Scottish Government

CHAPTER TWO
An Overview of Direct Payments across Scotland

Introduction

2.1 This chapter presents the main findings from the telephone survey of local authorities. A more detailed account of these results was submitted to The Scottish Executive in the interim report (Jones et al, 1999). The findings relate to data collected between October and December 1999. As noted previously, only one authority did not respond to the telephone survey. However in preparing this final report, contact was renewed with this authority in order to gather some basic details about its arrangements for making direct payments. The interview schedule used appears in the Annex.

2.2 Authorities were asked to identify the most appropriate individual to take part in an interview about direct payments. In most cases, these were people at middle management level, such as senior social workers or community care planners. In one case, a local authority councillor was the respondent.

Payment systems in operation

2.3 There are widely varying arrangements in place across Scotland to enable people to purchase their own support. There are also very different interpretations of the terms used to describe such arrangements. To summarise:

• Nine authorities reported they are running fully operational direct payment schemes, but two of these have no users;
• Eight authorities are running pilot direct payments schemes, but two of these have no users;
• Eleven authorities are running third party schemes;
• One authority is running a 'supplementary' scheme;
• Three authorities have no arrangements for making direct or indirect payments.

2.4 One of our first findings - which proved indicative of much that emerged later - was that some respondents were unclear about the type of scheme operating in their authority. For example, one respondent initially classified the local scheme as a direct payments but later in the interview he began to question if this was really the case. He later stated that no one was currently receiving a direct payment. It was further reported in local policy documents that "direct payments are only made in exceptional circumstances". A second authority began by reporting that it ran a direct payment scheme but went on to reveal that payments are made through a third party Independent Living Scheme. Both of these authorities were, therefore, classified as third party schemes.

2.5 A third authority stated that it had neither a direct payment nor a third party scheme but instead had a 'supplementary' system. This authority makes payments to disabled people or family members in limited circumstances under Section 12 of the Social Work Scotland Act (1968). These payments are made to enable recipients to enter into private arrangements to receive short-term 'respite' care at home over and above any local authority home care service they already receive.

2.6 The word 'scheme' also caused some confusion. One authority stated that it did not have a direct payment or third party scheme even though payments are made to two people through a third party agency. Other authorities said they had a scheme even though there were no disabled people receiving payments.

2.7 Four authorities who reported having direct payment schemes had no users despite the fact that the schemes had been 'operating' for between seven and thirteen months. The respondent in one of these authorities went on to answer the rest of the questions in relation to the third party scheme operating in that authority. As a result, nothing more can be said about the arrangements for making direct payments in that authority. The other three authorities had never turned down an application for a direct payment and had never made payments to disabled people in the past. Only one of these authorities had a disabled person awaiting assessment or approval for a payment.

2.8 Following our investigation, then, it is clear that a total of 13, less than half of the authorities in Scotland, have direct payment schemes in place which are making payments to disabled people.

2.9 The rest of this chapter focuses on information supplied by 16 of the 17 authorities which claimed to have set up direct payment schemes, including three of the four which had no recipients. As noted above, the fourth of these authorities supplied information relating to its third party scheme and thus it is not included here.

Consultation with disabled people

2.10 Twelve authorities had consulted to varying degrees with disabled people before setting up their schemes. Three of these had written to organisations of disabled people, 7 had met with such organisations, while 2 had used a variety of methods, including meeting with people in groups and as individuals, and holding conferences. Seven authorities were consulting disabled people on an ongoing basis, for example, by including people in steering or monitoring groups, in evaluations or training. The five authorities which had no arrangements for consultation also had low numbers of recipients (between 0 and 4).

Length of time schemes had been operating

2.11 The pilot direct payment schemes had been in operation for between 2 and 31 months. The fully operational schemes had been running between 13 and 39 months, including pilot periods. This shows considerable variation across Scotland in the pace at which authorities have responded to their powers under the Community Care (Direct Payments) Act 1996, and, by implication, in the priority they have given it.

Number and characteristics of recipients

2.12 The total number of people receiving direct payments in Scotland is very low - 143 people. This is an average of less than 5 in the 32 Scottish authorities and 9 in the 16 authorities reported as having schemes.

2.13 As already stated, 4 authorities reporting they had schemes but no users. Eight authorities each provide direct payments to between one and 6 people. Four authorities provide direct payments to between 10 and 17 people. The remaining authority estimated that it has 54 recipients. This authority first provided direct payments 23 months ago when members of an Independent Living Scheme were moved onto the direct payment system. According to the local disability organisation involved in the steering group for this scheme that there have been 7 'new' recipients and another 6 joining a pilot scheme for people with learning disabilities and/or sensory impairment.

2.14 Eighty-seven per cent (125) of those receiving direct payments in Scotland are people with physical or sensory impairments. Only 12% (17) have learning disabilities, while one person has Asperger's Syndrome. No one using mental health services was receiving a direct payment. These findings bear out the research by Holman and Bewley (1999) and by Maglajlic et al (1998), referred to in the previous chapter, concerning the low uptake of direct payments by people with learning disabilities and users of mental health services in England and Wales.

2.15 There were no people from a minority ethnic community receiving a direct payment.

2.16 There was no evidence to support a particular pattern of take-up in small or large authorities, or rural or urban locations. However, of the 3 authorities with no current recipients, 2 were island authorities and the third was a city. Low take-up in the islands may be partly due a somewhat restrictive policy operated by these authorities regarding the range of services which can be purchased with direct payments. Given that recipients are not normally allowed to employ their own relatives or household members as PAs, the difficulty of finding suitable people to take on this role may also be a factor in rural areas of low population, coupled with the scarcity of independent care providers.

2.17 Across Scotland, a total of 18 people were reported to be awaiting assessment for or approval of a direct payment. In terms of personal characteristics, a similar pattern emerged here to that already identified among recipients. Thirteen of these people had physical or sensory impairments and one had a learning disability. Two were people using mental health services and one was described as a mental health service user with a physical impairment. (One person's impairment was not specified). No one from an ethnic minority community was awaiting assessment. These findings indicate that the level and pattern of take-up is unlikely to change in the short term.

2.18 Several authorities stated that they want to encourage more people with learning disabilities to use direct payments. Four were addressing this issue with the help of People First and Values Into Action (VIA) who, as mentioned in Chapter One, are engaged in a project to increase take-up among people with learning disabilities. One authority had recently initiated a demonstration project working with day centre staff to encourage people with learning disabilities to apply for direct payments. Another has a policy of excluding people with learning disabilities from consideration for direct payments. A third reported that it had not extended the scheme to people with learning disabilities but was being pushed to consider doing so by other agencies. It called for more guidelines in this area. A fourth reported a willingness to extend direct payments to young people with learning disabilities but perceived them as not "wanting the hassle".

2.19 None of the respondents, however, reported any attempts to recruit more users of mental health services onto direct payments. It seems that local authorities have not yet given serious consideration to the needs of this group.

2.20 Four authorities reported that some people had dropped out of direct payments schemes. Numbers quoted ranged from one to 3 individuals, while one authority estimated 'a small number'. The reasons included: the complexity of the system, the level of bureaucracy and paperwork involved, and a reluctance to take on the role of employer.

Publicity and Recruitment

2.21 Thirteen authorities used materials developed in-house to inform people about direct payments, 12 used Scottish Office guidance and 5 used materials developed by Centres for Integrated/Independent Living. The emphasis in most authorities appears to have been on providing information to professionals rather than potential recipients. A few authorities had been imaginative in publicising the scheme, using a range of media including advertisements in the local press, conferences, a leaflet for home care users, a newsletter directed at user groups, a roadshow for professionals led by the local disability forum and an information service provided by a voluntary organisation.

2.22 Some authorities lacked any clear strategy in relation to publicity. One authority had decided not to publicise the scheme but neither to turn down anyone requesting a direct payment who met the criteria (this scheme had one user). Two authorities had not provided any information directly to disabled people, while 4 had issued information only in written form. There was some recognition among certain authorities of the limited nature of their publicity to date and an awareness that more could be done. However, there was also some concern that enthusiastic publicity might 'open the floodgates', creating a level of demand which authorities felt ill-prepared to respond to. Lack of dedicated time to set up the necessary procedures and promote the scheme was identified as a problem by many.

Eligibility Criteria

2.23 Most authorities applied the eligibility criteria set out in the regulations (discussed in the previous chapter). There was considerable uncertainty in a number of authorities about how to interpret the requirement that an individual "must be willing and able to manage" a direct payment (Scottish Office, 1997b, 12). In particular, respondents were uncertain how to interpret the requirement that the user remain in control of the arrangements, and accountable for the way in which the payment is used. The Scottish Office guidance allows a third party to be appointed to assist in managing the payment, but while 10 authorities agreed that recipients could appoint, only 2 authorities reported that such arrangements were actually in operation.

2.24 Linked to this concern about how to ensure an individual was able to accept and/or manage a direct payment, there was considerable anxiety in some authorities about the recent South Lanarkshire ruling ( see chapter one). Some authorities, including 2 with long running systems but no recipients, stressed the need for "guarantees" that "people are capable of understanding the process of being in control". Different interpretations and anxiety about this issue may in part account for the very low number of people with learning disabilities receiving direct payments. One authority required to be satisfied that a person could manage the payment on an on-going basis. Clearly this could militate against people whose conditions lead to fluctuating levels of energy, and those with recurring mental health conditions who may prefer to move between managing the arrangements themselves and having someone else to do so when they are less well.

2.25 Five authorities reported having imposed their own eligibility criteria over and above those contained in the legislation. Most often, these criteria reflected local priorities for community care: authorities which restrict community care provision to people whose needs have been assessed as falling into 'medium' or 'high' priority bands may restrict access to direct payments on the same grounds. The main criterion for the 'high' band is usually that the individual is at risk of needing residential care. Another criterion imposed for access to direct payments was that people must be in receipt of either the 'high' or 'middle' rate of Disability Living Allowance Care Component. To be more specific:

• One authority only makes direct payments available to 'Priority One' referrals and another to referrals assessed as high or medium priority.
• One authority stated that applicants must receive higher rate DLA and another, middle rate or above
• One authority stated that recipients must have less than £8000 income or capital
• One authority said the authority must be planning to purchase a service for the person rather than provide it in order for the person to qualify for direct payments.
• One authority stated;

"If a person is known to the department as not being in control of their own lives and don't make wise decisions, they would be considered unsuitable."

2.26 These findings point to considerable variation in the conditions which people in different parts of the country are required to meet in order to qualify for a direct payment. The last point listed above also indicates that subjective judgement on the part of individual social workers plays a significant role in at least one authority. These themes emerge strongly from the case studies later in the report.

2.27 Three authorities admitted making payments to people aged 16 and 17, although this is outwith the scope of the Act. Two authorities required individuals who met the ILF eligibility criteria to apply to the ILF before applying for a direct payment.

2.28 Most direct payment recipients were recruited through the community care assessment process. Some authorities described this as a two-stage process - the first being assessment of need, the second, assessment of eligibility for a direct payment. Only 5 authorities reported that people had referred themselves while, in two authorities, voluntary organisations were actively involved in recruiting people.

2.29 Two authorities reported their concern that people moving on from day centres to direct payments could result in reduced budgets or even job losses in day centres.

Support available to direct payment recipients

2.30 Fourteen local authorities reported having a support system in place for direct payment recipients. However it should be stressed that this included authorities with no current recipients. In such cases, the respondents were apparently referring to support which could be made available if required.

2.31 The support consisted of all or most of the following components: initial and on-going advice and information; deciding what type of assistance should be purchased; recruiting staff; operating a payroll; and supporting recipients to be good employers. Local authorities appear to take a lead role in: providing initial advice and information about direct payments; helping applicants decide on the type of support required; advising them about purchasing services; and providing ongoing support and advice. The provision of payroll advice to direct payment recipients is seen as a role for independent persons or agencies.

2.32 There is less consistency between authorities about which agency should provide support to recruit staff, support to be a good employer and training for recipients. This is sometimes the role of the local authority, sometimes the role of the supporting organisation but in some cases is not provided at all. Only 9 authorities offered training to direct payment recipients, and just 4 to the people employed by the recipients. It is worth noting that the 2 authorities with the least involvement of outside agencies in the support of direct payment recipients have no current users.

2.33 Two thirds of the authorities reported satisfaction with the support available to direct payment recipients. However an equal proportion raised a number of concerns and suggested that support should be increased. Support and advice for people with learning disabilities and training for direct payment recipients were identified as particular gaps. One authority identified lack of funding for this as a problem. Several highlighted the need for national guidelines and a stronger role for independent support agencies.

Costing and Accounting Direct Payments

2.34 There is great variation between authorities in the way direct payments are financed. When asked to give details about overall budgets and about payments made to individuals, some respondents quoted figures which included direct payments, ILF money and support service costs. Others included one or 2 of these items. Some respondents quoted figures for 1998/99; others gave the total payments committed at present. The inconsistency of these data means it is difficult to compare expenditure across authorities.

2.35 Five authorities reported that they have discrete budgets for direct payments, ranging from £39,000 to £165,000 per annum. One of these authorities reported that it may additionally have access to the community care budget. The remaining authorities finance direct payments through various community care budgets and may have access to additional money from ILF or to cover support service costs. Among those authorities who supplied data about levels of direct payment made to individual recipients, the highest figure quoted was £4,583 per month and the lowest, £153.

2.36 One authority stated that people are not required to make any financial contribution towards their care costs and another had no policy in place. The other 13 authorities all reported that recipients' contribution is calculated through a financial assessment. No authorities made any comment on the impact of charging policies on recipients. This issue was explored in more detail in case studies.

2.37 Thirteen authorities applied a standard hourly rate of payment to PAs. This ranged from £3.60 to £11.64 on one of the island authorities. Some of the rates quoted appear to include National Insurance, sickness pay and contingency money - many do not. The mean rate in these 13 authorities was £5.97. One authority with no standard rate recommends that no less than £5.00 per hour is paid. (One authority did not respond to this question).

2.38 The basis on which standard rates were calculated also varied across the country. In some authorities, it was based on the cost of a domestic worker or a home care worker; others used rates paid to independent agency care staff locally, while one referred to "the old cost of a manual worker in residential care". A number of authorities are currently reviewing their rates. None paid below the minimum wage although, as indicated above, one paid the minimum wage. Authorities reported that the legislation regarding the minimum wage had not had any impact as yet. Nevertheless, these findings give cause for concern, both in terms of the wide discrepancy in the rates of pay being paid across the country and also in the very low rate paid to some PAs .

2.39 Four of the 15 authorities make no provision to pay higher rates to workers with particular skills. The remaining 11 would consider doing so if this was identified as a particular need during an individual assessment. However, there did not appear to be any formal guidelines about when this would be considered appropriate. Only 4 of the 15 authorities pay PAs enhanced rates for unsociable hours. Ten pay a standard rate for sleepover or waking assistance.

2.40 In all but one authority, recipients were said to be able to use their discretion to vary the nature, timing and cost of support once an award has been made. However, the mechanisms for doing so varied. In 8 authorities, recipients can use formal review procedures to change their support arrangements. Reviews varied from six weekly to once yearly, with one authority stating that reviews can be called whenever necessary. Five of these 8 authorities reported that adjustments had been made through these formal procedures when needed.

2.41 Five other authorities stated that recipients could adjust arrangements at their own discretion within the allocated payments and they expected this to happen quite often. Any more significant adjustments would require reassessment by a care manager. One of these authorities also explained that flexibility could be built into the support package if this is identified as a need in the community care assessment.

Purchasing Services

2.42 Policies on what may be purchased with direct payments varied across the country. Most authorities permitted a wide range of assistance to be purchased. All or most of the authorities allowed people to purchase assistance with personal care, household tasks, leisure activities, work and educational activities. Some, including 2 of the authorities which had schemes, but no recipients, were more restrictive. Assistance with personal care, household tasks and leisure activities were most frequently purchased. Support with either work or education has been purchased in only 3 authorities . One authority would allow the purchase of day activities and transport, although this had not yet happened. Another stated that small pieces of equipment for independent living, which would otherwise be provided by the social work department, could in principle be purchased.

2.43 PAs can be employed on an individual basis or from an agency. Currently in 6 authorities all direct payment recipients employ individual workers only. In 3 authorities, recipients either employ individual workers only or employ agency staff only but do not employ both. In the remaining 3 authorities, recipients employ either individuals or agency staff or a mixture of both.

2.44 Nine of these 12 authorities reported that recipients have experienced problems identifying a suitable individual or agency to meet their needs. The most commonly reported difficulties were:

• Recruiting people with the right skills
• Low levels of pay
• Recruiting people of a particular gender
• Recruiting people of a particular age
• Recruiting people to work a small number of hours
• The requirement for workers to be self employed
• Recruiting people for split shifts
• Finding PAs with the right characteristics or qualities to 'match' with individual recipients

2.45 These problems were exacerbated in rural areas where it was often hard to find PAs with the right skills, willing to travel long distances and work split hours.

2.46 Authorities were asked how they were tackling recruitment problems. Their responses were a mixture of measures being taken, measures under active consideration and, in some cases, potential measures which occurred to the respondent when asked the question. Responses included:

• Linking workers into existing local authority and voluntary organisation training
• Offering disability awareness training
• Organising a peer support network
• Advertising more in rural areas
• Crossing authority boundaries to recruit staff
• Offering travel costs to workers traveling above average distances
• Working with existing agencies to develop their capacity to respond to the needs of recipients
• Suggesting that recipients should be able to purchase local authority services.

2.47 However, there was little evidence of a strategic response to these issues in many authorities. Some reported that they rely on care managers, social workers and support agencies to deal with problems on an individual basis as they arise. There was some anxiety about finding the right balance between offering support and avoiding interference with people's independence.

Future plans

2.48 All but one of the authorities currently running fully operational direct payment schemes intends to continue to do so. In one authority there were doubts about the value of developing the fully operational scheme further due to low demand.

2.49 Of the 6 authorities with pilot schemes that have users, 2 intend to continue with pilot schemes. The remaining 4 stated that they intend or hope to develop fully operational schemes. However, the future was by no means certain. Progress was sometimes dependent on committee or budget approval and in two authorities no timescale for development had been agreed. Of the 2 authorities with pilot schemes and no users, one intended to develop a third party scheme while the other was considering discontinuing the system.

2.50 Among those authorities with third party schemes, 3 were taking steps to develop pilot direct payment schemes and had a timescale for implementation. Several other authorities stated they would like to develop a direct payment scheme but there was no timescale for doing so. One social work department, which had intended to start a pilot scheme in April 2000, reported that this might be delayed while the South Lanarkshire appeal was taking place.

Summary

2.51 A number of people using traditional services, such as day centres, may never have received a community care assessment yet might value the opportunity to have more control over their support services. Current access, assessment and eligibility arrangements may mean that they cannot take up this opportunity. Overall, the data suggest that local rationing and less than flexible budgets may be more restrictive for potential applicants than the criteria set out in the direct payments legislation.

2.52 While most respondents expressed general support for the principles of direct payment schemes, many also expressed very real concerns about operating them. These included authorities with and without schemes in place. The concerns most frequently identified were:

• 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

2.53 A number of important implications for policy and practice can be drawn from these findings: they can be found in Chapter 7. Meanwhile, we go on to present the results from the 4 case study areas, which, as already explained, were selected from the findings of the telephone survey.