Scottish Government

Executive Summary

Definitions

A direct payment is money paid by the local authority directly to a disabled person whom it has assessed as needing community care services. The local authority makes the payment instead of arranging services. The person uses the payment to purchase the relevant services. In practice, recipients often employ their own Personal Assistants (PAs) but this is not a requirement. Support can be purchased through agencies or in the form of services, except for those directly provided by local authorities.

Direct payment schemes are distinct from:

• third party schemes, where payments are not made directly to the disabled person but through an agency which may or may not support the person in using the money;
• The Independent Living (extension) Fund which continues payments to those who were already receiving independent living fund (ILF) money. The ILF was a trust fund set up by government in 1988. It closed to new recipients in 1992;
• The independent living (1993) fund, which has much more restrictive criteria than the original ILF and involves assessment by social work departments;
• Independent living schemes, operated by a few local authorities in England and Lothian, to give disabled people money with which to employ personal assistants. Money was paid into trust funds because it was illegal to make cash payments direct to clients.

Aims and methods

The main aim of this 7 month study was to examine the effectiveness of current arrangements for direct payments across Scotland, to identify barriers to wider implementation and methods of tackling them.

The research was carried out in two parts. The first involved a telephone survey of all unitary authorities in Scotland. The second comprised detailed examination of arrangements in four case study authorities. Here interviews or focus groups were conducted with:

• 4 social work managers
• 4 care managers
• 4 organisations of disabled people/voluntary organisations - (which we call 'supporting organisations')
• 12 people receiving direct payments
• 7 people employing PAs through Independent Living Fund (ILF) monies

The study was as participatory as possible. It was jointly co-ordinated by SHS (Scottish Human Services) and the Lothian Centre for Integrated Living. Disabled researchers were employed and a respondent validation meeting was held once the initial analysis was completed.

Key findings from the all- Scotland telephone survey

Implementation of direct payments

There is considerable confusion among local authorities about what direct payments are and how they operate. Some authorities reported having a direct payment scheme, which turned out to be a third party scheme. Others did not identify direct payment recipients who, it later emerged, did exist.

Only 13 of the 32 authorities in Scotland have either fully operational or pilot direct payment schemes with current recipients. (Four others reported having schemes with no recipients).

Eleven authorities (including one which also has a direct payments scheme with no recipients) have third party schemes; one has a 'supplementary' scheme while three have no arrangements for making payments to disabled people.

It was reported that 143 people across Scotland were receiving direct payments. 125 (87%) had physical or sensory impairment and 17 (12%) had learning disabilities. One recipient had Asperger's Syndrome. There were no users of mental health services among the recipients. No one from an ethnic minority community was receiving a direct payment.

Eighteen people across Scotland were awaiting assessment or approval for a direct payment. Again, most of these individuals had physical impairments.

Promotion of direct payments

While some authorities had used a range of methods to publicise their schemes, others lacked any clear recruitment strategy. A few had decided not to publicise the scheme because they did not feel able to cope with increased demand.

Five authorities reported applying additional eligibility criteria to those set out in the legislation. Most commonly, recipients had to fall into the top priority category for community care - they should be at risk of entering residential care.

Four authorities were working with Values into Action (VIA) to promote take-up among people with learning disabilities. Others were uncertain how to interpret the requirement that people be 'able to manage' a direct payment, and about the implications of the recent South Lanarkshire ruling. Local authorities were giving considerably less thought to promoting take-up among users of mental health services.

Fourteen authorities with direct payment schemes reported having support systems in place for recipients, but these varied tremendously in form and scope. Social workers were concerned about gaps in support, particularly regarding support and advice for people with learning disabilities, and training for recipients about being an employer.

Funding issues

There is real variation across Scotland in the level and source of funding for direct payments. Lack of flexibility between budgets was identified as a major problem, particularly where there were no ring-fenced monies for direct payments. The highest reported payment to an individual was £4,583 per month, the lowest, £153.

Rates of pay and employment conditions for personal assistants (PAs) differed significantly between authorities. Where standard rates applied, as they did in most authorities, these ranged from £3.60 to £11.64 per hour. In some cases, these figures included employers' costs and contingency funds, but many did not. These rates are well below those offered to care staff by some independent agencies.

Difficulty recruiting PAs was experienced in most authorities, particularly rural ones.

Future plans

The future of many schemes was uncertain. One pilot scheme and one fully operational scheme were under threat of closure; most other pilots were to continue as pilots. Among those authorities with no direct payment scheme, only three had clear plans to develop one. While there was near unanimous approval for the principles underlying direct payments, development was hampered by concerns about:

• Lack of funding to operate schemes
• A perceived threat to the funding or future of local authority services
• Anxiety about perceived implications for social workers' role
• Anxiety about people's ability to manage payments
• Lack of adequate support for recipients

Key findings from the case study authorities

Benefits of direct payments

Given the low numbers of recipients, direct payments cannot as yet be said to have had a major impact in Scotland. In qualitative terms however, very significant benefits were identified for and by recipients. The most important was the opportunity to exercise choice and control: this was particularly marked for people who had previously used local authority services which had offered considerably less flexibility.

Other advantages reported for and by recipients included having a 'normal' life, acquiring new skills, broadening their horizons, and wider benefits to family members. Direct payments also enabled recipients to overcome certain barriers to Independent Living, such as inaccessible transport and employment, and had enabled a few to move into their own home. In some cases, such benefits added up to a dramatically improved quality of life. However, people who had transferred from Independent Living Schemes reported noticing little difference in the new arrangements.

Recipients identified very few, if any, disadvantages to direct payments. Where drawbacks were mentioned, these generally related to aspects of policy or practice in particular authorities (see below), rather than to direct payments per se.

There are benefits too for social work departments. Direct payments can lead to more efficient use of human and financial resources while improving the quality of support to recipients. Time invested in setting up a scheme can be recouped in the mid to longer term. Budgetary gains are also possible, meaning that more support can be purchased for the same outlay. Quality can be improved because direct payments allow for a much closer match of services to the particular needs of the individual. Similarly, despite operational difficulties, social work staff expressed firm support for the principles underlying direct payments. Some thought that the provision should be mandatory on local authorities.

Direct payments arrangements

Arrangements in the four case study authorities varied considerably. It emerged that Authority B was operating a third party scheme although social work managers, interviewed for the telephone survey, had described the arrangements as a direct payments scheme. In this authority, 5 other people were receiving direct payments but were not classed as such, as explained in Chapter 3.

• Authority A had just started running a pilot scheme with a discrete budget, targeting new or unmet needs within a small geographical area. It was having difficulty identifying potential recipients and currently there was only one. Support was provided by a local voluntary organisation. Payments were currently being made to that agency in the form of a lump sum, and not to the disabled person. This was an interim measure while the authority calculated the unit cost of employment support.
• Authority B initially claimed to have one direct payment recipient, who was in fact receiving support via a third party scheme. Meanwhile, it emerged that five other people were receiving direct payments but were not classed as such. There was no local supporting organisation; a payroll service and occasional advice was provided by a voluntary agency in another authority.
• Authority C was running a pilot direct payment scheme with only 3 users. It had publicised the scheme, but information produced was felt by some respondents to be inaccessible and off-putting. There was no active supporting organisation. However, a local disability organisation had just received local authority funding tofunding to provide support services.
• Authority D had 54 direct payment recipients. The vast majority in the main scheme had been automatically transferred from a pre-existing Independent Living Scheme. Only people at imminent risk of entering residential care were eligible and the supporting organisation knew of only 7 new recruits to this scheme. Direct Payments could only be used for services which the local authority purchased or was planning to purchase. They could not be used as a substitute for services which the local authority could provide and had staff to provide, as this was deemed to be paying twice. These rules did not apply to a separate pilot scheme targeted on people with learning disabilities, those with sensory impairment and mental health service users. This scheme had 6 recipients.

Discounting those who had been transferred from an independent living scheme in authority D, take-up in all four local authorities was very low. However, this common outcome was attributable to different reasons in each case.

Barriers to wider implementation

• Our respondents identified many reasons for the slow implementation of direct payments across Scotland. The factors identified most often, (echoing many findings from the wider telephone survey), were:
• Confusion in some local authorities about what constitutes direct payments
• Perceived need on the part of local authorities to limit demand
• Demands on care managers' time, especially where there was no supporting organisation, and in the context of existing heavy workloads
• Absence of operational infrastructure for direct payments within local authorities
• Lack of information and publicity
• Lack of active recruitment policies, or restrictive recruitment policies
• The national 'ban' on direct payments to older people
• The national 'ban' on employing relatives as PAs
• The application of additional local criteria, seen by social workers, recipients and support organisations as unnecessarily restrictive: for example, that potential recipients must be at risk of entering residential care, or that direct payments cannot be used to replace services already provided by the local authority, where the latter judges that these adequately meet the individual's needs
• Funding restraints - particularly where there is no ring-fenced money nor scope for flexible use of budgets
• The fact that direct payments are discretionary rather than rights-based and mandatory

The main operational features which caused challenges for respondents were:

• Difficulties recruiting PAs, partly linked to poor rates of pay
• Lack of clarity about monitoring and review procedures. Some care managers are maintaining a 'hands-off' approach, in order to avoid unduly interfering with arrangements: however, mechanisms still need to be in place to identify and address problems effectively
• Concern about any increase in charging policies, which would cause hardship for many. In addition, participants at the respondent validation meeting felt strongly that Independent Living should be seen as a right, and not a service for which people had to pay
• Taking on the role of employer - some recipients felt they had been thrown in at the deep end and left to work things out themselves. Others who had received some training wanted more. Choice about where support and training were purchased was usually minimal
• Paperwork and bureaucracy involved in administering direct payments. Some recipients suggested that making financial returns should be required less frequently than quarterly
• Lack of knowledge of local authority complaints procedures, which appeared to be poorly publicised

Implications for policy and practice

To achieve the positive outcomes identified for recipients, their families, social workers and the community more widely, action is required on a number of fronts. The order in which different elements are put into place was shown to be significant in setting in train either positive, or negative, dynamics.

Confused understanding about direct payments in many local authorities points to the need for changes both in national legislation and guidance and in the arrangements for local schemes. The following suggestions are based on the findings of the research and in some cases were directly suggested by respondents.

• The provision of direct payments schemes by local authorities should be mandatory i.e. all authorities should have the duty to develop and promote schemes. It is of equal importance that all applicants have the right to have their applications assessed against clearly defined and consistent criteria.
• The publication by the Scottish Executive of detailed guidance about all aspects of direct payments
• The extension of direct payments to people aged over 65
• A more flexible approach to employing relatives as PAs
• Clarification of the requirement that recipients must be "willing and able to manage" a direct payment "alone or with assistance". The emphasis should be on willingness and ability to exercise choice rather than capacity to manage a direct payment

The findings suggest a number of ways of overcoming fears about the impact of direct payments on social work workloads and relationships with clients. These fears were found to be closely related to lack of experience amongst managers and professional staff in this area of work. This indicates a need for:

• The development of independent supporting organisations and advocacy, both locally and nationally; this requires financial support and clarification of roles and responsibilities between supporting organisations and social work departments. Some respondents strongly believed supporting organisations should be user-led
• The development of knowledge and expertise among social work staff through training, support and information
• The development of support and networking mechanisms among local authorities for the exchange of information and experience about direct payments
• The development of support and networking mechanisms among supporting organisations for the exchange of information and experience about direct payments
• Review of the different forms of 'direct payment' schemes in operation, to explore the rationale for their differing criteria and ways of simplifying their interface

Once arrangements for making direct payments were developed and support arrangements put in place, specific groups of potential recipients audiences needed to be contacted. This indicated a need for:

• The development of effective publicity strategies by local authorities in collaboration with supporting organisations
• The promotion of take-up of direct payments among people with high support needs through the use of brokerage schemes, circles of support and supported decision-making (This was suggested at the respondent validation meeting)
• Promotion of direct payments to users of mental health services, again with the assistance of user-led organisations and specialist social work staff

Respondents themselves, at the respondent validation meeting, proposed the establishment of a Task Force made up of representatives from local and central government, the National Centre for Independent Living and the Scottish Personal Assistant Employers' Network (SPAEN), to promote direct payments and set and monitor targets.