, S., Manthorpe, J. & Cowley, S. (2007). Working on person-centred

planning: From amber to green light? Journal of Intellectual Disabilities,

Vol.11(1), pp.65-82.

Holburn, S. & Vietze, P. (1999). Acknowledging barriers in adopting person

centred planning. Mental Retardation, Vol. 37, No. 2 April 1999, pp,

117-124.

Holburn, S., Jacobson, J.W., Schwartz, A.A., Flory, M.J, Vietze, P.M. (2004).

The Willowbrook Futures Project: A Longitudinal Analysis of Person-

Centred Planning. American Journal on Mental Retardation, Vol. 109

(1) pp. 63-76

Kinsela, P. (2000). What are the barriers in relation to person centred

planning? Report: The Joseph Rowntree Foundation.

Lawlor, D. & York, M. (2007). Assessing goal attainment for quality

Edward Birt of 29

improvement. Journal of Intellectual Disabilities, 11, (3), pp.241 – 255.

Mansell, J. & Beadle – Brown, J. (2004). Person centred planning or person

centred action? Policy and practice in intellectual disability services.

Journal of Applied Research in Intellectual Disabilities, 17, pp. 1-9.

Mount, B. (1998). More than a meeting: Benefits and limitations of personal

futures planning. In J.O’Brien & C.Lyle O’Brien (Ed’s), A Little Book

About Person Centred Planning (pp.55-68). Toronto: Inclusion Press.

Mount, B., & Zwernick, K. (1988). It’s never too early, it’s never too late: A

booklet about personal futures planning (Pub. No. 421- 88-109). St.

Paul, MN: Metropolitan Council.

O’Brien, J. (1987). A guide to life-style planning: Using the Activities

Catalogue to Integrate Services and Natural Supports Systems. In G.T.

Bellamy & B. Wilcox (Eds.), A comprehensive guide to the Activities

Catalogue: An alternative curriculum for youth and adults with severe

disabilities (pp. 175-189). Baltimore: Brookes.

O` Brien J. & Lovett H. (1992). Finding a way to everyday lives: the

contribution of person centred planning. Harrisburg, PA: Pennsylvania

Office of Mental Retardation. (from the Research and Training Center

on Community Living, Center on Human Policy, Syracuse University).

Robertson J., Emerson E., Hatton C., Elliott J., McIntosh B., Swift P., Krinjen-

Kemp E., Towers C., Romeo R., Knapp M., Sanderson H., Routledge

M., Oakes P. & Joyce T. (2005). The Impact of Person Centred

Planning. Institute for Health Research, Lancaster University,

Lancaster.

Robertson, J., Emerson, E., Hatton, C., Elliott, J., McIntosh, B., Swift, P.,

Krinjen-Kemp, E., Towers, C., Romeo, R. Knapp, M., Sanderson, H.,

Routledge, M., Oakes, P. & Joyce, T. (2006). Longitudinal analysis of

Edward Birt of 29

the impact and cost of person-centred planning for people with

intellectual disabilities in England. American Journal on Mental

Retardation, Vol. 111, No. 6, Nov. 2006, pp. 400-416.

Robertson, J., Emerson, E., Hatton, C., Elliott, J., McIntosh, B., Swift, P.,

Krinjen-Kemp, E., Towers, C., Romeo, R. Knapp, M., Sanderson, H.,

Routledge, M., Oakes, P. & Joyce, T. (2007(a)). Reported barriers to

the implementation of person-centred planning for people with

intellectual disabilities in the UK. Journal of Applied Research in

Intellectual Disabilities 2007, 20, pp. 297–307

Robertson, J., Emerson, E., Hatton, C., Elliott, J. McIntosh, B., Swift, P.,

Krinjen-Kemp, E., Towers, C., Romeo, R., Knapp, M., Sanderson, H.,

Routledge, M., Oakes, P. & T. Joyce, T. (2007(b)). Person-centred

planning: factors associated with successful outcomes for people with

intellectual disabilities. Journal of Intellectual Disability Research, 51

(3), pp. 232 – 243.

Thompson J., Kilbane J. & Sanderson H. (2008) Person Centred Practice for

Professionals. Open University Press.

Wiese, M. & Parmenter, T. (2008). Contemporary approaches to case

management: Supporting people with a developmental disability. In E.

Moore (Ed.), Case management for community practice: A textbook for

students and practitioners (Chapter 9). Oxford, UK: Oxford University

Press.

Edward Birt of 29

ATTACHMENT 1. Questionnaire

Factors Impacting on Person Centred Individual Planning Questionnaire

Date: __________________

Name: __________________

Role:

1. Direct Support Professional

2. Coordination &/or Management

3. Family Member

4. Client

5. Other (describe): ____________

Engagement / Relationship to Life Without Barriers:

1. Employee

2. Contractor

3. Volunteer

4. Family Member

5. Client

6. Other (describe): _____________

Service Type in which you work / you access (N.B. complete one

questionnaire for each service type):

1. Supported Accommodation

2. Community Living / Drop In Support

3. Attendant Care

4. Respite

5. Alternative Family Care Services

6. Community Access and Participation Services

7. Employment Support Services

8. Clinical Services

9. Case Management

10. Other (describe): ___________

Edward Birt of 29

Length of involvement with Life Without Barriers:

______ Years, _______ Months

1. Key Features of Individual Person Centred Planning 1. Please describe what you consider to be the key / important features of individual person centred planning: 2. Does Life Without Barriers do Individual Person Centred Planning? a) Do you feel the Life Without Barriers service within which you work or have involvement presently conduct individual person centred planning for service participants as you have described it here?

1 2 3 4 5 Never Rarely Sometimes Usually Always

b) Comments:

Edward Birt of 29

3. Factors that Help and Hinder Person Centred Individual Planning For each of the items indicated below rate each one with a score of 1 to 5 (as per the scale below) for how important you feel it is in terms of being a barrier to or beig helpful to the development of individual person centred plans for clients in the service in which you work: Scoring Scale:

1 2 3 4 5 Always a Barrier

Can be a Barrier

No Impact on IPCP

Somewhat Helpful

Very Helpful

Item Score (circle one)

1. IP facilitators have a high personal commitment to

IPCP

2. The client has a key worker

3. The client has been with Life Without Barriers for a

long time (12 months+)

4. The client has few health problems

5. The client already has a current IP

6. The IP facilitator has lots of contact with the client

7. The IP facilitator provides direct support to the

client

8. Direct support to is provided by contracted support

workers

9. Direct support is provided by employed support

workers

10. The client has autism

11. The client has challenging behaviour

12. The IP facilitator is hostile to PCP

13. The client has active mental health issues

14. The client has emotional issues

15. The client currently lives in a large congregate

care facility

16. The client formerly lived in a large congregate care

facility

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Edward Birt of 29


17. The client has no known psychiatric disorders

18. The client lives near to family

19. The client has lots of contact with family

20. The client makes his/her own decisions

21. The client has a large network of unpaid supports

22. The client has a guardian appointed for decision-

making

23. The client has a large social network

24. The client has impaired mobility

25. The client is non verbal

26. The client uses alternative communication to

speech

27. Support worker to client ratios are 1:2 or less

28. Support worker to client ratios of 1:3 or more

29. Clear procedures for support worker support of

clients

30. Support workers provide active support to clients

31. Clear procedures are available for individual

planning

32. Clear procedures for activity planning

33. High support worker turnover

34. The client is new to the service

35. There is regular support worker training

36. There are high levels of service user involvement

37. Clear procedures for assessment

38. Clear procedures for teaching

39. Rigid routines or activities

40. Time management issues

41. Staffing issues, e.g. staff shortages

42. Arranging planning meetings

43. Participant reluctance to engage in process

44. Money

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Edward Birt of 29


45. Developing circle of support and involving others

46. Participant communication and understanding

47. Ability to access activities and services

48. Lack of knowledge and understanding of PCP

49. Family attitudes or disinterest

50. Participant health issues

51. Support worker attitudes

52. Management attitudes

53. Getting others to share workload

54. Systemic issues, please name them:

________________________________________

55. Participant behaviour

56. Inaction, nothing happens

57. Support worker turnover

58. Transport issues

59. Resource issues, please name them:

________________________________________

60. Communication between services

61. Participant mobility and access issues

62. Lack of staff skills and knowledge

63. Goal issues, e.g. unrealistic, difficult to meet

64. Linking different planning systems

65. Lack of social work, care manager, or social

services input

66. Risk issues

67. Other issues, please name them:

________________________________________

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

Further Comments (feel free to attach a separate piece of paper):

Edward Birt of 29

Thankyou for taking the time to complete this questionnaire

Your responses are confidential

Table from Robertson et al (2007), p.236 & Robertson et al (2007), p.305 Robertson, J., Emerson, E., Hatton, C., Elliott, J., McIntosh, B., Swift, P.,

Krinjen-Kemp, E., Towers, C., Romeo, R., Knapp, M., Sanderson, H., Routledge, M., Oakes, P. & Joyce, T. (2007). Person-centred planning: factors associated with successful outcomes for people with intellectual disabilities. Journal of Intellectual Disability Research, 51 (3), pp. 232 – 243.

e.birt - are we there yet pcp - 201109

Documents