Scottish Government

CHAPTER THREE
Key features of Direct Payments in Authorities A and B

Introduction

3.1 This chapter provides an overview of direct payments as they operate within two local authorities (A and B). In both of these, the individuals identified by senior social workers (during the telephone survey) as being direct payment recipients turned out to have third party arrangements. In Authority A this was an interim measure only. Chapter 4 gives an overview of Authorities C and D. These chapters draw on data from both the telephone survey and subsequent interviews with social work managers, care managers, support organisations and disabled people. The aim is to identify ways in which the nature and extent of operational arrangements for direct payments affects their impact.

3.2 While the intention is to provide a 'factual' account, information received from different respondents was not always consistent and was sometimes contradictory. Nor was it always possible to distinguish between perceptions, or understandings, and 'fact'. In addition, direct payment schemes are not implemented in a uniform way and therefore the approaches of key individuals charged with its implementation have considerable impact on the way it operates. These approaches may differ substantially within a given local authority, particularly in the absence of an authority-wide policy framework.

Local Authority A

Description of Locality

3.3 This local authority is situated adjacent to a major conurbation in the West of Scotland. The area had once been heavily industrialised, but is now in decline.

Type of Payment Scheme in Operation

3.4 During the telephone survey, this local authority reported it was operating a pilot direct payment scheme. In fact only one person was currently receiving an indirect payment (and thus was the only person interviewed for the study). Payments had been approved for 2 further people. The local authority did not appear to be applying additional eligibility criteria over and above those contained in the legislation. There were no restrictions on the type of assistance that could be purchased (for example, personal care, household tasks, leisure activities) or its setting (for example, the work-place, educational institutions).

3.5 There were two particular areas of flexibility. Recipients could 'save up' hours, i.e.; use fewer hours of assistance than they were entitled to in order to cover occasions when additional support would be required. They were also allowed to employ close relatives where they did not live in the same house. Although the Direct Payments legislation only permits the employment of close relatives in exceptional circumstances, it was permissible for a third party scheme such as this.

Setting Up the Scheme

3.6 The pilot project was being implemented by one social work team and was only available to people living in the geographic area covered by that team. It was supposed to have started in January 1999, but had been delayed, apparently partly because of the need to identify a suitable supporting organisation, and partly to allow for consideration of the South Lanarkshire judgement. The pilot eventually began in September 1999 and was scheduled to run for six months.

3.7 The scheme was set up in consultation with disabled people. Three local disability forums had been consulted and a meeting had been held to provide information about the scheme and to ask about support needs. Consultation was on going via meetings involving people accepted onto the pilot, the disability forums and the supporting organisation.

Take-up - Type of Impairment

3.8 This authority was aiming to find 6 people to participate in the pilot project, but at the time of interview (December 1999) had three participants, only one of whom was employing PAs. Of the 3 participants, 2 had physical or sensory impairments and one had learning disabilities. Three participants had dropped out, apparently because they felt the scheme was not for them, or because it did not meet their expectations.

Recruitment and Publicity Strategies

3.9 The social work manager reported that the local authority had no recruitment or publicity policy. There was no formal procedure for recording interest and no formal assessment procedure distinct from the standard one used for community care. The social work department was targeting people from its existing caseload who were entitled to services but for whom there was 'nothing obvious' to meet their needs. Care managers were expected to make judgements about individuals' capacity to take on direct payments. The authority had hoped that people on the pre-existing Independent Living Scheme might wish to transfer but none had done so.

3.10 Despite one report that various publicity materials had been produced and/or distributed, including Scottish Executive Guidance and materials from supporting organisations, the general consensus was that publicity was inadequate. One respondent highlighted the need for written information to give to prospective recipients.

Financial Arrangements

3.11 A separate budget of £60,000 p.a. (including £30,000 for the six month pilot) had been established for the scheme. The budget was under-spent because of poor take-up.

3.12 The authority appeared concerned to promote parity with other comparable services, even if this was not always achieved. It claimed to operate a means-tested charging policy on the same basis as other community care services. However, the recipient was not paying charges, despite having done so previously. The hourly rate paid for personal assistance was £5.10, equivalent to the social work department Home Care rate. However, because this included provision for sick pay, holiday pay, training, travel costs and emergency cover, the amount paid to PAs was £4.10. This was less than carers employed in other local authority services, such as Flexicare, received.

3.13 The supporting organisation received a grant to cover the costs associated with recruitment, payroll, training, bookkeeping and employer's insurance, as well as the payments for personal assistance. The PAs signed weekly time sheets, which the recipient sent to the supporting organisation who then paid the wages.

Services Purchased

3.14 The recipient was employing three PAs, including someone who had previously worked for him as a carer. In fact, all three already knew him. They provided assistance with personal care and leisure activities.

Monitoring and Review

3.15 As part of the shift in role required of care managers, 'hands on' monitoring was not seen as appropriate. Instead the care manager relied on the recipient to be proactive in reporting problems. Family members, PAs and the supporting organisation might also be instrumental in identifying and reporting problems. Social work staff acknowledged that much depended on trust between those involved.

3.16 There was no formal review procedure: the recipient was unclear about the frequency and process for reviews. The meetings held between users, social work staff, disability forums and supporting organisation played some part in monitoring and reviewing progress.

Support and Training for Social Work Staff

3.17 Neither the social work manager nor the care manager interviewed had received any training, despite the significant shift in role required by direct payments. The social work manager had been given 'things to read'. Both said they would like training about the role of the supporting organisation.

Support and Training for Direct Payment Recipients

3.18 The supporting organisation provided support to voluntary organisations generally: it was not an organisation of disabled people. Its brief was to provide support, information and advice on all aspects of voluntary sector work. The social work department also saw itself having a role in providing support to direct payment recipients. This involved providing initial advice and information, assessing need, monitoring expenditure and, with the support organisation, offering ongoing advice as necessary.

3.19 The supporting organisation saw its role as giving advice on purchasing services, providing advocacy and a payroll service, and offering support with recruitment and the employer role. Providing, or accessing, training for recipients was another of its tasks. However, there seemed to be considerable disagreement and uncertainty between this agency and the local authority about their respective roles. The agency also felt that its role was not well understood by service users.

The Impact of Direct Payments on Professionals

3.20 Again, partly due to low take-up, the impact on social work staff workloads had been less than anticipated. However, the role played by the supporting organisation was also cited as a significant factor in reducing workloads. For the care manager, the initial phase of setting up the scheme was time-consuming. However, once up and running, the 'hands off' approach meant less time was spent with the recipient than would have been the case for other service delivery options.

3.21 In contrast, the impact on the workload of the supporting organisation had been substantial. Its job entailed both addressing the requirements of the recipient employing PAs, and actively supporting the two potential recipients who were experiencing recruitment difficulties.

Overview - The Inter-relationship of Factors

3.22 At the time of interview the pilot project had only been in operation for three months. It was therefore too early for firm assessments of its overall effectiveness to be made. The main outcomes to date seemed to be:

• Poor take-up and a consequent under-spending of the budget;
• Difficulties in recruiting PAs;
• Improvements to the recipient's support arrangements;
• The freeing up of the care manager's time, following an initial period of heavy investment;
• An increase in the volume of work for the supporting organisation.

3.23 It was suggested that some potential recipients might have been deterred by the delay in setting up the pilot. The short duration of the scheme and uncertainty about its future, was also cited by one respondent as a possible deterrent given the length of time it can take to recruit PAs. Other factors may include the small size of the target area, the lack of a recruitment and publicity policy and the targeting of people with new or unmet needs as opposed to people whose needs were being met by direct service provision.

3,24 Difficulties in recruiting PAs again may be partly attributable to the duration and uncertain future of the pilot. They may also be related to low pay rates.

3.25 The eventual reduction in the care manager's workload, when compared to alternative ways of delivering services, seems to result both from her 'hands off' approach and, importantly, the role of the supporting organisation. This suggests that it was wise to delay implementation until a support organisation could be identified.

An overview of Local Authority B

Description of Locality

3.26 This local authority covers a large, mainly but not exclusively, rural area.

Type of Payment Scheme in Operation

3.27 Understandings of direct payments were very confused in this local authority. We had been told by a senior social work manager during the telephone survey that there was only one recipient. However, when the 'case study' interview took place with social workers, it emerged that the person concerned was 'receiving' an indirect payment, since the money was paid directly to a voluntary organisation. However, the social work department referred to this as a direct payment because the individual had chosen her own carers and had a choice as to whether money was paid to an agency or to her. She was the only recipient interviewed in Authority B. Data gathered about these third party arrangements are reported in some detail here, because this is what the authority (albeit mistakenly) considered to be their direct payment scheme.

3.28 In addition it emerged that 5 other people in the authority were receiving direct payments. However the social work department did not class these as such: two recipients were purchasing support from an agency, rather than employing their own personal assistants and the authority mistakenly thought that such an arrangement did not 'count' as a direct payment. In addition some of these arrangements pre-dated the direct payments legislation. It seems that the department had decided to make payments to certain individuals on a case by case basis, sometimes to formalise existing support arrangements, but without reference to the Direct Payments Act.

3.29 By the time we discovered that these 5 people were receiving 'proper' direct payments, it was too late in the research process to arrange interviews with them. (Our initial arrangements for conducting fieldwork in this authority had already been postponed twice, once due to the researcher's illness and once due to severe weather conditions). However, further discussion with the social work manager towards the end of the study revealed the following information:

• In one case, the individual's wife had given up work to look after her husband after he had a stroke. The social work department agreed to pay him £100 per week, which he gave to his wife for her help. This arrangement was set up several years ago but the payments have not increased;
• A young man with physical impairment and variable support needs was attending university. The social work department made payments to his bank account, which he passed on to his mother, who arranged his care, both at home and at university. Sadly, this man has recently died;
• Another recipient who recently died had been receiving unpaid help from a friend. The social work department paid her a direct payment to enable her to purchase support from an agency. The agency them employed her friend as a carer, thus again formalising a pre-existing arrangement;
• A fourth person who was also cared for by a friend, is now receiving a direct payment, along with ILF monies, enabling her to pay for this support;
• The area team leader had no details about the fifth person, who lived in a different part of the authority. Efforts to gain further data were not successful.

3.30 The authority's policy on what it understood to be direct payments did not include any formal additional eligibility criteria. However, to qualify for direct payments, the community care assessment had to place the person within priority bands 'one' or 'two'. The social work manager said that recipients must be able to manage the scheme (rotas, timesheets and insurance) by themselves. However, the care manager thought it was acceptable to manage the scheme with assistance. In practice, the person identified as a direct payment recipient had mild learning disabilities and her senior PA and her care manager were managing the scheme on her behalf.

3.31 Payments were not made for assistance with leisure activities, although it was in effect up to the recipient to choose how she spent the hours of assistance allocated, subject only to the PAs' willingness to accompany her. There was some flexibility over small-scale changes to staffing rotas and over limited additional expenditure, such as on occasions when two PAs were needed. However, holidays were unlikely to be feasible, on grounds of expense. There were no restrictions on who could be employed as a PA.

Setting up the Scheme

3.32 The scheme started in August 1997. Before it was set up, a workshop had been held with a local organisation of disabled people at which, according to a representative of that organisation, recommendations were made about the support services recipients would need if direct payments were to be implemented successfully. However, no such services had been established.

Take-up - Type of Impairment

3.33 The recipient of what transpired to be a third party scheme had both physical impairment and learning disabilities. Four of the 5 direct payment recipients referred to above had physical impairment. No information was provided by the social work department about the fifth person.

Recruitment and Publicity Strategies

3.34 There was no recruitment strategy targeted at people with specific types of impairment. Recipients were recruited by care managers.

3.35 With regard to publicity, there had been briefings to social workers and also to councillors approximately two years previously. Far from publicising direct payments, there was great concern at the implications of generating interest when social work department and other support infrastructure were not in place.

Financial arrangements

3.36 There was no separate budget for direct payments. Each adult care team has a budget and must keep within it. Lack of resources was cited as a major barrier to implementation. Nevertheless, the care manager commented that where this was combined with Independent Living Fund money, it was considerably cheaper for the social work department than other alternatives.

3.37 The charging policy was said to be the same as for other community care services. However, when it came to setting PA pay rates, equity with other services did not appear to be a consideration. Attempts were underway to find money to give PAs a pay rise, because the current rate, thought to be about £5.00 per hour, was seen as inadequate. It was unclear whether £5.00 was the amount that PAs actually received, or whether it included a contingency element for sick pay, holiday pay and other such costs.

Services Purchased

3.38 The recipient interviewed used the payment to employ 8 part-time PAs (including her mother) who together provided her with 24-hour assistance. One was appointed as the 'senior PA'. All were known to her beforehand, either because they were involved in providing her previous care package, or through social contacts.

Monitoring and Review

3.39 Although it was agreed that monitoring was the care manager's responsibility, a variety of people were identified as potentially having a role. This included the senior PA, the recipient's mother, other PAs and even staff at a day centre attended by the recipient.

3.40 The social work manager reported that arrangements should be reviewed every 6 months, but also as and when needed. The care manager stated that although reviews were supposed to take place annually, none had been held. The recipient and her senior PA reported meeting the care manager informally every three months, although the latter also visited on other occasions.

Support and Training for Social Work Staff

3.41 The care manager had received background information from a colleague and had attended a training day in Glasgow. She had read a substantial amount about direct payments and was sometimes approached by other social workers for advice. The social work manager had attended a day's training. He thought there would be little point in further training until adequate infrastructure was in place to deliver direct payments effectively.

Support and Training for Direct Payment Recipients

3.42 A key concern about starting the 'direct payment' scheme was the lack of adequate support arrangements for recipients. According to a representative from the social work department, efforts had been made to engage an organisation of disabled people to become part of the support infrastructure, but without success so far. A local coalition of disabled people, which took part in the study, expressed interest and willingness to become involved, suggesting some lack of communication locally. A pay roll service is provided by a voluntary sector organisation in another authority. This organisation also provides occasional advice and support to the recipient.

3.43 The role of the care manager in providing support to the recipient unable to manage the scheme herself is extensive. This has included drawing up contracts and other tasks, which would otherwise be performed by a supporting organisation.

The Impact of Direct Payments on Professionals

3.44 The impact on the disability organisation interviewed appeared to be non-existent, reflecting the extent of their current role. However, in contrast, the impact on the workload of the care manager had been very substantial, to the point that she would " certainly think twice before setting up another one". The social work manager, for the same reasons, was not encouraging care managers to take on more direct payment cases. Nonetheless, there was strong support for the principle of direct payments.

Overview

3.45 The main features seem to be:

• Confusion about what constitutes direct payments;
• Poor take-up and an unwillingness on the part of the local authority to increase it, particularly among people who would not be able to manage direct payments themselves;
• The absence of independent training and support services to direct payment recipients;
• The lack of social work department policy and procedures on direct payments;
• A very substantial increase in the workload of the care manager;
• Perceived funding constraints on extending the scheme.

3.46 The lack of support and operational infrastructure appears to result in a vastly increased workload for the care manager - and presumably for those recipients who are able to manage direct payments themselves. Although the care manager was aware of circumstances in which direct payments, combined with other funding such as ILF, could be a cheaper option than other ways of delivering services, the perception of funding constraints remained.

3.47 In this chapter, we have looked at arrangements in two authorities which, although identified as 'direct payment schemes' by the social work departments, were currently operating as third party schemes. Chapter 4 presents the findings from the two other case study authorities, both of which were offering direct payment schemes.