Co-Production and Consent in Ethical PBS: Making Voice Real in Daily Support

Co-production is frequently referenced in PBS, but ethical and values-based PBS requires it to be evidenced in daily practice, not just at the point of assessment. In adult social care, “voice” can be lost when risk escalates, staffing pressures increase, or a person’s communication is complex. Ethical PBS protects against this by treating consent and co-production as operational requirements: built into routines, risk planning, and review processes.

Providers working within ethical and values-based PBS frameworks should be able to show how core principles and values translate into concrete practices that keep people central to decisions about their own lives, even when behaviour is challenging and risk is real.

Where restrictive practices are used, there must be clear justification, review and reduction plans. This is explored further in reducing restrictive practices through PBS and human rights frameworks.

Why Co-Production is an Ethical Requirement, Not an Optional Extra

Co-production is not simply “consultation”. Ethical PBS requires that the person’s preferences, distress indicators, and goals shape the support approach. This matters because behaviour is often communication. If the service does not create mechanisms for the person to influence decisions, staff may misinterpret behaviour and respond in ways that increase distress and restriction.

Co-production must also be realistic. In practice, it means building repeatable methods for capturing voice and using it to guide decisions at the point of delivery.

Consent in Day-to-Day PBS Delivery

Consent is not a one-off event. For many people, consent is communicated through behaviour, body language, pacing, and choice responses rather than formal verbal agreement. Ethical PBS ensures staff are trained to recognise and respect these signals, and to adjust routines when consent is not present.

Practical approaches include:

• “Consent checkpoints” during personal care, medication prompts, and activities.
• Choice structures that are accessible (visual, objects of reference, simple options).
• Recording what the person consistently prefers, refuses, or tolerates.
• Reviewing routines that trigger distress and redesigning them with the person.

Operational Example 1: Co-Produced Morning Routine to Reduce Distress

Context: A person regularly became distressed each morning, often shouting and refusing support. Staff interpreted this as “challenging behaviour” and attempted to push routines through quickly due to shift timing.

Support approach: Ethical PBS required the team to treat distress as communication and prioritise autonomy and dignity. The person and family were involved to identify what “a good morning” looked like.

Day-to-day delivery: Staff redesigned the routine: later start time, preferred staff pairing, breakfast choice before personal care, and a predictable visual sequence. Staff stopped using time-pressured prompts and introduced “pause and reset” steps when early distress indicators were observed.

Evidence of effectiveness: Distress episodes reduced, staff recorded improved engagement, and the PBS plan was updated with co-produced routine details and reviewed after two weeks to confirm sustainability.

Co-Production in Risk Planning and Positive Risk-Taking

Ethical PBS requires that risk decisions are not made “about” the person without them. Positive risk-taking is central to quality of life, but it must be shared, planned and reviewed. Co-production in risk planning means making the person’s values and preferences explicit, then designing safeguards that enable choice rather than remove it.

This is also where commissioning logic is important: commissioners expect evidence that risks are managed proportionately, that independence is promoted, and that restrictions are justified and reviewed.

Operational Example 2: Co-Producing Community Access After Incidents

Context: Following a community incident involving verbal aggression, staff reduced community access and replaced it with indoor activities. The person became more isolated, and behaviour escalated in the home environment.

Support approach: The PBS lead used an ethical review to challenge restriction drift and re-centre the person’s goals. The person expressed a clear preference for specific places and routines in the community.

Day-to-day delivery: Staff and the person co-produced a community plan: quieter times, preferred routes, agreed exit strategies, and a “support signal” for when anxiety was rising. Staff documented de-escalation steps and agreed when to pause and return home. The plan was shared with family and reviewed weekly for the first month.

Evidence of effectiveness: Community access increased, incidents reduced, and staff confidence improved. Records evidenced structured positive risk-taking rather than blanket restriction.

Communication, Advocacy and “Voice” for People with Complex Needs

Ethical PBS expects providers to invest in communication approaches that make voice possible. This may include speech and language therapy input, communication passports, structured observation, and consistent staff approaches.

It also includes recognising when advocacy is needed—particularly where there are disputes about restrictions, consent, or best interests. Ethical PBS does not avoid this complexity; it plans for it.

Operational Example 3: Embedding Consent and Voice in Medication Support

Context: A person frequently refused medication. Staff responded inconsistently: some tried to persuade repeatedly, others escalated to “must take” language, increasing distress and conflict.

Support approach: Ethical PBS required a co-produced approach: understanding reasons for refusal (taste, timing, side effects anxiety) and redesigning prompts to preserve dignity and reduce coercion.

Day-to-day delivery: The team introduced a choice-based medication routine: preferred drink, preferred staff, clear information prompts, and a “return later” option. Staff recorded refusals without punitive language and used a structured follow-up plan agreed with clinical oversight. The person helped design a visual cue card indicating “not now” versus “never”.

Evidence of effectiveness: Refusal-related distress reduced, medication adherence improved where clinically appropriate, and the service could evidence that consent and dignity were prioritised alongside safe escalation pathways.

Commissioner Expectation: Evidence of Co-Production in Outcomes

Commissioner expectation: Commissioners expect providers to evidence co-production in practice, including how plans reflect the person’s goals and how risk decisions support independence. They will look for documentation that shows the person’s voice influenced support approaches, not simply that meetings occurred.

Regulator Expectation: Person-Centred, Respectful Care

Regulator expectation: CQC expects person-centred care that respects dignity, consent and choice. Inspectors will test whether people are involved in decisions, whether restrictive responses are challenged, and whether staff communication approaches are respectful and consistent—especially where needs are complex.

Governance and Assurance for Co-Production

Co-production becomes reliable when it is governed: regular plan reviews that require evidence of voice, supervision prompts that test consent practice, and quality checks that identify drift into directive or restrictive routines. Ethical PBS makes co-production a daily discipline, not a periodic workshop.

When consent and voice are operationalised, PBS becomes safer, more effective, and more defensible—because it aligns support to what matters most to the person, while maintaining proportional safeguards and clear accountability.