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309. Section 14: DIRECT PAYMENTS FOR OLDER PEOPLE
'…I am so very grateful for direct payments. I don't know what I would do without it now, it's such a great help'…. (Elderly lady with physical disabilities, also caring for husband with dementia)
310. All older people aged 65 and over are eligible for direct payments to meet their assessed personal care needs if they are living at home. This is their entitlement as part of the free personal and nursing care ( FPNC) available to people aged over 65 years in Scotland 36.
311. Older people may choose to have some services delivered by their local authority, and others via direct payments. Some may wish to introduce direct payments to their package gradually to enable them to gain confidence in their ability to manage them. Currently, very few people accessing FPNC do so via direct payments, but as local experience and support builds, numbers are expected to significantly increase. Local authorities need to ensure that direct payments options are routinely available for older people, as with any other eligible client group. Information and training is an essential part of this process, see para xx, and older people can expect to be given details of local people who can support them to consider and use direct payments. Local authorities should also fund pre-assessment work so that people can work out what their needs are and how best to meet them.
Eligibility, assessment and care
312. The services older people may be assessed as needing are anything from podiatry to equipment from the joint store, to home support services or community psychiatric nursing. For example, older people or those with disabilities may experience mental health problems such as depression from declining health, mobility and general activity; from financial problems; from feelings of social isolation, lack of friendships and support and/or mourning the death of partners, family, friends and colleagues; from periods of hospital care and even delayed discharge from hospital while their future care needs are being organised. Older people with learning disabilities or dementia should not be seen as different from older people generally, and they should have the same access to mainstream health and social care support.
313. Flexibility, choice and control over how their assessed care needs are met is a right of older people as much as any other eligible care groups. Older people can expect to be given the maximum possible informed choice and control over how their assessed needs are met including using DPs to meet some or all of their needs. Direct payments is one option to enable people to maintain their independence and individual quality of life and should be offered to older people who are eligible at every assessment and review.
314. Direct payments may be particularly valuable for those whose needs have been recognised as being less well served by available local authority services. Indeed, once direct payments packages are being properly managed with the necessary support, they may also offer increased security for some individuals wishing to avoid going into a care home, as it may be a means of establishing over time the necessary care arrangements for that person in their own home.
315. The nursing care element of Free Personal and Nursing Care is not available as part of a direct payments package unless it is for continuing health care needs i.e. primary care tasks carried out at the person's home that do not require to be carried out by a qualified health professional, for example routine aspects of diabetes and epilepsy care (see section 4). Arrangements need to be put in place across Scotland to encourage self-directed health care at home as part of a wider package to support independent living. The Joint Future partnership working between community care and health services is already leading to more flexible and better targeted care-at-home services, including direct payment packages. Integrating care and health through joint management and funding should lead to more responsive relationships between users and service providers.
"When I became ill, at first I needed care and companionship for most of the day. The direct payments system allowed me to choose a personal assistant from my own village community. This gave me a lot of confidence. As a result, my husband was able to continue work for two years, until his recent retirement." (Elderly lady with physical disabilities).
What older people can expect
316. Older 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
317. 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 personalised support that they need and they do not have as much say in the person visiting their home to provide support, and what they can or cannot do.
Employing PAs
318. Whilst use of service providers may best suit many older people, others may prefer to employ their own staff. Some people may already pay people for support using their own money, even on a casual basis. If they decide to accept FPNC funding using direct payments, they will have to adopt transparent bookkeeping systems and take on the responsibilities of being a PA employer. General guidance is offered at Section 4 including 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.
Example: Imaginative approach employing PAs taken by one rural elderly service user
Mr Scott has been on direct payments for 2 years and has a care package of 30 hours per week (17 hours of which is free personal care). He has contracts with five self employed personal assistants and is delighted with the care he receives, emphasising the importance of relationship building between himself and his PAs in order to achieve this. He is able to pay a small pay supplement to PAs from his own resources that has helped with recruitment and retention in the rural area in which he lives. Mr Scott's PAs also offer additional basic health care support. His experience of support from his local direct payments support organisation has been extremely positive. For example, they have been able to respond immediately to problems, have an over 65s representative, and organise Liability Insurance.
Local Support
319. Once funded to do so by local authorities, local direct payments organisations should try to expand their current support service to better accommodate older people's support needs. They need to be able to offer to older people the services they offer to 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, 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.
Consent and capacity issues
320. Older people, as with other eligible groups, need to consent to direct payments if the local authority judges them capable of managing them with the necessary support. Paragraphs 314 to 317 offer guidance on consent and capacity issues. For those lacking capacity, consent may be given by guardians and attorneys authorised to do so under the Adults with Incapacity (Scotland) Act 2000 ('The 2002 Act'). If direct payments are accessed using the 2002 Act, the least restrictive form of intervention must be used for the adult, as otherwise this may not empower adults as intended but instead may get in the way of providing the necessary care.
Cost ceilings
321. The total amount of funding received within the direct payments package needs to be sufficient to meet the older person's assessed needs. Local authority cost ceilings on some care packages for older people may be too low, for example, those strictly based on equivalent residential care costs can be very limiting and not properly meet independent living goals. The aim is to tailor a care package that allows users flexibility, choice and control over how their assessed needs are met.
How to mainstream direct payments for older people
322. Ensuring that there is adequate funding of local support services if the key for local authorities to ensure that direct payments are routinely available for older people. This support will help local authorities to:
- Promote direct payments for older service users aged 65 and over. There is still a low knowledge base within some communities. People may only hear of direct payments through word of mouth, as even many GPs have not heard of them.
- Ensure older users and potential users have access to information targeted to their needs.
- Train older users on pre-assessment and care management via local support organisations.
- Provide specialist support targeted to older people's needs, for example an advocate or support worker may be needed with specialist skills.
- Train local authority care managers, and encourage a culture of positive risk taking to enable more older people to benefit from direct payments if it meets their needs.
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