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Section 13: DIRECT PAYMENTS FOR USERS OF MENTAL HEALTH SERVICES
'…If I am having a bad day I can alter days or times - that takes away the pressure of a set commitment. In return I am also flexible with her (employee) where necessary, so it works very well. Looking back over the last 18 months of being on this scheme, I feel I have come along way from the isolation and depression. But the most important part of it all is that direct payments staff are always just a phone call away. I feel this is a vital part of the success of the scheme… (Lady, 61, referred by Mental Health Team, also has physical health difficulties).
291. When compared to uptake by other eligible groups, all local authorities need to take significant steps to improve access to direct payments in lieu of more traditional mental health services. This accords well with the new duties under sections 25-31 of the Mental Health (Care and Treatment) (Scotland) Act 2003 and the need to address social inclusion. Direct payments used imaginatively can lead to a positive impact on mental health, reduce inappropriate admissions to hospital or residential care, help increase confidence, self-esteem, assertiveness, independence, participation in mainstream activities, and increase individual's sense of purpose and optimism.
292. As a general principle, local councils should aim to leave choice in the hands of the individual by enabling people to address their own needs as they consider best, whilst satisfying themselves that the agreed care plan outcomes are being achieved. This is no different to self-directed care for any other eligible care group but it may be a particularly significant change of emphasis for mental health service users more used to receiving health treatment who may now be pursuing a journey of recovery by accessing a mixture of health and social care activities in the community.
293. In past years, mental health services have tended to focus on maintenance of chronic conditions and/or preventing crisis or deterioration. However, current thinking encourages people to live as full a life as they are able, in spite of their illness, and to pursue a journey of recovery, even if it does not result in a complete cure. This recovery agenda is much more in line with the social model of disability (see paragraph xx) and has real implications for the type of recovery-orientated services and individual responses that will need to be made available to individuals locally.
294. It also comes at a time when local authorities and health boards are working in more integrated ways. Social work and health staff need systems that enable them to help their clients get swift access to direct payments so that users can get on with the various stages of their recovery plans. It is about both users and practitioners thinking beyond the community based care and support services for rehabilitation and aftercare that may be currently available, to individualised or personalised support enabling recovery and independent living. It is about practitioners making the shift from assessing whether someone is ready to attend or requires a service to assessing what their needs are to aid their recovery.
295. This whole systems recovery approach is about looking both within and beyond mental health service provision at the whole range of opportunities and support that a person with mental health needs might utilise to enable them to live their life as they wish. It is an approach that is vital to the effective development of mental health services, and one that is promoted by the use of direct payments.
Eligibility, assessment and support
296. Paragraph 1.5 of Annex A lists those currently unable to receive direct payments under the Mental Health (Care and Treatment) (Scotland) Act 2003. However, local authorities, community health partnerships and non-statutory providers of mental health services and support must ensure that direct payments become routinely available to other people using mental health services.
297. There is sufficient UK experience available on the successful operation of direct payments by mental health service users and it is time to equip staff with the drive, skills and knowledge to make increased uptake a reality in Scotland. It may also be particularly valuable for those whose needs have been recognised as being less well served by collective provision land/or are less likely to access provided services, such as those who wish to avoid segregated services.
298. Direct payments may include support for the person's mental health problems, such as support with a relapse prevention plan, undertaken by PAs guided by specialist mental health staff. However, direct payments will usually be used to provide social aspects of recovery. This may include access to day opportunities, support workers, night sitters, respite breaks (holidays), therapeutic support, alternative and non-health provided physical therapies, education, transport, leisure, arts, childcare, training, vocational guidance and employment opportunities. Some recent innovative uses of direct payments by UK mental health service users to meet their needs have been: the purchase of equipment to help meet their needs (for example, a telephone to keep in touch with a carer and so reduce anxiety when out alone); improving access to rural community contact opportunities (for example, purchasing driving lessons); improving confidence and social interaction (for example, joining a violin group); engaging in a preferred form of meaningful activity instead of a day service (for example, joining a fishing club, or as a group of users, hiring an art teacher); moving into employment (for example, a group renting a workshop, or employing someone for a short period to get a small enterprise off the ground). All of these are uses of direct payments which fall outside of the description of services in most peoples' understanding, but which have proved to be effective in meeting the assessed needs.
299. Mental health partnerships need to share an understanding of and commitment to the goals of recovery and independent living. They need to apply a whole systems approach to funding, enabling more flexible contracting arrangements, and training and other direct payments support to be provided by all partners. Increased expenditure by local authorities on direct payments can be accommodated by changes in the balance of funding for other parts of the mental health system. There needs to be agreement over joint eligibility criteria to receive both health and social care services.
300. There also needs to be a joint strategy for the implementation of direct payments within mental health services that has fully involved users in its design. The strategy should include: joint training; shared language and straight forward systems; recognition that some needs can be met through either health or social care or a combination; provision of targeted support for direct payments users; guidance to mental health staff; and information to service users.
What mental health service users can expect
301. Mental health service users who are eligible for direct payments can expect:
- to be given choice and control over how their assessed needs are met
- to be offered pre-assessment work so that they can work out their needs and make informed choices about use of direct payment for some or all of their support
- to be given details of local support services for information, training and practical help
- direct payments to be offered at every assessment and review
- to be given direct payments training that is personalised to their needs
Using care agencies and other service providers
302. Section 4 looks at the support that can be purchased using direct payments. Using service providers has many advantages, including providing emergency back-up and illness/holiday cover, and the direct payments recipient does not have the responsibilities of being an employer. However, it may be difficult to ensure that the individual has the crisis support that they may need, and they do not have as much say in who the person is visiting their home to provide support, and what they can or cannot do.
Employing PAs
303. This option may offer the targeted support that many mental health service users seek. General guidance is offered at section 5 as well as advice on employing family members. The proposed Adult Support and Protection Bill to be enacted in 2007 will make it possible for local authorities to allow employment of family members in exceptional circumstances where this is necessary to deliver the required care.
304. The following case history illustrates the imaginative approach taken by one service user by employing PAs.
Local Support
305. Once funded to do so by joint mental health services, local direct payments organisations should work in partnership with mental health support organisations to try to expand their current support service to better accommodate these users. This may be particularly challenging if local users are not accessing traditional community care services in the first place, or in contact with their council for other services, but instead are used to receiving services from their health trust.
306. Local Support Partnerships needs to be able to offer to mental health service users the services direct payments organisations offer to other older or disabled people, including the facilitative roles they offer during the setting up stages of a package; general confidence building as people gain from the experiences of their peers, help setting up a separate bank account to track payments and expenditure as well as those wanting to employ PAs; help setting up employer's liability insurance, providing rooms for interviewing PAs; providing an address for responses to adverts; and help in resolving any difficulties that may arise. They need to expand their outreach so that the places where potential users routinely meet (for example, GPs, social networks) have the information they might need.
How to mainstream direct payments for mental health service users.
307. Ensuring that there is adequate funding of local DP support services is the key for local authorities and health trusts to ensure that direct payments are routinely available for users of mental health services. This support will help local authorities:
- Promote direct payments for mental health service users.
- Provide targeted information.
- Provide general direct payments advice supported by specialist mental health advice. A specialist advocate or support worker may be needed during pre-assessment, SSA, care planning and care management.
- Ensure pre-assessment work and the SSA process itself gives access to direct payments (see section 2).
- Provide training for council and health staff and users, include pre-assessment training, advance statements and the use of crisis plans with particular attention to the use of third party support at times of crisis as a means of managing risk. 35
- Encourage imaginative use of direct payments to develop partnerships between users, such that together they might be able to purchase training or education to assist their development (eg IT, graphic design, and drama).
- Encourage direct payments use as part of a culture of positive risk taking, enabling people to take first steps where previously they had encountered weariness or alarm associated with potential relapse.
- Provide flexible funding to meet anticipated variable demand for direct payments as part of a recovery plan.
Further Information
308. Direct Payments for People with Mental Health Problems. A Guide to Action (Department of Health February 2006).
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