!Person centred planning or person-centred action policy and practice in intellectual disability services

Journal of Applied Research in Intellectual Disabilities 2004, 17, 1±9

Person-Centred Planning or Person-Centred
Action? Policy and Practice in Intellectual
Disability Services
Jim Mansell and Julie Beadle-Brown
Tizard Centre, University of Kent at Canterbury, Beverley Farm, Canterbury, Kent CT2 7LZ, UK

Accepted for publication 25 September 2003

Background This critical review considers the nature and previous attempts at individual planning are analysed.
importance of person-centred planning in the context of The assumption that person-centred services will be pro-
current British policy and service development in intellec- duced by a new kind of individual planning is questioned.
tual disability. The difference between person-centred Conclusions Consideration is given to what would be
planning and other kinds of individual planning is dis- necessary to make services more person-centred, includ-
cussed. ing changes in power relations, funding arrangements and
Materials and method The scale of the task of implementing staff training and supervision.
person-centred planning as a national policy initiative is
considered. The limited evidence base for person-centred Keywords: individual plan, intellectual disability, person-
planning is reviewed and the reasons for the failure of centred plan, policy

In distinction to these methods, however, person-centred
Introduction
planning emphasizes three other characteristics found
wanting in them. Firstly, it aims to consider aspirations
What is person-centred planning?
and capacities expressed by the service user or those speak-
Person-centred planning is an approach to organizing ing on their behalf, rather than needs and de®ciencies. This
assistance to people with intellectual disabilities. Devel- emphasis on the authority of the service user's voice re¯ects
oped over nearly 30 years in the USA, it has recently dissatisfaction with the perceived failure of professionals
assumed particular importance in the UK because it forms to attend to what matters most to service users, the extent
a central component of the 2001 White Paper Valuing to which services are seen to constrain or impose goals
people. (Crocker 1990; O'Brien & Lovett 1992) and the observation
Person-centred planning is represented by a family of that services sometimes create arti®cial hurdles between
approaches and techniques, which share certain character- goals in an inappropriate `readiness model' (Wilcox &
istics (O'Brien & O'Brien 2000). It is individualized, in that Bellamy 1987) or `developmental continuum' (Taylor 1988).
it is intended to re¯ect the unique circumstances of the Secondly, person-centred planning attempts to include
individual person with intellectual disabilities in both and mobilize the individual's family and wider social
assessing and organizing what should be done. It shares network, as well as to use resources from the system of
this focus with other approaches to individualized plan- statutory services. This partly re¯ects the special interest
ning adopted in intellectual disability services, such as that family and friends have:
individual programme plans (Houts & Scott 1975; Blunden
1980; Accreditation Council on Services for Mentally Often it is family members who know the person best.
Retarded and Other Developmentally Disabled Persons They care about the person in a way that is different
1983; Jenkins et al. 1988) or individual service plans (Brost from everyone else and they will probably be involved
et al. 1982; Emerson et al. 1987), as well as with case in supporting the individual for the rest of their lives.
management methods adopted across many client groups They often bring huge commitment, energy and
(Challis & Davies 1986). knowledge to the table. (Sanderson 2000, p. 4)

# 2004 BILD Publications

2 Journal of Applied Research in Intellectual Disabilities

The implication is that families in particular have a stake implementation one of the priorities for the Learning
in the arrangements made to support an individual with Disability Development Fund and the Implementation
intellectual disabilities in a way that service employees do Support Team. (Department of Health 2001b, p. 50)
not.
Mobilizing the service user's social network is also Guidance issued subsequently (Department of Health
intended to broaden and deepen the range of resources 2001a) is intended to create a large-scale programme of
available to help them; indeed for some authors, there is training and implementation. The White Paper sets out an
the suggestion that services are part of the problem more ambitious programme of targets for the introduction of
than they are part of the solution (O'Brien & Lovett 1992, person-centred planning (numbers, unless otherwise indi-
p. 13). The social network is seen as a richer source of cated, from Valuing People (Department of Health 2001b)):
imagination, creativity and resources than the service 1 By April 2002:
system, not least in the area of forming and maintaining 1.1 Learning Disability Partnership Boards to agree a
social relationships, where intellectual disability services local framework
are seen as weak (Emerson & Hatton 1994). 2 By 2003 `speci®c priorities' for:
The third distinctive characteristic of person-centred 2.1 People still living in long-stay hospitals (about 1500
planning is that it emphasizes providing the support people)
required to achieve goals, rather than limiting goals to 2.2 Young people moving from children's to adult ser-
what services typically can manage. vices (number not known)
3 By 2004 `signi®cant progress' for:
Person centred planning assumes that people with 3.1 People using large day centres (about 50 000 people)
disabilities are ready to do whatever they want as long 3.2 People living in the family home with carers aged
as they are adequately supported. The `readiness over 70 (about 29 000 people (Mencap 2002))
model' is replaced with the `support model' which 3.3 People living on NHS residential campuses (about
acknowledges that everyone needs support and some 1500 people)
people need more support than others. (Sanderson
2000, p. 6)
The scale of the task
Taken together, these three characteristics are presented This is an extremely ambitious target for public policy, not
as making a fundamental break with previous methods of only because of the number involved but because of the
individual planning: nature of people's disabilities. The population of people
with intellectual disabilities include many individuals
It is not simply a collection of new techniques for with very severe problems, which are likely to hinder or
planning to replace Individual Programme Planning. impede the development and maintenance of relationships
It is based on a completely different way of seeing and with other people, making the maintenance of effective
working with people with disabilities, which is fun- person-centred planning dif®cult. For example, a recent
damentally about sharing power and community study of adults in residential care (Mansell et al. 2002)
inclusion. (Sanderson 2000, p. 2) found that 43% had major communication dif®culties, 63%
had impaired social interaction and 35% had severe chal-
lenging behaviour. Each of these, alone and in combination
Why is person-centred planning important?
with others, presents substantial dif®culties. For example,
Person-centred planning has been increasingly fashion- there is evidence that staff often misjudge the receptive
able in intellectual disability services, but it has assumed language ability of people with intellectual disabilities
particular importance since its adoption as a primary (McConkey et al. 1999; Purcell et al. 1999; Bradshaw
vehicle for change by the 2001 White Paper Valuing people. 2001), a common error being to rely too heavily on verbal
The White Paper identi®es person-centred planning as communication. Thus, in presenting and discussing
central to delivering the Government's four key principles options in the context of a person-centred planning meet-
(rights, independence, choice and inclusion) and a high ing, staff (and perhaps others too) risk failing to explain
priority for management attention and resources. possible courses of action adequately. Similarly, the extent
to which people with intellectual disabilities can under-
Given the importance of person-centred planning as a stand choices and decisions is often limited and requires
tool for achieving change, we will make supporting its careful assessment (Murphy & Clare 1995; Arscott et al.

# 2004 BILD Publications, Journal of Applied Research in Intellectual Disabilities, 17, 1±9

Journal of Applied Research in Intellectual Disabilities 3

1999). The nature of the dif®culties experienced by the are less important than they might once have been in
individual service user may also interfere with person- recruiting and sustaining a `circle of support', then other
centred planning. For example, aggression or self-injur- sources of motivation are important. Bulmer (1987) pointed
ious behaviour often results in negative emotional con- out that the most convincing general explanation of the
sequences for staff (Hastings 1995; Emerson & Hatton nature of caring relationships is reciprocity. What sustains
2000), which may make it more dif®cult to empathize with and nurtures helping relationships among people who are
the individual or to identify feasible means to achieve their not kin is a sense of exchange and balance in the relation-
goals. ship. Here, people with very substantial disabilities face a
None of these characteristics is, in itself, insuperable, particular problem in that they may have great dif®culty
and individual case illustrations (e.g. O'Brien & Mount maintaining the sense of balance required in the relation-
1989) show that irrespective of the level of intellectual ship. Qureshi et al. (1989) noted the importance of payment
disability or the nature of additional problems, people to community care helpers as a way of enabling recipients
with intellectual disabilities can have close personal rela- of care to feel that this balance is maintained. The dif®culty
tionships; but the studies cited indicate the scale of the of recruiting citizen advocates for people with intellectual
dif®culty to be overcome. disabilities perhaps re¯ects this as well as purely practical
It is therefore not surprising that many people with problems.
intellectual disabilities are extremely socially isolated.
Studies of people in residential settings, for example, often
Assessing the policy initiative
show low levels of contact from other staff and other
residents, particularly for people with severe and pro- There is now no serious alternative to the principle that
found intellectual disabilities (Emerson & Hatton 1994; services should be tailored to individual needs, circum-
Mansell 1994; Felce & Perry 1995). Studies of the social stances and wants. It is hard to remember a time when
networks of people with intellectual disabilities show that services for people with learning disabilities were not
they are often extremely restricted and dominated by expected to be individualized. But in the 1960s, in Britain
family and staff. Cambridge et al. (2001) found that, on and North America, custodial care, depersonalization,
average, people living in the community 12 years after block treatment and rigidity of routine were the norm.
deinstitutionalization had very limited social networks People did not have their own clothes; their possessions
compared to the wider population. They found that only were taken away, or lost, or destroyed, or stolen by
19% of members of these networks were unrelated to staff. There was no expectation of change and therefore
intellectual disability services. Robertson et al. (2001) found no need to plan anything (Blatt & Kaplan 1966; Morris
even smaller networks. Forrester-Jones et al. (2004) found 1969).
that people with mild or moderate intellectual disabilities Individualization of service organization has been
attending a supported employment programme had net- accompanied by the development of assessment and plan-
works averaging less than 50 people and nearly two-thirds ning tools, from early work on goal planning (Houts &
of network members were staff, family or other service Scott 1975) through to care management (Challis & Davies
users. Building the `circle of support' required around an 1986). However, it has also been accompanied by the
individual to undertake person-centred planning is there- investment of much greater resources in service provision
fore likely to be dif®cult for many people in the White and by new, smaller-scale services in the community
Paper target groups. (Mansell & Ericsson 1996). Greater individualization in
A third reservation about the scale of the task implied in practice may therefore be the result of a number of differ-
the White Paper is the general dif®culty in modern society ent aspects of the great changes in service provision, acting
of developing and sustaining relationships of the kind alone or of both in combination. It may owe at least as
required. The language of person-centred planning is much, for example, to changes in the kinds of services
the language of reciprocity, mutual interdependence provided and the associated changed attitudes of staff as it
and community. However, community, in the sense of does to particular methods of planning.
the closely knit, mutually supportive neighbourhood or Assessment of the weight given to person-centred plan-
village exempli®ed in sociological studies (e.g. Bulmer ning in the 2001 White Paper Valuing people therefore
1986; Young & Willmott 1986), is scarcer in reality than requires evaluation of the contribution made by planning
it is in rhetoric. In practice, it is family, and overwhel- systems as distinct from other changes in service organiza-
mingly women, who undertake the role of helping people tion (i.e. answering the question `are individual plans
with substantial needs (Dalley 1988). If tradition and duty effective?'). If person-centred planning is not likely to



deliver the bene®ts required in terms of individualizing in care management assessment, with evidence of stan-
services and driving their redevelopment, then its adop- dard assessments that do not address the particular needs
tion as a central plank of the policy seems problematic. In of people with intellectual disabilities (Challis 1999).
particular, the diversion of large amounts of time, effort There is also evidence from several larger-scale evalua-
and money into switching from existing planning systems tions that individual plans are not well-connected to the
to person-centred planning may not be justi®ed if this real lives of people using services. Shaddock & Bramston
turns out to be `more of the same'. 1991) found serious de®ciencies in the planning process in
50 plans drawn from group homes for people with devel-
opmental disabilities. Clients, relatives and advocates
Are individual plans effective?
were often not present when goals were set. Long-term
As Kinsella (2000) pointed out, there is almost no evidence goals were often omitted. Typically, goals and objectives
of the effectiveness of person-centred planning compared were not written in speci®c measurable terms, criteria
to other approaches. What evidence there is largely com- were not stated and the conditions under which the beha-
prises individual case studies referred to in the course of viour should occur were omitted. Cummins et al. (1994)
commentaries on the process and its desirability (e.g. found that 19% of plans for 199 people had no review date
O'Brien & Mount 1989; Certo et al. 1997; Everson & Reid and 30% of meetings were not attended by any family,
1997; Department of Health 2001a). A systematic review by friends or advocates of the individual service user. In a
Rudkin & Rowe (1999) found no statistically signi®cant later study, Cummins et al. (1996) analysed 163 plans from
outcome differences with good statistical power for people 11 community-living support services. The average level
receiving person-centred planning. of presentation was poor. Only 14% offered any criterion
Despite the lack of an evidence base, there are studies of for evaluating performance objectives, the average number
other forms of individualized planning, which share some of skill-building objectives was 3.25 per plan, and only 39%
characteristics with person-centred planning. These of plans were current. Conroy et al. (unpublished MSc
include studies of individual programme plans in intel- Dissertation, University of Kent) compared 18 people who
lectual disability services, studies of care management had functional individual programme plans with 18 who
arrangements and studies of the individualized planning did not and found no difference between the groups in
process in special educational needs. satisfaction, observed levels of engagement or records of
The ®rst observation from these studies is that, in prac- participation in activity. Stancliffe et al. (1999) evaluated
tice, individual planning only reaches a minority of service plan objectives for 126 adults with mental retardation
users. An inspection of day services by the British Social living in institutional or community settings and found
Services Inspectorate (1989) found that only 25% of service no signi®cant change in outcomes associated with having
users had an individual programme plan on ®le. Felce et al. an objective. Miner & Bates (1997) found that participation
(1998) reported that during the implementation of the All- in person-centred planning increased the extent to which
Wales Strategy for intellectual disability services, the high- parents or guardians contributed to individual educational
est level of individual plan coverage achieved was only planning or transition planning meetings. These families
33% of service users. Problems in resourcing the level of perceived that meetings were more favourable and almost
individual planning required are also evident in special all rated person-centred planning as valuable and effec-
education, where despite a legal mandate, half of educa- tive, although there was no difference in their satisfaction
tion authorities fail to achieve the 18-week target for with the meeting.
production of a plan (Audit Commission 1998), and in Thus, case studies suggest that person-centred planning
care management, where failure to hold effective reviews can be valuable and may change the perception of parti-
have been identi®ed as a common problem area (Challis cipants. There are no good-quality, systematic evaluations
1999). of person-centred planning, but as person-centred plan-
Where individual plans are created, they are often a ning shares many characteristics with previous attempts at
paper exercise. The Social Services Inspectorate (1989) individual planning, evidence from these is relevant. This
found evidence that plans were in case notes but not evidence suggests that when implemented on a large scale,
necessarily used. Radcliffe & Hegarty (2001) found that there are problems with coverage, quality and outcomes.
in two and three out of eight cases they studied in 1998 and In order to achieve greater individualization of service
1999, individual plan goals were not translated into the organization and delivery, it may therefore be helpful to
daily programme of support to service users. Cambridge analyse why earlier attempts at individual planning
(1999) suggests that administrative interests predominate appear to have failed.



be functional; it may serve the purpose of the organizations
Why do individual plans fail?
involved.
Resource constraints
Implementation gap
A recurrent theme in reviews of care management is that
an important factor shaping the operation of such indivi- A second feature evident in evaluation of individual plans
dualized planning systems is the need for service organi- is what might be called the implementation gap ± the failure
zations to control expenditure (Challis 1999). In the to carry through plans into practice. Although the evi-
absence of effective ®nancial information systems enabling dence is limited because so few studies have addressed
devolved budgets, the freedom for care managers to outcomes ± real changes in the lives of the people with
design individually tailored arrangements is likely to be intellectual disabilities studied ± there are suf®cient
constrained. This appears to be achieved through the grounds in the literature cited to be concerned that per-
introduction of waiting lists, the use of standardized pro- son-centred planning (or any other kind of individual
Á
cedures for assessment (prix ®xe rather than a la carte), the planning) is largely a paper exercise.
bureaucratization of management processes and the reser- The explanation for this implicit in the White Paper
vation of funding decisions to higher-level managers Valuing people is that there is insuf®cient understanding
removed from direct contact with service users. (and so the appropriate reform is more training in how to
An important factor in the British context may be that, do person-centred planning). The alternative formulation
unlike the USA, individualized service plans are not given above is that lack of resources prevents implementa-
legally mandated. The scope for redress if aspirations tion and undermines the motivation to take planning
are ignored or subverted is therefore very limited. Even seriously. In addition, there is a further aspect of indivi-
in British special education, where there is a legally dual planning, which may help explain its limitations in
enforceable right to a plan, delay and a restricted range practice; that is, the relationship between objective setting
of options appear to have been used to ration resources. and the skills and daily practice of staff providing support.
Administrative culture may therefore be as important as There is extensive evidence that front-line staff working
legal entitlement in promoting meaningful individual with people with intellectual disabilities, especially people
planning. with severe and profound intellectual disabilities, typically
If cost control does intrude in this way, the implication is provide little in the way of facilitative assistance to support
that simply changing the style of planning, from whatever engagement in meaningful activity at home and in the
went before to person-centred planning, is unlikely to community (Emerson & Hatton 1994; Perry & Felce 2003).
make any difference. It would be expected that, if person- In consequence, levels of engagement are low, with related
centred planning became at all widespread, mechanisms evidence that people do not continue to develop and grow
would be developed to constrain it within ®nancial in competence in adult life (Cambridge et al. 2001) and
limits. One particular risk that person-centred planning have restricted social networks and relationships. Only a
presents in this respect is that it explicitly embraces the small proportion of these staff are trained (Ward 1999), and
idea that informal care is important and possibly even recent Government initiatives acknowledge this and
preferable to formal service provision. Thus, it opens include attempts to substantially increase training
up the possibility for service agencies to now de®ne (Department of Health 2001c, 2002). Therefore, if indivi-
activities, which they would previously have funded, as dual plan goals are developed that involve providing
the responsibility of the `circle of support'. There is skilled support to the individual (for example, in accessing
some evidence from the care management literature of unfamiliar places and situations, or in coping with much
emotional support and counselling not being provided higher levels of stress and demand), it is likely that staff
even though identi®ed as areas of need in their own right will not be able to provide suf®ciently skilled help for
(Challis 1999), which might re¯ect rationing judgements people with more complex needs.
that some kinds of services are not to be provided by the Thus, where goals have resource implications ± moving
formal sector. from a residential home to supported living, for example ±
This suggests the possibility therefore that the failure of expenditure constraints may prevent their achievement.
individual planning is not primarily because of lack of Where they are concerned with changing individual
understanding or of the particular kind of planning experience without major new resources ± such as helping
approach used, but a by-product of the need for public a person with severely challenging behaviour to shop
agencies to control their budgets. In this sense, failure may more independently ± skill shortages among staff may



do so. Both situations are likely to lead to individual 3 More use could be made of direct payments and user-
planning becoming a paper exercise with little impact controlled trusts/independent living trusts for people
on real life. In a sense, staff working through these pro- with severe intellectual disabilities, as well as those with
cesses in services are once again in the grip of a `readiness' more mild disabilities. This would potentially empower
model, not for the client but for the service ± `we are service users in achieving their individual plan, providing
waiting until the person gets a new home/job/we get more security and consistency of service (in that once
training/policy changes/we are reorganised'. In this situa- agreed, it is harder for a direct payment to be taken away
tion, individualized planning becomes a kind of displace- or reduced in amount without evidence of mismanage-
ment activity, using staff energy, time and resources but ment of the direct payment). However, for this to happen,
not making any difference to people's lives. local authorities need to be more open to the possibility of
Is a new kind of planning going to change this? Is trust-managed direct payments.
pushing investment into training lots of people to make 4 National policy could set the expectation that personal
individual planning person-centred the best use of goals and plans would be resourced and achieved, instead
resources? of maintaining an equivocal stance that asserts on the one
hand that person-centredness is a high priority but avoids,
on the other, holding local social services departments to
What would it take to make services more
account for its delivery.
person-centred?
5 Performance management by government could focus
The implication of this analysis is that making British not on numbers of plans produced, but on the quality of
services more person-centred will not result from attempts the plans and the extent to which they are implemented.
to achieve the widespread introduction of a new model of The focus of policy implementation and monitoring could
individual planning. Rather, it directs attention to the way shift from person-centred planning to person-centred
services are funded and to the skills staff have. action. This would be likely to require a shift from a
The ®rst area in which change is needed to address the rationalist policy implementation framework, in which
balance of power that diminishes the potency of individual implementation is treated as a largely mechanical process,
aspirations in public planning processes is to strengthen to focus on what Wenger & Snyder (2000), cited in O'Brien
the hand of the individual service user against social & O'Brien (2000), called communities of practice ± `groups
services departments in determining the goals and imple- of people informally bound together by shared expertise
mentation of any individual plan. There are several ways, and a passion for a joint enterprise'. The development of
which are not mutually exclusive, in which this might be such communities, with evidence of real effects in the lives
achieved: of the people they serve, would be a higher priority than
1 Person-centred planning could be given legal weight, as extent or coverage of plans.
is the case in some other countries. This might be based on This directs attention to the quality of work of staff
legal entitlement to fair, humane and effective treatment providing support and advice to people with intellectual
based on a constitution or on human rights legislation. This disabilities and their families. Whatever national policy
would allow individual service users to challenge failure says, it is these staff who make it a reality or not. Here too
to provide services to help them achieve what they want there are several steps that could be taken to make services
and to test the decisions of public agencies in terms of their more person-centred:
reasonableness. As British special education experience 1 Training in the goals of service provision could empha-
shows, legal entitlements are not everything; but in those size action that makes a tangible difference in the daily
countries where they exist, there is evidence of them being lives of people with intellectual disabilities as a priority,
used to secure improved services. and distinguish this from action which is consistent with
2 Funding decisions could be decoupled from individual appropriate values but does not actually lead to change.
planning by replacing local budgets managed to a ®xed This is likely to require a balance to be struck between
level, with social security entitlements based on assessed relatively ordinary and more special activities. Ordinary,
status. This would give service users with disabilities of a even mundane activities, which occur frequently and do
set degree an absolute entitlement to a particular level of not necessarily require great resources to change (but from
funding; it would re-focus individual planning arrange- which many people with intellectual disabilities are
ments in social services departments on the content of the excluded through lack of appropriate staff support) may
plan and on helping people achieve better lives, instead of be important opportunities for personal growth, develop-
on rationing. ment and empowerment. The kind of dramatic, dif®cult,



expensive activities that are often identi®ed as important Beverley Farm, Canterbury, Kent CT2 7LZ, UK (E-mail
(because of the belief that they will transform expecta- j.mansell@kent.ac.uk)
tions about individual people with intellectual disabilities)
do not necessarily have much impact beyond the event
itself. References
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