Direct payment success comes under threat

Social workers and a service user offer advice on a case involving a young woman with profound learning and physical disabilities


Case Study


M has profound learning and physical disabilities. She is 19 and about to leave school this month.

She lives at home with mum A and mum’s partner B, both of whom are very caring and don’t want M to live in residential care.

M has been in receipt of direct payments for about three years to supplement the personal care and support given by A and B.

A suffered an injury a year ago, probably caused by all the manual handling. The direct payments were increased in a series of one-off payments to compensate for this.

M’s social worker is working with A towards an increased package for M in July which will require a further increase in funding. A has been imaginative in sourcing therapists and local resources that might provide a varied weekly programme for M.

The social worker is also applying for an allocation from the Independent Living Fund.


A continuing healthcare assessment was carried out on M a year ago, and the verdict was that she was not eligible. This was an unexpected outcome, and it has been suggested that she should be reassessed.

However, the social worker is worried that, if successful, continuing healthcare funding may result in less money which could threaten the success of M’s direct payments and tailored package.

But he also realises that it is illegal for social care to fund support that could be deemed to be more appropriately funded by health.


The social worker view: Ginny Moodie, the Services Solutions Team, Adult Care Services, Hertfordshire Council

The Independent Living Fund (ILF) assessment of M’s needs will determine M’s joint package of care and the funding split.

The council’s maximum care package limit of £785 was removed from April so, with ILF possibly contributing their maximum of £475, M’s personal budget from the local authority theoretically has no limits.

If continuing healthcare funding is awarded and the health contribution reduces the local authority’s direct payment to under £320, ILF will be withdrawn.

As a result, M’s individual budget from these two funding streams might be lower than from existing direct payments and ILF.

Health funding can be paid into a user-controlled trust or managed by the local authority and used as a direct payment.

However, the Health Bill, which has just received its second reading in the House of Commons, allows for the piloting of personal health budgets paid directly to clients.

The numbers are important here to maximise resources available to M. But it is also paramount to ensure that M remains in control and can direct her own support with assistance from A and B.

While direct payments cannot be used to buy health services and equipment, and ILF does not contribute towards respite, there is room with careful planning and clear outcomes to retain flexibility.

Assuming that A was undertaking most of M’s personal care, direct payments and ILF could be used to employ personal assistants and the personal health budget to meet nursing needs.

Depending on the therapies A has sourced, these might be paid for from either the health funding or direct payments, and social activities funded from direct payments and ILF.

The challenge is to form a plan which remains within the criteria of the differing funding authorities. Focusing on how M would like to reach agreed outcomes makes the task of matching activity to funding far easier than focusing on maximising resources and then asking how it should be spent.


The social worker view: Julie Stansfield, managing director, In Control

There are thankfully now more examples of people remaining in control while being funded via continuing healthcare.

While there are still some legal difficulties in giving health funding as a direct payment to individuals, people have found many other ways of having the life they choose.

There are options as to how to deploy the funding and, in some cases, community care funds still provide additional resource to the continuing healthcare funding, thus leading to the individual still being able to access and apply for ILF.

M and her family need to make a strong support plan looking at what is needed, what will help M to sustain her life at home and keep her safe and well, and what this would cost. These are just some of the questions that need to be addressed.

They should also call a meeting with both the local authority and the PCT to show them their plan and secure agreement to it. The plan will give a good base to start negotiations on the best ways for funding to be deployed for M.


The user view: Simon Heng, disability writer and activist and a wheelchair user

In the rush to enable people to continue to live in the community some of the practicalities about how direct payment and individual budget applicants actually obtain the money has been skated over.

The National Framework for NHS Continuing Healthcare was meant to standardise NHS contributions towards care in the community by offering a national framework for assessment and a standard rate of payment.

But it didn’t specify how this help should be provided when the assessment was for care in people’s own homes rather than in a nursing home.

The national framework website implies this care should be provided directly by the responsible health trust. However, this isn’t black and white – the PCT has the discretion to pay the money for M’s care to her directly.

A successful outcome for M’s funding is going to depend upon a clear understanding of her situation and the aims of her care package by the PCT’s budget holders.

I can sympathise with M’s carers – I’ve been through the process of reorganising my care package and funding.

It can be a frightening process which leaves people feeling their independence is under threat.

This article is published in the 23 July issue of Community Care under the heading Direct payment success comes under threat

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