Many older people do not want the responsibility of handling a direct payment, say practitioners
Personalisation implies that personal budgets should be tailored to the needs of the individual. But some councils appear to be restricting users to direct payments, finds Natalie Valios
“We want people to have the freedom to choose the services that are right for them from a vibrant plural market. That is why this vision challenges councils to provide personal budgets, preferably as direct payments, to everyone eligible within the next two years.”
So states the foreword to the government’s vision for adult social care published last November. But there is a fear that some local authorities have taken this too literally and are only offering direct payments instead of a range of personal budget options (see panel below). Indeed, one-third of social care professionals who responded to Community Care’s annual personalisation survey, commissioned by Unison, said that their local authority had changed their policies to make direct payments the default method of delivering personal budgets.
This is despite the fact, acknowledged in a 2010 advice note from the Putting People First consortium, that “most people using services will want to exercise choice and control, but they may not necessarily want to take on the responsibility of a direct payment”.
Caroline Bernard, deputy chief executive of older people’s charity Counsel and Care, is concerned at the situation: “Anecdotally we are seeing that choice and control is being read as a direct payment and that’s the box ticked. But the choice is whether someone wants a direct payment or not, and if they haven’t been told there is an alternative then it’s unlikely they’ll know about managed personal budgets.”
Simon Bottery, director of policy at older people’s charity Independent Age, agrees: “You can’t arbitrarily say most people should have a direct payment because you are making a judgement about what most people want before you have individually asked them.
“Personalisation is about what the individual wants. If they want a managed budget they should have it and the same goes for if they want a direct payment. It would be a concern if older people who didn’t want a direct payment were being overly encouraged to hold one.”
These concerns were echoed in our survey, with many respondents suggesting that service users were having responsibilities they did not want foisted on them, including through direct payments (see box right).
Local authorities that only offer direct payments will leave service users who don’t want the responsibilities that a direct payment entails disengaged from the whole personalisation agenda, says Bernard. “We have to think about how we can make [direct payments] more attractive to them; with the right advice and information upfront then they might want to do it.”
Support is key to helping an individual switch from being a service user to becoming an employer or commissioner of care, as follows from holding a direct payment, she says. It can particularly help in cases where service users employ family carers.
“Money can affect the relationship between the carer and the cared-for person, it becomes the underlying thing between family and friends and that can make it hard to disengage as a carer. And the cared-for person may not feel comfortable paying them.
“They need to be supported through that shift – as does the carer – so that they have the confidence to work together and not have the money hanging over them and causing friction.”
Even with all the right support in place, concerns linger about employment responsibilities and safeguarding risks, such as financial abuse. David Hambly, a social worker in a complex planning team at Barnet Council, is particularly worried about clients with drug and alcohol abuse problems having direct payments.
“There are real safeguarding issues if they have access to that funding, because the question is whether they will spend it on drugs or alcohol instead,” he says. “And older people are nervous about what being an employer entails. It is much easier with young people with disabilities, they are good advocates for themselves and just need you there for a bit of support but are able to manage it themselves. But even then a difference in opinion between the service user and the practitioner over the outcomes that they want to achieve can put a strain on the relationship.”
On the flipside, there has been criticism that council-managed budgets have left local authorities with too much control over the services that users purchase. Hambly says: “We are supposed to be putting the person at the centre of the care plan and doing more support planning with them. You would think that would lead to more innovative approaches but it seems to me we are still fitting clients into existing services rather than developing new ones.”
Direct payments were the original personal budgets – campaigned for by the disability movement in the 1990s – and they typically provide service users with a far greater level of choice and control than other personal budgets. Local authorities should see the government’s vision as symbolic of the importance it places on direct payments being at the heart of personalisation, but not to the exclusion of other options, says Jon Glasby, director of the University of Birmingham’s Health Services Management Centre.
“If councils interpret this as everyone having to have a direct payment that would be a bad thing, because there’s nothing in any policy context to say that,” he says. “It’s about everyone having a personal budget and we are assuming that more people would want that as a direct payment.
“The whole point is that we tailor support to people’s circumstances and by definition that will be different for all of us. There needs to be a spectrum of options available.
“The government statement is trying to emphasise that things have been shifting since the 1990s away from a direct service to a personal budget. It is part of the gradual evolution we have been on for the last 20 years.”
How personal budgets can be delivered
A personal budget is an upfront allocation of money so it is clear how much is available for a service user to meet eligible needs. There are several ways that users can receive this money. It can be:
● A direct (cash) payment, held by the service user. Here, the money changes hands and the service user is responsible for spending, administering and accounting for it, which means they employ people and commission services themselves.
● Held in an account by the council and managed in line with the person’s wishes. The user does not receive the money and is not responsible for it. The user agrees a support plan with their social worker about how the money will be spent to meet their assessed needs.
● Administered by a public, private or voluntary provider through an independent service fund. The provider administers the money on an individual’s behalf to provide a personalised package of care.
● There may be a mixture of these options.
Social workers’ views
“While a personal budget is great for many people it is not ideal for everyone. Working with older people can be personalised without insisting they manage their own budget. Many do not want this responsibility and would be much happier if greater efforts were made to provide a reliable social care workforce.”
“Although people have been allocated a personal budget the majority of service users that I have been involved with have made the choice for social services to manage it.”
“In practice many service users find direct paymentsconfusing.”
“Social workers now seem to need a degree in accounting as it is very rare for families/carers to want to manage a budget/commission services.”
Source: Community Care/Unison personalisation survey 2011
This article is published in the 2 June 2011 edition of Community Care under the headline “Choice without choice”
Special report: The state of personalisation 2011