independence at a price

As part of the government’s modernisation of health and social
services, local authorities now have a duty to provide direct
payments to older people who need care.¹

Recognising that direct payments have given younger disabled people
control over their services, health secretary Alan Milburn pledged
to oblige local authorities to offer older people the choice
between receiving either directly provided services or a cash
payment to buy their own care. Milburn says the intention is to
“empower older people, their families and their carers in a way
that has never been possible before”.

The Community Care (Direct Payments) Act 1996 enabled local
authorities to make cash payments instead of directly provided
services. Initially, this excluded those aged 65 and over (unless
they had started receiving payments before their 65th birthday),
although the policy has since been extended to older people and a
range of other user groups.

Direct payments is a policy that has been developed and promoted by
disabled people themselves, and the growing body of literature in
this area has begun to highlight a range of
benefits.²

These include:

• People receiving direct payments can buy more responsive
  services than they would otherwise receive from the local
  authority.
• People have greater choice and control.
• Morale and mental or psychological well-being are
  improved.
• Individual users can make more creative use of resources than
  the local authority.
• Direct payments are cost-effective.

Although progress has been slow in some areas of the country,
more people are receiving direct payments, and the act has been
extended to older people, carers, disabled people aged 16 and 17
and the parents of disabled children. More recently, the Health and
Social Care Act 2001 promises to signal a shift from a
discretionary to a mandatory system, increasing the availability of
direct payments further.

Against this background, Milburn’s decision to make direct payments
available to older people who want them is a major step forward.
The move promises to offer older people the same choice and control
enjoyed by other user groups.

However, turning the health secretary’s pledges into reality is
going to be more difficult than it may at first appear, and success
is by no means guaranteed without a significant investment of time
and resources. In particular, there are three key issues to
consider.

First, a crucial feature of any successful direct payments scheme
is the support services that are in place to help users take on new
responsibilities. By using direct payments to hire their own staff,
users become employers and incur new administrative, financial and
legal responsibilities. This is likely to include accounting for
all money received, recruiting staff, paying tax and national
insurance, taking out appropriate insurance policies and managing
personal assistants on a day-to-day basis. These are all complex
tasks which will require direct payment recipients to develop new
and often sophisticated skills. It is hardly surprisingly that
users will need to gain access to appropriate support in order to
ensure that they rise to the challenges that direct payments
offer.

Although different arrangements are in place in different areas of
the country, all support services should include access to
information, advice and advocacy services, training and peer
support. These services must equip people with the knowledge and
skills they will need to manage their own direct payments
package.

It is evident that such support is not always forthcoming. In some
parts of the country there are few support arrangements, and some
disabled people’s organisations are struggling for funding.
Elsewhere, support may be available only from front-line social
workers, who often have heavy case loads and lack specialist
knowledge about issues such as employment legislation or financial
management. As a result, the need for dedicated funding for support
mechanisms is a constant theme in much of the literature, and it is
difficult to see how a major extension of direct payments will be
possible without a substantial, ring-fenced injection of
resources.

A second consideration is the attitudes of some social workers and
their lack of training. For some workers, direct payments offer an
exciting new way of working which allows them to empower service
users and work with them rather than for them. For other
practitioners, direct payments represent a threat to directly
provided social services and a form of “privatisation by the back
door”.

Some are concerned about a policy that they fear could increase
their already heavy workloads and create a demand that their
departments cannot meet. Others simply lack knowledge about direct
payments and have not received adequate training. Whereas those
working with younger disabled people tend to be aware of direct
payments, those working with older people and people with mental
health problems or learning difficulties tend to be much less
familiar with the concept. As a result, any attempt to promote
direct payments among older people will need to be backed up by a
concerted educational programme to win over those workers who are
hostile to, or unaware of, direct payments.

Third, we know relatively little about how older people are likely
to respond to direct payments. Although more research is being
carried out, early studies suggest that older people can benefit
from direct payments in the same way as younger disabled people,
but that there may be specific barriers to overcome.

Many older people know little about direct payments and will need
access to appropriate information in order to make informed choices
about the services they want. Some may find the concept of direct
payments alarming and will not want the financial management
responsibilities. Others may be concerned about exploitation, and
will be reluctant to advertise for and recruit their own staff. The
evidence we have so far suggests that considerable effort will need
to go into providing accessible information and support services so
that older people feel able to take up the advantages that direct
payments offer. More time may also be required as part of the
assessment process so that older people can learn about direct
payments and to think through the options available.

Overall, Milburn’s announcement is good in theory, but weak on many
of the practical and resource issues that could make or break his
proposals. Although the government has pledged to work with older
people’s organisations, the task ahead will not be easy and
probably will not be cheap either. With local authorities already
struggling to meet the demands made upon them within their budgets,
the danger is that direct payments might not necessarily be seen as
a priority.

If we are not careful, there is a risk that too many older people
will be set up to fail by being offered direct payments without the
support to make their care packages work.

Jon Glasby is a lecturer at the University of
Birmingham’s health services management centre.

References

¹ Department of Health,
Expanded Services and Increased Choices for Older People,
DoH press release 2002/0324, July 2002

² J Glasby and R
Littlechild, Social Work and Direct Payments, The Policy
Press 2002