‘Mum feels that the decision has already been made’:From shared decision-making to negotiated compromise in Adult Social Care

Adult social care policies in England promise people choice and control over their care and support, often via a process of shared decision-making (SDM). An adult social care initiative – ‘single-handed care’ – involves care provided by two workers changing to a single worker using advanced equipment and techniques. We carried out interviews with key stakeholders (n=26) involved in single-handed care. This included people providing (homecare workers), assessing for (occupational therapists and social workers), and receiving single-handed care as well as family members. Interviews were transcribed verbatim and analysed using standard qualitative processes and thematic analysis. We identified that the people receiving the service, family members and homecare workers sometimes felt that the decision to move to single-handed care had been made by the assessors before the SDM process began. The successful organisation of single-handed care required SDM to be balanced with competing responsibilities towards professional authority and accountability, and fiscal responsibility. Where there was a disagreement between stakeholders about a move to single-handed care tensions between these three responsibilities emerged. We argue that social care policies and procedures need to be more explicit about the extent to which decisions can be shared and that there may need to be a process of ‘negotiated compromise’ which sometimes allows other responsibilities to prevail.